Running head: EMPD IN PREDICTING FEEDING TUBE PLACEMENT

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

Heather LaPoint
University of Central Florida
Department of Nursing
NGR 6813
Fall 2014

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

Abstract
Aim: To critique the evidence that electromagnetic placement devices (EMPD) are more
accurate in placing small-bowel feeding tubes as compared to abdominal radiography.
Background: Delay to feeding and untoward outcomes during feeding tube insertion as left an
opportunity for nurse educators to appraise new technology for critically ill adult patients in
small-bowel tube placement.
Design: A limited integrated literature review.
Methods: A limited integrated literature review using searches of Academic Search Premier,
Medline, CINAHL, and the Cochrane Database of Systematic Reviews for all years available.
Results: 9 primary studies reviewed and revealed EMPD insertion methods statistically
significant for improved insertion accuracy, patient safety, and financial benefit. Sample size
included 2254 adult ICU patients from 4 countries. EMPD can be done as a bedside procedure,
faster, more accurately, without adverse events, while preventing patient harm, and being fiscally
responsible.
Conclusion: Nurse educators can teach the technique academically or clinically, advocate for
the equipment use, provide longitudinal research results, advocate to administration the benefits
to patients concerning nutrition delivery versus cost analysis, and participate in grant writing.
Curriculum inclusion of EMPD technology will lead to a merging of didactic teaching and
clinical skill through lectures, EBP introduction, leadership theory, simulation, clinical offerings,
and research opportunities.
Key Words: Intensive care unit, electromagnetic tube placement device, enteral feeding tube.

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

Table of Contents
Title Page.1
Abstract2
Table of Contents.3
Introduction..4
Significance and Background...4-7
Research Question...7
Methods7-9
Findings..9-14
Recommendations14-16
Conclusions...17
References18-20
Appendix A, Table 1.....21-29

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

Electromagnetic Placement Device in Predicting Feeding Tube Placement

The changing face of healthcare and associated technology has led to a need for increased
impetus in nursing research and evidence-based practice. Vulnerable populations, such as
critically ill adults, are in particular need of evidence-based practice research for care changes.
An area of exploration is enteral feeding practices, most specifically, a review of the current
literature surrounding the efficacy surrounding small-bore feeding tube placement at the bedside
using electromagnetic placement device technology as opposed to traditional techniques and
methods of verification of placement. Nurse educators are strategically positioned to not only
teach to the findings, but participate in the research itself and assist in the interpretation of the
results for a cohesive synthesis of data that can be translated into practice. As educators, there is
an exposure to both clinicians and students wherein results and evidence-based practice can be
shared. This integrated literature review will examine literature related to EMPD insertion and
radiology verifications of feeding tubes in critically ill adults with further consideration to the
role of the educator to those results.
Significance and Background
Introduction of early enteral feeding in the critical care adult has demonstrated efficacy in
the reduction of translocation of bacteria from the gastrointestinal tract, enhanced innate immune
function, and aided in decreased morbidity while proving to be more financially viable than
parenteral methods of nutrition (Ackerman & Mick, 2006). Particularly, placement of feeding
tubes for enteral nutrition are often met with untoward outcomes in some instances.
Complications associated with insertion of small-bowel feeding tubes include pneumothorax,
hydrothorax, bronchopleural fistulas, empyema, pneumonitis, esophageal perforation, pleural
effusions, and pneumonia from inadvertent lung intubation or predisposing patient characteristics

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

that make interactive assessment of the patient difficult, such as the presence of an endotracheal
tube or altered level of consciousness (Ackerman & Mick, 2006). In the interest of patient safety
where nutritional support for the critically ill adult is contemplated, alternative techniques for
accurate feeding tube placement should be explored.
Attempting to place small-bowel feeding tubes beyond the pyloric sphincter can be
difficult and inaccurate. In many instances, the tube becomes coiled in the gastric fundus,
leading to a potential for aspiration or further delay in care when the tube must be continued to
be manipulated (Gabriel & Ackermann, 2004). Since enteral feeding to the stomach can lend to
an increase risk for aspiration, feeding tube advancement to the small-bowel is the preferential
placement (Gabriel & Ackermann, 2004). Patients who are fed via the duodenum are also more
likely to maintain caloric intake with fewer interruptions in delivery (Gabriel, McDaniel, Ashley,
Dalton, & Gamblin, 2001).
Traditionally, enteral feeding tubes are inserted blindly, possibly with the aid of
prokinetic agents, and then verification is sought through a variety of methods, depending on
area of practice. Methods of verification include auscultation of air insufflation, aspiration of
gastric contents, and radiologic exam (Ackerman & Mick, 2006). Prokinetic agents such as
metoclopramide and erythromycin can be an aid in tube advancement through increased gastric
emptying, which can be delayed in critically ill patients (Taylor, Manara, & Brown, 2010). The
risks of adding a new drug regimen to an ill patient do not outweigh the benefit when the
efficacy of pro kinetic agents cannot be attributed to the drug regimen itself, but instead are
linked to correct placement techniques (Taylor, Manara, & Brown, 2010). Successful placement
of post-pyloric feeding tube occurs at a rate of 30%-98% (Powers et al., 2010). Air insufflation
can be inconclusive related to the interference of sound produced from bronchial breath sounds

