Feature

Managing Spaghetti
Syndrome in Critical Care
With a Novel Device:
A Nursing Perspective
Jay Haynes, MD
Kelly Bowers, MPH
Richard Young, MD
Trudy Sanders, PhD
Karen E. Schultz, MPH

Background Managing spaghetti syndrome, the tangle of therapeutic cables, tubes, and cords at
patients bedsides, can be challenging.
Objectives To assess nurses perceptions of the effectiveness of a novel banding device in management of
spaghetti syndrome.
Methods A simple color-coded elastomeric banding strap with ribbed flaps was attached to bed rails of
adult critical care patients to help organize therapeutic cables, tubes, wires, and cords. Nurses were surveyed before and after use of the bands and after the nursing shift to assess the burden of spaghetti syndrome and the effectiveness of using the bands.
Results Use of the bands decreased the time spent untangling cords, reduced the frequency of contact of
tubing with the floor, and diminished disruptions in care.
Conclusions Use of a simple flexible latex-free elastomeric band may help organize therapeutic tubing at
patients bedsides and may promote improvements in nursing care. (Critical Care Nurse. 2015;35[6]:38-45)

ritical care patients often have numerous therapeutic connections (eg, cords, cables, and tubes)
at the bedside that can easily become disorganized and tangled, leading to contamination of the
connections, nurses confusion, a physical hazard that increases the risk for falls for both nurses
and patients, and the possibility of damage of medical devices.1-6 This phenomenon, known as spaghetti
syndrome, makes caring for patients challenging and difficult1,2 (Figure 1). Multiple instances of patients
deaths, permanent injury, and life-threatening situations related to entanglement with the cords of medical devices have been reported.5,7-14 Ensuring the organization of cords and tubes at a patients bedside
may reduce adverse outcomes such as entanglement of the patient, backflow in tubing, falls by both
patients and health care personnel, and connection errors or damage of medical equipment.5-7,12

2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015321

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Before

After

Figure 1 Managing spaghetti syndrome: flexible sleeved-strap banding devices are used to secure therapeutic tubing, wires,
and cords, keeping them off the floor and organized in a manageable state.

Therapeutic tubing, cables, wires, and cords are a fundamental aspect of daily health care for delivery of medications and fluids to patients. The often disorganized
tubing and cords at the bedside increase the possibility of
inadvertently connecting the wrong syringes and tubing
and then unintentionally delivering medication or fluids
via the wrong route. In 2006, the Joint Commission issued
Authors
Jay Haynes is the senior medical director for health and wellness,
JPS Health Network, John Peter Smith Hospital, Department of
Family Medicine, and an adjunct assistant professor, Department
of Medical Education, University of North Texas Health Science
Center, Fort Worth, Texas.
Kelly Bowers is a biostatistician, Department of Biostatistics and
Epidemiology, University of North Texas Health Science Center.
Richard Young is director of research and associate program director, family medicine residency program, JPS Health Network, and
a clinical associate professor of family medicine, University of
Texas Southwestern Medical Center, Dallas, Texas.
Trudy Sanders is the vice president of patient care services, JPS
Health Network.
Karen E. Schultz is a research assistant and epidemiologist in
Dallas/Fort Worth, Texas.
Corresponding author: Jay Haynes, MD, MSc, Senior Medical Director, JPS Health
and Wellness, Department of Family Medicine, John Peter Smith Hospital, JPS
Health Network, 1350 S Main St, Ste 1250, Fort Worth, TX 76104 (e-mail:
jhaynes@jpshealth.org).
To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
(949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

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Haynes12_15pgs.indd 39

alerts on tubing misconnections; interventions and procedures to manage and protect medical cords, tubes, and
cables as a standard of care, but only a few devices are
available to aid in this task.11,13,15
Few bedside devices for cord control are commercially available, and they vary in complexity and design.
The purpose of this study was to test use of a novel simple, sleeved-strap banding device in the management of
spaghetti syndrome in a critical care unit and to assess
nurses responses to use of the band. Before the study,
no devices or standard protocols were being used to
manage the syndrome.

