Prevention of Hospital-Acquired Transnasal Tube-Related Pressure Injuries: A Quality Improvement Project

Device-related pressure injury (DRPI) refers to pressure injuries caused by the use of devices for diagnostic or therapeutic purposes.¹ This type of injury often occurs on the skin and/or subcutaneous tissue (including mucous membranes) under and around medical devices, and the injury generally closely conforms to the pattern or shape of the device.^2,3 Worldwide studies indicate a wide variation in the incidence rates of DRPI between different settings and countries. A systematic review published in 2019 showed that DRPI rates ranged from 0.9% to 41.2% in the adult intensive care setting,¹ while studies from China⁴ and Australia⁵ yielded incidence rates ranging from 1.65% to 27.9% in tertiary hospitals. An incidence rate of 18.75% (calculated by the authors based on 6 pressure injuries associated with medical devices noted in 32 patients) was demonstrated in geriatric long-term care in Israel.⁶ Another study found that DRPI accounted for about a third of hospital-acquired pressure injuries (HAPIs), and patients with devices were 2.4 times more likely to develop a pressure injury (PI) of any kind than those without devices.⁷

Devices that cause DRPI are quite variable. Tubes are one of the most common devices in clinical practice,^8,9 with some examples being nasotracheal and nasogastric tubes.¹⁰ These tubes can also cause transnasal tube-related pressure injuries (TTPIs), which have a significant impact on patients in terms of physical and mental suffering, decreased quality of life, increased length of stay, and additional resource consumption.¹⁰ However, nurses face unique challenges besides inadequate awareness and attention being paid to TTPIs, in which the need to prevent TTPIs conflicts with the safety of tube fixation to prevent unplanned extubations (UEs), which are life-threatening adverse events.¹¹ In the authors’ hospital, nurses certified in wound, ostomy, and continence (WOC) track HAPIs and have noted an increasing trend of TTPIs in recent years. To reduce the incidence of hospital-acquired TTPIs, a quality improvement (QI) team was formed, which formulated an institutional guideline for TTPIs, conducted a tube care workshop, improved transnasal tube fixation methods, enhanced the information management, and improved clinical quality control. The main goal of this study was to reduce the incidence of TTPIs.

Study design and participants

A single-center, quasi-experiment study was conducted in a tertiary comprehensive hospital from 2017 to 2020. Inclusion criteria consisted of: (1) age of ≥18 years; and (2) inpatients with transnasal tubes such as nasogastric tubes (NGTs), nasojejunal tubes (NJTs), nasobiliary tubes (NBTs), or nasotracheal intubation (NTI). Exclusion criteria consisted of patients with an existing nasal skin/mucosal injury at the time of admission.  A total of 6329 patients who met the inclusion criteria from January 2017 to December 2018 were enrolled as the control group, and 7814 patients who met the criteria from January 2019 to December 2020 were enrolled as the experimental group. The differences in age, sex, and tube retention time between the 2 groups were not statistically significant (P > .05) and were comparable, as shown in Table 1.

Ethical considerations

The study was reviewed and approved by the Medical Research Ethics Committee of the Sun Yat-sen Memorial Hospital (approval #SYSKY-2022-006-01) and was conducted in accordance with the Declaration of Helsinki (1989) of the World Medical Association. Informed consent was obtained from all patients.

Control group

Routine precautions were taken, and patients with transnasal tubes were regularly checked. The raised platform method was used to secure the tube, and the adhesive tape was replaced if it became loose or dirty. The monitoring of TTPIs was not recorded in the nursing information system (NIS).

The QI team carried out root cause analysis based on the data, evidence-based guidelines, and field investigations to identify the risk factors for TTPIs. In addition to a patient's general condition—including factors such as age, malnutrition, edema, impaired mobility, or restricted perception, which are common risk factors for PIs—the occurrence of TTPIs was mainly related to the tube itself, the fixation method, and knowledge and skill of the nurses. Other risk factors were as follows: (i) the nasal skin was thin and lacking subcutaneous fat, and had a tendency to be warm and moist due to perspiration, respiratory moisture, and nasal secretions; (ii) improper fit of the tube (tubes often did not properly fit patients due to size and material) and longer tube retention time; (iii) inappropriate tube placement or lack of elasticity of fixation tape; (iv) incorrect fixation method, such as not using the elevated platform method; (v) delayed detection of TTPIs due to the difficulty of observing the apex nasi/internal nares under/near the tube; (vi) inadequate attention to the area under/near the tube by the clinical nurse due to lack of knowledge or familiarity with TTPIs; (vii) inadequate or incorrect preventive measures carried out by the clinical nurse; (viii) lack of documentation regarding tube fixation and skin/mucosal condition under/near the tube; (ix) lack of up-to-date institutional guidelines and systematic training.

