Educational Webinar: Medical Line Entanglement: Promoting Awareness and Action

Hello and welcome everyone to the mckesson Clinical Connection webinar series. I'm Patricia Howell and the mckesson Clinical Resource team. Our program today is sponsored by the mckesson Clinical Resource team and this series has been created to provide an opportunity for education and discussion related to clinical topics affecting the post acute care market. Following the call, the attendees will receive a copy of the presentation and recording via email if you'd like to an ask a question, locate the chat box at the bottom of your screen. Our topic today is medical line entanglement and I'd like you to take a moment to look at our disclaimer on this page and we have another disclaimer on this page. Medical line entanglement, promoting awareness and our speakers. Today. Our featured speakers today are Vanessa Sumner Clinical Training specialist and Kathy, a senior manager of clinical services for mog Medical. Kathy oversees MG external facing customer support and training for all products. And then NAA is a registered nurse with meg overseeing all internal product training and their ce program. Welcome, ladies and I will now turn the program over to you. Thank you Patricia. We are so glad to be here today. Um I'm Cathy Yon and as uh Patricia mentioned, I am an employee of Mog Medical and uh this is my colleague, Vanessa. Hi, thank you guys for joining today. Just to highlight our disclosures here. Both Kathy and I are employees of ZX, which is a MG company and I am a stockholder in MG as well. Ok. Let's jump into our objectives for today. We have three ec objectives. We will describe what medical line entanglement is. It can also be referred to as Mle and we'll discuss the patients who may be at risk for this. We identify the roles that a clinician can take in providing education on Mle to a layperson will also present and encourage discussion on ideas for incorporating policies to help identify patient environment, um environmental risks and what and what could be used for resources for prevention. Thanks Vanessa. So those objectives are the goals of what we hope you get out of this presentation. But we also want to dig into this topic by identifying what type of setting it can occur in and who medical line entanglement can happen to. We'll talk about prevention as well. Introducing the idea of integrating Mle into existing policies or maybe writing a new policy with directives for assessment using documentation tools, partnered with resources for education as well as ongoing reassessment support and reporting. The broad goal is to identify a pathway for the caregiver to be made aware of the risks. Keep in mind, medical secure devices have a place in prevention but fostering awareness is the first step to improving patient outcomes. In February of 2022 the FDA issued a safety communication to health care providers, parents and caregivers of pediatric patients who receive enteral feedings, identifying the risk of strangulation from the use of enteral feeding delivery sets. The FDA had received reports of two toddlers who died after being strangled by their feeding tube line. This is certainly an uncomfortable topic as anything related to loss of human life would be as health care providers. We come into this profession to do no harm. However, we're keenly aware of the devices and the support of resources we use to save a life can become equally to blame for taking a life while the FDA safety communication pertained to enteral feeding tubes. This statement was included in a published paper written by several mode clinicians on medical line entanglement. It encompasses all medical lines to include ivy lines, feeding tubes via pump or gravity bag, oxygen tubing, monitor cords. I mean, there's an endless list of medical equipment used in acute care and the alternate care space that should be included. These lines can become entangled around a body part causing falls, tubing, dislodgement, impaired circulation, ligature injuries and strangulation in acute care or in a complex home care setting. We're all keenly aware that medication errors can be a result of tangled and misidentified lines. It's called the Spaghetti Syndrome manufacturers. For infusion line products have developed countless ways to improve identifying lines and avoid those critical mistakes from happening. But we also need to be paying attention to the other lines that being said, we wanna know what type of medical devices come to mind for you. Hm. Mhm. So here is a a slide to kind of show what some of the responses are. You can see we as for medical line entanglement, it can be oxygen tubing power cords. The FDA statement pointed to enter tubing. But as you can see, there are a lot of other devices that can equally cause harm with medical line entanglement. Some things you may not have thought of maybe a wound back, a pulse oximeter ng tubes, catheters. That's a really good one, dialysis lines extension sets, there's a whole bunch of medical lines that can cause harm to patients. And the goal of this session is to spread awareness on this. Hey, thank you guys for chatting there. So that is what medical line entanglement is. Now, let's