An Empirical Study of Feedforward Control in Unplanned Extubation of Nasogastric Tube

Introduction

Due to the need of postoperative treatment after our surgery, many patients need to retain the nasogastric tube to promote the recovery of the disease. One more tube on the patient will increase the infection rate and our nursing staff will have more worries about unplanned extubation. Any unplanned adverse event of extubation will cause physical pain, increase economic burden and even endanger your life.¹ Feedforward control, in fact, is to collect information before the start of management, prevent and correct possible problems, and then take the corresponding measures to prevent them to the extent required to achieve the intended purpose.² In recent years, the feedforward control management method has also been widely used in the field of clinical patient care.^3–6 Luo has found that feedforward control can reduce the incidence of perioperative risk events and complications of elderly patients, and improve nursing quality and satisfaction.⁷ To examine the effectiveness of feedforward control, this comparative study takes the patients with nasogastric tube after surgery as the research object, analyzes the risk factors of unplanned extubation, and gives such patients nursing intervention based on the concept of feedforward control management, which has achieved good results.

Materials and Methods

General Information

One hundred and eighty-six patients with nasogastric tube after surgery in the eastern region of Affiliated Hospital of Yangzhou University from September 2020 to September 2021 were selected as the control group; At the same time, 186 patients with nasogastric tube after surgery in the western region of Affiliated Hospital of Yangzhou University were selected as the experimental group. This study was conducted in accordance with the declaration of Helsinki and with approval from the Ethics Committee of Affiliated Hospital of Yangzhou University (NO. YZUHL2020021). Written informed consent was obtained from all participants.

Inclusion criteria: ① Those who are expected to undergo surgery and have retained nasogastric tube or nasogastric tube; ② Patients without history of mental illness and consciousness disorder; ③ Obtain the informed consent of the patient and be willing to participate in the study; ④ The nasogastric tube of the patient is fixed and the identification is consistent. Exclusion criteria: ① mental retardation or severe cognitive impairment cannot cooperate with researchers; ② Those with a history of serious mental illness or family disease; ③ Unconscious person; ④ Unplanned unplugging due to incorrect location.

Methods

In the Control Group, the Patients Received Conventional Nursing Methods

In the control group, routine nursing was carried out and proper restraint was adopted. The nurses strengthened the patrol of patients with extubation risk.

In the Experimental Group, All Patients Received Relevant Nursing Measures of Feedforward Cognitive Intervention on the Basis of the Control Group

The nurse will carry out pre-operation health education for the patients and their families. After the education, the patient or family members will be asked to repeat the content of the education to ensure that they have understood the importance of retaining the nasogastric tube. The contents of the education mainly include: introducing the purpose of intubation, the relationship between intubation and disease treatment, the importance of early enteral nutrition, the possible discomfort after intubation and the consequences of extubation, etc. to the patients and their families in detail. And we will take the restrictive measures to make the patients cognitively accept intubation after the operation. We will also inform patients and their families of the common reasons for unplanned extubation and the common time period of extubation according to our experience, so that they can pay additional attention.

Observation Indicators

Inpatient Nursing Satisfaction Scale

The scale has five dimensions, including health education, medical facilities, safety management, timeliness of service, and humanistic care. It contains 19 items.⁸ It is evaluated with a 5-level scoring method of 1–5 points, representing satisfaction, partly satisfaction, general, dissatisfaction, and extremely dissatisfaction, with a total score of 19–95 points. The Cronbach’s alpha is 0.935. The higher the score, the better the satisfaction of nursing service.

Feedback Score of Nasogastric Health Education

This questionnaire was designed by ourselves. The main items included patients’ understanding of the role of nasogastric tube, the fixation method and the risk caused by extubation. Select 10 experts who were engaged in clinical nursing and medical work in relevant departments to revise the questionnaire, and analyze whether the questionnaire is consistent with the purpose of the survey, and put forward suggestions for revision. The CVI coefficient of the internal validity is 0.954. It has good surface validity and content validity.

Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS)

Self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used for evaluation.^9–11 The two scales both contain 20 items, with 1–4 points from “no”, “sometimes”, “most of the time”, and “frequently”, with a total score of 0–80 points. SAS is bounded by 50 points. The higher the score is, the more serious the anxiety is. The Cronbach’s alpha is 0.911, and the CVI value of content validity is 0.810. SDS is bounded by 53 points. The higher the score of >53 points, the more serious the depression of the patient. The Cronbach’s alpha is 0.927, and the CVI value of content validity is 0.826.

Comfort Assessment Form of Retained Tube

Each indicator in the table is divided into three levels: ① none; ② Mild, but acceptable; ③ Unbearable.¹² Observe the comfort degree of the two groups of patients, and compare whether there was statistical significance in nasopharynx pain, thirst degree, nausea and vomiting, ear pain, reflux and other aspects.

SF-36 Scale

It includes 36 items and is divided into 8 dimensions, including physical health (PF), social function (SF), role limits due to physical health problems (RP), body pain (BP), mental health (MH), role limits due to emotional problems (RE), vitality (VT) and general health (GH). Each dimension contains 2~10 entries.¹³

Perceived Stress Scale

It includes two dimensions of sense of control and sense of tension, with a total of 14 items.^14,15 The Likert 5-grade scoring method was used. Seven items in the scale were scored in reverse, with a score range of 14 to 70 points. The higher the score, the greater the pressure the patient felt. The Cronbach’s alpha is 0.872.

