Pediatric surgeons and gastroenterologists collaborate with outpatient community services to streamline outpatient gastrostomy tube placement

Gastrostomy tube (G-tube) placement is often a crucial component in a medically complex child’s care and one of the more common procedures performed at children’s hospitals; however, approaches to patient counseling and postoperative management for this procedure varies. Families often agonize over the decision and worry about their ability to care for their child after the tube is placed. Complications, such as early dislodgement, result in emergency department (ED) visits and potential readmissions, and lengths of stay (LOS) and feeding advancements vary between different centers and different providers.*

All these factors affect quality of care, patient and caregiver satisfaction, and health care costs. It has been shown that a standardized pathway for feeding tube placement can result in significant reduction in postoperative LOS and fewer ED visits.^† Appropriate preoperative family education is necessary to understand the procedure, but perhaps more importantly, to prepare them for what to expect once their child has a G-tube. Skills videos, including the American College of Surgeons’ (ACS) Feeding Tube Home Skills Program for caregiver education can be an easily accessed and is an efficient tool to help improve confidence levels, particularly for families with low literacy levels.^‡

G-tube referrals at Mary Bridge Children’s Hospital, MultiCare Health Systems, Tacoma, WA, before the intervention described in this article were a point of frustration for caregivers, providers, and the nursing staff. We experienced confusion on the part of caregivers, missing or incomplete preoperative work-up or education, delays in scheduling, conflicting instructions on postoperative feeding plans, and frequent ED visits resulting from dislodgement, feeding intolerance, and conflicting patient education.

There was wide variation among surgeons on postoperative feeding advancements and LOS, particularly on the weekends because of lack of coordination with home health services. The cost of in-person teaching by our pediatric gastroenterology (GI) clinic nursing team was becoming unmanageable and created an additional office visit and cost for families and caregivers. Early in our participation in ACS National Surgical Quality Improvement Program-Pediatric (ACS NSQIP^®-P), we learned through discussion with other centers that our LOS was longer than at other comparable hospitals.

Initiating the QI activity

Mary Bridge Children’s Hospital is a community-based, 82-bed, Level II trauma center pediatric hospital that is part of a larger, 1,802-bed, integrated health system located in the Pacific Northwest. With more than 30 pediatric specialties, our hospital and its network of primary care, specialty care, therapy, and urgent care visits serve more than 330,000 children each year. The Leapfrog Group named Mary Bridge Children’s Hospital one of the “Top Children’s Hospitals” in 2018 and 2019.

Patients requiring outpatient G-tube placements were noted to have wide variations in pre-consultation education, family preparedness, and completion of necessary diagnostic procedures, which resulted in longer clinic visits and delays in surgical scheduling. This situation led to family and provider dissatisfaction. In addition, variation was noted among the pediatric surgeons regarding postoperative education, feeding plans, and LOS. Having previously completed a successful quality improvement (QI) effort to standardize appendectomy care with improved patient satisfaction and LOS, the pediatric surgeons turned their attention to outpatient G-tube placements as their next area of focus.

Pediatric surgery teamed with another key stakeholder, pediatric GI, to decrease costs within the clinic, the number of unnecessary patient visits, and returns to the ED. The pediatric surgeons and pediatric gastroenterologists formed a task force to analyze the state of outpatient G-tube placements. Multidisciplinary teams of physicians, advanced practice providers (APPs), nursing staff, clinic medical assistants, and registered dietitians were developed to review steps in the process and to identify potential areas of improvement. The NSQIP-P Surgical Champion served as project manager, leading the task force.

The task force determined that QI opportunities spanned the entire process—from the initial pediatric GI consultation visit generating the referral to pediatric surgery through the postoperative pediatric surgery clinic visits. The multidisciplinary teams began working the improvements into their respective process pieces.

Implementing the QI activity

Several process pieces were identified as primary areas of focus: preoperative referrals and scheduling, patient education, and postoperative management.

Two areas of focus with regard to preoperative referrals and scheduling included the GI clinic referral process and clinic scheduling and the preoperative visit. The GI clinic referral process consisted of a pediatric gastroenterologist, pediatric surgeon, surgery clinic registered nurse, and GI clinic registered nurse. This team developed best practices for referrals and coordination between clinics, including the completion of a fluoroscopic upper GI series before being seen in the surgery clinic.

The surgery clinic scheduling and preoperative visit team was composed of a pediatric surgeon, surgery clinic registered nurse, and surgery clinic medical assistant. This team developed a standardized case request for surgery scheduling and a process for operations to be scheduled before clinic discharge, including postoperative two- and six-week follow-up visits.

