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ustralasian Emergency Nursing Journal (2013) 16, 136—143

Available online at www.sciencedirect.com

ScienceDirect

jo u r n al hom epage: www.elsev ier .com/ locate /aenj

ESEARCH PAPER

urse initiated reinsertion of nasogastricubes in the Emergency Department: Aandomised controlled trial

rystal Hiu Yan Ho, BSc (Hons), MSc, RN a,∗imothy Hudson Rainer, MD a,b

olin Alexander Graham, MD, MPH a,b

Trauma & Emergency Center, Accident & Emergency Department, Prince of Wales Hospital, Hong KongAccident & Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong

eceived 22 June 2013 ; received in revised form 30 August 2013; accepted 31 August 2013

KEYWORDSEnteral nutrition;Emergency service,hospital;Emergency nursing;Nurse practitioner;Professionalautonomy;Randomisedcontrolled trial

SummaryBackground: Patients sometimes present to the Emergency Department (ED) for reinsertion ofnasogastric tubes (NGT) because of tube dislodgement. They usually need to wait for a longtime to see a doctor before the NGT can be reinserted. This study aimed at investigatingthe feasibility of nurse initiated NGT insertion for these patients in order to improve patientoutcome.Methods: This is a prospective randomised controlled trial. Patients requiring NGT reinsertionwere randomised to receive treatment by either nurse initiated reinsertion of NGT (NIRNGT)or the standard NGT insertion protocol. Questionnaires were given to both groups of patients,relatives and ED nurses afterwards. Outcome measures included door-to-treatment time, totallength of stay (LoS) in the ED and the satisfaction of patients, relatives and nurses.Results: Twenty-two patients were recruited to the study and randomised: 12 in the standardNGT insertion protocol and 10 in the NIRNGT protocol. The door-to-treatment time of theNIRNGT group (mean = 45.6 min) was significantly shorter than the standard NGT insertion group(mean = 123.08 min; p = 0.003). No statistically significant difference was detected between thetotal ED LoS (p = 0.575). Patients, relatives and nurses were generally satisfied with the new

treatment protocol.Conclusion: Patients can undergated reinsertion of NGT (NIRNGT© 2013 College of Emergency

reserved.

∗ Corresponding author at: Trauma & Emergency Center, Accident & Eong Kong. Tel.: +852 93133012; fax: +852 26324513.

E-mail address: chococrystal@gmail.com (C.H.Y. Ho).

574-6267/$ — see front matter © 2013 College of Emergency Nursing Attp://dx.doi.org/10.1016/j.aenj.2013.08.005

o NGT reinsertion significantly faster by adopting a nurse initi-

) protocol.

Nursing Australasia Ltd. Published by Elsevier Ltd. All rights

mergency Department, Prince of Wales Hospital, New Territories,

ustralasia Ltd. Published by Elsevier Ltd. All rights reserved.

Can NG tube reinsertion be faster in the ED?

What is known?

• Patients presenting to Emergency Department fornasogastric tube reinsertion are commonly seen andthey usually need to wait for a long time to see adoctor before getting the tube reinserted.

• The long waiting time of nasogastric tube reinser-tion in Emergency Department correlates with poorpatient outcomes.

• While nurses initiate nasogastric tube reinsertionin ward and community settings, the author queryabout the possibilities to initiate nasogastric tubereinsertion in Emergency Department.

What this paper adds?

• Nurses initiated reinsertion of nasogastric tube inEmergency Department is highly recommended toput into practice as patient could benefit and auton-omy of nurses increased.

• In view of the advocacy of nurse practitioner world-wide, new nursing initiatives are encouraged andnurses are able to take up the role independently

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under the guidance of departmental protocol.

Introduction

Home enteral nutrition is becoming more common1,2 andnasogastric tubes (NGT) are one of the commonly usedroutes for enteral feeding. The most common indicationsfor home enteral feeding include chronic neurological prob-lems (usually stroke) and cancer.3—5 Despite much evidenceproving the safety of percutaneous endoscopic gastrostomy(PEG)6 (another type of enteral feeding), many communitydwelling adults with swallowing difficulties still have a NGTinserted for enteral nutrition. Although there are no localstatistics available to indicate the actual population requir-ing home enteral feeding, it appears that more patientsare requiring enteral feeding as mortality from stroke andcancer falls progressively.

