Resident-Driven Guideline to Reduce Iatrogenic Pneumothoraxes From Small-Bore Feeding Tubes: A Quality and Safety Improvement Project.

Small-bore feeding tubes (SBFT) in vulnerable patients carry a risk of iatrogenic pneumothorax by misplacement into the lung. This institution noted a series of iatrogenic pneumothoraxes caused by the placement of these devices. A resident-led, multidisciplinary team developed a hospital guideline through a consensus-driven process. The guideline mandated SBFT placement by approved "super-users" via the CORTRAK Enteral Access System or via non-CORTRAK Methods, including the 2-step X-ray Method, fluoroscopy, or direct visualization techniques. A "super-user" Program for the CORTRAK Enteral Access System was developed to assure competency and consistency. With the development of the guideline and "super-user" program, the authors observed a decrease in the number of SBFT-related iatrogenic pneumothoraxes. Following a brief period of adoption, the three-hospital organization has had no SBFT-related iatrogenic pneumothoraxes. This project demonstrates the effectiveness of developing a resident-driven, evidence-based hospital guideline for the safe passage of SBFTs.