Patient education centered on development of a standardized G-tube education video. The task force created a patient education video for caregivers to view at home preoperatively. The video was developed by Mary Bridge Community Services, a pediatric gastroenterology provider, a pediatric surgeon and APP, and nursing staff from both the GI and surgery clinics. A pediatric surgeon and the nursing staff from both clinics provided the on-camera education. Several families also shared their stories. The video was made available online or as a disc checked out from the clinic. The video is now available in English and Spanish.

In addition to the video, caregiver education handouts and a post-test were created to ensure comprehension of the materials. The posttest is used to identify families that need additional education, which the GI clinic nursing team provides either by phone or in the clinic.

We also provided bedside nursing education. A G-tube “Pathway to Home” flyer was created to educate inpatient nursing staff on postoperative and discharge teaching for caregivers (see Figure 1). Surgery clinic APPs conduct classes during the annual surgery super user pediatric surgical skills nursing program and in the registered nurse residency program.

Surgery clinic APPs developed standardized discharge instructions. Handouts and an electronic health record (EHR) smart phrase were created for gastrostomy care discharge instructions, which included information on site care, looping and taping of the extension tubing, bathing instructions, and feeding instructions for the first postoperative week.

To improve postoperative management, a pediatric surgeon and surgical advanced registered nurse practitioner developed a standardized order set, which included site care, preoperative antibiotics, feeding advancement with early resumption of feeds, social work and case management referrals, and registered dietitian consultation. Pediatric GI and a registered dietitian created post-placement feeding recommendations and goals for the immediate postoperative nutritional plan. A hydration goal was established for discharge, along with a nutritive goal to be achieved within one to two weeks postoperatively.

Pediatric surgeons developed standardized discharge criteria, which included the following:

• Afebrile <100.5o
• Pain well controlled:

-Typically obtained with acetaminophen and ibuprofen

-Minimize discharge with oxycodone

• Tolerating feeds at hydration goal
• Ambulating at baseline function
• Caregiver completion of the “Pathway to Home” with demonstration of skills competency and comfort with tube care

During the QI process, some team members began implementing pieces as they were developed in 2016 and 2017. All of the improvements were officially implemented in 2018.

Resources used and skills needed

This project involved six pediatric surgeons, two pediatric gastroenterologists, one registered dietitian, five APPs, four clinic registered nurses, two medical assistants, and two members of our community services health promotion team, as well as a contracted producer for the video. Because of the comprehensiveness of this project, each component was assigned to members of the surgery and GI teams to dedicate focus on that segment.

The only additional cost accrued was associated with the video production. The outside contractor cost $5,000. Translation of the video into Spanish was an additional $2,500. We received a personal grant of $5,000 from Amin Tjota, MD, PhD, and a $2,500 grant from the Mary Bridge Brigade, our philanthropic foundation.

Results

All outpatient G-tubes placed in 2018 were reviewed. Exclusions were applied to patients who were in the neonatal intensive care unit, inpatient consultations, concurrent procedures, postoperative admission to nonsurgical services (such as inpatient medical services and pediatric intensive care unit [PICU]), and patients who were not referred via Mary Bridge pediatric gastroenterology. We used a combination of chart review, automated dashboards through our EHR, and caregiver surveys to review the QI implementation.

Initially, the task force set a goal of 85 percent completion of the upper GI before the surgical clinic visit. In 2018, we were able to obtain a 100 percent compliance with this measure. In 2019 and 2020, we have maintained 100 percent compliance with this measure (see Figure 2).

Initially, the task force set a goal of 85 percent compliance with using the standardized postoperative order set. In 2018, we exceeded our initial goal and obtained 96 percent compliance with usage of the order set.

Average LOS in 2015 was 70.88 hours. In 2016, because of the soft implementation of some improvement activities, we dropped the average LOS to 49.17 hours. In 2018, we noted our average LOS to be 39.3 hours, which was a 44 percent reduction from our 2015 data. This exceeded our goal of a 30 percent decrease. In 2019 and 2020, LOS has remained consistently below our initial goal of 39.4 and 40.1 hours, respectively (see Figure 3).

Caregivers were queried through a postoperative survey completed at the final surgery clinic visit or by phone; 80 percent of caregivers reported feeling “comfortable” or “very comfortable” with caring for their child’s G-tube at time of discharge. This exceeded our goal of 75 percent.

Prior to the implementation of the new education video and process, the cost of G-tube teaching by an RN was $11,592 per year. By implementing the video, the estimated cost savings over a five-year period is $52,460.