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

or the interference of guide wires within the tube allowing for proper diffusion of the air
(Ackerman & Mick, 2006). Aspiration of gastric contents is unreliable unless both gastric and
respiratory secretions can be differentiated between in order to validate pH findings, especially
with the augmentation of gastric pH altering medication regimens in the critically ill adult
population (Ackerman & Mick, 2006). The most widely used and supported method of
verification includes radiologic exam. These exams, to include abdominal films, endoscopy, and
fluoroscopy can be complicated, time consuming, and costly (Ackerman & Mick, 2006).
An alternative method of insertion that verifies placement of the small-bowel feeding
tube at the time of insertion is an electromagnetic placement device. Electromagnetic placement
devices utilize communication between an external receiving plate on the abdomen of a patient
and the low energy electromagnetic field emanating from a coil in the tip of feeding tube (Young
et al., 2005). Real time imaging results on a screen, ultimately verifying placement instantly
(October & Hardart, 2009; Young et al., 2005). Average time to insertion is ten minutes with
near complete accuracy in insertion (Ackerman & Mick, 2006; October & Hardart, 2009).
Success rates of post-pyloric placement with this method range from 89%-100% (Powers et al.,
2010). When used, this method demonstrates increased safety for patients compared with blind
insertion methods verified with radiograph, decreased cost and harm associated with radiologic
exams, and a faster time to initiation of enteral feeding with the technique being readily available
at the bedside (Ackerman & Mick, 2006; Bercik et al., 2005). Synthesis of research has yet to
determine the difference in accuracy of placement between electromagnetic placement devices
and tubes verified with radiographs.

Research Question

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

In adult ICU patients, are electromagnetic placement devices (EMPD), compared with
abdominal radiographs, more accurate in predicting small-bowel feeding tube placement?

Method
A comprehensive search included literature obtained from Academic Search Premier,
Medline, and the Cumulative Index to Nursing & Allied Health Literature (CINAHL). The
Cochrane Database of Systematic Reviews was searched, but did not produce findings for this
research question. Key search terms, to include MeSH vocabulary, used in all database searches
were adult, ICU, intensive care unit, electromagnetic tube placement device, electromagnet,
magnet*, CORTRAK, abdominal radiograph, x-ray, feed*, small-bowel, enteral feeding tube,
and enteral nutrition. The search term CORTRAK was included after literature garnered from
other search terms determined a consistent pattern in mentioning this brand name of
electromagnetic placement device. Key words were secured as exact results within the literature
through the use of truncation, mapping, and the explode function within the search of the
databases. Because of the scarcity of results available for adult patients versus those found for
pediatric patients, the search was inclusive of all years available in the electronic database
without regard for year of publication.
The inclusion criteria were adult critical care patients, enteral feeding tubes being placed,
and comparison in verification of placement with radiograph or the tube was placed with an
electromagnetic device. Adult patients were defined as being aged 18 years or older. If pediatric
patients were included, the study was included if the data was analyzed by age group. Enteral
feeding tubes within studies were limited to small-bowel feeding tubes. Abdominal radiographs
were defined as abdominal x-rays or fluoroscopy for the purpose of tube verification. If other

