Introduction

Welcome to the APSA Quality and Safety Committee Enteral Access Toolkit. This page is intended to help anyone who is interested in Quality Improvement (QI) pertaining to the management of patients requiring enteral access.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Perioperative Gastrostomy Tube Management

Seattle Children’s Hospital (SCH) implemented a patient-facing checklist of requirements in preparation for gastrostomy tube (GT) insertion. This approach gives families visibility into clinic preparatory activities, allows them to plan and participate in their child’s care, and helps them partner with their surgeons and medical team.

Protocols:

Resources:

• SCH Patient Checklist/Timeline (InsideOut Platform)
• SCH Gastrostomy Tube Scheduler’s Script

Stakeholders: families, central and surgery scheduling, surgery nurses, surgeons, referring services (e.g. pulmonary, cardiology, craniofacial, neurodevelopmental)

Challenges and solutions:

• Challenges:
  1. Making sure that upper gastrointestinal series were ordered for patients
  2. Getting patient education buy-in
• Solutions:
  1. Automate a notification from scheduling to the general surgery nurse practitioner who can click yes/no with one button
  2. Give parents time to review and participate in developing family communications

Links to published data:

Submitted by: Adam Goldin, MD

Additional implementers: Linda Bruhns, RN (General Surgery)

In order to streamline the workup and treatment of children with feeding difficulties, the University of Iowa Stead (UI Stead) Family Children’s Hospital created a feeding tube/GT pathway. They sought to reduce variability, improve interservice coordination, and promote good care of children who are unable to eat. The project was a collaboration between the surgery, gastroenterology, speech and nutrition services.

Protocols:

• UI Stead GT pathway

Resources:

Stakeholders: surgery, gastroenterology

Challenges and solutions:

• Challenges
  • Substaintial variation at every step of the process: from indications for GT placement, surgical approach, postprocedure treatment, follow-up and management of complications. Resulting in poor resource utilization and, at times, suboptimal care.
• Solutions
  • A pathway was created through interdisciplinary collaboration with the help of clinical fellows on the surgical and medical services. It required some compromises but has led to improved communications and predictability in the early phases of application.

Links to published data:

Submitted by: Joel Shilyansky, MD

Children’s Mercy Kansas City (CMKC) created a same-day discharge pathway for patients undergoing laparoscopic GT placement. Preoperative consultation consists of a nutrition evaluation, social work assessment for durable medical equipment supplies, and GT teaching with families. On the day of surgery, feeds are initiated within 4 hours and further teaching is provided to caregivers. Patients are discharged once tolerating feeds and caregivers are comfortable.

Protocols:

• CMKC Work Flow for Same Day Discharge

Resources:

• CMKC Same Day Discharge Order Set
• CMKC Clinic RN Template

Stakeholders: surgery, nutrition, care management, perioperative services

Challenge:

• GT clinic was multidisciplinary, with specialists seeing patients in succession. Consequently, appointments were taking too long.

Solution:

The GT consultation was restructured in the following way:

• The patient was seen in the surgery clinic in consultation for the GT and teaching.
• They could then go to the nutrition clinic after their surgery clinic appointment or before (whatever was available and convenient for the family). If the family was not able to be seen by nutrition, a consultation would be arranged for the day of surgery.
• A member of care management services would receive a list of patients scheduled for GT placement and then contact the family for anticipated needs and arrange for DME services, if needed.
• Flexibility and dividing the outpatient services made the clinic appointment shorter and more convenient for the family.

Links to published data:[1]

Submitted by: Charlene Dekonenko, MD

Additional implementers: Amy L. Pierce, APRN, Beth A. Orrick, APRN,Kristen L. Sayers, APRN, Tolulope A. Oyetunji, MD MPH

Based on previous work from Seattle Childrens Hospital (SCH)[2], Nemours/Alfred I. Dupont Hospital for Children (Nemours/AIDHC) adapted a project which included a standardized preoperative work up, postoperative order sets and education to reduce utilization (emergency department revisits and readmissions). At Nemours/AIDHC, patients getting a GT have a preoperative checklist which has to be filled out prior to surgery. A key item on the checklist is the identification of a feeding tube medical home for the patient prior to tube placement (i.e. a health care provider responsible for managing feeds who can also troubleshoot simple GT-related issues like leakage and granulation tissue formation). This person is typically a primary care provider (PCP), gastroenterologist or other medical specialist and not the surgeon. Standardized ordersets for postoperative care, as well as standardized patient education and discharge instructions are used.

Protocols:

• Nemours/AIDHC GT Pathway
  • Flow chart of final pathway including Nissen pathway.

Resources:

• Nemours/AIDHC Summary of GT Presentation
  • Describes the project from top to bottom. It is used to introduce the concepts and explain how it works to all teams who are affected. Includes screenshots of EPIC ordersets.
• Nemours/AIDHC Feeding Tube Placement Readiness Checklist
• Nemours/AIDHC GT Placement Principles
  
  • Intraoperative guidelines for optimal GT placement, to be shared with surgeons, GI, IR and other performing teams.
• Nemours/AIDHC Postop GT Order Set
  
  • Components of the postoperative order set to be used for all patients having GT placement.
• Nemours/AIDHC Common GT Site Problems Presentation
  • Used to educate PCPs and other prospective GT medical homes about GT site problems.