Setbacks

One delay in implementation occurred in the construction of the standardized postoperative G-tube order set in the EHR. The provider team achieved consensus on its design quickly using our postoperative appendectomy order set as a model but was delayed because of demands created by a systemwide EHR upgrade. As a result, the order set was not available until almost two months into our implementation phase. In the interim, the ordering providers used the appendectomy order set, adding in the specific G-tube care and feeding advancement instructions manually. This setback has been resolved for future projects by planning EHR builds far in advance.

Turnover in both our quality and information technology teams created barriers to our ability to review compliance with the protocols and identify cases for review via the EHR, resulting in manual chart reviews. Surgeons were required to complete a form at the time of the initial consultation to identify the patient for inclusion in the data collection. We are now using ACS NSQIP-P for our G-tube abstraction, granting us concurrent access to the data.

We had significant contamination of our baseline data because some providers implemented various aspects of the protocol upon approval by the task force, rather than waiting for the implementation phase. As a result, we decided to use 2015 as our baseline.

A benefit of this staged introduction is that it allowed the providers, nursing staff, and care teams to adjust in smaller increments and made the unveiling of the new process less intimidating. The providers’ engagement in the process was further encouraged as we saw LOS gradually decrease with the addition of each new component.

Lastly, at the time of our implementation, several of our GI providers relocated, resulting in long referral delays, and several patients who would have been outpatient referrals became inpatient referrals. These patients were excluded from the evaluation, but as we educated referring providers, these patients received the same preoperative education and postoperative management when possible. As understanding grew among other services of our protocol, the frequency of gastroenterology consultation prior to surgical consultation increased.

Tips for others

We began this project using the lessons learned during our past experience with postoperative appendectomy pathways. Our guiding principle was making the process easier and more efficient for the families. Education beginning at the first encounter with consistent messaging was important. The video allowed families to do the education in their own homes at their own pace, resulting in improved retention. Having involved members of the team collaborate on each phase helped build a sustainable plan. Standardized order sets were helpful to ensure compliance with the protocol as well as give a short-term metric to follow, providing more immediate feedback to providers. Empowering the nurses to teach the skills with hands-on teaching sessions and easy-to-use tools increased buy-in.

Our keys to sustaining the improvements were frequent feedback, particularly sharing the results in reduction of LOS periodically during the implementation period. The standardized order set made it easier to follow the protocol than to deviate from it. Caregivers frequently reported that the process was much easier than they thought it would be, which reinforced the care teams’ desire to continue. This feedback was shared back with the involved providers.

Other tips and considerations are as follows:

• The ACS has a video for pediatric gastrostomy education, which could be used to avoid the video production costs. We intended to create one that more closely mimicked the teaching done in our hands-on G-tube class. We also included several families with G-tubes describing their experiences, which families reported was helpful.
• The post-video quiz enabled us to identify families who needed additional clarification/education. Depending on the knowledge gaps, this education was done either over the phone or at an in-person visit.
• While our initial post G-tube feeding advancement plan was moderate (six hours nothing by mouth, six hours Pedialyte continuous, then formula advancement, either continuous or bolus, achieving hydration goal within 24 hours), we migrated to more aggressive advancement as the team members became more comfortable.

Acknowledgments

The following individuals served on the task force that developed the G-tube protocol described in this column. Pediatric gastroenterology team members included Melawati Yuwono, MD; Rohit Gupta, MD; Lisa Philichi, ARNP; Rebecca Miller, RN; and Jennelle McClaughry, RN. Pediatric surgery team members included Mauricio A. (Tony) Escobar, Jr., MD, FACS; Randall M. Holland, MD, FACS; Meade Barlow, MD, FACS; Elizabeth Berdan, MD; Oliver Lao, MD, MPH, FACS; Marta Todd-Hashagen, ARNP; Kate Osborne, PA-C; Maria Lutes, ARNP; Jessica Works, ARNP; Abigail Schneidmiller, ARNP; Shannon Smith-Foreman, RN; and Lindsay Kain, MA. Pediatric nutrition services staff included Phuong Tran, RD, and community services team members included Erin Summa and Peggy Norman.

*Goldin AB, Heiss KF, Hall M et al. Emergency department visits and readmissions among children after gastrostomy tube placement. J Pediatr. 2016;174:139-145.

^†Devin CL, Linden AF, Sagalow E, et al. Standardized pathway for feeding tube placement reduces unnecessary surgery and improves value of care. J Pediatr Surg. 2020;55(6):1013-1022.

^‡Grady M. Moving beyond written reinforcement: Using video skill clips to reinforce pediatric patient education and increase caregiver confidence. Int J Nurs Clin Pract. 2018:5(1):287.