Long-term enteral feeding patients are usually taken careof by community nurses.3 However, sometimes they presentto the Emergency Department (ED) for reinsertion of theNGT when community nurses are not available, especiallyduring non-office hours, as feeding is a basic need for thepatient, although a short period of fasting is unlikely to belife threatening. In Prince of Wales Hospital (PWH), both theaverage door-to-treatment time for NGT reinsertion and theaverage length of stay in the ED overall are very prolonged,as these patients are a relatively low priority as they do nothave an immediate threat to life.

Long waiting times not only correlate with patientsdissatisfaction7 and crowding,8 but also cause conflictsbetween patients and health care professionals which maylead to a higher chance of workplace violence.9—12 The

potential risks of acquiring infection in the ED13 and pressuresore development within hours14 are very relevant for thesepatients. Poor patient outcomes,8,10,15,16 increased costs16

and poor ED efficiency8,17 are likely to result.

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137

While the responsibility for NGT insertion lies mainly withurses18 and nurse initiated care like NGT insertion is donendependently in the ward setting19 and community settings,t is standard practice in the ED at PWH to wait until theatient has been seen by a doctor and the order to rein-ert the NGT has been given. We wondered whether nursenitiated reinsertion of the NGT (NIRNGT) in the ED woulde feasible to improve the effectiveness of our service andmprove patient care for this vulnerable group. The inde-endent role of nursing care has been shown to be effectives demonstrated by the increasing trend of nurse practition-rs in emergency care settings20 and the positive outcomesf reductions in waiting time and length of stay in the ED.21

eview of NGT insertion procedure

nasogastric tube is a tube inserted through the nosento stomach. All registered nurses are trained to performhis procedure independently. The placement of the NGT isrstly checked by testing gastric aspirate with pH indica-or strips.18,19,22 Radiography is used to confirm the positionhenever there is any doubt.18,23 In the ED of Prince of Walesospital, doctors will order NGT insertion and/or subsequent-ray in writing after seeing the patient. Nurses will thennsert the NGT with a placement check. The aim of this studyas to investigate the possibility of shortening the waiting

ime to improve the effectiveness of the ED service by tri-lling nurse initiated reinsertion of nasogastric tubes (NGT)or long-term enteral feeding patients presenting to the ED.

ethods

esign

he study was a prospective randomised controlled clinicalrial comparing the effectiveness and waiting time of nursenitiated reinsertion of NGT (NIRNGT) and traditional doctorrescribed reinsertion of NGT in patients presenting to theD. A flowchart of the study designed is presented in Fig. 1.

etting

his study was conducted in the Emergency Department ofrince of Wales Hospital (PWH) in Shatin. It is a 1400-bedniversity teaching hospital in the New Territories of Hongong and is the regional trauma centre. The ED serves aopulation of approximately 1.5 million and has an annualensus of about 150,000 new patients, with 30% admissionate. There are approximately 6—8 patients visiting the EDer month requiring reinsertion of NG tube because of tubeislodgement.

atients

ll patients older than 18 years old presenting to the EDith dislodgement of NGT requesting reinsertion or requir-

ng a tube placement check during designated periods from 1ctober 2009 to 28 February 2010 were considered for studynrolment. Patients with acute variceal bleeding or basalkull fracture19,24 within one week were excluded. Patients

138 C.H.Y. Ho et al.

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Figure 1 Flowch

ith oesophageal carcinoma or nasopharyngeal carcinoma,atients with vomiting, fever, tachypnea or other signs ofulmonary complication of NGT feeding, and patients inn unstable clinical condition were also excluded. Patientsequiring Entriflex® reinsertion were excluded as Entriflex®

s not routinely inserted by nurses in Hong Kong. Entriflex®

s a small-bore feeding tube with a metal stylet to facilitateassage. During insertion, if the tube is blindly advanced tohe airway or the lung, the stylet provides enough rigidity toerforate the lung and cause pneumothorax.22 In addition,

single patient will be included once.

andomisation

atients were allocated with a random-number gener-ted by computer. The random allocation sequence was

mplemented with numbered sealed envelopes so that theequence was concealed until interventions were assigned.he triage nurse would obtain written informed consentefore randomisation. All recruited patients would receive

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f the study design.

reatment by either nurse initiated reinsertion of NGTNIRNGT) protocol (intervention group) or standard NGTnsertion protocol (control group). It was not possible tolind the patients or the nurses who carried out the inter-ention. However, we did try to perform single blinding asata entry was completed by the principal investigator whoas not involved in the clinical interventions.