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

methods of verification of tube placement were used, the study was included if the data was
analyzed separately by method. All inclusion criteria must be met within the study to be
included in this integrative review paper.
Studies were excluded if they contained verification of tube placement by one method
without concomitant assessment of successful placement by another method within the same
study. For example, studies were excluded when data was presented on the efficacy of
electromagnetic device placement assisted tube placement without a control group represented
by radiographic verification. Exclusion criteria also included literature that educated to the
insertion technique without dedication to the comparison of the verification methods.
Validity of database findings was increased when a random sample of three articles was
selected for peer review by nursing research students. Results of the random analysis revealed
that the sample submissions answered the research question, but may be further strengthened
with more current literature findings. Also suggested simultaneously were alternative key search
terms, which were included above as found to be successful. Study quality and level of evidence
were determined using criteria published by the American Association of Orthopedic Surgeons
(AAOS, 2002).
As the research studies were reviewed for validity, data was synthesized through thematic
analysis, or coding. Themes that emerged through literature appraisal included method of
insertion, method of verification, and effect on accuracy in placement. Coding with thematic
analysis allowed for a framework to develop in content organization in order to adequately
answer the research question and identify emerging relationships in data while accounting for
negative cases (Melnyk & Fineout-Overholt, 2011).
Findings

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

Search Results
Twenty-seven studies were discovered in the searches of Academic Search Premier,
Medline, and CINAHL. Systematic reviews were undiscovered in the search of the Cochrane
Database of Systematic Reviews. Despite comprehensive search strategies, primary research
studies comparing the efficacy of EMPD use as compared to radiology verification of placement
in the adult critically ill patient population set were sparse. Two studies were rejected when the
abstract identified non-adult patient population. Three studies were rejected when they could not
be obtained in the English language, available in only Chinese, German, and Russian,
respectively. The remaining twenty-two studies were printed in full text and critically appraised
utilizing inclusion and exclusion criteria. Of these, thirteen studies were excluded as containing
only EMPD insertion instructions, a lack of correct population or intervention, or an inability to
link results to clinical outcomes. Nine studies remained and are included in Table 1. Seven
Level II studies and two Level III studies are presented alphabetically by author and are further
summarized by design, level of evidence, interventions, and results. Sample size among the nine
studies included 2254 adult intensive care patients from the United States, Ireland, Germany, and
the United Kingdom (Table 1). Common themes within the studies were noted as: Effect on
Accuracy, Patient Safety, and Financial Stewardship.
Effect on Accuracy
All nine studies demonstrate improved efficacy with EMPD placed nasoenteric tubes
over blind insertion methods where the tube is then verified with radiology methods (Table 1).
One study confirmed that fluoroscopy placed nasoenteric tubes were more accurately inserted
than with the EMPD method, but cost analysis during the same study noted that the 17%
improvement in accuracy did not outweigh the substantial increase in cost of insertion (Dolan,

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

10

OHanlon, & ORourke, 2012). All studies note an increase in time by more than 47% in speed
of insertion via the EMPD method versus blind methods that rely on radiology verification of tip
placement.
Delays in tube insertion may lead to potential delays in ordered enteral feeding and
medications. Three studies note delays in feeding from two to twenty-two hours when radiology
confirmation is sought in tube placement verification (Gray et al., 2007; Hemington-Gorse et al.,
2011; Taylor et al., 2014). Through faster and accurate insertion of small-bowel feeding tubes
via EMPD, critically ill patients receive 900 kCal average increase in nutritional needs versus
radiology verified methods wherein a deficit and clinical deterioration can be noted in patients
from lack of nutritional intake (Dolan et al., 2012; Hemington-Gorse et al., 2011).
Speed of accurate insertion with ability to provide therapeutic interventions to critically
ill patients as ordered is noted in the literature with the EMPD method over other insertion
techniques with radiology follow ups. Using EMPD, the procedure can be done at the bedside
by a trained nurse and completed within four to twenty minutes (p=0.003) with one attempt and
no further verification than that of the insertion equipment (Kaffarnik, Lock, Wassilew, &
Neuhaus, 2013). Accuracy is noted to be 80-100% (p<0.0001) on first attempt insertions (Table
1). Discrepancies are noted when there is a difficulty in determining the portion of the small
bowel which the tube is located in (Kaffarnik et al., 2013; Powers et al., 2011). In those
instances, radiographs confirmed location of the tip of the tube with accuracy to nurse prediction
with EMPD technology (p = 0.005) in all cases which occurred 7.7% of the time (Powers et al.,
2013).
Patient Safety

