Ineffective Tube Securement Reduces Nutrition and Drug Treatment In Stroke Patients.

AbstractStroke patients with dysphagia often depend on nutrition, hydration and medication via nasogastric (NG)

feeding tubes. Securing tubes using tape was associated with repeated tube loss. We determined cause and

effect by auditing tube placement methods, delays incurred, duration and costs. Of 202 NG tube placements

in 75 patients, 67 placements occurred in 17 patients over a full course of enteral nutrition (EN) and 40 of

these placements were tracked. Tubes were secured by tape in 100%, mittens 31% and special observation

5.4%. However, over an EN course, inadvertent tube loss occurred in 82% of patients and was associated

with age (p = 0.049) and mitten use (p < 0.001): 64% of tubes were lost due to patients and 9% slipped.

Average 'tube life' was 2 days, less than 25% of the EN episode (p < 0.001). While tube placement occurred

within 2.55 hours of request, X-ray confirmation led to an 8-9h delay in feed and drugs per tube placement

and loss of 18.8% of feeding time per EN episode. Delays exceeded the 1h and 4h limits for antibiotics and

other medicines in 20% and 80%, respectively. In the 17 tracked patients, we estimate that 55% of the £5979

direct costs could be saved by nasal bridle use. In conclusion, most tubes studied were lost to inadvertent

tube removal leading to clinically significant delays to nutrition, hydration and drug treatments; this may

impair recovery. Reducing tube loss is likely to reduce patient distress, treatment cost and enhance recovery.

Short titleIneffective tube securement reduces nutrition.

Key wordsDelay, drugs, enteral nutrition, ineffective securement.

Key message1. Most stroke patients require 3 or more tubes per feeding episode due to inadvertent tube removal.

2. Tape and mittens are ineffective means of tube securement.

3. Frequent tube loss and delays to confirming replacement tubes greatly impairs nutritional delivery and

drug treatment.

4. Repeated tube replacement is costly; using nasal bridles could reduce this by 55%.

Conflict of interestNone.

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IntroductionIt is estimated that 152,000 strokes occur in the UK every year [Townsend, Wickramasinghe, Bhatnagar et

al, 2012]. Dysphagia occurs in 40-65% following an acute stroke [Martino, Foley and Bhogal et al, 2005;

Falsetti, Acciai, Palilla et al, 2009] but improves significantly during the early days post-stroke; after two

weeks 90% of patients can swallow safely [Martino, Foley and Bhogal et al, 2005]. ‘Those stroke patients

unable to maintain adequate nutrition or fluid, due to dysphagia and/or altered consciousness, should receive

tube feeding via a nasogastric (NG) tube within 24 hours of admission’ [Royal College of Physicians [RCP],

2016].

Unfortunately, inadvertent tube removal or dislodgement is common when using tape securement (up to

63%) [Meer, 1987; Seder, Stockdale and Hale et al, 2010]. Tube loss results in cumulative underfeeding,

dehydration, sub-optimal medication, excessive irradiation from repeated chest x-rays, trauma and anxiety

from repeated tube placement and a significant staff burden and cost. Furthermore, frequent inadvertent tube

removal can lead to an earlier PEG placement; this is associated with a higher mortality [Abuksis, Mor and

Segal et al, 2000; Hamidon, Abdullah and Zawawi et al, 2006].

Standard local securement is to use fabric tape to adhere the tube to the nose with either 'Posey Mittens' or

24hour, 1:1 nursing supervision ('specialling') used only after a patient repeatedly removes their NG tube.

However, Dietetic and Nursing staff perceived these methods to be ineffective. We audited tube placements

to determine the efficacy of securement methods with the reasons for tube removal, methods of confirmation,

delays incurred and treatment cost. This baseline data was used to estimate the potential improvement in

treatment efficacy and cost if in the future we substituted for bridle securement.

