Adapting to Hospital Culture and Resources: Development and Implementation of a Pediatric Gastrostomy Tube Medical Home Program

General Information 

Institution Name: Lehigh Valley Reilly Children’s Hospital, Lehigh Valley Health Network

Submitter Names and Titles: Heather Geist, MD; Adam Paul, DO; and Marybeth Browne, MD, MS, FAAP, FACS

Name of the Case Study: Adapting to Hospital Culture and Resources: Development and Implementation of a Pediatric Gastrostomy Tube Medical Home Program

What Was Done? 

Global Problem Addressed 

Pediatric gastrostomy tube (GT) placement is often required in medically complex pediatric patients with multiple co-morbidities. It is approximated within six months of GT placement, 25 percent experience a major or minor complication leading to increased usage of health care resources, as well as additional procedures.^1,2 An associated high rate of emergency department (ED) visits and hospital readmissions within the 30-day postoperative period have also been noted in larger studies.³ The medical home concept has been published as a program used to help successfully coordinate the multispecialty care of patients with complex medical conditions and improve outcomes.^4,5

Identification of Local Problem 

Prior to implementation, there was no clear preoperative or operative care plan for pediatric patients with GTs or new patients requiring GTs at our institution. This lack of continuity and standardization led to short- and long-term complications and care inconsistencies. Utilizing resources from an established program at a free-standing children’s hospital, this quality initiative was aimed at adapting the GT medical home concept at a children’s hospital within a health care network to evaluate changes in length of stay (LOS), complications, readmissions, and ED visits after GT placement.

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

Lehigh Valley Health Network (LVHN) is a large health network located in Northeastern Pennsylvania consisting of eight campuses and more than 1,800 acute-care beds. Lehigh Valley Reilly Children’s Hospital is a children’s hospital within a hospital located at the largest campus in Allentown, PA. It is the region’s only children’s hospital with 100 acute care beds, a Level IV NICU, a children’s emergency room, and PICU. There are more than 30 different pediatric specialties and pediatric and surgical residencies.

Planning and Development Process 

The lack of continuity of care was identified in early 2015 with the arrival of new pediatric surgeons. We learned about the GT medical home process developed at Seattle Children’s through presentations at the American Pediatric Surgeons Association (APSA) in May 2015. Aspects of their process was shared with our team and reviewed in detail. We identified resources that were vital to the success of their program, resources that were not always readily available in our smaller center, and cultural differences that may be an obstacle to our success. The pediatric surgery division was determined the “quarterback” of this quality initiative because of their standing involvement in the GT process, as well as their willingness to facilitate the coordination with other involved team members. Key stakeholders at Lehigh Valley Reilly were identified within pediatric gastroenterology, pediatric nutrition, inpatient pediatrics, neonatology, and nursing. The local pediatric rehabilitation facility was also included in the planning due to their large feeding program and referrals for GT placement. Individuals within involved departments were selected based on their existing association with pediatric patients requiring GTs. Prior to the GT program development, individuals were interviewed in regards to their current understanding of their role in the GT process, how they envision their potential role in a modified GT medical home program at LVHN, and any important questions or considerations they have prior to its development. Throughout the development process, key planning meetings were coordinated and held between the stakeholders to agree upon and modify processes prior to implementation.

Both inpatient and outpatient process maps were developed and modified in conjunction with medical documents and checklists. All involved members of the project were given the materials and provided any feedback for possible modification. The project was shared at our institution’s monthly pediatric research meeting in July 2016.

Description of the Quality Improvement Activity 

In preparation for the project implementation, various elements were created by the team. A gastrostomy tube placement checklist was developed to ensure patients had completed their visits with GI, developed feeding plans, completed an NG trial, and had a medical team/support in place prior to surgery consult for GT placement. A medical plan form was also developed, and it contained components of admission information, nursing care, nutrition plans, social work, surgery, and upcoming appointments to assist families and the medical team in coordination of care. Both inpatient and outpatient process maps were developed and approved by key members. These maps addressed the evaluation process prior to GT placement, the operative pathway, post-operative follow up, and the removal process. These essential planning documents were uploaded onto a network-wide drive for full access and utilization by providers. They were integrated into the electronic medical record system as needed.

The pediatric surgery division agreed upon all preoperative and postoperative orders to be placed for patients receiving GTs to ensure consistency. The information sheets were compiled for patients and the GT medical team and assembled into packets for distribution upon initial surgery appointment or inpatient consult. A GT education packet was also developed for families focusing on understanding terminology, what they need to know before surgery, who they should call after surgery and when, wound care, feeding and medication administration guidance, and troubleshooting their GT.

Coordination was put in place between pediatric surgery and GI to assist in scheduling same-day appointments when possible after initial evaluation. The pediatric GI dietician assumed responsibility for all feeding plans and nutritional orders. Pediatric nursing staff was educated by the pediatric surgery clinical coordinator in regards to educational components and pathways and neonatology nursing was educated by the neonatology nurse practitioner involved in the planning and development of the program. 

Resources Used and Skills Needed

Staff 

This project required a total of 12 members from various pediatric specialty departments, including pediatric surgery, pediatric GI, neonatology, inpatient pediatrics, pediatric rehabilitation, and nursing. 

