An Observational Study Examining Adverse Events and Effectiveness of the Nasal Bridle Securement Device in ICU Patients

BACKGROUND/JUSTIFICATION: Adequate nutritional support is an important part of treatment in critical illness. It is usually delivered via a nasoenteric feeding tube because ICU patients may have an altered level of consciousness, delirium, and/or dependence on mechanical ventilation. Feeding tubes are traditionally secured with adhesive tape, making dislodgement of the tube possible. Dislodgement of feeding tubes can lead to suboptimal caloric intake and increased risk of aspiration of feeds/pneumonia. An alternative to this is the nasal bridle securement device (NBSD), which has been shown to have lower rates of tube dislodgement, but the evidence is limited as it is a relatively new medical device. There is also little documented about any adverse events associated with use of the NBSD.

Prior to 2016, all small bore feeding tubes inserted in ICU patients at St. Paul's Hospital were secured with adhesive tape exclusively. The ICU team began using NBSD in 2016 only in patients who were at higher risk for, or with, tube dislodgement. The clinical indications outlined in our Nursing Practice Standards (i.e., "Nursing Practice Standard NCS5652 - Nasal Bridle") are: recurrent nasoenteric tube dislodgement, confused and/or agitated patients, fluoroscopically or endoscopically placed nasoenteric tube, history of difficult tube placement, facial burn victims with nasoenteric tube and/or oily skin causing decreased adhesion of traditional securement.

PURPOSE: The purpose of this study is three-fold, in patients who demonstrated a higher risk for, or with, tube dislodgement: to describe the incidence and characteristics of adverse events associated with NBSD; to examine the effectiveness of the NBSD at prevention of inadvertent dislodgement; to assess if use of this devise is associated with a difference in the proportion of total caloric goal delivered.

RESEARCH QUESTIONS:

1. To determine the incidence and characteristics of all types of adverse events associated with the use of NBSD to secure small bore feeding tubes in ICU patients who have demonstrated a high risk for, or with, tube dislodgement.
2. To determine if there is a difference in the rate of inadvertent dislodgement of small bore feeding tubes in ICU patients who demonstrate a high risk for, or with, tube dislodgement between ICU patients whose feeding tube is secured with a NBSD versus those who were secured with tape. Rate of tube dislodgement is defined as number of tube dislodgements per total number ICU days with a small bore feeding tube in place. Null hypothesis: there is no difference in the rate of inadvertent tube dislodgement. Alternate hypothesis: there is a difference in the rate of inadvertent tube dislodgement.
3. To determine if there is a difference in the proportion of total caloric goals delivered in ICU patients with small bore feeding tubes with a high risk for or with tube dislodgement in ICU patients whose feeding tube is secured with a NBSD versus those who were secured with tape.

Null hypothesis: there is no difference in the proportion of total caloric goals delivered.

Alternate hypothesis: there is a difference in the proportion of total caloric goals delivered.

RESEARCH DESIGN: The prospective observational treated group will include all ICU patients who required a NBSD securement for their feeding tube as per standard practice (i.e., PHC Nursing Practice Standard NCS5652 - Nasal Bridle) from when ethics and operational approvals are obtained until December 31, 2018.

A historical comparison group will be selected from patients admitted to ICU between September 1, 2014 and September 30, 2015 (prior to use of NBSD in the ICU) who have a small bore feeding tube and match key variables.

Since the NBSD is used only in a selected number of ICU patients, in order to select an equivalent sample for the historical comparison group, the investigators will use the ICU database to identify key variables for matching. The patients who were admitted to the ICU from October 1, 2016 until October 30, 2017 and had a small bore feeding tube will be the Interim Group. Using the ICU Database, a statistical comparison of variables in patients from the Interim Group who had, versus did not have, a NBSD to secure their small bore feeding tube will be used to identify what key variables should be used for selecting the historical comparison group.

INCLUSION/EXCLUSION CRITERIA: Inclusion criteria for both the historical and prospective groups are: Admitted to the ICU at St. Paul's Hospital; had a small bore feeding tube in place during their ICU admission.

In addition, the prospective observational treated group will also need to have a NBSD inserted at some time during their ICU admission as per the criteria outlined in the Nursing Practice Standard NCS5652. These clinical indicators include: recurrent nasoenteric tube dislodgement, confused and/or agitated patients, fluoroscopically or endoscopically placed nasoenteric tube, history of difficult tube placement, facial burn victims with nasoenteric tube and/or oily skin causing decreased adhesion of traditional securement. The historical comparison group only need to have a small bore feeding tube, secured by tape, and are matched by key variables.

For both the prospective observational treated group and the historical comparison group who were admitted to the ICU and had a small bore feeding tube in place during their ICU admission, the only patients who are excluded are:

1. those where were not permitted to be fed by the gastrointestinal system (as per Doctor's Orders);
2. and/or did not meet the criteria for use of a NBSD as per the "Nursing Practice Standard NCS5652 - Nasal Bridles"

MEASUREMENT: Demographic data (i.e., age, gender, comorbidities etc.), diagnosis and admission history (i.e., admission date, diagnoses, length of stay, feeding tube placement etc.) will be used to describe and compare the historical comparison group and the prospective observational treated group. To address the first research question regarding adverse events, all types of adverse events associated with the use of the NBSD will be recorded, including adverse events associated with its insertion, use, and removal. To address the second research question regarding inadvertent dislodgement, both the number of inadvertent dislodgements, and duration of tube retainment will be compared between the treated and historical comparison group. To address the third research question regarding caloric intake, the proportion of daily total caloric goal delivered will be compared between the treated and historical comparison group.

DATA COLLECTION: There are three sources of data for this study. The ICU Database has data from every admitted ICU patient. It includes demographic data, diagnoses, admission history, information on a number of procedures and interventions like the use of small bore feeding tubes, patient assessments, and patient outcomes. The ICU Nasal Bridle Database collects information for every ICU patient which has a NBSD inserted (see "Nasal Bridle Tracker Form" attached in Section 9.8.B.). It records data on insertion details, removal details and additional information on adverse event or other issues. The patient chart will be reviewed to collect additional information about the caloric goals and actual total caloric intake. See the NBA-ICU Data Collection Form (Section 9.8.A.) for further details.

STATISTICAL ANALYSIS: Descriptive statistics will be used to compare demographic variables between the prospective observational treated group and the historical comparison group. All types of adverse events including unintentional tube dislodgement, events associated with insertion, use or removal of the NBSD and all other will be qualitatively and quantitatively described. The Goodness of Fit Test or the non-parametric equivalent (Fisher's Exact Test) will be used to assess if there is a difference in the rate of inadvertent dislodgement. The Student T Test will be used to assess if there is a difference in proportion of total caloric goal delivered between treated and historical comparison group.