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MethodsOver a 4 month period a Dietitian (SB) recorded patient demography, clinical details and the reason for tube

placement on all patients requiring NG tube placement on the acute Stroke Unit. Patients were referred to

the Dietetic Department by bleeping SB Monday-Friday, 08:00-16:00. For each 'tracked' referral the

procedure time, staff band and method of confirmation, use of H2-blockers or PPI drugs, method of

securement, delays to placement, confirmation, feeding and drugs, duration of tube use and EN episode

were prospectively recorded by SB on a spreadsheet. From these data we costed disposables (tube, X-ray

radiology cost), staff time (salary band mid-point) for tube placement and travel to X-ray confirmation and the

overall cost of maintaining EN. Lastly we estimated costing had we intervened using nasal bridle

securement. To ensure all NG tubes were included in the survey during the 4 month period, a ward sheet

was used to record all NG tubes inserted outside of this funded time. This allowed data to be collected

retrospectively on these ‘out of hours’ (‘untracked’) NG tubes.

Data were collated in Excel. Statistics were analysed in R studio V0.98.977 software. Descriptive statistics

are presented as the number and percentage. Most data was not normally distributed and is therefore shown

as the median [interquartile range, IQR] and differences determined using the Wilcox test. Due to the

hierarchical nature of this data and as there are a different number of repeated measures per case, mixed

effects regression models were used in preference to more common repeated ANOVA models, using patient

identifiers as random effects and all other variables as fixed effects.

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ResultsFrom 25/1/16 to 16/5/16 202 10FG NG tube placements took place in 75 patients on the Stroke Unit (Table

1). Patients were elderly, with more female patients and all but one had 'stroke' as the primary diagnosis.

Only 20% of NG tube placements were tracked because staff for data collection were only available between

08:00-16:00, Monday to Friday (Table 2). However, there were no demographic or clinical differences

between tracked versus untracked patients. Most tube placements occurred when overall staffing is lower,

between 16:00-08:00 and weekends.

Table 1: Demography and clinical characteristics.

Parameter All Tracked

N (%) or median [IQR]

Placements 202 40

Patients 75 17

Age (y) 79.9 [71.6-85.9] 81.3 [73.9-87.9]

Sex (% male) 31 (41.3%) 7 (41.2%)

National Institutes of Health Stroke Scale (NIHSS)

15 [9-21] 12.5 [5-21.25]

Primary diagnosis:Stroke 74 (99%) 17 (100%)

Huntington's chorea 1 (1%) 0 (0%)

Secondary diagnosisBiochemical 1 0

Cancer 3 0

Cardiopulmonary dysfunction 13 2

Infection 16 8

Neurological 5 1

Table 2: Reason for tube not being tracked.

Track vs untracked N %

Not tracked: Non-stroke 1 0.5

Staff unavailable: - shortage 6 3

- 16:00-08:00 Mon-Fri 91 45

- weekend 64 31.5

Tracked 40 20

Most NG tubes were placed by band 5 nurses (Band 4: 12%, 5: 78%, 6: 10%). Procedure times were short

(median 5.0 minutes). However, this did not include peri-procedure preparation, securement, disturbances

and requesting of X-rays. Aspiration of gastric fluid with a pH equal to or less than 5.0 was only possible in

33%, though in these patients pH was low (equal to or less than 3.5). Acid suppression was common (H2-

blockers: 7.5%, PPI: 33%). X-ray confirmation occurred in 65%. Although time spent off-ward was short

(0.35h: To and from Radiology=0.12h, in Radiology=0.23h) because of the number of X-ray confirmations

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patients were frequently without nursing or medical escort.

SecurementIn both the un-tracked and tracked tube placements,

most tubes were secured by tape alone (Table 3,

Figure 1a). In those patients perceived at most risk of

inadvertent tube removal, mittens were fitted to their

hands or, where risk was greatest, both mittens and

‘specialling’ was used. When posey mittens were

required, local protocols were followed appropriately.

Table 3: Securement.

Securement All TrackedN % N %

Tape 128 63.4 27 68Tape+mitt 63 31.2 8 20Tape+mitt+special 11 5.4 5 13

Out of the 202 tube placements, the 124 inadvertent

tube removals by patients were found to be associated

with age and use of mittens as restraints (Table 4). In

addition, increasing age was associated with mitten

use (Table 5).

