‘Radiographers are the solution’: update on the NG tube pathway
The SoR has collaborated on work to develop a radiographer-led pathway for nasogastric tube position checking. Synergy sat down with the team who started it all to find out about their journey
By Will Phillips
How can we raise awareness of the essential role radiographers play? This is a question with a multitude of answers and one we regularly seek to answer in the pages of SoR publications like Synergy.
From World Radiography Day to exhibitions at careers fairs, there is a huge amount of work being done to promote the radiography profession to the wider world. But there is also hard work being done behind the scenes, with the aim of expanding the scope of radiographers and, in turn, raising their profile in the health service.
An example of this pioneering work is the NG tube pathway. In October 2019, the Health Services Safety Investigations Body (HSSIB) launched an investigation into the placement of nasogastric (NG) tubes in NHS patients, which deliver fluid, food and medication via the nose into the stomach.
While pH testing of gastric aspirate is the first port of call for checking NG tube positions, research suggests X-ray confirmation of NG tube placement is the most accurate method – if a standard process is consistently followed. However, X-ray misinterpretation is the most common cause of NG tube incidents, the HSSIB found.
Since then, a coalition of professional bodies and clinical experts have launched into action. The SoR, the British Association for Parenteral and Enteral Nutrition, the British Society of Gastrointestinal and Abdominal Radiology, Report and Image Quality Control and the Royal College of Radiologists (RCR) have joined forces to create a standard radiographer-led pathway for NG tube placement to be adopted across the NHS.
The process is simple – radiographers will enter into a structured training and assessment programme, including e-learning modules, to help them develop the necessary skills and confidence to accurately evaluate and record NG tube positions. Once trained, radiographers can perform these evaluations independently, reducing delays and providing a safe, consistent and structured clinical evaluation.
NHS sites are being encouraged to pilot the pathway with support from both the SoR and RCR, with continuous learning supported through local audits to ensure quality and safety.
Synergy sat down with stakeholders from Leeds Teaching Hospitals NHS Trust, where they have successfully piloted this new initiative.
‘It’s transformed how radiographers are viewed’
Across the country, there is a lack of consistency in the process of placing and confirming the position of NG tubes. While this allows hospitals a fair amount of flexibility, it can also raise safety concerns.
The development of the radiographer-led pathway hopes to bring a UK-wide, step-by-step process. Patients will have their NG tube inserted on the ward; if they need a check X-ray, a radiographer will perform one; and importantly, now, they can immediately and consistently interpret and act upon that X-ray.
Damian Tolan, consultant radiologist at Leeds Teaching Hospitals NHS Trust and based at St James’s Hospital, became involved in NG tube service improvement through his specialisation in gastrointestinal radiology. A few years ago, the team at St James’s identified problems in Leeds with patients having misplaced NG tubes, predominantly in the lungs. The team decided that they needed a big change in approach. “We very quickly settled on the idea that radiographers were the solution,” Damian explains.
“It came through continuous effort. Getting the radiographers trained to do the important work has been really supported by the leadership. It’s transformed how radiographers are viewed by teams outside of radiology, too.”
Damian says the current system in most hospitals is really complex – there are just so many people with points of intervention along the pathway once an X-ray is taken who have to be involved in the decision to use the NG tube. “We realised we had to strip the process back to involve the absolute minimum number of health professionals,” he explains. “Just one person who has accountability and empowerment. All the delays when a radiographer takes the X-ray, someone else looks at the image, waits two or three hours for the radiologist to report it, then someone on the ward reads the wrong report – this all creates more opportunities for harm.”
This pathway, he says, cuts out all those delays and opportunities for harm. The new NG tube pathway has also created a “virtuous cycle of change” in the trust, adds Damian – radiographers are upskilled, which means patient safety is improved, which then makes more radiographers want to take on the training.
Damian worked alongside Gill Roe, an extended imaging practitioner in Leeds, who is now co-leading and supporting the national rollout. Gill’s job was to roll out the pathway to radiographers in the trust – a role that started 11 years ago.
‘It’s a no-brainer’
In 2013, Gill helped to implement the process for NG tube checking, which was based on a system already in place in Bristol. This Bristol model, while successful, wasn’t quite suitable for a trust of Leeds’ size. “It was quite a big ask, but we worked hard and we had the right training for the radiographers,” she says. “One of the main facets of the training was explaining to radiographers what impact they could have on patient safety. We don’t usually see the direct impact we have on a patient, even though we’re helping them on their pathway.”
Getting the chance to see the direct results of their efforts on patients immediately after the X-ray scan has had an immense impact. With UK-wide ‘never events’ – significant safety incidents that could have been avoided by adherence to available guidance – for NG tubes rocking healthcare sites, the chance to change the game couldn’t come soon enough. Several years ago, Leeds experienced five NG tube-related never events, including four deaths, over a two-year period. “If this system was in place back then, those events would never have happened,” Gill says. “The radiographers would have prevented them. That’s why we need to do this.”
From there, it was just a case of giving radiographers the training they would actually need – training that was clearcut and absolutely to the point on what the procedure was.
