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Comparing use and cost effectiveness of tracheostomy tube securing devices.

Cost containment is a key issue in the health care community. In an effort to contain health care costs, hospitals and other health care institutions are becoming increasingly conscious of where each health care dollar is spent. Nurses have long been cautioned to provide quality care at the least expense (Campbell, 1992). Traditionally, nurses have had little access to cost information (Hanneman & Curry, 1994) although "no other provider has [greater] opportunity to learn costs and be able to teach others the costs of care" (Campbell, 1992, p. 398). Nurses often employ interventions and procedures that were taught in school with little thought to cost benefits. Products in use for a long time cannot be assumed to be the most appropriate choice for patient care (Hanneman & Curry, 1994). Nurses now participate in selecting equipment and supplies and must consider the cost of a product both in actual dollars and in staff time used to implement the product.

While the health care field has been inundated with high-tech devices to care for patients and residents, some procedures seem immune to change. In reviewing the current literature to determine the most common method of securing tracheostomy tubes, the conventional twill tape ties remain a tradition (Craven & Hirnle, 1996; Elkin, Perry, & Potter, 1996; Ignatavicius, Workman, & Mishler, 1995; Smeltzer & Bare, 1996). Few texts (Elkin et al., 1996; Nettina, 1996; Taylor, Lillis, & LeMone, 1997) refer to the use of other methods, such as Velcro[R] ties, to secure the tracheostomy tube. In an exhaustive search of the literature, standards of practice specifically related to securing tracheostomy tubes were not found outside published textbooks.

Many nurses assume that the traditional twill ties are more cost-effective than manufactured devices used to secure tracheostomy tubes. Economic analysis is complex and must take into account both the direct costs of health care usage (salaries and medical supplies) as well as indirect costs (Pillar, Jacox, & Redman, 1990) such as increased patient comfort. Cyr (1990) defines the point of service as the place and time that health care providers plan and initiate patient care and suggests that cost containment is best begun at this time. Health practitioners must continually study interventions that will improve quality of care and decrease health care expenditures (Goode et al., 1991).


The purpose of this study was to determine the difference in time needed to secure a tracheostomy tube using conventional twill ties and a Velcro tracheostomy tube holder. The study also addresses the cost effectiveness of the selected methods (twill and Velcro) to secure the tracheostomy tube as well as nurse satisfaction with the tracheostomy tube holder.

Design and Methods

A quasi-experimental design was used to answer the study questions. The convenience sample consisted of critical care registered nurses recruited at a national critical care conference held in a major metropolitan city on the western coast of the United States. Participation in this study required the nurses to meet two selection criteria. The first criterion required that the nurse practice in a medical or surgical intensive care unit or in a pulmonary medicine unit. The second criterion required current experience (within 6 months) with the care of patients with tracheostomy tubes secured by twill tape.

A total of 120 registered nurses attending an Association of Critical Care Nurses convention volunteered to participate in the study and were given an appointment time for participation. Eighty-two subjects kept their appointments. Based on more detailed questioning of current practice, 65 subjects met both selection criteria and completed the study. All the nurses gave their verbal consent to participate in the study.

Based on a review of the literature as well as input from nurse educators, a nurse anesthetist, and a quality control officer, the study compared the amount of time required to change the tracheostomy tube holder using two methods of securing a tracheostomy tube. The tracheostomy tube stabilization study monitored RNs' ability to secure the tracheostomy tube with the conventional twill ties and with a Velcro tracheostomy tube holder.

The tracheostomy tube stabilization study consisted of timed testing at two stations. At one station, the participant changed the tracheostomy tube ties on a mannequin using conventional twill tape. At the second station, the participant changed the tracheostomy tube ties on a mannequin using the Velcro tracheostomy tube holder. Participants were timed at both stations.

Nurse researchers planned the study, incorporating recommendations made from the pilot study, to provide consistency in implementing each test station. During the pilot study, participants reported variation of skills with securing tracheostomy tubes. To eliminate the variable of unfamiliarity with the products, display and practice stations were available for both the twill ties and the Velcro tracheostomy tube holder. Participants were informed that practice stations were available, but few participants (n = 6) actually used the practice stations.

Each nurse completed a demographic data record to establish current practice setting and frequency of contact with patients with tracheostomy tubes. After completing both testing stations, participants completed a subjective evaluation of the nurse's perceptions about the two techniques using a five-point Likert scale. Participants could decide to end the study at any time.