Figure 1: a. Tape bridges and b. Posey mittens.

a. Tape bridges

b. Posey mittens

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Table 4: Mixed effects models of associations with inadvertent patient tube removal. Model Parameter Odds Ratio Confidence interval p-value

2.5% 97.5%Demography Age (per year) 1.05 1.01 1.08 0.005

Sex (male) 0.84 0.42 1.62 0.59Disease severity score (NIHSS) 1.00 0.97 1.05 0.87

Restraint Restraint_mitt 10.23 4.15 32.09 <0.001Restraint_specialing 2.45 0.31 51.66 0.45

Demography and Restraint

Age (per year) 1.03 1.00 1.07 0.05Sex (male) 0.90 0.44 1.87 0.79Disease severity score (NIHSS) 0.98 0.94 1.02 0.38Restraint_mitt 7.85 3.21 22.45 <0.001Restraint_specialising 3.80 0.45 84.52 0.28

Demography and Restraint (simplified model)

Age (per year) 1.03 0.999 1.06 0.049Restraint_mitt 8.51 3.62 24.99 <0.001

Table 5: Relationship between age and a mitt being used.

Model Odds Ratio Confidence interval p-value2.5% 97.5%

Intercept 0.0000 0.0000 0.0001 0.0045Age (per year) 1.2156 1.0785 1.5090 0.0098

While only 12% and 29% required 1 or 2 tube placements, respectively, per EN episode, 59% required 3 or

more; the maximum was 11. Inadvertent tube loss occurred in 73% of placements due to the patient (64%)

and slippage (9%) (Table 6). This is confirmed by the average 'tube life' (2 days) being shorter than the EN

episode (8.5 days, p = <0.001), a ratio of about 4:1. For the 17 patients tracked, the total 'life' of the first tube

was 34.2 days versus 144.5 days for the EN episodes, a deficit of 110.3 days.

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Table 6: Reason for tube placement* and EN cessation.

Event Reason Tube loss

All TrackedN % N %

Tube placement Blocked 4 2.0 1* 2.5

Displaced 2 1.0 1 2.5

Misplaced 2 1.0 2 5New 63 31.2 14 35Patient 124 61.4 21* 52.5Slipped 7 3.5 1 2.5

Tube loss Blocked - - 1 2.5Died: Tube in situ - - 1 2.5Discharged: Oral diet - - 3 7.5Patient removed - - 26 65Removed: Clinical reason - - 5 12.5

Slipped - - 4 10EN cessation Discharged - - 10 58.8

Oral nutrition - - 3 17.6Palliative - - 3 17.6PEG/J or jejunostomy - - 1 5.9Removed: Not needed - - 0 0

*In tracked patients, 3 had lost tubes prior to inclusion: 1 blocked, 2 inadvertent patient removals.126

DelaysEach tube loss and subsequent placement resulted in treatment delays (Table 7). While placement is done

relatively rapidly, the delay to confirm position when X-ray was required explains most of the delay to feed or

'other' drugs given. The short median delay to antibiotic administration was because the dose was timed later

in the day, by which time tube position was confirmed, or it was given IV. Nevertheless 20% of placements

incurred delays exceeding the 1h Pharmacy-target for optimal antibiotic treatment and 10% of placements

incurred delays of 10-50h. For other drugs, 80% of placements incurred delays that exceeded the 4h target

(Figure 2).

Table 7: Delayed actions and treatments (median [IQR]).

Delayed action Median [IQR]Placement 2.55 [0.9-24]Confirmation 7.83 [4.5-12]Feeding 9.00 [4.9-23.62]Antibiotic 0 [0-0]Other drugs 8.62 [3.5-24]

Figure 2: Delays to antibiotics and other drugs by centile.