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

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Six of the nine studies correlate increased patient safety with the use of EMPD for
nasoenteric tube insertion as opposed to other insertion methods with radiology exams for
verification of placement. The use of EMPD for small bowel feeding tube insertions allows
clinicians to note a potential insertion into an inadvertent location, such as the patients airway.
7-10% of patients studied benefited from potential trauma reduction through preempted airway
intubations during nasoenteric tube insertions using the EMPD technology as compared to other
insertion methods then verified with radiology exams (Powers et al., 2011; Taylor et al., 2014).
Powers et al. (2011) prevented fifteen airway intubations that may have resulted in airway
trauma with traditional radiology verification with the use of EMPD.
The EMPD equipment allows for visualization of the path of the tube insertion at point of
care with immediate correction of misguided direction based on technique or patient
presentation, such as hiatal hernia or surgical changes to the gastrointestinal tract. Ectopic tubes
to the gastric system can be rerouted or the procedure aborted entirely prior to patient harm
100% of the time with zero adverse events noted across all six studies, which is unavailable with
other insertion techniques and radiology verification follow up (Table 1). Kearns and Donna
(2011) identified 11 ectopic tubes prior to procedure completion with zero adverse events noted
(p<0.0001).
Gray et al. (2007) noted that patients with blindly inserted feeding tubes as opposed to
EMPD assisted tubes have twice as many radiology procedures to verify not only raising cost,
but safety concerns (p = 0.0001). Remington-Gorse et al. (2010) confirmed this with a cost
analysis that included sixty-four different x-rays for forty-four patients, thus demonstrating the
exposure, sometimes doubled, for insertion techniques not using EMPDs. There is also benefit

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

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to EMPD in that there is no exclusion for major abdominal surgery patient populations with no
adverse effects noted (p = 0.003) (Kaffarnik et al., 2013).
Financial Stewardship
Five of the nine studies note a reduction in financial costs associated with radiology
exams after feeding tube insertions when EMPD methods are employed (Table 1). Traditionally,
a small-bowel feeding tube is inserted and an X-ray is performed to verify placement. If the tube
is improperly placed, subsequent films will need to be garnered, thus raising the cost of
treatment. With EMPD inserted tubes, there are no associated radiologic exams which can save
approximately $6,400 per patient for an uncomplicated, traditionally inserted tube (Table 1).
Average cost for an EMPD is $8700 with each tube $150 (Hemington-Gorse et al., 2011).
Traditional tubes cost only $40, but are one use only and are associated with radiology fees of a
minimum of $3700 (Hemington-Gorse et al., 2011). The increased cost of EMPD equipment can
be offset by primary insurance carriers and recoverable expenses through increased savings from
reduction in X-ray use (Hemington-Gorse et al., 2011). The tubes are also able to be rewired and
reused in case of accidental dislodgment which is contradictory to traditional small-bowel
feeding tubes, thus further reducing cost of potential reinsertion (Hemington-Gorse et al., 2011).
Endoscopic and fluoroscopic exams resulted in an increase of both efficacy in insertion and cost
(Table 1). The increased cost does not outweigh the benefit as the same level of accuracy and
safety can be obtained with less expensive EMPD equipment that requires less training and
healthcare dollars in the form of time and resources totaling on average $32000 for an
endoscopic or fluoroscopic assisted exam (Dolan et al., 2012; Hemington-Gorse et al., 2011).
Traditionally inserted small-bore feeding tubes typically take two x-rays to confirm
placement (p = 0.0001), thus doubling potential cost because of an inaccurate insertion method

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

13

(Gray et al., 2007). EMPD demonstrates a cost effective, superior insertion method with a 50100% reduction in radiology use (p = 0.0001) (Gray et al., 2007; Kearns et al., 2011). Savings
were noted with 834 patients with a lack of radiology confirmation or lack of reimbursement for
secondary abdominal radiographs in the Powers et al. (2013) study (p = 0.005).
Limitations
Some studies were limited by sample size, thus potentially not creating enough power to
accurately determine a difference between the groups presented. The Dolan et al. (2012) study
was the smallest of the nine presented and was also limited by the omission of the mention of the
patients not included in the study and a lack of statistical analysis for success rates. Gray et al.
(2007) also limited their evidence by a smaller blind insertion patient population as compared to
the EMPD population. Generalizability is limited to adult critical care patients and study results
should be easily reproducible in facilities where EMPD equipment exists, however Kearns et al.
(2001) made generalization to morbidly obese patients impossible as this patient subset was
excluded from the study. Blinded cohort studies were reviewed, but bias may have been
introduced in several studies as some documentation was obtained by members of the EMPD
insertion team, thus negating true blinding.
Several studies had a dearth of statistical analysis but generalized findings or provided
percentages of success rates, thus weakening validity. Radiograph statistics provided in one
study may have been contaminated as there was a delay in radiograph confirmation during which
a tube may have migrated into proper position, which is not a true reflection on insertion results
(Hemington-Gorse et al., 2010). The financial statistics noted in the same study may also be less
accurate in that radiology confirmation of EMPD placed tubes is no longer a standard, which was