Each participant changed the tracheostomy tube holder (twill and Velcro) unassisted. To simulate a more realistic environment encountered in the acute care setting, nurse researchers applied measured amounts of a diluted egg white solution (representing tracheostomy secretions) to the tracheostomy tube ties on the mannikin. The nurse researcher initiated timing from the moment the participant began preparations to change the ties until completing the procedure.

A stopwatch was used to record elapsed time for each procedure. The researchers' ability to accurately measure the time required to change the tracheostomy tube ties was validated by test-retest reliability. The time elapsed for changing the tracheostomy tube ties was recorded on a flow sheet coded to track each participant through both stations. Interaction between the nurse researcher and the participant during the study did not occur.

Data Analysis and Findings

Data analysis methods include the use of descriptive statistics and t tests using Statistical Package for Social Sciences (SPSS) 7.5 for Windows (Norusis, 1996). A significance level of 0.05 was set.

Demographic data regarding the participant's nursing practice are presented in Table 1. Of the 65 RNs participating in the study, an even distribution across three levels of nursing experience with tracheostomy tube care occurred. Forty-nine participants (75.4%) reported current employment in intensive care settings, including surgical intensive care, medical intensive care, and combined medical and surgical intensive care units. The majority (n = 56; 86.1%) of the participants interacted with one to five tracheostomy patients weekly with 78.5% (n = 51) of the participants reporting a frequency of one to five tracheostomy tube holder changes per week.
Table 1. Participant's Nursing Practice

                                                   n     %

Area of Practice
  Intensive care (combined medical and surgical)   16   24.6
  Surgical ICU                                     15   23.1
  Medical ICU                                      18   27.7
  Coronary care                                     9   13.8
  Pulmonary unit                                    2    7.7
  Other                                             2    3.1

Years of Tracheostomy Care Experience
  1 - 6                                            22   33.8
  7 - 15                                           23   35.4
  More than 15                                     20   30.8

When asked to identify whether the nurse usually received assistance during tracheostomy tube holder changes, participants reported more unassisted changes (n = 39; 60%) than assisted changes (n = 26; 40%). Of the participants who reported using assistance during tracheostomy tube holder changes (see Table 2), most of the assistance was provided by another RN (n = 13; 50%).
Table 2. Participant's Experience with Tracheostomy Tubes

                                                   n    %

Number of Tracheostomy Patients/Week
  1 - 5                                            56   86.1
  6 - 10                                            4    6.2
  More than 10                                      5    7.7

Number of Weekly Tracheostomy Tube
Holder Changes/Week
  1 - 5                                            51   78.5
  6 - 10                                            7   10.8
  More than 10                                      6    9.2
  No answer                                         1    1.5

Tracheostomy Tube Stabilizing Protocol
  Yes                                              50   76.9
  No                                               15   23.1

Assistance with Changing Tracheostomy Ties
  No                                               39   60
  Yes                                              26   40
  Registered nurse                                 13   50
  Respiratory therapist                             6   23.1
  Nurses' aide                                      7   26.9

Type of Tracheostomy Tube Securing Device
In Place upon Arrival to Unit
  Twill                                            47   72.3
  Velcro trach tube holder                         12   18.5
  Other                                             6    9.2

Usual Type of Tracheostomy Securing Device
  Twill                                            29   44.6
  Velcro trach tube holder                         27   41.5
  Other                                             9   13.9

The participants perceived ease of use of the Velcro tracheostomy tube holder as overwhelmingly easier (95.4%) when compared with the conventional twill ties (see Table 3). Subjective comments by the participants supporting use of the Velcro tracheostomy tube holder over the conventional twill ties included: "Quick to change," "decreases manipulation of the tracheostomy," and "less time consuming."
Table 3. Perceived Ease of Use of Tracheostomy Securing Devices

                                                    n    %

Twill Ease of Use
  Very easy                                         5    7.7
  Easy                                              4    6.1
  Uncertain                                        20   30.8
  Difficult                                        16   24.6
  Very difficult                                   20   30.8

Velcro Ease of use
  Very easy                                        47   72.3
  Easy                                             15   23.1
Uncertain                                           0    0
  Difficult                                         3    4.6
  Very difficult                                    0    0

Fifty of the 65 participants (76.9%) identified that the institutions in which they practice had established protocols in place for stabilizing tracheostomy tubes (see Table 2). The majority of participants (n = 47; 72.3%) identified that the securing device most commonly used when a patient arrives on the nursing unit with a tracheostomy tube in place is twill tape (see Table 2). When asked what type of device the participant used to secure the tracheostomy tube when performing routine tracheostomy care, the participants were evenly distributed between twill tape and the Velcro tracheostomy tube holder (see Table 2).