Now, the culture of radiography in the trust, and the culture across the Trust itself, has gone through a massive shift. There have been zero X-ray related NG tube never events at the Trust in the 11 years since the system has been in place. “It’s a bit of a no-brainer,” Gill adds. “If we can do this in a Trust of our size, this can be brought in across the NHS and different Trusts and health boards.”
‘It’s a no-brainer’
In 2013, Gill helped to implement the process for NG tube checking, which was based on a system already in place in Bristol. This Bristol model, while successful, wasn’t quite suitable for a trust of Leeds’ size. “It was quite a big ask, but we worked hard and we had the right training for the radiographers,” she says. “One of the main facets of the training was explaining to radiographers what impact they could have on patient safety. We don’t usually see the direct impact we have on a patient, even though we’re helping them on their pathway.”
Getting the chance to see the direct results of their efforts on patients immediately after the X-ray scan has had an immense impact. With UK-wide ‘never events’ – significant safety incidents that could have been avoided by adherence to available guidance – for NG tubes rocking healthcare sites, the chance to change the game couldn’t come soon enough. Several years ago, Leeds experienced five NG tube-related never events, including four deaths, over a two-year period. “If this system was in place back then, those events would never have happened,” Gill says. “The radiographers would have prevented them. That’s why we need to do this.”
From there, it was just a case of giving radiographers the training they would actually need – training that was clearcut and absolutely to the point on what the procedure was.
Now, the culture of radiography in the trust, and the culture across the trust itself, has gone through a massive shift. There have been zero X-ray related NG tube never events at the trust in the 11 years since the system has been in place. “It’s a bit of a no-brainer,” Gill adds. “If we can do this in a trust of our size, this can be brought in across the NHS and different trusts and health boards.”
‘The patient is at the centre’
Sue Johnson, professional officer for clinical imaging at the SoR, was involved in developing and supporting the rollout of this pathway at a national level. She emphasises the importance of strong leadership to help to ensure the working relationship between radiologist and radiographer stays positive – the project requires the two professions to have a very close working relationship, she adds.
“It’s not just about one or other of the professions,” Sue says. “It’s very much about the patient at the centre of the work we’re doing. This has the potential to have a massive impact on patient safety, to prevent patient deaths. We’re very keen and pleased we can promote the role of radiographers in this, too.”
Empowering radiographers has helped to ensure they feel motivated to, and capable of, providing this unique service. Radiographers always have a responsibility to act upon anything unexpected or untoward that they see upon an X-ray, Sue says. The only difference now is the creation of a consistent response.
Some 30 years ago, any professional could have taken the results of an X-ray in any number of directions. Now, an IT system records the actions taken, and the roles and responsibilities of radiographers are made far more clear. “The SoR has a document from 2012 that says NG tube interpretation is something radiographers should do,” Sue continues. “What we didn’t have was the instructions on how to do it, how to protect patients, how to make it safe.
“Radiographers are the only people who acquire X-rays to check for NG tube placement. There aren’t any other AHPs or nurses or doctors who do that. We have a very clear place in the NG tube pathway – many different professionals are involved along the way, but we are the obvious ones, because we are the first people to see that X-ray.”
The embedded aspects of continual feedback and support has not only helped to reduce never events and improve patient safety – it’s also helped radiographers. Gill explains: “If you give them [radiographers] a little bit of extra responsibility, they really go with it. They became very vigilant with NG tubes in all areas, even when they weren’t doing an X-ray specifically for that. They’ve highlighted where we need to tighten up on practice and which wards need additional training, and they feed that back to me so we can continually improve the service.”
Empowerment in this way has forced the trust to change and evolve as a whole – radiographers having the ability to feed back their own thoughts on the system means their job satisfaction has shot up since the system’s introduction.
But, says Gill, the key is to keep pushing: “What’s helped is dissemination of what we’re doing. We speak about it periodically; I’ll do a talk at a national or international conference, or within the trust, to showcase the work we’re doing. That empowers them further, because they can actually see we’re doing a good thing here. That’s why it has to be rolled out nationally.”
‘The patient is at the centre’
Sue Johnson, professional officer for clinical imaging at the SoR, was involved in developing and supporting the rollout of this pathway at a national level. She emphasises the importance of strong leadership to help to ensure the working relationship between radiologist and radiographer stays positive – the project requires the two professions to have a very close working relationship, she adds.
“It’s not just about one or other of the professions,” Sue says. “It’s very much about the patient at the centre of the work we’re doing. This has the potential to have a massive impact on patient safety, to prevent patient deaths. We’re very keen and pleased we can promote the role of radiographers in this, too.”
Empowering radiographers has helped to ensure they feel motivated to, and capable of, providing this unique service. Radiographers always have a responsibility to act upon anything unexpected or untoward that they see upon an X-ray, Sue says. The only difference now is the creation of a consistent response.
Some 30 years ago, any professional could have taken the results of an X-ray in any number of directions. Now, an IT system records the actions taken, and the roles and responsibilities of radiographers are made far more clear. “The SoR has a document from 2012 that says NG tube interpretation is something radiographers should do,” Sue continues. “What we didn’t have was the instructions on how to do it, how to protect patients, how to make it safe.