nterventions

n the intervention group (NIRNGT protocol), the nurseould reinsert the NGT before the patient was seen by theedical officer. Placement was confirmed by aspiration of

astric content with pH ≤ 5.18 The nurse would initiate aheck chest X-ray for the patient whenever placement wasn doubt. The patient then awaited the medical officer’s

ssessment for discharge. In the control group (standard NGTnsertion protocol), the patient would be in the standardueue for the medical officer’s assessment. The ED nurseould then reinsert the NGT after medical officer’s written

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Can NG tube reinsertion be faster in the ED?

prescription. The patient then waited for the medical offi-cer’s reassessment before discharge. A short questionnairewas completed by patients and relatives after reinsertionof the NGT in both groups. Another short questionnaire wasdistributed to the ED nurses at the conclusion of the study.

Training of nurses

As every nurse in ED performs NGT insertions and more thanhalf of the eligible patients visit the ED out-of-office-hours,including weekends and midnights, investigators included allED nurses on duty. In order to standardise the procedure, aleaflet was distributed to all nurses as a treatment guideline.With the support of Emergency Department senior staff, afew briefing sessions were arranged to inform the nursesabout the flow of the study and the NGT insertion proce-dure. By having nurses as investigators instead of havingsmall number of investigators, the generalisability of thestudy was increased.

Sample size calculation

The current mean door-to-treatment time of standard NGTreinsertion protocol was calculated by retrieving the pre-vious 6 months’ data; it was 120 min. We assumed NIRNGTcould shorten door-to-treatment time by half. Using aneffect size of 60 min (half of the current waiting time for NGTreinsertion), we used an online tool (http://department.obg.cuhk.edu.hk/researchsupport/Sample size CompMeanIndependent.asp) to derive the sample size for this study.Based on the anticipated difference in means between twogroups of 60 min and an anticipated standard deviation of45 min, with a ratio of 1:1 between the two groups, the esti-mated sample size was 10 in each group in order to detect asignificant difference with an alpha error of 0.05 and powerof 80%. In view of the possibility that some patients maynot agree to enter the study and others may withdraw, weaimed to recruit an extra 30%, i.e. 13 patients per group.

Data collection and outcomes

The principal investigator reviewed the ED records afterNGT reinsertion. Data collected included patient charac-teristics, time of registration, time of NGT insertion andtime of ED departure. The primary outcome was the door-to-treatment time of each patient (i.e. waiting time fortreatment) of each patient. The secondary outcomes werethe total LoS, patients’/relatives’ satisfaction and nurses’satisfaction (Questionnaires were shown in appendices 1 and2). The endpoint of the study was patient discharge from theED. We used total LoS as a secondary outcome because fromthe patients’ perspective, the time staying in ED after treat-ment was regarded as ‘waiting time’ and the total time inthe ED is a critical variable.

Definitions:

1. Door-to-treatment time: from the time of registration tothe time of successful NGT insertion.

2. Total LoS: from the time of registration to the time ofleaving the ED.

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139

thical considerations

thical approval was obtained from the joint university andocal institutional ethical committee. Informed written con-ent was obtained from each patient or his/her relative (seeelow) before voluntary participation.

rior consent

ost of the patients requiring long term enteral feeding liven local homes for the elderly. When dislodgement of an NGTccurs, they usually present to the ED with an ‘old age home’OAH) staff member who cannot sign the consent form. Withhe help of the Shatin Community Geriatric Assessment TeamCGAT), the principal investigator visited 19 private OAHs inhatin. The study was explained to the managers of theseomes. The consent forms together with a letter explaininghe study were given to the relatives who had family mem-ers requiring NGT feeding by the OAH staff on behalf of therincipal investigator. The contact number of the principalnvestigator was printed on the consent form so that theelatives could ask for further explanation if they had anynquiries. Whenever a patient needed to visit the ED forGT reinsertion, OAH staff would bring the signed consentorm to the ED.

ata analysis

ata were analysed using SPSS version 17.0 (SPSS Inc.,hicago, IL, USA). P < 0.05 was considered as statisti-ally significant. As the time data did not conform to

Gaussian distribution, non-parametric tests were used.oor-to-treatment time and total LoS were analysed usinghe Mann—Whitney U test. Demographic data were summa-ised using means or presented in percentage.

esults

uring the study period, 26 patients presented to the EDequiring NG tube reinsertion, of whom one was excludedecause of a past history of nasopharyngeal carcinoma. Theemaining 25 patients were randomised; three were laterxcluded because they had entered the study twice. Twelveatients were randomised into the control group (standardGT reinsertion protocol) and 10 patients were randomised

nto the intervention group (NIRNGT) (CONSORT diagram,ig. 2). No patients withdrew from the study. All patientsere discharged home and there were no immediate com-lications in either group.