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

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the case during the time of the study, so the reduction in cost savings may appear skewed
(Hemington-Gorse et al., 2010).
Recommendations
Improving practice on behalf of patients and enhancing education efforts both for patient
care and the future of nursing is a duty beholden to nurse educators. Nurse educators, like all
nurses, are accountable to the recognition of evidence-based practice and the distribution of said
practice. EBP would dictate that a recommendation for the use of EMPD be made as critically ill
adult patients can begin receiving medication or nutrition exponentially faster than through
radiology verified methods. The Strength of Recommendation Taxonomy (SORT) strength of
recommendation for this evidence is an A. Quality Level II cohort studies that were patient
oriented, blinded, consistent, and noted their own limitation were reviewed to make this
recommendation in nurse education practice. Educators should be confident to advocate the use
of EMPD methods, teach the technique of use both academically and clinically, and continue to
research its benefits in a longitudinal manner, to include long-term benefits to patients.
Training in EMPD use can be completed in a matter of hours (October & Hardart, 2009).
Nurse educators can then, whether clinically or academically, train students or fellow nurses in
the procedure. Simulation labs if equipment is present at the collegiate level over one alternative
to a live environment as the feeding tubes allow for reuse with stylet reinsertion unlike other
feeding tube options. Incorporation of the benefit of EMPD use into the curriculum could
include the efficacy in accuracy, safety for patients, financial stewardship as nurses are also
accountable to that component in care, the anatomy associated with insertion technique, and the
improvement over other options available. Curriculum inclusion could also allow an opportunity
for introductions to topics on nursing promoting evidence-based practice on behalf of patients

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

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and the profession. Through these opportunities to curriculum changes, the nurse educator
provides an environment that allows the student to grow in a role as a graduate ready to lead,
advocate, teach, communicate, change, care, coordinate, use technology, collaborate, and be the
decisive decision maker of the care team (Cannon & Boswell, 2012).
Safety in nursing, rooted in evidence-based practice, is a hallmark of primary practice
and education efforts. EMPD inserted small-bowel feeding tubes provide a safer method of
insertion technique that results in no adverse events through a recognition of malpositioned tubes
prior to insertion completion as opposed to after with radiology verification or traumatic patient
presentation. SORT strength of recommendation for this evidence is an A. Studies were quality
Level II cohort studies that demonstrated consistency, patient orientation, blinding, and a
notation of limitations. Nurse educators should feel confident in teaching to the procedure of
EMPD insertion, the benefit to patient safety versus traditional methods, and advocating for
patient change in practice based on the strength of this recommendation. Through the advocacy
of EMPD and the teaching of the technique and theory both academically and clinically, nurse
educators will be able to instill in students the importance of clinical reasoning and critical
thinking. As a profession, nurses emphasize rationale in action during clinical practice,
especially in deference to safety concerns (Benner, Sutphen, Leonard, Day, 2010). By having
knowledge of the evidence-based practice EMPD recommendations and its applicability, the
student will be able to translate that into various clinical situations as they are presented by the
educator (Benner et al., 2010).
Consciousness in healthcare expenditures is a responsibility of advanced practitioners, to
include nurse educators. EMPD assisted insertions of small-bowel feeding tubes has a
recoverable increase in expenses. This is weighed with the benefit of the technique to patient

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care and safety. As healthcare costs continue to rise, nurse educators are poised to offer EBP
changes that can offer fiscally responsible answers while also providing safe and accurate care.
Nurse educators should advocate for clinical sites to obtain EMPD devices for patient tube
insertions after providing cost analysis scenarios. Academic educators should advocate for
simulation equipment as an alternative to traditional tube insertion only education. The EMPD
tube is reusable so a minimal investment in future education would be required on the University
behalf. Educators could also assist in simulation or equipment grant writing. Nurse educators
may also attempt to foster clinical relationships with sites that utilize EMPD technology so that
their students can have that experience. SORT strength of recommendation for this evidence is
an A. Studies were quality Level II cohort studies that demonstrated consistency, patient
orientation, blinding, and a notation of limitations.