Stakeholders:

Challenges and solutions:

Links to published data:

Submitted by: Loren Berman, MD

The University of Rochester (UoR) Golisano Children’s Hospital has an interprofessional team working to standardize GT insertion in an effort to streamline all phases of care. They developed pre- and intraoperative checklists, as well as postoperative feeding protocols, and revised their educational materials for families to make them simpler to follow. Early change ideas focused on standardizing care across the care continuum (pre-, intra-, and post-operative) for G-tube insertion with a goal of preventing dislodgement and emergency department (ED) visits. Recent changes have focused on improving outcomes of out of the hospital for children with new G-tubes. Specifically, implementing a G-tube Buddy Peer mentor program in which an experienced G-tube caregiver is paired with a parent going home with a child with a new G-tube. This is done partly to reduce disparities in outcomes related to social determinants of health.

Protocols:

• UoR Intraoperative Checklist
  • Best practices for GT cases, includes both laparoscopic and open GT checklists.
• UoR Postoperative Feeding Checklis
  • Standardized feeding pathways to facilitate floor, step-down, and ICU feeding based on patient risk category (i.e. low vs. high risk)

Resources:

• UoR Preoperative Consult Checklist
  
  • Disseminated to referring services for the proper workup of children suspected of requiring a GT in the future.
  • UoR Epic Consult Checklist
    
    • Note: Upper GI previously requested to be performed for all children before GT placement, but now this study is omitted in select patients.
  • UoR GT Consult Epic Template
• UoR Nursing Assessment and Education
  
  • Bedside nursing assessment completed during routing nursing assessments of children with GT (typically every shift/q8hrs).
• UoR Caretaker Education Pathways
  
  • Includes a checklist for ensuring preparedness for discharge after GT placement, video education for GT-related issues, and step-by-step home instructions for replacing a dislodged GT with a primary button or foley catheter in an attempt to prevent unnecessary ED visits due to dislodgment.
• UoR Feeding Tube-Related ED Visit Questionnaire
  
  • Epic template for tracking ED visits related to feeding tubes, which serves as a “Study” item in PDSA cycles, along with audits of nursing bedside assessments and tracking of GT dislodgment events within the hospital.
• UoR Team Building Resources
  • Pursuing Excellence Summary
  • Team Based Care Symposium Poster
  • Anatomy of a Team Presentation
• UoR Run Charts of GT dislodgments within 30 Days of Insertion
  • Combined Inpatient and Outpatient GT dislodgments
  • Inpatient GT dislodgments
  • Outpatient GT dislodgments
• UoR GT Buddy Program Handbook
  
  • Peer support program guide for new caregivers and families with a GT
• UoR Laparoscopic GT training video
• American College of Surgeons Case Study: Reducing gastrostomy dislodgements and ED visits after G-tube insertion; Improving health equity for children with G-tubes

Stakeholders: pediatric surgical team (MD’s and APN’s), nurses (floor, ICU, OR), families, discharge coordinators, pediatric gastroenterology, clinic staff, ED providers, quality improvement (QI) staff

Challenges and solutions:

• Challenges
  • Many of dislodgments happen in the hospital setting.
  • As the QI team grew, it became more challenging to maintain accountability across a diverse group of members with only monthly 1 hour meetings.
• Solutions
  • The UoR Team is working to educate their nursing staff about how best to secure tubes during feedings to prevent accidental dislodgment. They are also trying to physically secure extension tubing during feedings so that pulling on the tubing does not result in dislodgment.
  • Maintaining accountabiity vastly improved by creating smaller (3-6 member) subcommittees which met separately to address discrete obstacles and tasks. These smaller groups then provided follow up of their progress during the at-large monthly meetings. This also allowed individuals to gravitate to certain tasks which they were more innately capable of (e.g. surgical residents felt more comfortable analyzing readmission data than organizing a GT Awareness week, and vice versa with nursing leadership).

Links to published data: [3][4][5][6]

Submitted by: Derek Wakeman, MD

Additional implementers: Marsha Pulhamus, NP, Luis Ruffolo, MD, Peter Juviler, MD

At the University of British Columbia Children’s Hospital (BCCH), the GT/Jejunostomy Tube Home Care instructions were designed as an "all-in-one" package to assist in transitioning families from in-hospital to in-community care. The instructions include a written list of common complications after GT insertion as well as 6 unique QR codes to instruction videos describing these complications and standard troubleshooting strategies.

