Date of Graduation


Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Susan Mortell


Problem: Variation in gastric tube placement practice has resulted in incorrect placement depth, resulting in four gastric tube perforations in a level III neonatal ICU within the last year. Gastric perforations have increased infant length of stay, increased surgical interventions, delay in oral feeding, increased hospital cost, and potentially lower family satisfaction with care.

Context: IHI’s 5 Why’s: Finding the Root Cause identified a lack of standardization in policy and practice and lack of consistent staff education as the primary reason for misplaced gastric tubes. Additionally, a cost-benefit analysis projected the estimated cost of additional infant length of stay for gastric perforations to be between $3,000 to $138,000, which does not include surgical cost or additional treatment costs for gastric perforation-related complications.

Interventions: Infant measurements were collected by measuring infants from the corner of the mouth to the earlobe for orogastric tubes, insertion site nare to the earlobe for nasogastric tubes, earlobe to the xiphoid process, and xiphoid process to umbilicus. Infant x-rays were assessed to determine appropriate gastric tube placement. They were then compared to the most appropriate insertion method for placement, including NEX, NEX +1, NEX +2, NEMU, and weight-based methods.

Measures: The primary measure of the gastric tube initiative is to have zero gastric perforations and see an improvement in gastric tube placement on x-rays on the initial insertion attempt.

Results: Since initial gastric tube insertion method education, it was identified that 42.6% of gastric tubes were incorrectly placed. Thus, a weight-based trend identified the need to use a different gastric tube insertion method for each weight class. The NEMU method presented too deep for infants less than one kilogram, and the NEX method was too shallow for infants weighing more than two kilograms. Additionally, the weight-based formula for gastric tube insertion proved to place tubes in 92.6% of insertion attempts incorrectly.

Conclusion: The proposed gastric tube measurement guidelines include using the NEX method for infants weighing less than one kilogram, using the NEX +1 method for infants weighing between one to two kilograms, and using the NEMU method of infants weighing more than two kilograms. At this time, the weight-based method should not be used to guide practice as there is insufficient evidence to support the correct placement of orogastric tubes, and infants on oxygen therapy and intravenous therapy have been excluded from previous studies.