Experimental group

Based on cause analysis, the researchers identified a need for QI to reduce the risk of TTPIs, with the specific measures as follows.

      (1) Establishing a QI team: The QI team was comprised of the PI specialist and the tube working group. The PI specialist focused on the TTPIs management consisted of certified WOC nurses, section and district nursing chiefs from a department with a high DRPI incidence rate, and head nurse of the nursing department. The tube working group, which was responsible for improving the quality of tube fixation, was comprised of surgical nursing chiefs and nursing cadres.

(2) Formulating an institutional guideline for TTPIs (Table 2).

(3) Conducting tube care workshop: A workshop on TTPIs, which was held by the PI specialists, adopted the form of case-based learning (CBL). The training content consisted of the newly issued international guidelines; the definition and risk factors of DRPI; the assessment and prevention of TTPIs; different tubes’ materials and sizes; nasal skin cleaning techniques; and prophylactic dressings application including indications, contraindications, and skills when applied in the nasal area. The tube fixation training workshop was held by the tube working group, which consisted of chief nursing officers from department such as surgery and the ICU, and the training content consisted of proper transnasal tube fixation methods. The trainers instructed the nurses to carry out group exercises using the model teaching aid after tube care field operation, and a summary assessment of the group exercise results was performed so that the nurses could receive feedback. After the workshop, the charge nurses were required to communicate the workshop knowledge to other nurses in the department, and the tube care workshop team issued a tube care atlas and videos in the hospital education platform for all nursing staff to download or study online.

(4) Improving transnasal tube fixation method: Before fixing the tube, nurses were instructed to clean the skin using saline or alcohol-free wet wipes when replacing the tape to reduce the irritation to the skin, and to use barrier film to protect the skin if necessary. 3M elastic tape (Multipore-Light Brown, 2733-50, Minnesota Mining and Manufacturing, America) was utilized uniformly, and the tape was required to be changed every other day or replaced promptly when it was wet, rolled, or loose.

The following fixation methods were available for NGTs, NJTs, and NBTs: (i) "I-shaped" fixation method, suitable for patients with no visible nasal secretions and unconscious patients. The tape was cut into 1.3 cm × 8 cm pieces and fixed directly to the patient's philtrum, with the corners cut in an arc to reduce the risk of curling (Figure 1). For male patients, facial hair was shaved and the patient's nasal cavity and philtrum were cleaned before taping. The tube was fixed to the ipsilateral cheek with tape using the elevated platform method (Figure 2), which avoided both the discomfort of pulling and pressure caused by the swinging of the tube during the patient's activities and adverse events such as displacement and dislodgement of the tube. (ii) "Y-shaped" fixation method, suitable for patients with significant nasal secretions. This method helps to avoid damage caused by contamination and moisture that may cause the tube to shift or slip out. The tape was cut into 2 cm × 8 cm pieces, applied tension-free to the nasal flanks, and shaped close to the nostrils to preserve a certain gap between the gastric tube and the nasal cavity (Figure 3), thereby avoiding pressure on the inner mucosa of the nasal. Nurses were instructed to remove the release paper from the lower end of the elastic tape to cross-wind around the tube, pay attention to the tension of the tape when applying it, avoid pulling on the elastic tape with force, and fix the new tape to the cheek in the same way as before (Figure 4).

The following fixation method was available for NTI: A thin hydrocolloid dressing (DuoDerm Extra Thin, ConvaTec Limited, UK) was cut into a 2 cm-diameter fan shape and the curved surface was cut radially and applied to the nasal flank on the side of the cannula. The end of the dressing was adhered to the nasal flank, the fan end was aligned with the inner side of the nasal cavity, and the swab was placed inside the nasal cavity and gently rotated to shape the dressing so that it adhered fully to the nasal mucosa (Figure 5). After placement of the NTI, a foam dressing (Mepilex, Mölnlycke Health Care AB, Sweden) was cut into a Y-shape and placed between the NTI and the sideband (Figure 6). Tape was cut into 2.5 cm × 15 cm pieces and applied tension-free to the nasal flanks. The release paper was removed from the lower end of the elastic tape to cross-wind around the tracheal intubation, and the threaded connection between the NTI and the ventilator tube was held up with disposable inflatable rubber gloves (Figure 7) to prevent the tube from sagging and avoid compression due to the gravitational effect of the tube.

