Problem Detailing
Local Issue
Every year ~ 11,000 children undergo gastrostomy tube placement for enteral feeding access in the US. Unfortunately, nearly 10% of these children present to emergency departments (ED) within 30 days of placement due to tube dislodgement or dysfunction.
Our team was faced with a large number of children experiencing accidental G-tube dislodgement both in the hospital and at home. Accidental dislodgements have led to a considerable number of preventable ED visits and admissions, as well as avoidable contrast-imaging studies. Variations in practice, along with inconsistent education for families and staff may be contributing factors to G-tube dislodgement.
Problem Statement
Pediatric G-tubes are associated with significant healthcare utilization including ED visits and re-interventions. Query of our G-tube related ED visits showed that the majority of our G-tube related visits were due to dislodgement, a potentially preventable problem.
Further, retrospective review demonstrated that children from less advantaged homes have more healthcare resource utilization after G-tube insertion.
Aim Specification of QI Project
SMART Goal
We aimed to reduce pediatric G-tube dislodgement within the first 3 months of insertion by 25% in one year.
We aimed to reduce pediatric G-tube-related ED visits by 25% in one year.
Later, we sought to improve health equity for children with G-tubes (reduce disparities in outcomes based on race and socioeconomic status).
Strategic Planning
Description of QI Activity
In 2018, an interprofessional, multidisciplinary QI team was formed. Significant efforts were made to standardize across phases of care (preoperative, intraoperative, and postoperative).
In 2022 we developed a peer support program.
Description of Intervention
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Preoperative: We created check lists for consulting services and standardized the pre-operative workup. In most cases a preoperative upper gastrointestinal study is not needed.
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Intraoperative: Standardized processes in the OR and encouraged surgeons to adopt similar practices and streamline OR cases and supplies. A G-tube-specific intraoperative checklist was created to ensure safe surgery and placement of securement devices. We created a video to educate OR nurses and surgical trainees.
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Postoperative: We created standardized feeding pathways in partnership with ICUs to streamline feeding goals to shorten length of stay. We created discharge education pathway for families to make the process to discharge home transparent. We created two videos to fill in gaps in content. Nursing care was standardized and now being charted in the electronic medical record. Audits were routinely completed to ensure process measure compliance.
Since 2021 we have engaged with families and community partners to improve the psychosocial support structure for families of children with G-tubes. In 2022 we piloted a G-tube Peer Support Program, also known as the “Buddy” Program, that pairs an experienced G-tube caregiver with a family going home with a G-tube for the first time. Our hope was that the added psychosocial support fosters resilience in caregivers, which could translate to fewer G-tube related ED visits in the future. In the beginning, peer support was offered to families believed to be most at risk for worse outcomes. In 2023, the program was expanded for all children receiving a G-tube at our hospital. 1
Improvement Team
Stakeholders included representatives from: Pediatric General Surgery, Pediatric Gastroenterology (including nutrition clinic), hospital quality office (Quality Improvement coach, NSQIP Surgical Clinical Reviewers), Pediatric Emergency Medicine, Interventional Radiology. Roles included attending physicians; residents; undergraduate and medical students; nurses (floor, ICUs); care coordinators; social workers; Diversity, Equity, and Inclusion consultant; child caregivers.
Outcome Evaluation
Intervention Data
Since starting our quality improvement project, fewer children are experiencing G-tube dislodgement within the first 90 days of insertion.
We have seen a “shift” in the median number of patients that are presenting to the ED with G-tube related problems. The median number of ED visits for G-tube related problems per month has decreased from 9.5 to 7 after our PDSA cycles began in April 2018.