“Radiographers are the only people who take X-rays. There aren’t any other AHPs or nurses or doctors who do that. We have a very clear place in the NG tube pathway – many different professionals are involved along the way, but we are the obvious ones, because we are the first people to see that X-ray.”
The embedded aspects of continual feedback and support has not only helped to reduce never events and improve patient safety – it’s also helped radiographers. Gill explains: “If you give them [radiographers] a little bit of extra responsibility, they really go with it. They became very vigilant with NG tubes in all areas, even when they weren’t doing an X-ray specifically for that. They’ve highlighted where we need to tighten up on practice and which wards need additional training, and they feed that back to me so we can continually improve the service.”
Empowerment in this way has forced the trust to change and evolve as a whole – radiographers having the ability to feed back their own thoughts on the system means their job satisfaction has shot up since the system’s introduction.
But, says Gill, the key is to keep pushing: “What’s helped is dissemination of what we’re doing. We speak about it periodically; I’ll do a talk at a national or international conference, or within the trust, to showcase the work we’re doing. That empowers them further, because they can actually see we’re doing a good thing here. That’s why it has to be rolled out nationally.”
Hurdles
One of the first hurdles the team encountered in getting the NG tube pathway started was actually getting the engagement from radiographers in the first place. Such a big change was met in the first instance with a fair amount of doubt – Gill highlights how important it was to give their radiography team the self belief that they were capable of doing this was, that it was a safe thing and that it would have a significant impact on patient care.
“You have to have your radiography managers on board with this, so they understand the value of the radiographer in this role and that, while it adds a few minutes to these examinations, often in very busy departments, that is outweighed by the reduction in risk to the patient,” she continues. “You create the capacity for it within your workforce.”
Sue agrees with Gill, adding that a key feature of this patient safety initiative is that it is a single, reproducible pathway. Professional body guidance is there to guide.
Meanwhile, Damian says radiographers interested in developing this pathway, or a similar advancement, within their own department should focus on developing allies outside radiology. Having the medical director or the nursing director fully behind the pathway means they can be strong advocates for the change. “The only reason we could do what we did is because we had very strong medical leadership outside radiology, who basically said the change had to happen,” he explains. “They were prepared to take any bumps in the road as learning points that would be smoothed out on the path to actually getting this problem fixed.
“Having that mindset was critical to us actually achieving what we did and, without that, all the efforts of a great radiographer or a radiologist will come to nothing.”
Hurdles
One of the first hurdles the team encountered in getting the NG tube pathway started was actually getting the engagement from radiographers in the first place. Such a big change was met in the first instance with a fair amount of doubt – Gill highlights how important it was to give their radiography team the self belief that they were capable of doing this was, that it was a safe thing and that it would have a significant impact on patient care.
“You have to have your radiography managers on board with this, so they understand the value of the radiographer in this role and that, while it adds a few minutes to these examinations, often in very busy departments, that is outweighed by the reduction in risk to the patient,” she continues. “You create the capacity for it within your workforce.”
Sue agrees with Gill, adding that a key feature of this patient safety initiative is that it is a single, reproducible pathway. Professional body guidance is there to guide.
Meanwhile, Damian says radiographers interested in developing this pathway, or a similar advancement, within their own department should focus on developing allies outside radiology. Having the medical director or the nursing director fully behind the pathway means they can be strong advocates for the change. “The only reason we could do what we did is because we had very strong medical leadership outside radiology, who basically said the change had to happen,” he explains. “They were prepared to take any bumps in the road as learning points that would be smoothed out on the path to actually getting this problem fixed.
“Having that mindset was critical to us actually achieving what we did and, without that, all the efforts of a great radiographer or a radiologist will come to nothing.”
Expectations and goals
Radiography as a whole can sometimes be invisible, says Damian. That’s part of what makes this initiative a “really nice problem to solve” – it’s simply something that radiographers can do that will prevent deaths.
He’s glad radiographers can get out of the shadows and take on such an important role in influencing the care of patients. But Damian sees an even brighter future for projects like this. “I think there are many other areas we could potentially start to do this a little bit more,” he adds. “Just as a model, as an idea. There are so many areas where we can evaluate and act – radiographers can make a massive difference if we can cut out those delays between spotting, for example, a blood clot on the lung and getting started on treatment.”
For now, though, rollout of this pathway is limited to a small number of first phase pilot sites that are trialling it over the course of the coming months. Once those pilot sites have evaluated their results, the team will use this learning in the continued expansions to a wider cohort. Within two years, a full rollout will be completed.
More about the NG tube pathway
NHS sites are being encouraged to pilot this pathway, with support from both the SoR and RCR. Trusts and health boards need to obtain local governance approval and work with key stakeholders to integrate the pathway into existing clinical workflows.
The pathway involves a structured competency-based training programme, including e-learning modules, to equip radiographers with the skills and confidence to perform NG tube position checks independently.
For further details, please visit the RCR website.
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