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Implementation of a nasogastric tube securement device in a tertiary care intensive care unit.

Although nasoenteric tube insertion is a relatively routine nursing procedure in the intensive care unit, it does carry the risk of potentially catastrophic complications such as inadvertent tracheal placement, aspiration pneumonia, pneumothorax, epistaxis, and esophageal irritation (Durai, Venkatraman, & Ng, 2009; McWey, Curry, Schabel, & Reines, 1988). Replacement of dislodged nasoenteric tubes, in turn, impacts nursing workload and increases healthcare costs due to the increased use of medical supplies and services associated with radiographic placement confirmation (Seder & Janczyk, 2008).

The use of a nasal bridle securement device has been shown to significantly reduce the risk of unintentional nasoenteric tube dislodgement and improves the delivery of adequate enteral nutrition (Brandt & Mittendorf, 1999; Burns et al., 1995; Gunn, Early, Zenati, & Ochoa, 2009; Hegazi et al., 2008; Parks, Klaus, Staggs, & Pena, 2013; Seder & Janczyk, 2008; Seder et al., 2010). The bridle system includes a piece of umbilical tape that is threaded through both nostrils and around the vomer bone, using a magnetic insertion catheter and probe (refer to Figure 1) (Brandt & Mittendorf, 1999; Burns et al., 1995; Gunn et al., 2009; Hegazi et al., 2008; Parks et al., 2013; Seder & Janczyk, 2008; Seder et al., 2010, The AMT Bridle[TM] Nasal Tube Retaining System, n.d.). The umbilical tape is then secured to the nasoenteric tube with a clip. If the patient pulls on the nasoenteric tube, it provides a small amount of pressure to the vomer bone (The AMT Bridle[TM] Nasal Tube Retaining System, n.d.). Although it is not painful to the patient, the small amount of discomfort deters pulling and helps reduce accidental dislodgement (The AMT Bridle[TM] Nasal Tube Retaining System, n.d.). With continued pulling the outside diameter of the nasoenteric tube will narrow, allowing it to slip through the clip before damage to the vomer bone occurs (The AMT Bridle[TM] Nasal Tube Retaining System, n.d.).

Although there is literature describing clinical outcomes with the nasal bridle device, there are currently no publications describing education, implementation, or monitoring procedures in a clinical setting. Therefore, we developed a clinical procedure, training, and monitoring process to trial the use of the nasal bridle with the goal of reducing unintentional nasoenteric tube dislodgement in our intensive care and high acuity patients.

Implementation

During the eight-month trial phase, all patients admitted to the intensive care unit and high-acuity unit with a length of stay greater than four days and with an existing small bore nasoenteric tube were screened for indications and contraindications for the nasal bridle system, as a part of the routine clinical assessment (Refer to Table 1). A training program, which included didactic teaching and simulation-based learning using a facial model, was implemented on the units to teach the registered nurses criteria for insertion, insertion technique, required documentation, patient and family education, and monitoring parameters. The clinical procedure for insertion of the nasal bridle system, based on the instructions from the product manufacturer, was also added to our local clinical skills resource manual. There was no involvement or sponsorship from the product manufacturer, other than the provision of commercially available educational material, in the implementation and the authors have no conflicts of interest to declare.

After each nasal bridle insertion, the registered nurse (RN) was asked to complete a survey to document whether the insertion was successful, the number of insertion attempts, and any adverse reactions, including pain, as assessed using the critical care pain observation tool (CPOT), associated with insertion (Gelinas, Fillion, Puntillo, Viens, & Fortier, 2006). The RNs were also asked to rate the ease of insertion of the nasal bridle on a five-point Likert scale (very easy, easy, moderate, difficult, or very difficult).

Ongoing daily monitoring of the patient, nasoenteric tube position, and integrity of the nasal bridle securement clip was done by the bedside RN and documented in the patient care record. If the patient experienced any clinically significant adverse events (e.g., epistaxis, local pain or irritation, symptoms of sinusitis or skin breakdown), the nasal bridle device was removed. If the nasoenteric tube position changed, correct enteric placement was radiographically confirmed and the securement clip was replaced.

The nasal bridle device was removed once the nasoenteric tube was no longer indicated (e.g., the patient was able to eat orally), or transfer of the patient outside of the intensive care or high-acuity units.

The implementation and evaluation of this clinical procedure was reviewed by our institution's research ethics board and was defined as a quality improvement study. Although the requirement for a full ethical review was waived, all ethical standards outlined by our department of research and evaluation, including those regarding patient confidentiality, were maintained throughout the review and dissemination of the results of this evaluation.

Results

During this trial and observation phase, 19 patients met at least one indication and had no contraindications for nasal bridle insertion. The median number of insertion attempts for all patients was two (IQR 2.5). The nasal bridle device was successfully inserted in 16 (84.2%) patients. Of the survey respondents who successfully inserted the nasal bridle device (n=16), four (25%) reported the ease of insertion as 'easy', nine (56.2%) as 'moderate, three (18.8%) as 'difficult'

There were few patient-reported adverse reactions during the insertions. Mild discomfort (CPOT score of 1-3) was observed in one (5.2%) patient and moderate discomfort (CPOT score of 4-6) was observed in two (10.5%) patients. There was one documented episode of mild epistaxis after insertion, which resolved spontaneously.