Descriptive statistics revealed a reduced length of time when changing the tracheostomy tube ties using the Velcro tracheostomy tube holder compared to the twill ties (see Table 4). Almost twice as much time was needed to change a tracheostomy tube using twill ties (mean = 146.2 seconds, SD = 47.1) when compared to use of the Velcro tracheostomy tube holder (mean = 73.6 seconds, SD = 28.1). A paired t-test revealed that the time required to change the tracheostomy tube ties was significantly lower (p = 0.05) using the Velcro tracheostomy tube holder when compared to the time required using conventional twill ties (see Tables 4 and 5).
Table 4. Descriptive Statistics

         n     Mean     SD    Std. Error

Twill    65    146.2   47.1     5.8421
Velcro   65     73.6   28.1     3.4899

Note: Mean reflects time in seconds.
Table 5. Paired Sample Test

              Paired Differences

                     Std.         Std.
          Mean     Deviation   Error Mean
Velcro   72.5538    52.5479      6.5178

          95% Confidence
          Interval of the

           Lower     Upper      t

Velcro    59.5331   85.5746   11.132


Four limitations to the study are identified. First, the researchers relied on subjects' self-report of experience with clients with tracheostomy tubes in selecting the participants. The actual experience of the nurse in providing care to patients with tracheostomy tubes may have influenced the nurses' ability to perform the selected study skills. Second, the participants' actual prior experience with tracheostomy tube care may have affected the subjective evaluation of the ease of use regarding each method of securing the tracheostomy tube. A third limitation of the study was the setting in which the study occurred. Participants waiting to complete a testing station were not isolated from observing other participants performing the skill at the testing station. The timed studies may have been influenced in those participants through observational learning. A fourth limitation is the controlled environment in which the study occurred. This controlled environment may not reflect actual practice settings, for example, assistance with tracheostomy tube tie change, time required, Hawthorne effect, etc.


Two conclusions may be drawn from this study. First, significantly less time was needed to change tracheostomy ties using the Velcro tracheostomy tube holder when compared with the use of conventional twill ties. This finding supports reported subjective reports of current users of the Velcro tracheostomy tube holder (McElaney, personal communication, March 22, 1996). Second, most participants found the Velcro tracheostomy tube holder easier to apply than the twill ties. The ease of use was substantiated by the lower mean time for the tracheostomy tube tie change (twill = 146.2 seconds; Velcro = 73.6 seconds) when using the Velcro tracheostomy tube holder. Such reduction in nursing time directly correlates with reduced procedure costs to the institution (see Table 6).
Table 6. Cost Analysis

                                        Twill        Velcro

Nursing Time to Complete Tracheostomy Tube Tie Change(1)
  Weekly                             0.853 (hr)    0.429 (hr)
  Annual                             44.35 (hr)    22.22 (hr)

Labor Corn
(time x hourly salary(2))
  Weekly                              $14.54       $7.31
  Annually                           $756.17       $378.85

Tracheostomy Tube Holder(3, 4)
  Weekly                             $1.10(3)      $4.00(4)
  Annual                              $57.33       $216.00

Total Procedure Costs
Cost of tracheostomy tube holder +
labor (nursing time x salary)
  Weekly                              $15.64       $11.31
  Annual                             $813.50       $594.85

(1) Based on one nurse performing three tracheostomy tube tie changes daily.

(2.) Based on $17.05 per hour average nurses salary. 1996-1997 Occupational Outlook Handbook

(3.) Based on average cost of twill tape ($4.50/100 yards).

(4.) Based on manufacturer's average price ($2.00) and recommendations of two tracheostomy tube holders per patient.