Methods
After a comparison of commercially available products, a novel sleeved-strap band crafted from elastomeric
latex-free material (JanaBand, JMC Global Technologies)
was chosen for the study. This device was selected because
of its relative value, flexibility, and ease of application
(Table 1, Figures 1 and 2). The color-coded sleeved banding devices were donated for the study by their creator
and manufacturer, JMC Global Technologies, Keller, Texas.
In tests of the effectiveness of the device in an inpatient setting, 2 colors (red and blue) were used to distinguish between afferent tubing carrying medications or
fluids into the patient and efferent tubing removing fluids
from the patient or holding wires and cables (Figure 2).

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Table 1
Feature

Comparison of bedside devices

Comparison devices

Study device (JanaBand)

Cost

Variable depending on quantity

$5-$9 depending on quantity

Design

Clasp: securing holes are the same size and accommodate 3-4 tubes, cords, and/or wires, prefitted

Strap sleeve: larger opening allows for variety of tube

sizes and numbers of tubes, cords, and wires

Material

Foam, rubber, and plastic

Latex-free elastomeric flexible strap

Attachment

Designed to fit on bedrail

Secures on multiple posts, including bedrails, and

intravenous poles; can be adjusted for multiple sizes

Afferent

Efferent

Figure 2 The JanaBand strap device system (JMC Global Technologies, Keller, Texas).

The banding device is approximately 29.2 cm (1112

in) long and 4.8 cm (178 in) wide. The flap sleeves allow
quick release and gliding of the therapeutic connections.
In addition, the banding device added structure and
strength to support a wide variety of sizes and weights of

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therapeutic tubing. In order to ensure sanitation, once

a band is removed from a patients bed, it cannot be
reconnected and is therefore disposed of immediately.
The intended use of the band is to manage spaghetti
syndrome by bundling therapeutic tubing, wires, cables,

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and cords at the bedside and to prevent the tubing from

dropping to the ground and potentially becoming tangled, damaged, or contaminated (Figures 1 and 2).
During a 1-month period (October 2013), the effectiveness of the banding device was determined at a tertiary urban care hospital and academic medical center in
an adult intensive care unit with 36 private patient rooms.
The unit was staffed and monitored by 74 intensive care
nurses; each nurse worked 12-hour shifts 3 days/week.
Several methods were used to teach the nurses how
to use the banding device correctly. Nurses were introduced to the device during their rounding huddles or
at meetings before the start of a shift. A member of the
study team demonstrated how to attach the devices to
the bed and how to remove them after each use. In addition, nurses received an e-mail with a link to an instructional video demonstrating proper use of the band.
Additional educational sessions available to the nurses
in the break room provided detailed pictures and directions on how to use the device and a contact number for
study personnel if a nurse had questions about the band.
Of the 36 patient rooms 18 (50%) were selected for
use of the banding device; the other 18 patient rooms
served as control rooms, with no use of the device. Once
the study rooms were identified, 2 sealed packages of the
bands were placed by medical technicians at the patients
bedside before a new patient was admitted. In order to
ensure consistency, nurses were instructed to place the
banding device on the patients bed rails, securing appropriate tubing, cords, and cables. This particular location
for the banding device was chosen because of proximity
to medical equipment and to avoid interfering with movement of the bed rails and the patients mobility. The
location was tested before the study to ensure consistency and to determine the ideal place for the bands.
Surveys
A voluntary survey consisting of 10 questions was
administered before and after use of the bands. The
purpose of the survey administered before use of the
bands was to determine nurses perceptions of the burden of the spaghetti syndrome in the critical care unit
before the study took place. The survey given after use
of the bands was used to measure nurses perceptions
of the effectiveness of the banding device.
Surveys after each nursing shift were completed
voluntarily by nurses for each of the patient rooms

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monitored during their shift. Complete surveys were