Patients Constrained

The patient must be evaluated and made a decision before starting constraint. During the implementation of the constraint, attention should be paid to ensuring the safety of the patient, doing a good job in observing the condition, maximizing the comfort of the patient, and taking measures to distract the patient. Evaluate whether it is necessary to continue the constraint, and evaluate the condition and result of the constraint. No matter how many times a patient is constrained, it is defined as a constrained patient.

Statistical Methods

SPSS22.0 statistical processing software was used. The measurement data were expressed by mean ± standard deviation (). F-test was used for inter-group comparison, and t-test was used for two independent samples. The counting data were expressed as percentages (%), with comparisons made by means of the χ² test. Rank sum test was used to grade data of nursing satisfaction, and the possible influencing factors were analyzed by binary unconditional logistic regression based on single factor analysis. A value of P < 0.05 was considered to be statistically significant.

Results

Basic Clinical Characteristics of Research Subjects

There is no significant difference between the two groups in general information, including age, sex, education, drinking and smoking, marital status, and family genetic history (P > 0.05) (Table 1).

Table 1 Baseline Characteristics Description and Comparison Between the Control Group and the Study Group

Univariate Analysis of Unplanned Extubation

Compared with the group without unplanned extubation, the constituent ratio of constraint, perceived pressure score, anxiety score, nasogastric intestinal health education feedback score, and indwelling comfort of patients with unplanned extubation increased significantly (P < 0.05), as shown in Table 2.

Table 2 Univariate Analysis of Unplanned Extubation in Patients

Logistic Regression Analysis of Risk Factors for Unplanned Extubation

Two-category non-conditional logistic regression analysis was carried out on the risk factors with statistical significance screened out in univariate analysis. The results showed that patients’ constraint, perceived pressure score, anxiety score, depression score, nasogastric intestinal health education feedback score, and indwelling tube comfort were independent risk factors for patients’ unplanned extubation (P < 0.05), as shown in Table 3.

Table 3 Relevant Results in Logistic Regression Analysis of Risk Factors for Unplanned Extubation

Comparison of Restraint Rate and Unplanned Extubation Rate Between the Two Groups

The restraint rate and unplanned extubation rate of patients in the experimental group were lower than those in the control group after the feedforward cognitive intervention (P < 0.05), as shown in Table 4.

Table 4 Comparison of the Incidence of Unplanned Extubation Between the Two Groups (%)

Comparison of Nursing Satisfaction Between the Two Groups

The nursing satisfaction of patients in the experimental group after feedforward cognitive intervention was significantly higher than that in the control group (P < 0.05), as shown in Table 5.

Table 5 Comparison of Nursing Satisfaction Between the Two Groups After Intervention [n (%)]

Discussion

Unplanned extubation refers to the patient pulling out the pipe without the consent of the medical staff, and also includes the extubation caused by improper medical operation.^16,17 According to statistics, 296 nursing adverse events occurred in the East and West region of our hospital from December 2018 to June 2020, of which 49 were unplanned extubation, accounting for 17.75%. The results cannot be ignored. It is urgent to solve this problem. Feedforward control, also known as advance or preventive control, refers to predicting the consequences of management activities and taking preventive measures before management to avoid possible deviations.^18,19 The application of feedforward control in the medical field can minimize the risk of patients and ensure that the care they receive conforms to their best interests.²⁰ One study shows that the number of patients involved in ICU catheters decreased from 55 to 23 after the implementation of feedforward control system, which indicates that feedforward control management can also be used as an effective method for ICU nurses to manage catheters.²¹ The research results show that patient constraint, perceived stress score, anxiety score, feedback score of nasogastric intestinal health education, and comfort of retained tube are independent risk factors for unplanned extubation. Reasonable use of constraint measures can shift the patient’s focus, indirectly enhance the patient’s understanding of the tube and nursing awareness, play a role in relieving negative emotions, and reduce the incidence of spontaneous extubation.^22,23 Patients with long-term nasogastric intestinal tube are prone to fear, irritability, anxiety and other negative psychology. This study adopts feedforward cognitive intervention to explain the disease and relevant knowledge of gastric tube indwelling to patients, which can help patients understand the importance and necessity of gastric tube indwelling during treatment, thus effectively reducing the occurrence of accidental extubation.²⁴ Research shows that it can prevent patients with gastrointestinal tube from suffering from dry throat, swelling and pain, so as to reduce the incidence of accidental extubation, improve their comfort during postoperative intubation, and ensure nursing safety.²⁵ The study also showed that the constraint rate and unplanned extubation rate in the experimental group were lower than those in the control group after intervention. The nursing satisfaction in the experimental group after feedforward cognitive intervention was significantly higher than that in the control group. It may be related to the feedforward cognitive intervention, which reduces the unplanned extubation rate, reduces the treatment costs, reduces the economic burden of patients and families, and improves the nursing satisfaction.¹⁷

Limitation

Because this study is not a randomized controlled study, and there are individual differences in the study, different selection results lead to bias. In the future, a larger randomized controlled study is needed to confirm the results of this study and determine whether there are other factors affecting the results; only in this way will we be able to draw firmer conclusions.

Conclusion

To sum up, the safety nursing management method of feedforward cognitive intervention has increased the communication between nurses and patients, improved the quality of catheter care and the comfort of patients with indwelling catheter, reduced the hospitalization costs, increased the awareness about the harm of unplanned extubation and the importance of catheter for disease rehabilitation, and enhanced their self-protection awareness to reduce the incidence of unplanned extubation in hospitalized patients. It is worthy of further promotion and application in nursing work.