Evaluating multifaceted strategies to prevent nasoenteral tube complications and achieve significant cost savings in critically ill patients: the ENHANCE-CRIT trial

Abstract

Background: Nasoenteral tube (NET) use is common in critically ill patients but is associated with significant complications, including accidental dislodgement, malpositioning in the bronchial tree or mechanical failures, which can impede nutritional therapy. These complications often lead to adverse events that increase hospital stay, costs, and patient morbidity.

Objective: This study aimed to reduce complications related to the placement and maintenance of NETs in critically ill patients using multifaceted strategies.

Methods: We conducted an observational cohort study between February 2022 and March 2023 using the Institute for Healthcare Improvement's (IHI) Model for Improvement. Data were collected from electronic forms, and process indicators were analysed for adequacy of tube fixation and complication rates. The study compared preintervention data to outcomes following five strategies: nasal bridle fixation, staff training, integration of a decision-support tool, restructuring of the NET care plan and practical simulation-based training.

Results: After implementing the interventions, complications related to NET decreased from 41% to 28%, preventing 200 adverse events. This reduction led to an improvement in patient outcomes, including a shorter hospital stay by 10 days on average, freeing up a total of 6520 bed days. The intervention not only reduced complications but also optimised hospital resource utilisation. An economic analysis revealed total savings of US$95 208, demonstrating both clinical efficacy and financial benefits.

Conclusion: The multifaceted strategies significantly reduced NET-related complications, improved patient outcomes, and enhanced resource efficiency in critical care settings. These interventions demonstrated substantial cost-effectiveness, underscoring the value of structured, preventive measures in improving patient safety and reducing healthcare costs.

Keywords: COST-EFFECTIVENESS; Critical care; Decision support, clinical; Efficiency, Organisational; Patient safety.

Figure 1. Driver diagram for reducing complications related to nasoenteral tube placement.

Figure 2. Process indicators—adequacy of nasoenteral tube fixation and use of mechanical restraints (March 2022–March 2023). (A) Significant improvement in the percentage of enteral tube fixation adequacy, which rose from around 50% to a peak of 95% following practical training, maintaining levels above 80%. (B) Fluctuations in the percentage of patients with positive delirium using mechanical restraints, varying between 60% and 100%, indicating ongoing adjustments are needed to consistently meet the 80% target.

Figure 3. Indicators of complications, accidental dislodgement and repositioning of nasoenteral tubes (March 2022–March 2023). (A) Rate of complications related to the use of nasoenteral tubes, showing a reduction after the introduction of the nasal bridle and stabilising below 30%; (B) rate of accidental nasoenteral tube dislodgement, with a significant drop following the implementation of the nasal bridle, remaining below the target of 10%; (C) rate of nasoenteral tube repositioning, stabilising around 10% after an initial peak in June 2022.

Figure 4. Cost comparison in US dollars before and after the intervention. The figure compares the costs before and after the implementation of the intervention. The ‘Before’ bar represents the costs in the preintervention phase (US$182 340.41), while the ‘After’ bar shows the costs in the postintervention phase (US$87 132.82). The ‘Incremental’ bar demonstrates the total savings generated (US$95 207.58).