returned to a locked ballot box. This survey consisted
of 3 multiple-choice questions on the nurses perceptions of the frequency that therapeutic tubing and
wires were tangled, disorganized, or damaged severely
enough to disrupt care; the frequency that the tubing,
wires, and cables were in contact with the floor; and
the amount of time required to reorganize or untangle therapeutic cords, cables, and tubing to administer
necessary care to the patient during the shift. On each
survey, the respondent indicated if the banding device
was used with the patient the nurse was describing and
provided the room number for verification.
Statistical Methods
The data were analyzed by using SAS, version 9.2,
software (SAS Institute Inc). Findings were considered significant at =.05. Survey items were summarized using
descriptive statistics. A sample-size calculation was performed before the study to ensure that an adequate number of surveys were collected to achieve a statistical power
of 80% during the 1-month study period. The responses
from the survey given after the nurses shifts were dichotomized, and 2 analysis with odds ratios was done to
determine the differences in the number of disruptions in
care, the number of times tubing may have been in contact with the floor, and the estimated time spent managing tubes,
A simple flexible elastomeric sleeved
cords, and
latex-free banding strap can be used in
wires at the
the intensive care unit to help organize
bedside with
therapeutic tubing and may promote
and without
improvements in nursing care.
the use of the
banding device. The Bowker test of symmetry was used to
test for differences between the responses to surveys given
before and after use of the bands. Because of small cell
counts, several of the response categories on these 2 surveys were dichotomized as agree or disagree, and a zerocell correction was used as necessary.

Results
Before Use of the Bands
A total of 43 surveys (58%) were collected before use
of the bands. The results suggested that nurses were concerned about the management of spaghetti syndrome
in the critical care unit (Tables 2-4). All 43 respondents
acknowledged that a system for organizing therapeutic

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Table 2

Survey questions and responses before and after use of strap band device: agree vs disagree questions

Results before use of

device
(n = 43)
Before question

Results after use of

device
(n = 30)

Agree

Disagree

Agree

Disagree

44%
(n = 19)

56%
(n = 24)

80%
(n = 24)

20%
(n = 6)

.04

37%
(n = 16)

63%
(n = 27)

77%
(n = 23)

23%
(n = 7)

.007

91%
(n = 39)

9%
(n = 4)

37%
(n = 11)

63%
(n = 19)

<.001

98%
(n = 42)

2%
(n = 1)

69%
(n = 21)

31%
(n = 9)

.005

100%
(n = 43)

0%
(n = 0)

70%
(n = 21)

30%
(n = 9)

<.001

84%
(n = 36)

16%
(n = 7)

63%
(n = 19)

37%
(n = 11)

.08

98%
(n = 42)

2%
(n = 1)

73%
(n = 22)

27%
(n = 8)

.53

After question
Cords, tubes, and cables are well organized around the patients bed.
When the strap band device was on a patients bed, the cords,
tubes, and cables were well organized.
Our hospital has an effective solution for organizing bedside
cords, tubes, and cables.
Compared with our hospitals current method for organizing bedside cords, tubes, and cables, using the strap band device could
be an effective solution.
Patient bedside cords, tubes, and cables are often on the floor.
When the strap band device was used, patient bedside cords,
tubes, and cables often fell on the floor.
A system for bedside organization of cords, tubes, and cables
would provide a comfortable and calming environment for the
patient and the patients family.
Using the strap band device as a system for organizing therapeutic tubing provided a comfortable and calming environment for
patients and their families compared with not using a banding
device.
A consistent system for the organization of cords, tubes, and
cables would lead to improved efficiency for patient bedside care.
Using the strap band device system for the organization of cords,
tubes, and cables would lead to improved working conditions
during administration of patient bedside care.
At shift change, I have to spend time reorganizing patients cords,
tubes, and cables.
When strap band devices were being used, I had to spend less
time at shift change reorganizing patients cords, tubes, and cables.
An organized, clean, and calm bedside environment contributes
to a valuable health care experience.
The strap band devices helped create a more organized, clean,
and calm bedside environment and helped to contribute to a
better health care experience.

tubing and wires would improve the efficiency of patient

bedside care, and 98% stated that the banding system
would provide a more comfortable and calming environment for patients. In addition, 91% of the respondents
acknowledged that the patient bedside cords, tubes, and
cables were sometimes on the floor, and 84% reported
that they were spending a large amount of time at shift
change reorganizing the cords, tubes, and cables. The
majority of the nurses (56%) thought that the tubing,
wires, and cables around the patients bedsides were
not organized, and 93% thought the tubing, wires, and
cables were apt to become tangled (Tables 2 and 3).