talk about where does medical line entanglement happen? Most, look at these types of settings. Where do you think mle occurs most? Is it maybe an acute care setting like in a hospital setting? A pediatric or adult medical daycare could be a skilled nursing facility or an LT A or maybe is it in home care? Really? The answer is we just don't have enough data to know. In fact, we have minimal data because of lack of reporting the actual events as well as well as the near misses in the acute care or hospital setting. We might logically assume medical line entanglement happens less as we hope that there are more health care professionals interacting with the patient on a more frequent basis. But the reality is patients are presenting thicker to the hospital and are requiring more nursing care. And also there is a critical nursing shortage today. So staffing shortages can lead to higher patient to nurse ratios that put more stress on the staff. This can potentially result in poorer patient outcomes and a higher risk of harm in most hospitals. A patient assessment is done at triage prior to the patient being admitted, that patient is then assigned an acuity level of 1 to 4 based on clinical patient characteristics and the care that is involved. So a a one maybe the patient is more stable. Two is a more moderate risk. Three means a complex patient and then four is high risk. Each level then helps designate a nurse to patient ratio for delivering safe care. When the patient is admitted, a plan of care and a falls risk assessment is initiated. Both of these should be updated during the stay to further evaluate the patient care needs. Illness is impactful to humans. It's kind of a straightforward statement, isn't it that many of us have been down with COVID this past several years, our daily routine disrupted our eating and sleep schedule off. We felt anxious, irritable and foggy when we woke from sleep. Some of you may be able to relate to being admitted to the hospital for sickness or surgical procedures. It's possible that you were attached to various medical lines that kept you from a deep healing sleep, hearing monitors, alarming, you probably woke, feeling disoriented at times, not knowing what day it was and had to remind yourself not to pull up the ivs or the cords touching you that are there to help. Let's look at a patient who's recovering from a surgical procedure. Post op, they require time to awaken from anesthesia and may become agitated, requiring sedatives, making them in a semi awake state. They may require hemodynamic stabilization with IV meds and a multitude of cords connected to many monitors as well as temporary oxygen support. There are bright lights, constant noise, ongoing medication, uh medical interventions and frequent interruptions to sleep. The patient I described is a patient you may not normally consider as high risk of line entanglement or dislodgement, but in reality, they are at risk if not monitored closely as many documented cases of accidental line removal or falls. There are I imagine there are as many or more undocumented near misses. Personally speaking, in 1993 I worked in Syracuse New York as an IC U nurse in an open heart unit. A record breaking storm dropped 43 inches of snow in less than two days, 10 hours into a 12 hour day shift. We were informed the next shift was unable to make it in and we were mandated to stay indefinitely until they could relieve us. We did take breaks and a two hour nap during the night shift. My new open heart patient will call him Mr C. Woke up from anesthesia, disoriented and agitated to the point of crawling over the side rails with multiple central ivs and monitor lines attached to him and tethered to the machine supporting him. It happened so quickly as I was caring for another patient due to the short staffing, amazingly, nothing bad happens but the potential was great. And to this day, I can still see him standing at the side of the bed. There was also a well publicized death of an infant in Canada in the early two thousands, an 11 month old died when his IV tubing became wrapped around his neck during his stay in a Canadian hospital. According to the report, the patient's mother had pointed out that the tubes were becoming tangled but she was told not to worry about it. She said the staff was more concerned about him pulling the IV out. Another report we discovered stated that an 8.5 month old was resuscitated after Ivy lines were found around his neck. And there was also a documented near miss strangulation on a seven month old with tubing and an to an oxygen monitor. So these are just a couple of examples of medical line entanglement events. The bottom line, we need more awareness and reporting of events as well as near misses. That's a great story, Kathy. So let's consider the alternate care space as well. We're talking home care, pediatric and adult medical daycare programs and skilled nursing facilities or lt more medically complex patients are being managed away from the hospital space with prescriptions for things such as IV therapy, oxygen feedings, CPAP machines, et cetera. As we already mentioned, staffing in these spaces can be challenging with higher patient to nurse ratios. These staff are tasked