ETT Securement and Position Change

AngelRN27 · Jul 9, 2013

Wow, tape is sort of "old school" at this point, and I've really only seen it immediately after a fresh intubation. My facility also uses a Hollister but we change position of the ETT q shift, not q4... Thus far I haven't seen any breakdown or negative outcomes (skin/membrane-wise) while changing position q shift.

ICUNurseStat · Jul 10, 2013

My facility is roughly 350 beds with 35 ICU beds. We tape ET tubes and the tape gets changed daily or when soiled or loose. We are a not for profit facility so we typically don't have the latest and greatest equipment. We truly very rarely have skin breakdown or other issues related to the tape but I'm sure taping an ETT is not even in the realm of best practice.

Sun0408, ASN, RN · Jul 10, 2013

Every facility I have worked uses the hollister's. My current facility's policy is to rotate nightly. The main issues we have had with them is due to swelling,the foam lip guard causing breakdown. I have only seen it 3 times in a few years but still not good.. Taping the ETT was not allowed at my last facility, we didn't carry the tape for it..

TraumaSurfer · Jul 10, 2013

Sometimes the "old school" way should not be forgotten. Recently I was doing a transport from a rather large ED when another patient nearby was intubated. OMG! the Hollister bin was empty! The ED seemed to go into a panic mode including the RN who had been giving me report. The two rather young RTs had no clue how to use tape if a Hollister was not available. Seeing I was not going to get any further in the report, I walked over to the doctor holding the ETT while watching the scene before him in amazement. I did a skin prep and neatly secured the tube "old school". Someone else was still yelling to call another hospital across town to have a Hollister brought by taxi or "Code 3" by the fire department. As I was leaving with my patient I heard them calling the FD to fetch a Hollister from another hospital. I would hate to be in any hospital that can not bring out some "old school" stuff since the words "on back order" and "recall" do appear in health care a lot. It is just SCARY BAD to not have a back up like "tape" around in an emergency.

After CMS put forth the hospital acquired wounds demands, some units had both their RNs and RTs documenting skin integrity. RTs would sometimes do this with their q4h ventilator assessment. RNs might do the same. This was really a big issue for face masks and NIV. Some RT departments give the whole mess to nursing and in many hospitals RNs do all the taping and mask placement care for NIV. RNs are trained for the necessary documentation where as this is a foreign area for most RTs. Also, with the new prefab ETT securing devices, due diligence had to be taken since some were just bad. The Dale holder is one of the worst right behind the Thomas which is used by EMS. The Thomas should not be on any patient for more than 4 hours.

The Hollister is also not without a few faults much like the Neobar. Some don't have a knack for applying it. It doesn't fit all faces. And, several tubes have been lost because some don't monitor the fastening device or know how it works. I have picked up patients where the RN said 23 at the lip but the tube was tromboning out to where one patient had to be reintubated before transport. Another was telling me how agitated the patient was but the Hollister was taped to her lower eye lashes and was pulling the skin down very tightly. I also get the "it's holding" or "that is the way it is suppose to dangle" when clearly it is not according to the manufacturer and the patient.

Whether your policy says qshift, q4, qday or qWeek (Hollister) find out if there is a reason as to why the policy is that way. It also does not mean you can not move a tube with a device like a Hollister more often. RNs do all the time for oral care, tube placement or procedures. Just document you moved it so someone else doesn't move it 10 minutes later thinking no one moved it.

If you feel your RT department is not doing their job, have your manager talk to theirs. If nothing else nursing can easily take over this task by using the wound care issue in your favor. RNs are better suited for this assessment and that should be a strong point made to the managers.

arnwest · Jul 10, 2013

I worked at a large teaching hospital and we use tape. I didn't know there was any other way. It's changed q 24h and as far as I know we haven't had issues with skin breakdown. I also did a clinical at another hospital in a level III NICU and they, too, used tape.

AngelRN27 · Jul 10, 2013

I want to clarify (no sarcasm here) that my use of the term "old school" was in no way meant to be taken as a negative thing. I simply meant to convey that tape no longer seems to be the standard, as per my observation in my area.

I completely agree with TraumaSurfer that "old school" or "tried and true" strategies are something that health care workers should be comfortable with. Luckily I have had the pleasure of working with many experienced nurses (many of them Doctors in their native countries) and have had practice with some of these types of things. My facility does tape ETT's when they are first placed. We don't run around screaming for Hollisters, LOL. I have taped two myself in the past 3 months-- they weren't as "pretty" as I wanted them, but they were secure as hell LOL

nrsang97, BSN, RN · Jul 11, 2013

We still use tape. At both facilities I have worked at we used tape. Occasionally we would use tube holders but they usually were switched out for tape.

beckster_01, BSN, RN · Jul 11, 2013

I work at a large teaching hospital/regional trauma center.We use Hollister tube holders, which are to be changed q5 days, but the position of the tube is changed q2 hours with oral care. I have seen tubes taped on a few special occasions- one patient had a thick beard. He was very agitated hemodynamically unstable, so shaving it was very low on the priority list post-intubation. The other had a wound that would have been aggravated by the straps of the Hollister, so they used tape and secured it above his ears instead. So yes, tapes still have a place, but where I work only RT and older nurses know how to do it.

As far as pressure ulcers go, I have seen at least one from an ET tube, but it was on a patient who was transferred from an outside hospital. I've definitely seen several wounds on the lips, but most of them were likely from the patient biting their lip/tongue, and not related to a device.

detroitdano · Jul 12, 2013

We use tape, we're a pulmonary specialty ICU and a teaching hospital. And I never see skin breakdown from the tape itself, it's only when someone fails to rotate position.

With the Hollister it's just too easy for the patient to grab it and pull it out. It takes a bit of effort to break that tape away from your face.

SticU <3 · Jul 19, 2013

Thanks to everyone for their replies. It's interesting to read all the different experiences that fellow nurses have had with this topic. Personally, I'm partial to the Hollister but I can see the benefits to taping. At the facility that I work at, it's more of the nurses' responsibility to rotate retape which is hard to do with the various issues that arise while caring for critical patients. My biggest concern is that the tubes are often not rotated daily which from what literature I've read suggests is best practice. Anyone have article suggestions on this topic? Also, I think the Hollister is more visually "appealing" because it doesn't press into the face giving the patient an even more unusual appearance to those that knew them before this critical illness (at least from my experience). Thoughts???

ICUPrincessNurse · Jul 20, 2013

We use ties or an ETAD which sounds like a hollister. We changes ties and position once a shift, we change our ETADs as needed and position on them q2-4. ETADs are only used if our patients have all their teeth, particularly the top front row. No teeth = ties! We RARELY use tape. Occasionally they'll come from the OR still taped if they were unable to extubate but we change that out pretty quick. I've had one sutured into a patients gum once. Needless to say, that guy got restraints and sedation for airway management. Gotta love ENT!!