Insertion and Care of Nasal Retaining Loops to Secure Naso-Enteral Tubes for Adult Patients - Safe Practice Guidelines for the
|Publication: 26/06/2012 --|
|Last review: 02/10/2019|
|Next review: 02/10/2022|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Safe Practice Guidelines for the Insertion and Care of Nasal Retaining Loops to Secure Naso-Enteral tubes- Adult Patients
- What are nasal retention loops (NRLs)?
- Duties and responsibilities
- Competence and training requirements
- Treatment / Management
- Insertion of CORGRIP NRL
- Insertion of AMT BRIDLE NRL
- Frequently asked questions
- Appendix 1: CORGRIP PICTURES
- Appendix 2: AMT BRIDLE PICTURES
- Appendix 3: Nasal Retaining Loop Assessment Tool
- Appendix 4: Competency Documentation
- Appendix 5: Information Sheet for patients
- Appendix 6: Information Sheet for carers
- Appendix 7: Procurement information
- Appendix 8: Ethical considerations
Naso-enteral nutrition is an essential part of patient care which is used when patients are unable to meet their nutritional requirements via the oral route and have a functioning gastrointestinal tract.
Naso-enteral feeding tubes can frequently become dislodged or removed which is a major limitation, leading to loss of feeding hours, uncomfortable reinsertion procedures and exposure to radiation if an X-ray is used to confirm tube position, as well as significant cost implications in terms of health care practitioners’ time, cost of X-rays and tube usage (Popovich, M (1996)).
The nasal retaining loop (NRL, bridle or Corgrip) consists of a piece of umbilical tape that is looped around the vomer bone at the rear of the septum and attached with a specially designed clip to the enteral feeding tube, making tube placement very secure. It is inserted using two catheter mounted magnets, each of which is introduced into a separate nostril so that the magnets connect at the nasopharyngeal space, allowing umbilical tape to be fed around the nasal septum, leaving tape exiting from both nostrils, which is then attached to the feeding tube (pictures in Appendix 1).
Patients who repeatedly remove Nasoenteral Tubes (NETs – these include both nasogastric (NG) tubes and nasojejunal (NJ) tubes) or other indwelling devices such as catheters or cannulas, despite other measures should be assessed for a nasal retaining loop (NRL). This assessment should be made by suitably qualified staff
NRLs are usually simple to place and optimise the ability of the feeding tube to meet nutritional requirements by reducing accidental removal. A NRL is suitable for bed side placement by trained practitioners in both NG and NRL placement.
Consent is a difficult but important issue. Informed verbal consent should be obtained prior to NRL insertion whenever possible and must be documented in patients’ notes. See the section on consent.
This guideline should be used in conjunction with the enteral feeding policy and nasoenteral tube insertion guidelines.
All aspects of decision making, placement technique and aftercare will be addressed in the guideline.
Nasal Retaining Loop (NRL): A piece of equipment which reduces the chance of inadvertent displacement or removal of fine-bore NETs in patients requiring enteral administration of feed, fluid or medication. Tape is fed round the nasopharynx and out through each nostril and then clamped to the NET, holding it in place.
Corgrip: Preferred nasal retaining loop device used within the trust provided by Halyard Health.
AMT Bridle: Alternative nasal retaining loop device (which may be found on wards as stocks are used up) used within the trust provided by GBUK.
Fine bore naso-enteral feeding tube: -
Defined as between a 6fg - 8fg tube. The length of the tube is measured in cms starting at the distal tip. Measurements are seen along the length of the tube, but the tube length will vary depending on manufacturer. The tube is made of silicone or polyurethane which is passed through the nostril via the naso-pharynx into the oesophagus, then stomach (NG tubes) or through the stomach and duodenum, sitting in the jejunum (NJ tubes).An 8fg NET needs to be in situ to place a NRL, although smaller NRLs can be ordered via materials management if necessary.(i.e if a patient has a smaller bore NET in situ). The NET and NRL MUST be the same size.