Conclusion
EMPD assisted small-bowel feeding tube placement is a superior method as compared to
other methods with radiology verification of placement. Nurse educators should feel confident
to advocate for the introduction of this equipment to clinical facilities as it is more accurate in
placement technique, produces safer results, and more cost effective over time. Educators in
academic institutions could use simulation technology, theory learning, and an evidence-based
approach to teaching to promote clinical competence in the use of EMPD. Other opportunities
for curriculum inclusion are clinical observations, skills labs, feedback sessions, lectures,
mentoring projects, research projects, the merging of didactic learning with clinical or highfidelity application is case presentation. These experiences should be highly planned and
organized by the educator to be the most beneficial for the student. Academic institutions should

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begin to teach to the technology as an alternative to traditional techniques. Access to new

resources such as EMPD technology will assist in the merging of didactic teaching and clinical
skill for the benefit of both student education and patient care. Educators are exposed to
students, clinical staff, and administrative personnel both in academic and clinical environments
wherein advocacy and education can easily be facilitated. Long-term studies with patient
benefits would be beneficial to aid in a formal evidence based practice change.

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References
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of enteral feeding tubes. AACN Advanced Critical Care, 17(3), 246-249).
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http://www.orthobullets.com/basic-science/9081/level-of-evidence

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Transformation. San Francisco, CA: Jossey-Bass.
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Noninvasive verification of nasogastric tube placement using a magnet-tracking system:
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magnetic guidance. Journal of Parenteral and Enteral Nutrition, 28(2), 119-122. doi:
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guided nasoenteral feeding tubes: A new technique. The American Surgeon, 67(6), 544549.
Gray, R., Tynan, C., Reed, L., Hasse, J., Kramlich, M., Roberts, S.,Neylon, J. (2007). Bedside
electromagnetic-guided feeding tube placement: An improvement over traditional

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placement technique? Nutrition in Clinical Practice, 22(4), 436-444. doi:

10.1177/0115426507022004436
Hemington-Gorse, S.J., Sheppard, N.N., Martin, R., Shelley, O., Philp, B., & Dziewulski, P.
(2011). The use of the Cortrak enteral access system for post-pyloric feeding tube
placement in a burns intensive care unit. Burns, 37, 277-280.
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electromagnetically guided nasointestinal tube for jejunal feeding of critical ill surgical
patients. Technology and Health Care, 21, 1-8. doi: 10.3233/THC-120704
Kearns, P.J. & Donna, C. (2001). A controlled comparison of traditional feeding tube verification
methods to a bedside, electromagnetic technique. Journal of Parenteral and Enteral
Nutrition, 25(4), 210-215. doi: 10.1177/0148607101025004210
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A guide to best practice (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
October, T.W. & Hardart, G.E. (2009). Successful placement of postpyloric enteral tubes using
electromagnetic guidance critically ill children. Pediatric Critical Care Medicine, 10(2),
196-200.
Powers, J., Fischer, M., Ziemba-Davis, M., Brown, J., & Phillips, D.M. (2013). Elimination of
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Rivera, R., Campana, J., Hamilton, C., Lopez, R., & Seidner, D. (2011). Small bowel feeding
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Confirming nasogastric tube position with electromagnetic tracking versus pH or X-ray
and tube radio-opacity. British Journal of Nursing, 23(7), 352-357.
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Appendix A
Table 1
Citation
Dolan, et al.
(2012)
Ireland

Patient
Group and
Sample
Size
n = 24

Study
Design and
Level of
Evidence
Retrospectiv
e analysis &
Prospective
analysis

Outcome
Variables

Compared the
success rate
Radiology
and cost
(n = 24)
analysis of
nasojejunal
EMPD (n = Levels III & tube (NJT)
0)
II,
insertion
respectively between a
Prospective
retrospective
n = 12
sample of
adult ICU
Radiology
patients with
(n = 0)
radiology
assistance and
EMPD (n =
a prospective
12)
sample of
adult ICU
patients
assisted with
NJT insertion
with EMPD.

Key Results
DATA
Patients with
radiology
assisted NJT
placement (i.e.
fluoroscopy)
achieved more
accurate
placement than
the patients
undergoing
placement with
EMPD.
Secondary cost
analysis reveals
that the success
rate of radiology
placed tubes
does not
outweigh the
financial
burden.
Retrospective:
Radiology =
100%
Prospective:
EMPD = 83%

Validity
Small sample
sizes.
Does not
discuss the
exclusion of
the ICU
patients not
included in the
study sample.
Statistical
analysis not
shared, just
percentage of
success rates.

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

22

Table 1
Gray, et al.
(2007)
United States
of America

n = 101

Prospective
analysis

Blind
insertion (n Level II
= 20)
EMPD (n =
81)

Compared the
adverse events,
success rate of
insertion, time
to initiation of
feeding,
number of
radiographs
needed, and
cost savings
between adult
ICU patients
having smallbowel feeding
tubes placed
via blind
insertion or
EMPD.