CostsTotal cost of tube placement was significant because of the frequent use of X-ray (£25) (Table 8). However,

overall the cost per day and per episode were considerably higher when using mittens and 'specialling'. Data

was not normally distributed but outlying 'expensive patients' make the average cost per EN episode more

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representative; this was £351.7 for a mean of 8.5d. For the 17 patients tracked, EN cost was £5979. This

does not include all costs, for example time organising extra treatments (mittens, 'specialling') or, more

importantly, the effects of losing 8-9h of drug and nutritional treatment 4 times per 8.5d of an EN episode.

Table 8: Treatment costs.

Category Item Median [IQR]Procedure Disposables 37.60 [12.6-37.6]

Staff 11.50 [10.2-15.5]Total 49.16 [23.0-53.1]

Overall Total per tube day* 48.25 [11.5-331.3]Total per EN episode* ^^ 159 [92.03-291.8]

*Including mitts (£44 per pair) and specialling (£14.58 per h). ^^Because 3 patients removed a tube prior to the audit, this figure is an underestimate.

As a theoretical comparison, the same group was costed as if they had a nasal bridle fitted that had been

80% effective in preventing inadvertent tube loss (patient, slippage), where 90% of bridles are successfully

placed and therefore one patient, instead of 5, required 'specialling'. This would cost £2712 for the 17

patients, saving 55% of the current cost.

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Discussion Of 202 NG tube placements in 75 patients, 40 were tracked in 17 patients Monday to Friday 08:00-16:00.

Tracked and non-tracked patients were similar for demography and diagnoses, therefore the findings in

tracked patients may be generalisable to this entire stroke sample. Most tubes were placed by band 5 nurses

and all were initially secured with tape. Mittens and special observation were used in 31.2% and 5.4% of the

overall group, respectively, when NG tubes had been repeatedly removed. Local protocols were followed

when mittens were required in these circumstances. Most NG tubes are removed inadvertently (tracked:

64%), with an average ‘tube life’ of 2 days, less than 25% of the EN episode. This is similar to other studies,

where inadvertent patient removal or slippage of NG tubes was found to be up to 63% [Meer, 1987; Seder,

Stockdale and Hale et al, 2010; Gunn, Early and Zenati et al, 2009; Taylor et al, 2015]. Among the 17

tracked patients, 59% required 3 or more tube placements during their EN episode. An additional 9% of

tracked tubes slipped out, so overall 73% of tubes were lost because securement was inadequate. Similarly,

only 27% of all tube removals were planned (eating, PEG, clinical removal), the majority of tube losses being

potentially preventable with better securement. In a hospital-wide survey most patients removed at least 1

tube (1 tube: 61%, 2: 40%, more than 2: 28%) and if a patient removed 1 tube, 66% removed a 2nd; if a

patient removed a 2nd tube, 70% would eventually remove 3 or more tubes [Taylor et al, 2015].

Of the tracked NG placements, only 32.5% had a successful aspiration and pH confirmation of gastric

position. The reason for failure of pH confirmation was not recorded but would be a combination of inability to

obtain ‘gastric fluid’ or pH equal to or more than 5.0, the Hospital Trust (NBT) threshold for gastric

confirmation; the latter may have been influenced by a high incidence of acid suppression (H-2 blocker:

7.5%, PPI: 32.5%) [Taylor, Allan and McWilliam et al, 2014]. However, better dissemination of the standard

operating procedure to change patient and/ or tube position or use a 'safe swallow' of acidic orange juice to

aspirate gastric acid may improve pH confirmation rates. One tube was removed by the patient prior to

position confirmation and the remaining 65% required the patient to go off-ward for X-ray confirmation.

Previous study found failure to obtain gastric aspirate in only 17% [Taylor, Allan and McWilliam et al, 2014].

However, this study used electromagnetically-guided tube placement to make multiple aspiration attempts at

different points within the stomach; failure to obtain an aspirate of less than or equal to 5.0 occurred 44% and

was associated with PPI-use. Similarly, in the hospital-wide survey pH confirmation was only successful in

45%, requiring X-ray in 51% and EM-guidance in 4% [Taylor et al, 2015]. The high percentage of inadvertent

tube removals and subsequent failure of aspirates and pH confirmation results in excessive irradiation from

repeated chest X-rays.