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After the Nursing Shift

A total of 404 surveys were collected after nursing
shifts during the 1-month study period. Of these, 55%
described a nurses encounter with a patient with the
banding device, and 45% described an encounter without
any banding device (Table 4). Survey responses indicated
that if a banding device was in place on the bedrail, the
patient was less likely to have a disruption in care due to
problems with tangled therapeutic tubing (P = .006; odds
ratio = 1.75; 95% CI = 1.18-2.61). Nurses were more likely
to spend less than 1 minute organizing tangled tubing
if a banding device was used (P = .002; odds ratio = 1.93;

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Table 3

Survey questions and responses before and after use of a strap band device: how likely questionsa

Results before use of

device
(n = 43)

Question
How likely do you think it is that the tubing, wires,
and cables may become tangled at the bedside?b
Extremely likely
Very likely
Somewhat likely
Not very likely
Not at all likely

P
.03

44% (n = 19)
37% (n = 16)
12% (n = 5)
7% (n = 3)
0% (n = 0)

10% (n = 3)
17% (n = 5)
26% (n = 8)
47% (n = 14)
0% (n = 0)
<.001

How likely do you think it is that tubing, wires, and

cables can become damaged in the bed rails?b
Extremely likely
Very likely
Somewhat likely
Not very likely
Not at all likely

23% (n = 10)
37% (n = 16)
21% (n = 9)
19% (n = 9)
0% (n = 0)

3% (n = 1)
7% (n = 2)
30% (n = 9)
53% (n = 16)
7% (n = 2)
<.001

How likely do you think it is that tubing can

become contaminated from being on the floor?b
Extremely likely
Very likely
Somewhat likely
Not very likely
Not at all likely
a

Results after use of

device
(n = 30)

67% (n = 29)
26% (n = 11)
7% (n = 3)
0% (n = 0)
0% (n = 0)

6% (n = 2)
6% (n = 2)
47% (n = 14)
40% (n = 12)
0% (n = 0)

Because of rounding, not all percentages total 100.

The categories extremely likely, very likely, and somewhat likely were combined to make a category, and the categories not very likely and not at all likely were combined to make a category for the statistical analysis.

Table 4 Impact in daily practice: survey results after

nurses shifts

Percentage of group

Question
Banding device used
Yes
No

Total
sample
(N = 404)

Banding device used

Yes
No
(n = 223) (n = 181)

55
45

No. of times care was disrupted because of tangles in

therapeutic tubinga
56
Never
62
48
24
Once
24
25
12
Twice
9
15
8
3 or more times
5
12
Extra time (minutes) spent untangling therapeutic tubinga
64
<1
71
56
25
1-5
18
32
8
> 5-10
7
9
2
> 10-15
3
2
1
> 15
1
1
No. of times therapeutic tubing was on the floora
57
Never
61
22
Once
25
11
Twice
8
10
3 or more times
6
a

53
17
15
15

Statistically significant difference (P < .05) between the group that used the
banding device and the group that did not.

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95% CI = 1.29-2.91), and the therapeutic tubing was less

likely to ever have been on the floor (P < .001; odds
ratio = 2.53; 95% CI = 1.54-4.13).
After Use of the Bands
A total of 30 surveys (40%) were collected after use of
the bands. Results suggested that using a banding device
at the patients bedside significantly aided in managing spaghetti syndrome (Table 2). A total of 80% of the
respondents indicated that the banding device was effective in organizing therapeutic tubing and wires at the bedside (P = .04), and 69% indicated that the banding device
accomplished the task of creating an organized, clean, and
calm bedside environment (P = .005). The nurses indicated that, in general, the perceived likelihood of the risk
of contamination from therapeutic tubing being on the
floor was significantly decreased when the banding device
was used (P < .001), as was the perceived likelihood of
therapeutic tubing being damaged (P < .001) or being
tangled in the bed rails (P = .03; Table 3).

Discussion
Introduction of a new process in health care usually meets some resistance and questioning. The results
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suggested that before use of the banding device, nurses

