Our study adds an objective measure of the benefits provided by bridle kits. Not only was there a reduction in the number of NGT insertions required, but we were also able to show a significant reduction in the number of chest radiographs required as well in the amount of time feeding is missed. While apprehension regarding bridle kits may be focused on cost, this study has shown that the savings more than make up for the initial cost of the kit itself.
Although the patient demographics, systemic effects, and treatment of COVID-19 are similar between different ICUs, a single-center study does have limitations. One of these is the potential for an intervention in a single-center study to lead to a larger effect than that of multicenter studies.11 But as seen in previous studies, the dislodgment of NGTs is not just an issue in this ICU.12 COVID-19–specific risk factors for NGT dislodgment also apply to all patients requiring invasive ventilation and proning.
Identification of whether a new NGT was inserted, or whether the existing NGT was replaced following dislodging of an NGT, relied on accurate documentation by the relevant staff. The case notes did not always make this explicitly clear. Unlike other procedures commonly performed, documentation of NGT insertion is not formally done under the procedures heading, and, on occasion is not done at all. We recognize that manually searching notes only yields NGT insertions that have been formally documented. There is a potential for the number recorded to be lower than the actual number of NGTs inserted. However, when x-ray requests are cross-referenced with the notes, there is a significant degree of confidence that the vast majority of insertions are picked up.
One patient identified in the study required a Ryle’s tube as part of their critical care treatment. While similar in nature to an NGT, these are unable to fit into a bridle and are at increased risk of dislodging during the patient’s critical care stay. The intended benefit of the bridle kit does not therefore extend to patients with Ryle’s tubes.
Conclusion
The COVID-19 critical care population requires significant time on invasive ventilation and remains dependent on NGT feeding during this process. The risk of NGT dislodgment can be mitigated by using a bridle kit, as the number of NGT insertions a patient requires is significantly reduced. Not only does this reduce the risk of inadvertent misplacement but also has a cost savings, as well as increasing safety for staff and patients. From this study, the risk of pressure injuries is not significant. The benefit of NGT bridling may be extended to other non-COVID long-stay ICU patients.
Future research looking at the efficacy of bridle kits in larger patient groups will help confirm the benefits seen in this study and will also provide better information with regard to any long-term complications associated with bridles.
Corresponding author: Rajveer Atkar, MBBS, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom; r.atkar@nhs.net.
Financial disclosures: None.