Request to tube placement was quick (2.55 hours), but confirmation took almost 8 hours, delaying feed and

drugs by 8-9 hours per tube placement. This means the median loss of feed or medication time per 8.5 days

EN episode is 38 hours, 18.8% of potential feeding time. 80% of placements delayed medicines by more

than 4 hours and for 20% delayed antibiotics by more than 1 hour, classed by Pharmacy as critical time

thresholds. Delays to antibiotics would have been worse had doses not been given IV or late in the day, after

which time tube placement had occurred. In addition, there would be risk from cumulative under-nutrition and

dehydration. Taken together nutritional and drug treatment were impaired to a clinically significant degree.

Furthermore, the majority of untracked tubes were inserted out of usual working hours or on weekends,

times when expert staff may not be available and therefore risk increased [NPSA, 2011]. Anecdotally,

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nursing staff cite limited porters and access to Radiology out of hours as the main delay to X-ray so the

current study may have underestimated the delay to confirmation and its consequences.

The identified delays to nutrition and hydration occur early post-acute stroke. This is when dysphagia most

commonly necessitates NG tube placement to ensure enteral access and is most critical to recovery. A

randomized controlled trial of 146 patients with acute stroke and dysphagia found that those with better

nutritional status and treated using early and sufficient nutrition had improved short term prognosis of acute

stroke [Zheng, Zhu and Liang et al, 2015]. Furthermore, intensive nutritional supplementation and early

energy intake following acute stroke were associated with recovery of activities of daily living and functional

motor scores [Nii, Maeda and Wakabayashi et al, 2016; Rabadi et al, 2008]. It is important to note that nurse

focus groups report the greatest problem during EN is patient distress to tube insertion, therefore, reducing

the need for NG tube reinsertions has particular clinical value.

In terms of securement, a patient using mittens was more than 8 times more likely to remove a tube, even

after taking age into account. This probably reflects that mittens had been used with patients likely to remove

their tube and that they were largely ineffective at preventing subsequent removal.

Age was also associated, though less strongly, with inadvertent tube removal. Increasing age is associated

with the increased use of mittens, (OR = 1.2, 95% CI (1.08,1.51), p=0.0098). Again, age may be a surrogate

for causal factors such as confusion. Some staff perceive that restraint using posey mittens is less distressful

than a nasal bridle, but this hasn't been holistically tested [RCN, 2016]; and the alternative concern is that

mittens restrict movement and subsequent rehabilitation of stroke patients. Mittens are considered a

‘restraint’; a nasal bridle is securement [NNNG, 2017].

Nasal bridle placement has been shown to minimise dislodgment and removal of NG tubes [Seder et al,

2010], thereby enabling the maximum amount of time for patients to receive nutrition, fluids and medications.

After appropriate training, nasal bridles are easy and quick to place (84.8% success, 4 failed due to blocked

nose, 1 to poor technique) [Power, Smyth and Duggan et al, 2010] and are cost effective [Gunn, Early and

Zenati et al, 2008; Power, Smyth and Duggan et al, 2010]. Many centres only use a bridle when 1 or more

tubes have been inadvertently lost to patient removal or slippage. In the current sample, a threshold of 1 or 2

tube losses would result in 88% or 59% of patients, respectively, suffering 1 or more tube placements before

being considered for bridle securement. Conversely, if all 17 patients had bridles fitted, 12% would have

suffered an unnecessary procedure but 88% would have fewer or no extra NG tube placements, less

irradiation and better nutrition and drug delivery; there would also be reduced staff burden and treatment

cost.

In an RCT, compared to unbridled tubes, fewer bridled tubes were unintentionally dislodged (18% vs. 63%,

p<0.001) [Seder, Stockdale, and Hale et al, 2010] and the percentage of goal calories delivered was higher

(median 78% vs. 62%, p = 0.016). Again, compared to tape, nasal bridles reduced tube removal from 36% to

10%, a rate per 100 tube fed days of 6.4 to 1.6 [Gunn, Early and Zenati et al, 2009]. In one study, NG tubes

were displaced in 58% of dysphagic stroke patients [Anderson, O'connor and Mayer et al, 2004].