had genuine concerns about the management of bedside
tubing and cords in the critical care unit. The results of
surveys completed after use of the bands and after each
nursing shift suggested that the nurses in this critical
care unit thought that use of the new standard process
with use of the color-coded banding devices had a positive impact on patient care. Use of the banding device
to manage the therapeutic tubing yielded significant
improvements in perceptions of efficiency and resulted
in fewer disruptions in care and less nursing time spent
untangling cords.
Nurses felt that the bands allowed a sense of organization, saved time, and had a potential for process
improvement. The findings also indicate that use of the
banding device might protect against damage to tubing, cables,
With a simple innovative focus on
and cords
fundamental efforts to increase efficiency,
used at the
decrease variability, and minimize risk
patient bedand error, improvements may occur in
side. Addiboth patient and employee satisfaction.
tionally,
using a standard process of bundling and suspending tubing and cables with color-coded sleeved-strap
devices may help differentiate clean from dirty tubing,
minimize potential errors and damage to equipment,
and may help create a more controlled, safe, and sanitary environment.
The results suggest that a quality benchmark might
be achieved by implementing a routine standardized process that focuses on the prevention of entanglement of
therapeutic tubing, cords, and cables by using a simple bedside apparatus such as a sleeved-strap banding
device. Although spaghetti syndrome has been considered a serious patient care issue for many years, few studies have proposed a solution to this problem.1-3,5,6,10,11,15,16
We hope that the results will reenergize the interest in
solving the problem of spaghetti syndrome and lead to
the development of protocols and standard processes
for use of a simple solution to control entanglement of
bedside tubing and wires for all hospitalized patients.

Limitations
Although the banding device was initially tested
in several small internal pilot studies, with favorable
results, the findings in this larger study are limited
because the data are from a single critical care unit and

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were self-reported and voluntary. Thus, the results may

not be applicable to other types of patient care settings.
Although the results were favorable, the study was only
1 month long. For better understanding of the implications of using a banding cord-control device in a critical
care unit, a longer study period is warranted to measure
the health care outcomes and the impact on the delivery
of the quality of care due to use of the band. Additionally, the impact of the process on infection risk or other
clinical outcomes was not determined, so conclusions
cannot be drawn about improvements due to use of the
band in these types of outcomes. Although the results
suggest that use of the banding device may lead to
marked improvements in efficiency of nursing care, several nurses did not express any perception of improvements in the management of spaghetti syndrome. Some
nurses even reported that use of the banding device
added more time to tending to the tangle of therapeutic tubing. This finding could be attributed to the lack of
familiarity with the new process. A longer study period
in which nurses could become more comfortable with
using such a device might yield different results.
Because the data were self-reported by the nurses, the
information collected via the surveys reflects recall bias.
Ideally, future studies should address this limitation by
having dedicated observers gather quantitative instantaneous measurements about time and the number of times
the therapeutic tubing became tangled or was in contact
with the floor in the patients rooms. The participation
rate in the study decreased from 43 respondents in the
survey before use of the banding device to 30 respondents
in the survey after use of the device, and because of the
voluntary and anonymous nature of the study, we could
not determine if the nurses who completed the before
survey also completed the after survey. In addition, we
could not determine how many different nurses completed the surveys administered after the nursing shifts.
Future studies should take this lack of specificity into
consideration and determine a more unique method of
reporting that maintains anonymity.

Conclusion
Our findings indicate that a simple flexible sleevedstrap banding device can be used in the intensive care
unit to organize therapeutic tubing, cables, and wires at
patients bedsides and that use of the device may promote improvements in nursing care.

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Our results also suggest that the banding apparatus

promoted perceptions of improvements in efficiency and
quality of nursing care. With a simple innovative focus
on fundamental efforts to increase efficiency, decrease
variability, and minimize risk and error, improvements
might occur in patient as well as employee satisfaction.
If use of a color-coded banding devices could potentially protect and organize therapeutic tubing, cables,
and wires at the bedside and reduce the risk and likelihood of error, then developing standard protocols for
use of such devices should be considered and implemented. These results and the desire of nurses to
improve patient care and increase safety in the workplace warrant future studies to investigate use of these
bedside devices and the relative impact of their use to
prevent damage or contamination of therapeutic tubing, cables, and cords; incidents of hospital-acquired
infections; length of stay; and improvements in the
quality and value of critical care. CCN

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Acknowledgments

The authors thank the Tarrant County Hospital District, Fort Worth, Texas,
nursing staff and administration, Gary Floyd, MD, Josephine Fowler, MD, Dan
Casey, MD, Mark Oltermann, MD, and Daniel Ziegler, MD, for their essential
help and guidance.

Financial Disclosures
None reported.

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d tmore

To learn more about patient safety, read Safety Culture In Australian

Intensive Care Units: Establishing A Baseline For Quality Improvement by Chaboyer et al in the American Journal of Critical Care,
March 2013;22:93-102. Available at www.ajcconline.org.
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