Of the 22 recruited patients, 12 were female and 10ere male with a mean age of 81.7 years. The mean agef the control group and intervention group were 82.8 and1.5 years respectively. Twelve patients (54.5%) were OAHesidents and 10 (45.5%) were living at home.

The median door-to-treatment time of the interven-ion group was 32.5 min (25th percentile 23.8 min, 75th

ercentile 67.5 min and interquartile range [IQR] 44 min).he median door-to-treatment time of the control groupas 111 min (25th percentile 55.8 min, 75th percentile77.8 min and IQR 122 min) (Fig. 3). There was a significant

140 C.H.Y. Ho et al.

Figure 2 CONSORT diagram of the study. One subject was excluded before randomisation because of past history of nasopharyngealcarcinoma. Three subjects were excluded after randomisation because of entering the study twice.

difference (p = 0.003) between the door-to-treatmenttimes of two groups. The majority of patients in theintervention group (n = 7, 70%) received treatment (nurseinitiated reinsertion of NGT) within 20—45 min after reg-istration, with five patients (50%) receiving treatmentwithin 30 min. The remaining three patients (30%) in theintervention group received treatment within 60—100 min(Fig. 4).

On the other hand, most patients in the control group(n = 9, 75%) received treatment within 50—150 min after reg-istration. Two patients (17%) in the control group receivedtreatment within 200 min and one patient who came on aSunday received treatment within 35 min.

However, there was no significant difference (p = 0.575)between the total LoS of the two groups. The mediantotal LoS of the intervention group and control group were173.5 min and 174 min respectively, with IQR of 953 min(25th percentile 143 min; 75th percentile 1095.8 min) and569 min (25th percentile 108 min; 75th percentile 677 min).The longest total LoS in the intervention group was 1317 min(22 h) and 979 min (16 h) in the control group. Of the 22patients, six had a total LoS of more than 720 min (12 h)and five of them were OAH residents.

Figure 3 Box plot showing door-to-treatment time of bothgroups.

Questionnaires were given to all patients and rela-tives (n = 22); 12 questionnaires were collected afterwards(response rate 54.5%). Of the 12 respondents, half of themhad visited the ED for NGT reinsertion more than once. Allof them (n = 12) wanted the service of nurse initiated rein-sertion of NG tube (NIRNGT). Of these 12 participants whowanted the service of NIRNGT, 3 of them preferred to seea doctor before NG tube reinsertion at the same time. Theremaining 9 respondents did not express a preference to seea doctor before treatment. All respondents (n = 11, 1 par-ticipant did not answer this question) thought that NIRNGTcould shorten waiting times.

Forty questionnaires were given to ED nurses and 30 werecollected (response rate 75%). The 30 nurses were dividedinto 3 subgroups: 22 were registered nurses (RN), 5 werenursing officers (NO) and 3 were advanced practice nurses(APN). Average years of clinical experience were 12.8 years,and average years of clinical experience of the 3 subgroups(APN, NO and RN) were 18.3 years, 24.6 years and 9.4 yearsrespectively.

Overall, the nurses were comfortable in performingNIRNGT (26 out of 30 strongly agree or agree). Three partic-ipants (3 RN) did not agree that they were comfortable to

Figure 4 Box plot showing total LoS of both groups.

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give the treatment before medical officer’s assessment and 1participant was neutral. Seven nurses (2 APN, 5 RN) stronglyagreed and 19 nurses (5 NO, 1 APN, 13 RN) agreed (87%,n = 26) that they were comfortable to carry out this pro-cedure, while 1 RN was neutral. Twenty-eight participants(93%) strongly agreed or agreed (1 did not answer and 1 neu-tral) that NIRNGT could increase the autonomy of nurses andall nurses believed that NIRNGT could shorten waiting timesfor the patients.

Discussion

This is the first prospective clinical randomised controlledstudy evaluating the effectiveness of a nurse initiated pro-cedure for patients who visit the ED requiring reinsertion ofNGT in Hong Kong. Our results revealed that the door-to-treatment time in the NIRNGT protocol was much shorterthan traditional NGT insertion protocol, i.e. patients couldget NG tube reinserted faster in NIRNGT protocol. However,both groups stayed equally long in the ED as there was nosignificant difference in total LoS.