Literature supports that tracheostomy care for new tracheostomies, including changing tracheostomy ties, be performed at least once a shift (Ignatavicius et al., 1995; Nettina, 1996). Using this as a guide, tracheostomy ties would be changed a minimum of 21 times each week. The observed times from both the twill and Velcro tracheostomy securing device time study were used to calculate weekly and annual procedure nursing times. The weekly nursing time was based on the mean time in seconds (see Table 4) multiplied by the minimum 21 changes per week to arrive at the weekly time in seconds. Additional calculations converted this time in seconds to hours per week and hours per year. In determining nurses' salary, the 1996-1997 Occupational Outlook Handbook(U.S. Department of Labor, Bureau of Labor Statistics, 1996) provided the hourly average nurses' salary of $17.05. This hourly salary was used in calculating weekly and annual labor costs based on a 40hour week. While the Velcro ties ($216.00/year) are more expensive than the twill ($57.33/year), labor cost savings come from the reduced time needed to change the tracheostomy tube ties ($756.17 for twill versus $378.85 for Velcro). These numbers reflect a 50% reduction of labor costs and become more significant when applied to multiple patients. Total procedure costs were determined by adding the costs of the tracheostomy securing device to the labor costs. A 27% reduction in total procedure costs is seen when the Velcro tracheostomy securing device is used to secure the tracheostomy. The reduction of total procedure costs will vary when multidisciplinary team members perform or assist with the procedure.

Implications for Practice

Study findings provide objective evidence of the time efficiency gained by using the Velcro tracheostomy tube holder. While the study looked at the time required for a single participant to change the tracheostomy ties, it is noted that fully 40% (n = 26) of the participants stated that agency policy dictated using an assistant during tracheostomy tie changes (see Table 2). This study used professional RNs as subjects. In the current health care environment, the multidisciplinary team includes the increasing use of unlicensed assistive personnel. The investment in a simpler tracheostomy tube device (Velcro) may provide a greater margin of safety when applied by the multi-skilled worker. While a complete cost-benefit analysis is beyond the scope of this study, it is evident that using the Velcro tracheostomy tube holder results in the reduced total procedure costs per patient to the institution (see Figure 1).


Future research is needed to measure the effectiveness of the type of tracheostomy securing device in producing positive patient outcomes. Such research might include studies that examine patient and family satisfaction and outcome of care differences, for example, comfort, infection rates, skin integrity, etc. using the Velcro tracheostomy tube holder.


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Cyr, J. (1990). Critical care staff nurses' attitudes toward cost containment. Nursing Management, 21(9), 128f-128p.

Elkin, M.K., Perry, A.G., & Potter, P (1996). Nursing interventions and clinical skills. St. Louis: Mosby.

Goode, C.J., Titler, M., Rakel, B., Ones, D., Kleiber, C., Small, S., & Triolo, RK. (1991). A meta-analysis of effects of heparin flush and saline flush: Quality and cost implications. Nursing Research, 40(6), 324-330.

Hanneman, S.KG., & Curry, J.L. (1994). A research-based product evaluation model. Nursing Dynamics, 3(2), 5-11.

Ignatavicius, D.D., Workman, M.L., & Mishler, M.A. (1995). Medical-surgical nursing: A nursing process approach. Philadelphia: Saunders.

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Norusis, M.J. (1996). Statistical Package for Social Sciences (SPSS) 7.5 for Windows. Chicago: SPSS.

Pillar, B., Jacox, A.K., & Redman, B.K. (1990). Technology, its assessment, and nursing. Nursing Outlook, 38(1), 16-19.

Smeltzer, S.C., & Bare, B.G. (1996). Brunner and Suddarth's textbook of medical-surgical nursing (8th ed.). Philadelphia: Lippincott.

Taylor, C., Lillis, C., & LeMone, R (1997). Fundamentals of nursing: The art & science of nursing care (3rd ed.). Philadelphia: Lippincott.

U.S. Department of Labor, Bureau of Labor Statistics. (1996). 1996-1997 Occupational outlook handbook. Washington, DC: Author.

Lois Dixon, MSN, RN, is an Adjunct Faculty Member, Trinity College of Nursing, Moline, IL.

Dianne Wasson, MSN, RN, is Assistant Professor, Trinity College of Nursing, Moline, IL.

Acknowledgment: The authors wish to thank Franklin Shaffer, EdD, RN, for his assistance in the preparation of this manuscript.
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Author:Dixon, Lois; Wasson, Dianne
Publication:MedSurg Nursing
Date:Oct 1, 1998
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