with competing priorities, things such as bathing, feeding and transferring to wheelchairs, all of these activities take time. Often, you know, leaving another patient alone with a medical advice that can be detrimental to maybe a confused or cognitively challenged patient. There is an increased risk that they may trip and fall over oxygen tubing or tangle a line around a limb resulting in circulation compromise. Again, there is little reporting of these events and less of that when they are near misses. So according to polling collected by the Kaiser Family Foundation, the number of people living in nursing facilities has decreased as well as hours of care. Each person received reports show that it is lower today than it was in 2015 by about 22%. This address staffing and financial challenges for both the facility and patients families. For these reasons, patients may be kept in the home setting for care. In many home care cases, responsibility of that care is left up to a parent or a caregiver who is likely not medically trained caregivers in the home have many distractions. Some caregivers hold down jobs and work remotely from home, which seems like a great simple financial solution for keeping a loved one out of a facility. But they may not have taken into account the time needed for monitoring the patient for safety. So in addition to working, they may have other family members to care for and upkeep for the home. The burden can be heavy and can easily, they can easily become fatigued. They must manage the physical care of the patient, co ordination of medical supplies and health care visits. Not to mention the constant anxiety of making sure they get the therapy administration correct or getting the machinery to work right. With this in mind, the patient may be left alone, not just while sleeping or napping. It. It's really unrealistic to think that they can be with the patient nonstop, but bringing awareness to the risk of medical line entanglement is crucial. Very true. So who is most at risk? Pediatric patients seem to be most logical at risk as they toss and turn in their cribs and beds and tangling lines while they sleep or they're just curious toddlers pulling at tubing. But statistics show that the current life expectancy for the US in 2024 is 79.25 years and it's trended um at, at 0.18% increase for the past three years trended up. So people are living longer according to the 2023 special report on Alzheimer's disease by the Alzheimer's Association. 5.9 million Americans aged 85 and older are living with a family member at home. 83% of help provided to those older adults in the US comes from family members, friends or unpaid caregivers to challenge those caregivers even more. An estimated 6.7 million Americans aged 65 and older are living with Alzheimer's in 2023. Also, we should consider the adult brain injured patient or patients receiving chemotherapy or post surgical narcotics for pain, all causing potential for disorientation or commonly called brain fog. The point is any age is at risk circling back again to the point to point out that unfortunately, there's not a lot of research or data reporting around this topic, but we can make an argument that no matter what the environment is, we care for patients with medical equipment, we can assume that there's safety risks that should be identified. Documenting near misses are equally important to reporting actual events as they may give insight to patterns of patient behaviors or environmental risks that can help avoid an actual event. Establishing patient safety reporting systems is an important step for improving patient safety. We wanna know if you've ever reported an event or near miss of an Mle, we will send a survey out now where you can type in your response. So we want to know if you have ever reported an event or even a near myth of medical line entanglement, I'll give you a couple of seconds to answer that. Ok. So just think in your head, you know, if, if you've had an experience where you've had a patient that you noticed to be cords, anything entangled with them. So let's move on to our next slide here and we'll talk about some data. So, a group of mo clinicians performed this study here. There were three groups in the United States that were identified as targets to receive an anonymous online survey titled Medical Line Entanglement Awareness. These groups included parents or caregivers of patients with a medical line and clinicians from outpatient pediatric G I clinics or from pediatric acute care facilities and then specific questions were developed for each individual group. The results were of the clinicians in pediatric acute care. 88% responded that they were aware of the risks of mle yet only 3% reported that their facility had a policy addressing this issue. The next group containing clinicians from an outpatient pediatric G I clinics, they responded similarly, 80% of those polled were aware of the risks of Mle but only 8% reported that their facility had a policy or procedure in place. The rest of the respondents didn't know if there was a procedure or policy. The final group though which was comprised of parents and caregivers of patients with the medical line reported. The following 86% reported that their child or patient received feedings or infusions while sleeping. 