(5) Enhancing information management: Previously, the NIS did not record information on TTPIs. As part of this study, the authors added sections for PI type (skin/mucous membrane), tube type, and tube site in the NIS reporting content template, and nurses were required to fill in the prognosis of TTPIs in the NIS.

Indicators

Primary indicator: Incidence of TTPIs (%) = number of new cases of TTPIs in inpatients (n) / total number of inpatients with transnasal tubes (n) × 100%. Secondary indicator: Incidence of unplanned extubations (UEs) (%) = number of new cases of UEs of transnasal tubes in inpatients (n) / total number of inpatients with transnasal tubes (n) × 100%. Unplanned extubations are defined as self-extubation determined by the patient,¹² and the UEs refers specifically to transnasal tubes in this study.

Statistical method

The data was quantified and entered into a computer to create a database and was statistically analyzed using SPSS 20.0 (IBM Corp. Released 2020. IBM SPSS Statistics for Macintosh, Version 27.0. Armonk, NY: IBM Corp). All analyses were performed using a two-sided test with a confidence level of α = 0.05, with P < .05 being a statistically significant difference. General information was described using mean ± standard deviation, and enumeration data was treated with the chi-square test.

General information of participants

The differences in age, sex, and tube retention time between the two groups were not statistically significant (P > .05) and were comparable, as shown in Table 1.

TTPIs and UEs

  Tubes that caused TTPIs and the stage of the TTPIs are shown in Table 3 and Table 4, respectively. Data on UEs are shown in Table 5.

Incidence of TTPIs and UEs

The incidence of TTPIs in the experimental group (0.69%) was significantly lower than that in the control group (1.20%), and the difference was statistically significant (P = .001), as shown in Table 6. The incidence of UEs in the experimental group (1.63%) was significantly lower than that in the control group (2.40%), and the difference was statistically significant (P = .0001), as shown in Table 6.

In this study, the incidence of TTPIs and UEs in the experimental group were 0.69% and 1.63%, respectively, and 1.20% and 2.40% in the control group. The incidence of TTPIs and UEs in the control group were 1.747 and 1.489 times higher than the experimental group, respectively, suggesting that the QI project successfully reduced the incidence of TTPIs and UEs. These results are consistent with those seen in Schroeder et al,¹³ which found that the incidence of nasogastric tube-related HAPI decreased 100% by creating and implementing a clear and specific guideline.

There is growing evidence for the prevention of DRPI worldwide but relatively few published QI reports on TTPIs. This QI project was set within the context of a growing interest in the prevention of TTPIs. One of the most essential measures implemented by the QI team was creating a standardized institutional guideline, which achieved continuity management of the occurrence, progression, and regression of TTPIs and UEs, and was helpful in improving the awareness and attention to tube care of clinical nurses. In addition, the QI team identified that hospital-wide education was urgently needed. Zhang et al¹⁴ also highlighted that a comprehensive approach should be conducted to raise the level of knowledge, attitude, and practice of nurses in terms of preventing DRPI. The key aspect of the education was the tube care workshop for frontline care providers and adopting a teaching method of CBL with the use of authentic cases to prepare trainees for clinical practice, which improved nurses’ ability to find and solve problems.¹⁵ The trainers used real clinical cases of patients with TTPIs and UEs to introduce the workshop theme and related questions, and guided nurses to have group discussions around those questions. The workshop with CBL helped nurses to develop a mindset centered on ensuring tube fixation safety to prevent TTPIs and UEs.

TTPI occurrence was found to be multifactorial, with improper fixation material and method as primary causes. The previous fixation material and method were deficient and not standardized, and thus it was essential to establish proper practice that followed evidence-based guidelines. Firstly, in terms of fixation material, the guidelines for the DRPI prevention¹⁷ stated that tubes should be fixed with a special fixation device or elastic tape; the tape used in this study had the advantage of being gentle, nonallergenic, and less likely to leave adhesive marks when removed.¹⁶ The QI team uniformly specified the use of the selected tape for transnasal tube fixation, and the clinical practice results confirmed its good performance.

Secondly, in terms of fixation method, the control group pursued a firm fixation that was not easy to be removed, while neglecting the concern of TTPIs. The tape was excessively pulled to ensure the tube was fixed as tightly and securely as possible in the nose, and the cotton cord was wrapped around the tube and was fixed on the neck through the ear, resulting in the tube being tight against the nasal cavity and thus causing skin/mucus damage. The experimental group was modified to adopt a standardized fixation method such as the Y-shaped fixation method, which gave the tube a larger range of movement at the entrance of the nasal cavity and could effectively relieve local pressure, or the I-shaped fixation method, which had the advantage of simplicity by fixing the tube in the philtrum, thereby reducing the risk of TTPIs because of the thick subcutaneous fat and flat skin of the philtrum.