In the NIRNGT protocol, the mean door-to-treatmenttime was 45.6 min and the mean total LoS was 472.6 min.The waiting time for the Non Emergency Ambulance Trans-port Service (NEATS) accounted for the long total LoS inboth groups. Six patients went home using NEATS, and fiveof these patients had a total LoS of more than 12 h. Threepatients who were in the NIRNGT protocol had a door-to-treatment time within 30 min but a total LoS more than1000 min (>16 h) because of the wait for the NEATS service.

Patients who were waiting for the NEATS service for trans-port to their homes often needed to wait overnight as theyusually came during the ‘out-of-office hour’ period, and theNEATS service was unavailable. Although they were usuallyrelatively clinically stable, having to care for these patientsin the ED increases the workload of the health care pro-fessionals. Bedside care and basic needs like vital signsmonitoring, NG tube feeding and napkin changing are usuallyprovided. It represents a further burden on the busy ED inaddition to the large number of attendances, resuscitationsand access block patients.

To avoid patients waiting in the ED overnight for NEATS,the NEATS service hours could be extended. In our study, 11patients (50%) registered from 1630 h to 1900 h; if the NEATSservice hours were extended to 2100 h, all these patientscould be discharged if the NIRNGT protocol was followed.Written information could be given to the OAHs advisingthem not to bring these patients to the ED during out-of-office hours unless they can manage to transfer them backafter treatment.

In our study, there were patients with a total LoS of>1000 min a prolonged wait for NEATS to get back home;these three cases were all in the intervention group. Thismay account for the lack of significance in the differencein total LoS between the intervention group and controlgroup. A very significant difference was detected (p = 0.003)in the door-to-treatment time between the two groups. It is

well known that waiting times in all Emergency Departmentshave been rising for many years.25,26 The long waiting timenot only impedes individual access to ED care,27 but alsoleads to negative outcomes. Poor patient outcomes, patients

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141

issatisfaction, crowding, conflicts between patients andealth care professionals, higher chances of workplace vio-ence, increased costs and poor professional ED efficacy areaused.7—17 On the contrary, a short waiting time to havereatment is a great benefit for patients because nutritionan be resumed as quickly as possible. From a nursing per-pective, maintaining a patient’s hydration and nutritions our concern and responsibility. Therefore, the authorselieve that nurse initiated reinsertion of NG tubes shouldecome routine clinical practice. This is also supported byatients, relatives and nurses on the basis of the question-aire done in the study.

In Hong Kong, nurses do not usually do extended pro-edures independently. This new initiative of treatmenty nurses also parallels the increasing worldwide trendf introducing nurse practitioners to emergency careettings.20,25,28 Because of the increasing demand, workloadnd working hours of medical residents,29 nurse practi-ioners are not only rising in number,25 but also expandingnd becoming more and more important in the healthcareystem.28 The role and function of nursing has ushered in

new era,30,31 and it is now recognised that the nurse is knowledgeable professional and appropriately skilled toerform many roles that were traditionally performed byoctors.30

In our questionnaire of nurses’ satisfaction, 87% of theD nurses felt comfortable to carry out the procedureefore medical officer’s assessment and 93% of the nursestrongly agreed or agreed that this initiative of treatmentould increase autonomy. Autonomy is a vital ingredi-nt for professionalism and an essential element for fullecognition.32 It also plays a fundamental role for emer-ency nurse practitioners (ENP).28 Autonomy in practiceas a positive relationship between nurses’ job satisfac-ion, working environment, nurse retention and quality ofare.28,33

Feedback from patients and relatives also provided sup-ort for this nurse treatment initiative. All participantstated they would like to receive nurse initiated care andll of them believed that waiting times could be shortened.ot only is the nursing perspective changing, the patient’serspective is changing too. Patients are accepting nursenitiated care and nurse practitioners more than expected.

study carried out in this ED in 200734 showed that many59.3%) younger patients (<65 years old) would rather choosen ENP for treatment if the waiting time for a medical offi-er’s consultation was longer. A similar study from the UShowed that the majority (65%) of patients were willing toe seen by an ENP.29 Patients were even more satisfied withhe treatment provided by ENPs than with that from junioroctors.25

Although we believe that NIRNGT is worth implementing,0% of ED nurses thought that difficulties exist because ofxternal factors. The very busy environment may be onef the reasons contributing to the hesitation of the nurses.owever, any new initiative in clinical practice is challeng-

ng as people are generally fearful of change. According tohe three-stage unfreezing, moving and freezing model of

hange theorised by Lewin,35 some external forces mighte needed for these steps. Encouragement from managersnd senior staff, group discussions and continuous evaluationay facilitate the change process. The nursing role could

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Questionnaire on nurses’ feedback of nurse initiating rein-sertion of NGT in the Emergency Department.

