Although use of nasogastric tubes is common in critically ill patients, their placement can be uncomfortable, traumatic, time-consuming, and costly. Furthermore, displaced tubes usually have to be replaced. We designed a study to determine the best method for securing nasogastric tubes in our patient population and to identify the variables that affected failure of tube securing methods. Our hypotheses were that the mean time until failure of our standard taping method would be less than for other selected taping methods; small-bore duodenal feeding tubes would stay secured longer than standard sump tubes; and factors leading to a short mean time until failure would include restlessness, confusion, and combativeness, whereas sedation, immobilization or paralyzation, and the use of restraints would favor a longer mean time until failure.

Background
Although numerous studies can be found describing use, placement, and assessment of nasogastric tubes, to our knowledge none have compared different securing methods for use in critically ill patients. For example, Metheny et al¹ and Meer² described the frequency of nasoenteral tube displacement and also identified associated risk factors such as confusion, restlessness, obtunded state, accidental dislodgment by staff, and severe coughing and vomiting. Eisenberg et al³ identified some patient characteristics that correlated with tube removal such as presence of head or neck trauma, sepsis, or cerebrovascular accident. Complications of tube displacement are many,^{1 3~5} yet little has been written about securing methods. To the authors' knowledge, a study by Sax and Bower6 was the only one that described a securing method for uncooperative patients. The method involved using two tubes sutured and looped into the nose and out of the mouth so that soft palate pressure resulted when the patient pulled on the tube. Although this method may be effective, it is extreme and obviously not a reasonable choice for most critically ill patients.

Methods
A convenience sample of all patients in the medical ICU of a 750-bed teaching hospital requiring nasogastric tubes for feeding, medication delivery, or decompression (N=103) was studied for 3 months in 1991-1992. Patients in whom tubes were secured by suture material were excluded, as were those with oral nasogastric placement and those with nasal skin breakdown. Subjects were randomly assigned to three securing methods that included

The nasogastric tubes used in the study included Salem sump tubes (Sherwood Medical, St Louis, Mo), which were size 14F or greater, and small-bore duodenal tubes (Keofeed; IVAC Corp, San Diego, Calif, or Entriflex Dual Port Feeding Tubes; Biosearch Medical Products, Inc, Summerville, NJ). All duodenal tubes were size 12F and for ease of labeling were called KF (Keofeed) tubes.

Random assignment of the taping methods was done by the unit clerks, who blindly drew a colored chip, each representing a method, from a box at the desk when a nasogastric tube was placed. The clerks placed an information sheet, each colored to represent the corresponding chip and assigned method, in the nurses' bedside workbook. The front of the information sheet identified the securing method and described the appropriate skin preparation. Data collection information was on the back of the sheet (Table 1).

Individual inservices were given to all medical ICU nurses about the study, securing methods, and data collection. During these inservices, variables related to displacement were clarified. For the category titled "cognitive status," the nurse was asked to record all variables that best described the usual cognitive status of the patient for the last 24 hours. Although it was acknowledged that cognitive status might change over time, we asked for this broad definition because similar definitions are usual in critical care environments and decisions related to care planning and interventions (ie, restraints and sedation) are based on such descriptions. Furthermore, we believed that descriptions of shorter time intervals (eg, 1 hour before tube placement and last 4 hours) were not inclusive enough and that we would lose characteristics that might predict securing method failures and ultimately tube displacement.

When a taping method failed and tube replacement was necessary, the nurses secured the tubes with the same securing method and completed the existing data collection sheet. A new sheet was started for each resecuring episode; thus, one patient could account for more than one taping episode. The definition of securing method failure was loose, partially adhered, or completely disengaged tape. Investigators reviewed each patient's chart daily and updated the information sheets as needed. Because at least one investigator worked on each shift, they were often available to assist with questions and help other nurses. The taping materials were placed in a clear plastic bag in a standard position that was easily seen and accessible in patient rooms. The unit supply clerk was responsible for daily restocking.

Statistical significance was determined by the Mann-Whitney U test, with the Bonferroni correction (exceptions are indicated). This statistical method was selected because of the highly skewed nature of the data and to correct for multiple comparisons.

The skin surface was prepared by cleaning and drying the nose, applying a protective skin barrier (Skin-Prep; Smith and Nephew United, Inc, Largo, Fla) and allowing it to dry. Following confirmation of accurate tube placement, each tube was marked under the top of the nose by placing a half-inch wide strip of white waterproof tape (Kendall Products Co, Mansfield, Mass) around the tube twice, which helped with verification of tube position. The taping methods varied slightly and are described in Figures 1, 2, and 3.