The median duration of nasal bridle device use was seven and one-half days (IQR 10.5). During the ongoing monitoring period, there were no reported skin complications, septal irritation, or epistaxis and there were no identified cases of symptomatic sinusitis. Given that the primary indication for nasal bridle use in this cohort was presence of agitation and delirium, pain or discomfort directly related to the insitu bridle was not able to be reliably evaluated. Of the 19 patients trialed with the nasal bridle device, only one patient had nasoenteric tube dislodgement. This occurred, despite the nasal bridle device being securely in place, due to the patient pulling the nasoenteric tube out from above the securement clip. However, no immediate or delayed associated adverse events were noted and a new nasoenteric tube and nasal bridle device were inserted without complication.

Discussion

Previously published literature supports the use of the nasal bridle to reduce unintentional nasoenteric tube displacement and potential associated complications with reinsertion, as well as improved nutritional intake and fewer missed medication doses (Brandt & Mittendorf, 1999; Burns et al., 1995; Gunn et al., 2009; Hegazi et al., 2008; Parks et al., 2013; Seder & Janczyk, 2008; Seder et al., 2010). As the use of the nasal bridle was a novel practice in our critical care units, we believed it would be valuable to systematically trial its use and identify any needs for ongoing training and education. Most importantly, we wanted to ensure that patients were adequately monitored for adverse events.

Using the results of the user evaluations, ongoing education and simulation of insertion on a model were implemented in an effort to improve the ease and skill of insertion with the aim to minimize the number of attempts to successful insertion, as well as insertion-related discomfort or adverse events.

Given that this practice evaluation only examined a limited number of patients, we decided not to compare this implementation cohort with a historical control group. Rather, we thought that the available published controlled and observational studies supported the use of the nasal bridle device to reduce unintentional nasoenteric tube dislodgement, improve clinical outcomes, and reduce the costs associated with nasoenteric tube reinsertion in our population.

Conclusion

Using a systematic training and evaluation approach we were able to successfully trial and monitor the use of the nasal bridle nasoenteric tube securement device in our critical care units. Based on the available literature and the results of this evaluation, we hope to integrate this device into our routine clinical practice.

Sarah N Stabler, BSc (Pharm), ACPR, PharmD, Clinical Pharmacy Specialist, Critical Care, Surrey Memorial Hospital, Surrey, British Columbia

Judi Ku, BSN, RN, Clinical Nurse Educator, Critical Care, Surrey Memorial Hospital, Surrey, British Columbia

Linda Brooks, BSc (Nutrition), RD, CNSC, Clinical Dietitian, Critical Care, Surrey Memorial Hospital, Surrey, British Columbia

Rochelle Gellatly, BSc (Pharm), ACPR, PharmD, Clinical Pharmacy Specialist, Critical Care, Surrey Memorial Hospital, Surrey, British Columbia

Gregory Haljan, MD, Department Head, Critical Care, Surrey Memorial Hospital, Surrey, British Columbia

Corresponding Author: Sarah N Stabler, BSc (Pharm), ACPR, PharmD, Clinical Pharmacy Specialist, Critical Care, Surrey Memorial Hospital, 13750 96th Avenue, Surrey, British Columbia V3V 1Z2

Email: Sarah.Stabler@fraserhealth.ca

Phone: 604-839-5771; Fax: 604-953-4782

REFERENCES

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Bergeron, N., Dubois, M.J., Dumont, M., Dial, S., & Skrobik, Y. (2001). Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Medicine, 27, 859-864.

Brandt, C.P, & Mittendorf, E.A. (1999). Endoscopic placement of nasojejunal feeding tubes in ICU patients. Surgical Endoscopy, 13, 1211-1214.

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By Sarah N. Stabler, BSc (Pharm), ACPR, PharmD, Judi Ku, BSN, RN, Linda Brooks, BSc (Nutrition), RD, CNSC, Rochelle Gellatly, BSc (Pharm), ACPR, PharmD, and Gregory Haljan, MD

Caption: Figure 1. Graphic illustration of nasal bridle device insertion and securement. (Image used with permission, courtesy of Applied Medical Technology, Inc.)
Table 1: Indications and Contraindications for Nasal Bridle Device
Insertion

Indications                              Contraindications

* Recurrent nasoenteric tube             * Facial trauma
  dislodgement                             with nasal
* Confusion, agitation, or delirium        (vomer) bone
  ** Richmond Agitation and                involvement
     Sedation Scale Score (Ely et al.,   * Recurrent
     2003) +2 or +3                        epistaxis
  ** Intensive Care Delirium             * Nasal ulceration
     Screening Checklist (Bergeron,      * Nasal pain
     Dubois, Dumont, Dial, &             * Nasal obstruction
     Skrobik, 2001) Score 4 or greater     or abnormalities
* Fluoroscopically placed nasoenteric    * Patients
  tube                                     attempting
* History of difficult tube placement      to remove
* Facial burns limiting securement         nasoenteric tube
  options                                  with severe force
* Unable to secure with adhesive tape
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Author:Stabler, Sarah N.; Ku, Judi; Brooks, Linda; Gellatly, Rochelle; Haljan, Gregory
Publication:The Canadian Journal of Critical Care Nursing
Article Type:Report
Geographic Code:1CANA
Date:Mar 22, 2018
Words:2199
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