88% reported that their child or patient have become entangled in a medical line. And that's a very high percentage and 36% reported the sight of entanglement being the neck, very scary. And only 10% reported that they have received information about the risks of medical line entanglement when they first received education about their medical device. Those who did receive information said that it came from a nurse, a dietician or ad me provider. So from this data, you can see that there is a deficit in reporting and prevention. Despite being aware of the risk, there isn't always a policy or procedure in place to address Mle. And most concerning is that there is a lack of providing this education to parents and caregivers as they are navigating new medical equipment in a new environment. A descriptive study was performed at, oh, I guess I need to skip to the next slide. There we go. A descriptive study was performed at Nationwide Children's Hospital in Ohio in 2011. Uh the purpose of this study was to observe patient safety when it came to medical lines. The research included all Children under the age of six that were hospitalized, excluding any patients in the IC US. These patients were observed for 5 to 10 minutes during each study session. Initially, there was a reactive effect. Meaning the nurses on the floor understood that the patient's lines were being monitored so they would adjust them. However, over time, the nurses became desensitized and the observers noticed less manipulation of lines from the staff. After the study was completed, it showed that 30% of kids had at least one episode of entanglement. Now remember again, entanglement can be around a body part or lines that are tangled with each other. Observers also saw two Children that were found with tubing around their necks, toddlers were noted to have the most amount of entanglement episodes. One interesting observation though during all of this was that a caregiver was present with the patient. 80% of the time we want to bring your attention that the infusion nurse society or ins recently updated their standards of practice and identified medical line entanglement as a notable subject to address. They include a statement to minimize risk of strangulation or entanglement related to the use of administration sets. They identified that research is needed to test preventative strategies strategies such as developing individual risk assessments, assessing the ongoing need for continuous versus intermittent infusions. This recognizes the importance of minimizing the time a patient is tethered to an IV. The need for increased supervision. Be it in person or using a video surveillance, avoiding the use of extension sets that elongate tubing. Suggesting a coiling technique be used for excess tubing and integrating accessories to stabilize flexible lines. For example, clear plastic sleeves over the administration set, we greatly appreciate ins promoting this awareness. So how do we prevent medical line entanglement? Documenting assessments and reassessing the patient are an integral part of quality improvement for any institution reporting outcomes holds practitioners and organizations accountable for the efficiency of their performance. When shared with a reporting body such as a state or federal agency, it's then able to be shared with the public creating health care awareness. It also creates a reliable comparative of information that the public can then make informed decisions about their care. The website at the bottom of this page takes you to the FDA MedWatch online voluntary reporting form that can be used by healthcare professionals and consumers. So our last polling is we are wondering, does your facility have a policy or procedure that addresses medical line entanglement? Ok. So we'll send that survey out to you guys here to see if whatever facility organization you work for. Do they have a policy or procedure that we le and if it's similar to the study that Mo did for Mle, we might not have any people that have a any organizations that have a policy or procedure. So we'll give you a minute to answer that and some of you may not even know if you have a policy or procedure. That's one great thing about this session is just spreading awareness. You can go back and ask your manager supervisor if you have one, it might even be buried in the one that you have. It could be which we'll talk about right here. So we'll move on to the next slide. So Saskatoon Health which consists of 75 facilities, they've created a policy and procedure that assesses patients for entanglement, strangulation entrapment and falls. So we mentioned acute care facilities initiate a falls risk assessment upon admission. So this looks very similar as they incorporated all of their risks into one document. Patients are scored based on their mobility. They identify if they have had a history of falls or ese as they call it ese which stands for entanglement strangulation or entrapment as well as any medications that might increase their risk, you know, such as benzos or opioids. And then lastly, the patient's cognitive development. If the patient scores within a