Results
Randomization resulted in assignment of 35 patients to the butterfly method, 33 to clear tape, and 35 to pink tape. There were 264 taping episodes, but because the butterfly method failed more frequently and reassignment was to the same method, the distribution to different methods varied (Table 2). Of the tubes, 67% were Salem sump and 33% were small bore duodenal tubes. One hundred eight episodes were eliminated from further analysis because the securing material was electively removed for a clinical procedure, the nasogastric tube was no longer required, or the patient was transferred from the study unit. This attrition further skewed the distribution of episodes by securing method (Table 3).

The mean time until failure for the remaining 156 episodes by tube type are shown in Table 3. Mean time until failure for pink tape was 100 hours; clear tape, 56 hours; and butterfly, 30 hours. All differences were significant (pink tape vs clear tape, P=.012; clear tape vs butterfly, P<<.01; pink tape vs butterfly, P<<.01). No differences among securing methods were found when the reason for failure was patient self-extubation (clear tape, 4 out of 80; butter fly, 5 out of 106; pink tape, 3 out of 78).

The small-bore duodenal tubes stayed secured significantly longer than Salem sump tubes (mean time until failure, 86 vs 41 hours; P<<.01) and al though this difference was seen for all taping methods, as shown in Table 4, only the butterfly method demonstrated a significant difference between tube types (P<<.01). This finding, however, must be interpreted cautiously because some of the cell sizes were very small. When the mean time until failure for each securing method was compared for each tube type separately, the only significant differences were pink tape versus butterfly for Salem sump tubes (P<<.01) and pink tape versus clear tape for small-bore duodenal tubes (P<<.01).

Variables such as alertness, sedation, confusion, mobility, and use of restraints were not significantly related to displacement. When the mean time until failure was evaluated between nasogastric tube types in relationship to the respiratory device (nasotracheal tube, endotracheal tube, face mask, face tent, and tracheal collar), the numbers were too small for reliable analysis.

Discussion
The results of this study supported our first two hypotheses. The pink tape method was superior to the other two methods for our medical ICU patients, and small-bore duodenal nasogastric tubes stayed secured longer than Salem sump tubes. When variables related to failure were evaluated, no significance was demonstrated; however, there was a trend toward longer securing times when the patient was sedated, and a tendency toward shorter securing times when restraints were used. Although our third hypothesis, related to factors that favor longer securing times, was not supported, nurses should continue to be especially vigilant with patients who are restless, confused, or combative. A larger sample size may have demonstrated differences in these variables.

Studies such as those done by investigators^1-3 who studied nasogastric tube displacement rather than securing method failure are difficult to compare with this study, because the primary outcome variable (displacement vs securing failure) was different. It is likely, however, that the two are related. In our study population there were only 12 episodes of patient self-extubation. The increased vigilance associated with the study protocol possibly prevented self-extubation. Another explanation is that the increased care and attention given to securing material application resulted in better overall tube adherence. Although the total number of nasogastric tube self-extubations was small, 8 of the 12 patients who self-extubated were confused. Studies are needed to further explore the relationship between confusion and self-extubation.

The pink plastic tape is elastic and tends to become "gummy" after prolonged use, encouraging retaping. Possibly, these properties of the pink tape help in preventing total securing failure. The other materials studied were much less flexible and tended to fail totally (butterfly) or tear (clear tape) rather than stretch. The tapes were skin-toned (pink tape and butterfly) or clear (clear tape); therefore, it is unlikely that securing times were adversely affected because the securing method colors were annoying to the patient. The piece of white tape wrapped around the nasogastric tube at the tip of the nose, which was used to mark tube placement and help with accurate and early identification of nasogastric slipping or dislodgment, may have enhanced the adherence of the securing materials to the nasogastric tubes.

The finding of longer securing times with the duodenal tubes versus the standard Salem sump tubes is not surprising, because the Salem sump tubes are more rigid and larger than the feeding tubes, increasing discomfort leading to their dislodgement.

Nasogastric tube replacement is costly, dangerous, and time-consuming. We must continue to explore safe and pain-free methods to secure nasogastric tubes in critically ill patients to ensure quality outcomes.

REFERENCES
1. Metheny NA, Spies M, Eisenberg P. Frequency of nasoenteral tube displacement and associated risk factors. Res Nurs Health. 1986;9:241-247. 2. Meer JA. Inadvertent dislodgement of nasoenteral feeding tubes. Incidence and prevention. J Parenter Enteral Nutr. 1987,1 1:187-189. 3. Eisenberg PG, Spies M, Metheny NA. Characteristics of patients who remove their nasal feeding tube. Clin Nurse Spec. 1987;1:94-98. 4. Eisenberg PG. Pulmonary complications from enteral nutrition. Crit Care Nurs Clin North Am. 1991;3:641-649. 5. Koher CL, Keithley JK. Enteral nutrition: potential complications and patient monitoring. Nurs Clin North Am. 1989;24:339-353. 6. Sax H Bower R. Method for securing nasogastric tubes in uncooperative patients. Surg Gynecol Obstet 1987;164:471-472.