Costs 

The only direct additional cost required during the implementation were the costs for the parental educational material. 

What Were the Results?

Overall Results 

Utilizing our American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) database and conducting a retrospective chart review, a total of 77 patients were identified as having GT placement during the period of interest (01/2015–07/2018). Five patients were excluded from analysis due to factors affecting accurate data collection and representation.

As a result, 72 total patients were included in this study. Of these patients, 26 were in the pre-implementation group (prior to 09/2016) and 46 were in the post-implementation group (after 09/2016). The patients were divided into two cohorts and evaluated based on admission type (inpatient/outpatient).

Prior to implementation in the outpatient cohort, LOS was greater than two days. This was decreased to an average of 1.29 days with the GT medical home. Postoperative complications and readmissions were also reduced (Table 1). The two main complications noted were cellulitis and GT dislodgement in the 30-day post-operative period. GT-related ED visits increased after implementation from 10.5 to 17.6 percent. Four of the six GT-related ED visits after implementation were due to GT dislodgement. Compliance to the pathway was evaluated based on chart review and documentation of completed components of the process maps developed. Patients coming from the local pediatric rehabilitation facility did not have to see GI prior to surgical consultation. This adjustment was made due to the availability of GI appointments and the pediatric rehabilitation facilities involvement in development of the GT medical home. The pathway compliance was 82.4 percent of outpatient cases.

Inpatient LOS was decreased from 16.6 days to 11 days on average, with many patients having prolonged NICU stays after placement. Postoperative complications, readmissions, and GT related ED visits were all decreased in this cohort (Table 1). The preoperative pathway was followed in 58.3 percent of cases.

Throughout the period of interest, an increase in surgical volume was noted after medical home implementation, with an increase from 0.72 GTs/month in 2015 to 2.4 GTs/month in 2018.

Setbacks

A process obstacle that was identified pre-implementation was a delay in access to our pediatric GI and nutrition outpatient office. Because of this, we did determine that referrals from the pediatric rehabilitation center could bypass the GI/nutrition consultation if they were able to complete the medical home checklist with their nutritionist and social worker. For other patients, the pediatric GI/nutrition office made preoperative GT patients a priority and scheduled their appointments within two weeks.

A cultural obstacle that was identified preoperatively was that most inpatient referrals historically went directly to pediatric surgery for placement. With bypassing GI, we were concerned that this would delay discharge and outpatient follow-up. The pediatric hospitalist and intensivists were educated on the pathway, but this part of the pathway was not always followed.

One additional obstacle that was not predicted prior was the resistance of many parents to the NG trial prior to GT placement for older children. Despite the GI and surgery divisions agreeing that this step was vital to success in the majority of patients, some parents refused and the GT was placed without trial.

An increase in emergency room (ER) visits was not a predictable outcome for this quality improvement project. Cellulitis and GT dislodgement were the main reasons for ED visits. The incidence of cellulitis temporarily increased due to change in procedure type from PEG to laparoscopic. This has only occurred twice since the first year of implementation. We recognize the rate of GT dislodgement to be too high and it is now a main point of our parental education. We had no children who required reoperation for placement.

Cost Savings

Cost savings were not measured as an outcome in this quality initiative. Additional review and studies need to be conducted to evaluate possible cost savings due to decreased length of stay, improved complication rates, and other measured quality outcomes. This may be difficult due to the increased GT volume seen in the institution over the study period.

Tips for Others 

Getting Started

In consideration of development of this project, the team recognized the success of another institution’s pathways and utilized existing resources to begin planning. Though these resources were a vital template, it is necessary to identify your own institution’s weaknesses, possible obstacles, and workflow culture. It was important to the success of the project to meet with those already involved in the pediatric GT process at our institution and understand their perspective and role. With a greater understanding of our own institution’s culture and resources, we were able to develop a successful quality improvement project.

This also helped to create buy-in from key stakeholders, as their thoughts and opinions were woven into the project’s creation.

Sustaining 

In order to sustain this success, we continue to share the GT medical home between pediatric GI and nutrition and pediatric surgery. Our roles are clearly delineated, the checklist is followed, and staff education is preformed yearly. We continue to grow our parental education component of the project. 

References

1. Franken J, Mauritz FA, Suksamanapun N, et al. Efficacy and adverse events of laparoscopic gastrostomy placement in children: results of a large cohort study. Surg Endosc. 2015;29:1545-1552. doi:10.1007/s00464-014-3839-5. 
2. Mcsweeney ME, Kerr J, Jiang H, Lightdale JR. Risk factors for complications in infants and children with percutaneous endoscopic gastrostomy tubes. J Pediatr. 2015;166:1514-1519. doi:10.1016/j.jpeds.2015.03.009. 
3. 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. doi:10.1016/j.jpeds.2016.03.032. 
4. Larson IA, Hoffman A, Artman M. Maximizing Health Outcomes in a Medical Home for Children with Medical Complexity: The Beacon Program. J Pediatr. 2017;183:4-5. doi:10.1016/j.jpeds.2017.01.024. 
5. Cooley WC, McAllister JW, Sherrieb K, Kuhlthau K. Improved Outcomes Associated With Medical Home Implementation in Pediatric Primary Care. Pediatrics. 2009;124(1):358-364. doi:10.1542/peds.2008-2600.