- To provide guidelines to facilitate correct and timely patient selection.
- To provide guidelines for the safe, effective and comfortable placement of a nasal bridle.
- The use of NETs is a common procedure across many different specialties. This procedure is documented in the LTHT Policy for Insertion and Ongoing care of Fine Bore Feeding Tubes in Adults.
- Naso-enteral tubes become displaced for a variety of reasons and a small group of patients appear to be particularly intolerant of the tube and require repeated reinsertions. This can be distressing for the patient and their family and detrimental to their recovery as it means missing feed and medication due to delays until the tube is replaced.
- An alternative fixing device has been developed called the Nasal Retaining Loop. This provides a means of securing the NET to prevent accidental or intentional tube removal by the patient. The NRLs used within the trust are Corgrip or Bridle
- This guideline has been written to enable suitably trained practitioners to follow an agreed decision making, assessment and procedural process.
- See pictures in appendix 1 and appendix 2
- The main purpose of NRLs are to ensure the provision of feed, fluid and medication via NETs by reducing the chance of dislodgement.
- They are a gauze loop fed around the nasopharynx and fixed to an external clamp attached to the NET.
- They can still be dislodged and may cause discomfort or nasal erosion and bleeding, especially in confused or agitated patients.
Doctors: It is a medical decision to commence enteral feeding and decide on the appropriateness of the NRL after consultation with the patient, carers and multidisciplinary team (MDT). See Appendix 3.
Registered Nurse: it is the nurse’s responsibility to care for the NET and NRL as per Trust Policy/Guideline
A registered practitioner is needed who has completed relevant education and training in the insertion of nasal Corgrips or AMT bridles.
A NRL should only be placed by a trained practitioner. If a trained practitioner is not available on your ward please contact the Enteral feeding nurses.
Training for insertion of NRLs should be limited to practitioners working within areas of high usage to gain competence and experience such as the stroke unit, neurosciences, intensive care, liver unit and the enteral feeding nurse team.
All staff who insert NRLs must have completed the ward based training and competency assessment (see appendix 4). Training sessions can be arranged by contacting the Enteral Feeding Clinical Nurse Specialist (bleep 80-4727, tel. 0113 2068690). It is recommended that in all areas of high usage, arrangements are made to keep a record of trained staff. For doctors in training, competency may be documented on their e-portfolio.
- There are various options to facilitate NET feeding which include forms of restraint (the use of mittens for example) and, as such, are ethically sensitive and fraught with emotion for the patient, their family and for staff. Such tensions have to be managed alongside the need to provide optimal treatment. It is important to remember that a nasal retaining loop is best thought of as a retaining device, rather than a restraining device.
- Staff are required to be skilled in the consent process. They need to consider the patient’s capacity to be involved in the decision-making process. Where possible they should gain the patient’s consent, or alternatively, the assent of a person close to the patient. Guidelines for obtaining patients’ consent are to be found inThe Mental Capacity Act 2005 Procedure
- If, after using the two stage process for determining mental capacity, detailed in the procedure above, it is determined the patient has capacity to make the decision, it is very important to acknowledge that they have the legal right to decide. When a person has the mental capacity to decide, they must be given all the necessary information to enable them to make their decision, including pros, cons and likely outcomes.
- If the two stage capacity test shows that a patient lacks the capacity to decide on this issue, their best interests are taken into account given all the circumstances.
- The least restrictive method of restraint, with the lowest risk and discomfort, should be used at any point.
Identifying appropriate patients (refer to Appendix 3)
Suitable patients are:
- Those with documented evidence of inadvertent displacement of the NG/NJ tube on more than two occasions.
- Those with enteral feeding tubes placed peri-operatively and where enteral access will no longer be available if the tube becomes misplaced or removed.
- Patients who are pulling at other devices such as urinary catheters and intravenous cannulas, and who require an enteral tube for feeding or medication.