Both patient
groups had zero
adverse events
and the same
relative success
rate of tube
placement. The
blind insertion
group had a
success rate of
63% versus 81%
in the EMPD
group. Tubes
placed with
EMPD
assistance led to
an initiation of
feedings within
7.8 hours (p =
0.003) whereas
the blind
insertion group
had a time to
feed of 22.3
hours (p =
0.003). Patients
with tubes
inserted blindly
required twice
as many x-rays
as EMPD
assisted tubes to
confirm
placement (p =
0.0001),
doubling the
cost of x-rays
associated with
feeding tube
insertion.

Limited by
blind insertion
group size.
Confounding
variables such
as hospital
policies
prohibiting
further blind
insertions and
lack of trained
staff for EMPD
assisted tube
placement were
noted to
possibly be
contributing
factors to small
sample size and
delay in
feeding,
respectively.

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

23

Table 1
HemingtonGorse, et al.
(2010)
United
Kingdom

n = 44

Retrospectiv Compared the

e analysis
accuracy of
EMPD
tube placement
correlates
Level III
in ICU burn
with
patients
radiograph
following
(n = 38)
EMPD use
based on the
Uncorrelate
device reading
d with
of placement
radiograph
and
(n = 6)
radiographic
evidence.
Secondary data
noted a
decrease in
both time to
feed and
financial cost
of radiograph
usage.

EMPD
predicted
placement in
86% of patients.
Radiographs
determined 14%
of tubes were
not placed
where the
device specified
them to be. No
adverse events
were noted.
EMPD use
resulted in an
average time to
feed of 7.4
hours, with a
delay in feeding
being
augmented by
waiting for xrays (46%). A
reduction in the
amount of xrays needed to
confirm
placement with
EMPD use was
associated with
a cost savings of
$6,400.

Possibly
contaminated:
All EMPD
patients had
previously
undergone
blind insertion
attempts.
Uncorrelated
with radiograph
results may be
confounded by
tubes migrating
while waiting
for x-ray
confirmation.
Also, financial
benefits may be
higher now as
x-ray
confirmation of
placement postEMPD use is
no longer
required, thus
reducing cost
associated with
this method
further.

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

24

Table 1
Kaffarnik, et
al.
(2013)
Germany

n = 70

Prospective Compared two

cohort study insertion
EMPD 1st
attempts using
attempt
Level II
EMPD with
success (n
associated
= 55)
radiography
EMPD 1st
confirmation
attempt fail
of placement.
(n = 15)
Secondary
findings were
EMPD 2nd
the speed of
attempt
placement
success (n
using EMPD.
= 63)
EMPD 2nd
attempt fail
(n = 7)

EMPD 1st
attempt:

Unsuccessful
attempts may
be
78.6% success
misrepresented
with 100%
as the study
accuracy in
designers
radiograph
instituted a 20
confirmation in minute
successful
insertion time
placements.
limit before
Time to
declaration of
insertion
failure of
average = 7.6
placement
+/- 4.7 min (0.5- based on their
20 min).
own personal
p=0.003
experience.
EMPD 2nd
This time limit,
attempt:
however, may
present a
90% success
clearly defined
with 100%
line of failure
accuracy in
for placement
radiograph
where study
confirmation in measurements
successful
are concerned.
placements.
Complications
of the
procedures,
follow up to the
study
participants,
and reasons for
exclusion were
included.
Not
randomized nor
controlled, so
bias cannot be
excluded.

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

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Table 1
Kearns, et al.
(2001)
United States
of America

n = 113
EMPD
correlates
with
radiograph
y (n = 113)
EMPD
does not
correlate (n
= 0)

Prospective
blind trial
Level II

Compared
EMPD,
auscultation,
and pH
sampling to
radiology
results for tip
verification.
Secondary
findings
include quick
time to
insertion,
patient safety,
and cost
analysis
savings.

EMPD accurate
as compared to
radiology 100%
(p<0.0001) of
inserts and
identified 11
ectopic tubes
(8%; 3% to
13%, 95% CI).
Auscultation =
84% (p<0.02);
pH = 56%
(p<0.03).