Protocols:

• BCCH GT/Jejunostomy Tube Home Care Instructions

Resources:

Stakeholders: surgical faculty, nurse cinician, NSQIP surgical clinical reviewer, surgical fellow, the Office for Pediatric Surgical Evaluation and Innovation

Challenges and solutions:

Links to published data:

Submitted by: Robert Baird, MSc, MDCM

Additional implementers: Al Ghalya Al Maawali, MD, Christine Adamson, RN, Carmina Gogal, (NSQIP SCR)

Postoperative Gastrostomy Tube Feeding Regimens

At Texas Children’s Hospital (TCH), a standardized postoperative feeding regimen after elective GT placement was instituted for patients who have been receiving nasogastric feeds at home. The protocol promotes early consultation of inpatient dietician/nutrition services and a feeding regimen which begins four hours postoperatively. An order set based on this protocol was developed. This project is part of a larger effort led by a Multidisciplinary Outcomes Improvement Team that has been appointed to optimize clinical care, length of stay, patient education and resources for GT patients.

Protocol:

• TCH Clinical Algorithm for GT Postoperative Feeding Pathway

Resources:

• TCH Post Pediatric GT Orders
• TCH Evidence-Based Outcomes Center Postoperative GT Management Literature Appraisal
• TCH Postoperative GT Balloon Button (Parent Education Sheet)
• TCH GT Education Survey

Stakeholders: pediatric hospital medicine physicians, gastroenterologists, surgeons, nursing staff, nutrition services, social services, quality/outcomes leadership

Challenges and solutions:

• Challenge:
  • There was some difficulty in reaching consensus regarding who would be eligible patients (inpatient, neonatal, outpatient), as well as the actual timing of reinitiation of feeds.
• Solution:
  • These issues were addressed by engaging all relevant providers, reviewing data and existing evidence, as well as planning ongoing monitoring of outcomes and broadening of this pilot intervention.

Links to published data:

Submitted by: Sohail Shah, MD

Gastrostomy Tube Dislodgement

Rush University Medical Center (RUMC) implemented a postoperative GT tube placement standardized teaching session/discharge instruction protocol and examined its effect on postoperative hospital utilization. The teaching session/discharge instruction protocol consisted of a 30-minute teaching session detailing how to care for the GT tube, how to manage common complications, a practice session for providers, a written handout of the instructions as well as details of the tube placed and follow-up. Ideally, the session took place on the day of discharge. The intervention resulted in reduced postoperative unplanned office visits and ED visits.

Protocols:

• RUMC GT Tube Protocol
  • A trained advanced practice provider (APP) spends ~30-minute in a teaching session with the patient (when appropriate) and caregivers as close to the day of discharge as possible. A discussion takes place detailing:
    • How to use the GT (feeding, medication administration, flushing, care of g-tube site)
    • How to manage common problems (dislodgment, leakage, erythema, granulation tissue) and what to do when they occur.
    • How to vent and replace the GT practice session (using an inanimate doll with a GT)
    • Provides written instructions with details and answers questions
    • Discusses follow-up and provides written specifications of GT, surgery performed, surgeon who performed it, and follow-up date

Resources:

• RUMC GT Tube Handout (English)
• RUMC GT Tube Handout (Spanish)

Stakeholders: patients, families, surgery APPs, surgery residents, surgeons, referring Service

Challenges:

• Ensuring protocol and instructions were followed.
• Having trained available providers. The biggest hurdle occurs when patients are discharged on weekends, when our APPs are not in the hospital.

Solutions:

• Inpatient service checking EMR prior to discharge that a note by the surgery APP is on file (we recommend this being an Epic notification requiring that the team check), if not, paging the surgical service for teaching.
• The admitting team should ensure the surgery service has provided teaching prior to the weekend, which requires foresight and coordination with the surgery service.

Links to published data:

Submitted by: Ami Shah, MD

Additional implementers: Rona Tiglao, General Surgery RN

Emergency room visits for GT-related complications are common and many are related to GT displacement. Evidence-based practices including staff and provider education along with an established algorithm regarding GT displacement can improve care. At Ann & Robert H. Lurie Children’s Hospital (LCH) a displaced GT evidence-based algorithm was implemented in the Pediatric Emergency Department to improve documentation, decrease use of contrast studies, and increase referrrals to the GT specialty clinic.

Protocols:

• LCH GT Tube Displacement Algorithm

Resources:

• LCH GT Tube Skills Assessment

Stakeholders: APPs, physicians and staff nurses

Challenge:

• Small convenience sample in pediatric ED at a community hospital, patients identified by triage nursing as a “GI Problem”

Solution:

• Provider education and algorithm to improve care.

Links to published data:[7]

Submitted by: Sandra Weszelits, APN

Additional implementers: Guillermo Ares, MD

Recent Research

For recent research pertaining to the management of patients with GT tubes, please refer to the following references:[8][9][10][11][12][13][14][15][16][17][18][19][20]

Toolkit Curators

Derek Wakeman, MD, Begum Akay, MD

Migration Editors

Raquel González, MD MHCM, Andrew Mudreac, MD, Kristen Kaiser, MD

References

Media

SCH Patient Checklist/Timeline (InsideOut Platform)

UoR Surgical G-tube Dislodgement Run Chart

UoR Inpatient Run Chart

UoR Outpatient Run Chart

Lurie Children’s Gastrostomy Tube Skills Assessment