- Patients who demonstrate skin irritation from tape secured to the nose.
- Patients discharged to the community on long term NG feeding.
- Those who have elective nasogastric or nasojejunal tubes when replacement is of high risk or technically difficult.
- NRLs are used following careful assessment in patients who have removed two or more NETs and in whom other methods of restraint such as better fixation, distraction and mittens have failed. In some cases, reducing time attached to a pump with fast rates of feeding may be a better solution in agitated and confused patients, as in these patients the NRL may cause nasal trauma if the patient mobilises whilst attached to the pump".
Relative contraindications for bridle placement:
- Patient with deranged clotting (consider risks vs. benefits if INR/platelets abnormal)
- Extremely confused/agitated patients who may continue to pull at the NG tube and cause trauma to the nasal septum.
- Patients with grossly deviated nasal septum or other anatomical challenge such as nasal polyps, or any structural deformity of the nose or nasopharynx.
- Patients with facial or cranial trauma.
- Patients that are unable to demonstrate appropriate response to painful stimuli: e.g some head injury patients, advanced dementia.
- Patients who would be likely to dislodge gastric or jejunal tubes because of frequent coughing, retching or vomiting.
- History of epistaxis.
Absolute contraindications for NRL placement
- Patients who are competent and refuse treatment.
- Patients for whom nasal tubes are contra-indicated, for example those with basal skull fracture or nasal obstruction.
- Patients judged to have an excessive local bleeding risk
- Excessive agitation
- Grossly deviated nasal septum
- Mechanical obstruction-i.e nasopharyngeal airway in situ
1. Assess the patient for appropriateness for nasal loop insertion.(Appendix 3)
2. If the patient has capacity the procedure should be explained to gain verbal consent. If the patient is deemed to lack capacity, then a best interests decision should be made and documented in the medical notes. A check should be made to determine whether anyone has ‘Lasting power of attorney’ or whether a valid ‘Advance decision to refuse treatment’ exists. The options should be discussed with any people close to the patient who are available and this discussion should also be recorded. The procedure should be explained and an information leaflet provided. (see appendix 8 for ethical overview)
- The purpose of the NRL and procedure for insertion should be explained to the patient, or people close to the patient if they lack capacity to decide on the issue. The information sheets should be provided (see appendix 5/6)
- Verbal consent or assent should be obtained and recorded in the medical notes/PPM+ (appendix 3).
3. The patient should be positioned upright and be alert, to enable ease of placement.
4. Wash hands and apply gloves and apron in preparation for procedure.
5. Check nose for any signs of obstruction and that the nose is clean as this may impede insertion.
5a. It is generally better to have the NET in place before the corgrip as occasionally the NET will not pass and so the corgrip is not needed
6a Direction for CORGRIP insertion
9a CORGRIP REMOVAL
6b It is generally better to have the NET in place before the bridle as occasionally the NET will not pass and so the bridle is not needed.
Will a patient still be able to remove a NET whilst a NRL is in-situ?
Yes, it is still possible for a NET to become displaced, despite a NRL securing the tube. Patients may vomit the tube out of their mouth, or they may pull the tube out of their nostril by accessing the tube above the clip. This is why it is important to ensure good placement of the clip outside the nostril.
What if a patient vomits the NET out of their mouth whilst secured to a NRL?
Do not cut the NRL to release the NGT, use a plectrum, (they come in the NRL packs) to open the clip and release the NGT. Tape the strings to the side of the patient’s face. Then an assessment about reinserting a feeding tube with a NRL in-situ can be made by the medical team.
|Picture 2||Picture 3||Picture 4|
|Picture 5||Picture 6|
Supplier AMT Bridle :
Blackwood Hall Business Park
Tel no. 01757 288587
Feeding tube securing device
Corgrip (Halyard Health)
Nasal anchoring system 8fg tube retention system
Box of 10
£600 (£60 ea)
According to the Mental Capacity Act, when a decision-maker for someone who lacks mental capacity is working out what is in that person's best interests, they should consult the following people 'where it is practical and appropriate to do so':
- anyone the person has previously named as someone they want to be consulted
- anyone involved in caring for the person
- anyone interested in their welfare (for example, family carers, other close relatives,
or an advocate already working with the person)
- an attorney appointed by the person under a Lasting Power of Attorney, and
- a deputy appointed for that person by the Court of Protection.
