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 of the management of patients requiring enteral access - specifically gastrostomy tubes.

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.

video link Enteral access systematic review from the APSA 2020 virtual meeting

Gastrostomy Preparation

Seattle Children’s Hospital

Seattle Children’s implemented a patient facing checklist of requirements for gastrostomy tube (GT) preparation. This approach give families visibility into clinic prep activities, allows them to plan and participate in their child’s care and helps them partner with their surgeons and medical providers appropriately.

Resources

• scheduling script
• patient checklist screenshot

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

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

Submitted by Adam Goldin

Additional implementers: Linda Bruhns

University of Iowa Stead Family Children’s Hospital

The primary goal of the feeding tube/gastrostomy tube pathway was to streamline the work up and treatment of children with feeding difficulties. Additionally we aimed to reduce variability, improve interservice coordination and promote good care of children who are unable to eat. The project is a collaboration between surgery, gastroenterology, speech and nutrition services.
The initial step is a pathway to direct patient care.

Protocol

• gastrostomy pathway

Stakeholders: surgery, gastroenterology

Challenges and solutions: The challenge we faced was substantial variation at every step from the indications for GT placement, surgical approach, postprocedure treatment, follow-up and management of complications. This resulted in poor resource utilization and, at times, suboptimal care. The 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 early phases of application.

Submitted by Joel Shilyansky

Perioperative Gastrostomy Management

Nemours

Nemours adapted a project based on a protocol implemented at Seattle Childrens [1] which included a standardized preoperative work up, postoperative ordersets and education to reduce utilization (emergency department revisits and readmissions). All patients getting a gastrostomy (GT) have a preoperative checklist which has to be filled out prior to surgery. A key item on the checklist is to identify 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 leak and granulation tissue). This person is typically a primary care practitioner (PCP), gastroenterologist or other medical specialist and not the surgeon. We use standardized ordersets for postoperative care and have standardized patient education and discharge instructions.

Protocol

• Standardized clinical work GT presentation describes the project from top to bottom and is used to introduce the concepts and explain how it works to all teams who are affected. Includes screen shots of EPIC ordersets.
• Nissen pathway. Flow chart describing work up to guide decision making around concurrent fundoplication with GT placement.

Resources

• pre-GT checklist
• Common GT site problems presentation used to educate PCPs and other prospective GT medical homes about GT site problems.
• Intraoperative placement principle guidelines for optimal GT placement to be shared with surgeons, gastroenterology, interventional radiology and whoever is performing GT placement.
• GT postoperative order set. Word document with the components of the postoperative orderset to be used for all patients having GT placement

Submitted by Loren Berman

Postoperative Gastrostomy Feeding

Texas Children’s Hospital

TCH standardized the postoperative feeding regimen after elective gastrostomy tube placement in patients who have been receiving nasogastric feeds at home. The protocol promotes early consultation of inpatient dietician/nutrition services and a feeding regimen which begin four hours postoperartively. An order set was developed.

Protocol

• standardized postoperative feeding algorithm

Resources

• parent education sheet
• education survey
• literature appraisal
• postoperative order set

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

Challenges and solutions: 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 gastrostomy tube patients. 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. 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.

Submitted by Sohail Shah

Reducing Gastrostomy Dislodgement

University of Rochester Golisano Children’s Hospital

The University of Rochester has an interprofessional team working to standardize gastrostomy insertion with a goal of preventing dislodgement and emergency department visits iun an effort to streamline all phases of care. They developed pre- and intraoperative checklists and revised their educational materials for families to make them simpler to follow.

Protocol

• intraoperative checklist

Resources

• consult checklist

Stakeholders: pediatric surgical team, nurses (floor, intensive care unit, operating room), families, discharge coordinators, gastroenterology, clinic staff, emergency department providers, quality improvement staff

Challenges and solutions: Preventing GT dislodgement remains challenging. Many of our dislodgements happen in the hospital setting. We are working to educate our nursing staff about how best to secure tubes during feedings to prevent accidental dislodgement. We are also trying to physically secure extension tubing during feedings so that pulling on the tubing does not result in dislodgement.

Submitted by Derek Wakeman

Additional implementers: Marsha Pulhamus, Theresa Foito

References

Media

Seattle patient checklist