certain number, they offer a list here of preventative strategies that the clinician can implement. Another means of prevention is to offer resources by developing written materials to leave with the caregiver, to continually remind them of the risk of Mle. So this document here, um this awareness document, this comes from Children's Hospital of Colorado with tips for safe sleep, for babies, with medical equipment. They address the medical equipment. They may provide, giving reassurance when using the equipment at home, but they do get real in the second paragraph, identifying the risks. They follow up with some tips for managing lines and encourage communication with the hospital care team. Here is another example from our colleagues at nationwide Children's Hospital. They added a family resource and education page to on their website with the entanglement risk warning. Um They also provide tips for prevention and how to report an event. We've talked a lot about reporting. So they've added a great um website here uh to access that FDA website, MedWatch to report an event. Ok. Then, so best practices for prevention start with incorporating a policy that includes medical line entanglement into the admission process. And in turn, holding clinicians accountable for reassessing with each patient interaction. Things for clinicians to consider in their assessment. Besides the obvious environmental status is that of the caregiver, do they have a language barrier that makes reading support material challenging? Can they really understand what the prevention techniques include? Let's face it. Caregivers get fa fatigued with added responsibilities. Do they have support for themselves? Approximately one quarter of dementia caregivers are in the sandwich generation, meaning that they care not only for the aging parent but also for at least one child of their own. Are there other family members or friends that should be educated. Are there further professional respite referrals needed? Let's back up. Awareness starts with staff education. Be it a clinician or a lay person person? A driver reviewing how to use equipment with a caregiver, consider contracting with an outside training agency or develop an internal staff education program that includes assessment skills to promote safety and prevention of injury. When using medical equipment that's provided, develop resources and provide practice sessions for those employees to teach proper documentation requirements and give them reporting support, reporting an event or near miss can be concerning and stressful for an employee management should provide a safe work environment and support system. It's necessary to be able to capture details of the event documented around the occurrence for proper reporting. These details should then be used to help with future prevention support should include meeting regularly as a team to discuss challenges and share ideas. I know as a ma manu manufacturer, our team meets once a week to talk about calls that we get and how we handle them and to train each other by just simple example. And then lastly, I just wanna say, please encourage research about Mle. There's not a lot out there. So lastly, there has been uh developed literature materials uh from mo that you can leave with your caregivers as a reminder to stay aware of the risks of medical line entanglement. This one we're proud to show was developed by our team of clinicians here in support of this awareness. So we'll leave the link here for you, feel free to use. And then thank you for this opportunity to raise awareness on this very important topic. So we have some references here and then we'll go ahead and turn it over to any Q and A questions that might have come through. Thank you ladies. That was really informative. Um Little heart wrenching to find out about people who have died because of medical line entanglement. I like your this um handout where that QR code was. I scanned that. That's excellent. So we do um have some questions and again, if anybody wants to ask a question, if you got here after I explain the Q and A at the bottom of your screen type in your question and we will try to get to it. So we have a question here. Who should be providing education and medical line entanglement to caregivers? Oh, thank you for that. I'll go ahead and answer that one. That's a great question. So like we had mentioned sometimes a member of the health care team um may not know to provide this type of education. We have talked a lot about how a lot of people are aware, but then they don't have, you know, something to fall back on or maybe they assume that someone else has already provided this education. So like we said, it wouldn't hurt one bit if every member of the health care team, discussed it with a parent or caregiver. So, think of your facility or organization. Um Do they have like a care coordinator meeting or do they do like rounds on a patient every day or something on a routine basis? Uh Those would be a great opportunity to discuss patient safety. Um For instance, I have a friend of mine who's a pediatric physical therapist and she stated to me that she discusses medical line entanglement with almost all of her patients. Um 11 interesting thing