Bias eliminated
when clinicians
inserting the
tubes were not
allowed to
observe any
other portion of
the study. 5
different
observers
collected data
from 5 different
sites by random
assignment. A
physician who
was blinded to
the bedside
EMPD results
read the
radiograph
results.
May not be
able to
generalize
findings as one
patient subset
excluded from
the study is
morbidly obese
patients.
Misplacement
of a tube may
be statistically
low, but
clinically
significant.
EMPD
sensitivity =
100
specificity = 75

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

26

Table 1
Powers, et al. n = 904
(2013)
United States EMPD
of America
alone (n =
834)
EMPD with
radiograph
y (n = 70)

Prospective
analysis
Level II

Compared
verification of
tip with EMPD
by 2 trained
nurses as
opposed to
using EMPD
and
radiography.

92% of EMPD
assisted tubes
placed without
additional
verification
required.

Clinically
relevant in that
although there
was some use
of radiography
to confirm
exact
Radiograph
placement,
confirmation
those cases
occurred when a where it was
Secondary
discrepancy in
used, the tube
findings
tip verification was in the
include the
occurred
small bowel
savings cost of between two
irregardless.
lack of
verifying nurses,
radiograph
most often when Limited by data
confirmation
it was
completion on
for 834
indeterminate as an audit form.
patients.
to whether the
tip was in the
duodenum or
the jejunum.
7.7% (p =
0.005)

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

27

Table 1
Powers, et al. n = 152
Prospective
(2011)
analysis
United States EMPD with
of America
1st
Level II
radiograph
(n = 132)
EMPD with
2nd
radiograph
and
contrast (n
= 148)

Compared the
accuracy of
tube placement
with EMPD
between plain
film and a
secondary film
taken after
injection of
contrast.
Secondary
findings
included an
avoidance of
inadvertent
airway
placement
when EMPD
was used.

EMPD
placement
results
correlated with
the first
radiograph
86.9%.
Accuracy of
interpretation
increased to
97.4% after
contrast was
injected and a
2nd x-ray was
reviewed.
Radiologist
reviewed films
increased the
agreeance of
proper insertion
placement by
EMPD to
99.5%. No
adverse events
were reported,
but 15 airway
placements were
avoided prior to
insertion or
patient trauma
when the EMPD
was used.

Pediatric and
non-ICU data
were excluded.
Groups of
patients studied
were in various
ICU settings
and not
homogenous.
The only
qualifying
factor to the
study was to
have an order
for a small
bowel feeding
tube.
Convenience
sampling was
used thereafter.

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

28

Table 1
Rivera, et al.
(2011)
United States
of America

n = 719

Prospective
analysis

Accurate
placement Level II
confirmed
with EMPD
(n = 641)
Accurate
placement
confirmed
with both
EMPD and
KUB (n =
583)

Compared the
accuracy of tip
of tube
confirmation
between
EMPD
analysis and
radiographic
findings.

Moderate
agreement
beyond chance
in tip
verification
between EMPD
analysis results
and
confirmation
with radiograph
(66.1%; k score
0.62 [95%
confidence
interval 0.580.67])

Bias eliminated
by not
revealing to
interpreting
radiologists
tube insertion
techniques
when
requesting film
interpretation.
However, bias
may have been
introduced
when
discrepancies
between
radiology
results as
reported by the
radiologist and
EMPD
readings were
further
interpreted and
accuracy
recorded by
members of the
tube insertion
and study team.

EMPD IN PREDICTING FEEDING TUBE PLACEMENT

29

Table 1
Taylor, et al.
(2014)
United
Kingdom

n = 127
EMPD
correlates
with
radiograph
(n = 127)
Uncorrelate
d with
radiograph
(n = 0)

Prospective
analysis
Level II

Compared the
accuracy of
tube placement
in ICU patients
following
EMPD use
based on the
device reading
of placement
and
radiographic
evidence.
Secondary
findings
indicate that
EMPD tubes
are more
accurate in
identifying
potential
patient safety
issues, such as
near lung
placement and
decreased time
to feeding.

All patients
receiving
EMPD assisted
tube insertion
had a
confirmation of
placement with
radiograph with
100% accuracy
in match.
7% of patients
avoided an
airway insertion
with potential
trauma when
EMPD tracings
during insertion
immediately
noted a potential
airway
placement.
Gastric
placement was
confirmed
immediately
with EMPD
within a median
of 6.4 minutes
(IQR: 4, 10.4),
whereas x-ray
confirmation
delayed feeding
by 2 hours
(IQR: 1.3, 2.5).

The majority of
EMPD assisted
insertions were
completed by 3
trained
individuals,
with the bulk of
insertions
(78%) owed to
one team
member in
particular.
Could
confound
results as the
same expert is
not always
available for
every insertion,
questioning and
crediting the
actual accuracy
of method or
degree of
training.

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