The role of those who are consulted is to give their opinion about what is in the patient's best interests. They are not really being asked to either consent or assent, but they are able to provide information that supports a broader interpretation of best interests than a purely clinical one.
The exception to the very limited role of family and friends in the consent process is the more authoritative one of attorneys holding a 'Lasting Power of Attorney' for health and welfare decisions. They must be consulted and formal consent obtained.
Also check if the patient has completed an Advance Decision to Refuse treatment in relation to restraint for NG feeding as this should be respected if applicable to the clinical situation.
The MCA doesn't refer to relatives as 'next of kin' as they may not be the people who are closest to the patient. The MCA prefers to use the term 'people close to a person who lacks capacity.'
The MCA Code of Practice describes the use of restraint:
Any action intended to restrain a person who lacks capacity will not attract protection from liability unless the following two conditions are met:
- the person taking action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity, and
- the amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood and seriousness of harm.
When might restraint be ‘necessary’?
Anybody considering using restraint must have objective reasons to justify that restraint is necessary. They must be able to show that the person being cared for is likely to suffer harm unless proportionate restraint is used. A carer or professional must not use restraint just so that they can do something more easily. If restraint is necessary to prevent harm to the person who lacks capacity, it must be the minimum amount of force for the shortest time possible.
What is a ‘proportionate response’?
A ‘proportionate response’ means using the least intrusive type and minimum amount of restraint to achieve a specific outcome in the best interests of the person who lacks capacity. On occasions when the use of force may be necessary, carers and healthcare and social care staff should use the minimum amount of force for the shortest possible time.
|Objective:||To provide evidence-based recommendations for appropriate management of patients who require a nasal loop retaining device.|
|Target patient group:||All adult inpatients|
|Target professional group(s):||Secondary Care Doctors
Allied Health Professionals
Secondary Care Nurses
References and associated documentation
Anderson M.R., O’Connor M. Mayer, P. et al (2004). The nasal loop provides an alternative to percutaneous gastrostomy in high risk dysphagic stroke. Clinical Nutrition. 23(4)
Eisenberg P, Spies M, Metheny N., (1987). Characteristics of patients who remove their nasal feeding tubes. Clinical Nurse Specialist.1(3):94-98.
Great Britain National Patient Safety Agency (2005). Patient Safety Alert 05. Reducing the harm caused by misplaced nasogastric tubes. NPSA, London.
Meer, J.A. (1989). A new nasal bridle for securing naso enteral feeding tubes. Journal of Parenteral and Enteral Nutrition. 13(3) p331-34.
Norton B. et al. (1996). A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. British Medical Journal.; 312:13-16.
Pancorbo-Hidalgo, P.L., Fernandez, F.P., Rimirez-Perez, C. et al (2001). Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. Journal of Clinical Nursing. 104 p482-90.
Popovich, M.J. Lockrem, J.D., Zivot, J.B. (1996). Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small bore nasoenteraic feeding tubes. Critical Care Medicine. 24(3) p429-31.
Royal College of Nursing (2004). Restraint Revisited – rights, risks and responsibility RCN London.
The FOOD Trial Collaboration (2005). Effect of timing and method of Enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The Lancet. 365:764-72.
Williams J. (2005) Using an alternative fixing device for naso-gastric tubes. Nursing Times. 101(34):26-27.
Portsmouth Hospitals NHS Trust guideline for insertion of NRL
The AMT Bridle. Nasal tube retaining system. Product information leaflet.
Trust Clinical Guidelines Group
LHP version 2.1
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