Displacement within or after 28 days was treated with a nasal bridle or PEG. The nasal bridle was used for a

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median of 15 days and median prescribed feed increased from 0% to 100% post-bridle. Furthermore, in 104

acute stroke patients fed by NG tubes in 3 UK stroke units, the NG tube was secured using either a nasal

bridle (n= 51) or a conventional adhesive dressing (n= 53) [Beavan, Convoy and Harwood et al, 2010]. Over

14 days, patients randomised to nasal bridle securement received 17% more prescribed feed and fluid

volume (~5.5L), required fewer NG tube insertions (median 1 vs 4) and had fewer electrolyte abnormalities

than controls. Similarly, feed delivery improved from 20% of the goal pre-bridle, to 98% post-bridle; this

obviated the need for PEG placement and may thereby reduce PEG-associated mortality [Donaldson, Earley

and Sheilds, 2007]. Meta-analysis confirms reduced tube dislodgement with bridle use compared to adhesive

tape [Bechtold et al, 2014]. However, there is an increase in skin complications (erythema to frank

ulcerations) (13% vs 3%) and sinusitis (0% vs 5%). Risk may be reduced by bridling with surgical tape not

tubing, not over-tightening and removing once clinically indicated.

Conclusions from this study are limited by the small number of patients 'tracked' for their EN episode (n=17)

and require confirmation in larger studies. However, 'tracked' patients appear representative of whole sample

in terms of demography and disease pattern and have a similar pattern of tube loss, comparable to previous

studies.

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Conclusion and implications for practiceThis study details the 73% rate of inadvertent tube loss, when secured with tape (with or without mittens and

specialling) in stroke patients. Furthermore, those who remove one NG tube are more likely to remove two or

more. Repeated NG tube loss and replacement increase risk from tube misplacement, irradiation from x-rays,

cost and delays to nutrition, fluid and medications; overall these are likely to increase patient distress and

impair clinical recovery. Mittens and 1:1 specialling did not prevent NG tube removal but greatly increased

costs. Nasal bridles may be a safe and effective alternative that could improve patient recovery and

experience while halving costs. Implementation and audit of the cost-effectiveness of bridle use is planned. If

found to be beneficial, adequate training plans would need to be implemented to ensure appropriate

decisions are made regarding bridle use and put care guidelines in place, particularly regarding the

prevention of skin complications and sinusitis.

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Questions for reflection1. Inadvertent tube removal is the largest cause of tube loss among mixed patient populations. Why might

patients suffering acute stroke be more likely to remove a feeding tube?

2. Most stroke patients inadvertently remove multiple tubes despite tape and mittens and each blind tube

placement has a 0.5% risk of causing pneumothorax or pneumonia or 20% risk of leaving tube in the

oesophagus. Consider the possible benefits versus harms of different methods of securement.

3. Similar to findings in other studies, most patients required >3 tube placements and missed 20% of their

feed time and multiple medications. Consider what effects these factors may have on patient comfort,

distress and clinical outcome.

4. Consider what change(s) in nursing practice might impact inadvertent tube loss and how this could affect

patient comfort, clinical outcome and treatment cost.

5. CPD reflective questions6. ■■ This article describes several methods of reducing the risk of stroke patients

inadvertently removing their nasogastric7. (NG) feeding tubes. Consider the reasons why patients who have had an acute stroke

would need an NG tube, why8. they might be likely to dislodge them, and the rationale behind the different securement

methods used9. ■■ What are the clinical issues involved in placement of enteral feeding tubes?10. ■■ From what little research there is, the part of enteral feeding that patients find

most distressing appears to be tube11. placement. Reflecting on your experience with enteral feeding, or with distressed

patients, what can nurses and other12. health professionals do to reduce patient distress from (repeated) tube placement?

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