I thought was that the nurses and dieticians and physicians she worked with um when she brought up medical and entanglement, they had never really considered it because in most instances, you know, the the patient, when the nurse went in to do their assessment or something, the patient was already in their bed or maybe in their chair um to make payment to do their visit. But since my friend who's a physical therapist, you know, and they're always assisting patients while they're moving and ambulating, um you know, they're having to care for all these lines during the transport patient who was constantly dealing with medical man. So her perspective was really eye opening to other members of the healthcare team. So I would encourage all members of the team to have a conversation with parents or caregivers and with their colleagues to really understand if there's a concern about Mle and the best way to address it right, every patient is different. So it may take some different perspectives to really figure out what will be the best and safest option for that patient. So great question there. This question, I'm not sure if they're talking about for professionals or for patients and families. The question is who should receive training on medical line entanglement? Well, if you're a health care professional, you should all training. So attend our session, download the info gra you know, spread awareness, talk about it. But if we're talking about uh caregivers in the home care setting or um you know, a patient who's going home with a device. So those who receive training and education, um really anyone who's involved in that patient's care. So if the patient, you know, if they have a parent siblings, um other members who are living with them at the home, uh maybe think, you know, does the patient go to daycare or do they go to school? Um you know, do they have like a frequent babysitter or another caregiver if the family is unavailable, like we mentioned a lot during the session, Mle can happen anywhere at any time. So every person that may be involved in providing care to that patient should be aware of medical line entanglement and the steps that they can take to minimize risk. So if you're a health care provider, you know, provide education to your team, that way they can kind of spread the education around to everyone else as well. So we've talked a lot about awareness and education. So let's just keep that going here. That's another good question. OK. If you, um if an organization doesn't have an Mle policy or training, what might be a good first step to get them created? Uh I, I'll take that one. So a good first step is, as Vanessa just said, bringing awareness of this issue. Do your colleagues even know about this issue? You can hand them one of our downloadable handouts or refer them to this presentation just starting to spread the word. I would also start discussing with the stakeholders in your organization to review the patient safety sections of documentation and assessments like we mentioned in our presentation, don't let writing a new policy overwhelm or delay getting this actionable item under underway. Uh Some facilities have already incorporated their medical line entanglement section within their fall risk assessment. So take a good look at the patient assessment guidelines or risk mitigation strategies already in place. You might find them to be similar if you have a patient safety committee at your organization, I think um Vanessa just mentioned that um it, it'd be helpful to send them this information and involve them. Um You don't have, if you don't have an official policy or getting an official policy might be down the road for your organization, simply talking about it can help spark a conversation and start initiate to initiate some change and the discussion might just be enough to spark an individual or group to do a research project to share and in turn increase awareness. Thank you. Um Kathy and Vanessa. This is a comment. Let me know if either one of you are aware of this device, it's called clamp tie, CL A MP Tie. It seems to be a newer device on the market to prevent for prevention of entanglement and infection prevention. You know, we have heard of that and I, I can't keep, I can't speak to um how it works. But um I think I did say earlier that um devices have a, have a um for sure a place in um prevention and should be considered and um researched out if they fit for your facility. Um for our purposes, we're really um just really starting at the basics of awareness. And so the more the merrier of uh devices that are out there that can help prevent human loss of life um is, is just, it should be at the top of the, of the awareness. Um So thank you for promoting that, making people aware is really very important. So thank you so much for your presentation today. Thank you to all of um the attendees and listeners for being here and you'll all get a recording copy of the webinar in an email probably tomorrow or the next day. So everyone have a great day and again, Vanessa and Kathy. Thank you so much for your presentation. Thank you for allowing us to uh to come and be, be a part of this. Yeah, thank you very much. Have a good day guys. You too. Bye bye.