Date: Year of clinical experience:Rank:

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42

hen evolve and the effectiveness of the service could bemproved.

tudy limitations

ne limitation of this study was the small sample size, withnly 22 subjects recruited in the study. There is no similartudy in the literature available for reference. The com-aratively small sample size was due to the limited dataollection time. It is possible that some eligible subjectsay have been missed because of external factors like theusy ED environment or the non-availability of a writtenonsent form. However, the small sample size can be jus-ified by its ability to detect a significant difference in thetudy. Also, the cognitive state of the patient may affecthe outcome as the insertion procedure might be easier foro-operative patients. In addition, the study was conductedn a single centre, which may limit the generalisability ofhe results. Our questionnaires had not been validated prioro use, which is not ideal, but we believe they have facealidity. The response rates for the relative’s questionnaireould have been better but the low response rate proba-ly reflects the reality of long patient waiting times and theesire to leave the ED as soon as treatment is complete andransport is available.

onclusion

his study demonstrated a shorter waiting time for patientseceiving treatment by nurse initiated reinsertion of NGT.lthough the total time for the patient stay in the ED was theame for both the nurse initiated treatment protocol or tra-itional NG tube reinsertion protocol, this new initiative wastill worthwhile putting into practice. It was supported byhe patients/relatives and nurse satisfaction questionnaire,nd the increasing scope of practice of emergency nurses.he quality of care, effectiveness of clinical services and theutonomy of the nurse could be improved by this initiative.uture research on a larger scale in Hong Kong and in otherountries could confirm our findings and encourage othermergency providers to set up similar services to improveatient care.

uman research ethics approval

thical approval was obtained from the joint university andocal institutional ethical committee (Joint Chinese Univer-ity of Hong Kong — New Territories East Cluster Clinicalesearch Ethics Committee) CRE-2009.295-T.

unding

his study received no specific grant from any fundinggency in the public, commercial, or not-for-profit sectors.

rovenance and conflicts of interest

e are unaware of any conflict of interest, and the studyeceived no specific grant from any funding agency in the

SD

C.H.Y. Ho et al.

ublic, commercial, or not-for-profit sectors. This paper wasot commissioned.

cknowledgements

e thank Mr. Stones Wong, Departmental Operational Man-ger, Miss. Celestina Luk and Miss. Chan Yee Ming, Wardanagers of the Emergency Department at the Prince ofales Hospital for their full support to carry out the study.e also thank the nursing staff of the Emergency Depart-ent at Prince of Wales Hospital for their great help as

nvestigators and for data collection despite the very busyorking environment. We thank the Shatin Community Geri-tric Assessment Team (CGAT) for their help in obtainingrior consent. We also thank Miss. Josephine Chung, Nurseonsultant in the Emergency Department at Prince of Walesospital for her help and valuable opinion for the study.

ppendix 1. Short questionnaire onatient’s/relative’s satisfaction

uestionnaire on patient’s/relative’s satisfaction of nursenitiating reinsertion of NGT in the Emergency Department.

Date:Please circle either ‘‘Yes’’ or ‘‘No’’ for each question.

. Is this your first time coming/accompanying someone tothe Emergency Department with dislodged NG tube?

es No

. Do you want a service of nurse initiating reinsertion ofNG tube in the Emergency Department before a doctor’sassessment?

es No

. Do you prefer a doctor’s assessment before reinsertionof NG tube?

es No

. Do you think that the waiting time will be shortened ifnurses reinsert NG tube before doctor’s assessment?

es No

ppendix 2. Short questionnaire on nurses’atisfaction

Please put a ‘‘ ’’ in the appropriate box below.

A = Strongly agree A = Agree N = Neutral = Disagree SD = Strongly disagree

Can NG tube reinsertion be faster in the ED? 143

SA A N D SD1. I am comfortable to carry out the procedure (reinsertion of NG

tube) before medical officer’s assessment.� � � � �

2. I think this procedure (nurse initiating reinsertion of NG tube)increases the autonomy of nurses.

� � � � �

3. I think this procedure can help patient in terms of waitingtime and quality of nursing care.

� � � � �

4. I think difficulties exist for nurse initiating reinsertion of NGtube because of the external factors, e.g. the busyenvironment.

� � � � �

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