For patients whose tubes were well fixed but for whom TTPIs were unavoidable—due to, for example, poor general condition—the researchers noticed the stress-relieving effect of hydrocolloid dressing applied in those patients. Considering the unevenness of the nasal skin and the moist local environment, it was advised to choose a dressing that easily conformed to the skin and did not interfere with the placement of the tube. A hydrocolloid dressing satisfied those considerations, and the effectiveness of hydrocolloid dressings in reducing the incidence of TTPIs was also demonstrated by Yang G et al¹⁷ and Clark et al.¹⁸ The latter authors systematically evaluated the literature on dressings for PI prevention and found the use of prophylactic dressings such as semi-permeable dressings, hydrocolloid dressings, and foam dressings was effective in reducing friction and alleviating pressure, thereby reducing the incidence of TTPIs.

Reducing the risk of UEs is also important, as UEs are becoming more and more relevant in clinical care.¹¹ Agitation, especially when combined with inadequate sedation, and decreased patient surveillance were major risk factors for UE; however, inexperienced personnel and improper tube fixation might also be important factors.¹⁹ Nurses seemed to play an important role in UEs,²⁰ and as such, the authors of the current study adopted a collaborative model comprised of nurse experts to improve the safety of tube fixation. Training for nurses and regular quality analysis meetings were used to improve overall nursing competence, and the reporting of tube indwelling/removal increased the attention of nurses to tube care and their sense of responsibility, thereby reducing the rate of UEs. The information management could be helpful in the comprehensive and real-time awareness of nurses on indwelling tubes of patients and facilitate the supervision of tube management. Tube fixation method, tube material, and rolled or loosened tape were found to be risk factors affecting the occurrence of UEs. In this study, after improving the fixation material and method, the tape was changed regularly, which made the fixation area more comfortable and secure for patients. Shimizu et al²¹ concluded that increasing the length and width of the tape for fixing endotracheal tubes could enhance the effectiveness of tape fixation, with 2.5 cm × 15 cm piece of tape being the most effective, and this size was what the authors of the current study used to fix NTI.

To ensure the standardization and sustainability of the QI improvements, the QI team kept track of TTPIs and UEs through the NIS and a cross-sectional survey and included TTPI incidence as one of the hospital's sensitive quality indicators of PI management. Departments with high rates of TTPIs and UEs were required to carry out cause analysis and rectification measures, and the QI team summarized and analyzed the data quarterly and formulated improvement measures in hospital-wide quality analysis meetings.

The outcomes attained from this PI project highlighted the need for the care of patients with a medical device, particularly those with transnasal tubes. However, during clinical practice, the authors found that the Braden scale was relatively inadequate for screening patients at high risk of DRPI. Therefore, the authors advocate for more research focusing on developing a targeted scale to better evaluate the risk of DRPI. The strategies used in this project may be transferable to other health care settings faced with a similar high incidence of TTPIs. Future work could assess whether a similar bundle of interventions aimed at preventing TTPIs can produce the same benefits in other health care settings

This study had several limitations. First, this QI project was carried out in 1 hospital, and the root cause analysis that was conducted on those limited samples may not include all possible causes for TTPIs. Second, the study design was not a randomized controlled trial, and the quasi-experiment study design was prone to confounding from temporal changes, which might influence the results. Third, the inspection of the nasal cavity had practical difficulties due to the narrow space, insufficient lighting, and nasal hair obscuration, so there may be some bias in the determination of mucosal injuries. Finally, as this was a multifaceted QI project, the authors could not determine which specific aspects might be associated with the reduction in TTPIs.

Following the implementation of the multifaceted QI project, the incidence rate of TTPIs and UEs decreased. The authors plan to continue both the QI project and monitoring the rate of TTPIs and UEs, thus striking a balance between transnasal tube fixation security and prevention of PI.

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Affiliation: Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China

Acknowledgments: XW and LQ contributed equally to this work, including the conception and design of the study, data collection and data analysis, and manuscript writing. YQ assisted with the official help and manuscript revising. MC, YH, and YW contributed to the data collection and manuscript drafting. The authors wish to thank the Sun Yat-sen Memorial Hospital, Sun Yat-sen University.

Disclosure: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. No conflict of interest has been declared by the authors.

Correspondence: Yihong Qiu, BD, RN; Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China 510120; qiuyihong@126.com