Final or Most Current Results
Following implementation of our clinical practice guideline (care bundle), we observed a 65% reduction in dislodgements per month compared to the year prior (mean dislodgement rate 30% vs. 10%, P=0.04). This finding was driven by a statistically significant reduction in early dislodgement occurring in the in-patient setting (Mean dislodgement rate 12% vs. 2%, P=0.032). In the out-patient setting, we observed no significant change in the rate of early dislodgments (Mean dislodgment rate 19% vs. 11%, P=0.35).2
Further, we have found disparities in outcomes after G-tube insertion related to social determinants of health. Specifically, children from less advantaged neighborhoods (based on Area Deprivation of their neighborhood) are more likely to present to the ED multiple times after G-tube placement. Much of these disparities were mitigated after starting our improvement work and standardizing care.3
Limitations/Setback
While the number of outpatient G-tube dislodgments and G-tube-related ED visits has decreased to some degree, the improvement has been less than we had hoped. Since 2022, our improvement team has shifted our focus to better understanding what life is like outside the hospital for these families.
Unintended Consequences
Though it was not the primary intent of the quality improvement effort, we observed a trend towards shorter length of stay over these two time periods (mean LOS 11.6 days vs. 6.4, P=0.076; Figure 2). In addition, since we have been engaged in G-tube improvement work, our hospital has intentionally shifted toward sending more neonates home with feeding nasogastric tubes (NG). Our early experience suggests that most children sent home with NG tubes mature and never require a G-tube. As such, most of our G-tubes placed now (2024) are in children coming in from home (when we began this work 80% of the G-tubes we placed were in children already admitted to the hospital). Now, when children need G-tubes, we have more time to plan and the caregivers are more prepared.
Cost, Resources, and Value Evaluation
Cost of Project
There were no direct costs for the initial phases of the project (2018-2022). The improvement team were all employed by the hospital and worked the improvement efforts into their daily roles. Time was volunteered. Ultimately, caregivers of children with G-tubes joined the improvement team as volunteers. In 2021 we received 2 x ~ $10,000 awards from the University of Rochester and Vermont Oxford Network to develop the G-tube Peer Support Project. In 2023 we received $100,000 of internal funding over two years to further develop the Peer Support Project. At this point, the G-tube Buddy program’s main expenses are paying a program coordinator (15-20 hours per month).
Team and Stakeholders' Perspective on Value
The G-tube QI project has been well received by the team and hospital administration. The team continues to meet monthly and donate our time to improve the care for children and their families because we believe the program adds value. The improvements in dislodgement and healthcare utilization motivate us to continue our work. The team has been recognized by hospital leadership. Our G-tube Buddy program participants (mentors and mentees) consistently provide feedback that the program is helpful.
Resources Used
The award is used to pay for FTE support for program coordinators (15-20 hours per month), a Diversity, Equity, and Inclusion consultant, surgical resident, and medical student support. The award also funds mentor focus groups and periodic ways to show our thanks to program mentors for their time.
Knowledge Acquisition
Key Takeaways
The improvement in in-patient dislodgement and concomitant trend towards reduction in length-of-stay are likely borne from care standardization, engagement of discharge coordinators, and improved education of unit nurses centered around G-tube care during focused awareness initiatives. Family engagement is key to understanding issues these families face outside the hospital, so that meaningful improvement efforts can be designed with their needs in mind. For instance, we have learned that nearly all G-tube dislodgements occur when the extension tubing is connected to the G-tube and the child is feeding. We now emphasize disconnecting the extension tubing when the child is not feeding and being especially careful when moving a child during a feeding. Ultimately, the G-tube Peer Support program grew out of this improved awareness. Stakeholder involvement, including patients/families/caregivers is key to understanding the challenges these families encounter in maintaining the tube, so that we can develop effective solutions to their problems. More information about our intervention can be found on the American Pediatric Surgical Association’s Quality and Safety Toolkit.
Problems Encountered
As the quality improvement team grew, it became more challenging to maintain accountability across a diverse group of members with only monthly 1-hour meetings. This was improved by creating smaller (3-6 member) subcommittees which tackled discrete obstacles and tasks. These subcommittees would then meet “offline” and provide follow-up of their progress during the at-large monthly meetings. Interestingly, this also allowed individuals to gravitate to certain tasks which they were more innately capable of (for example surgical residents felt more comfortable analyzing readmission data than organizing a G-tube Awareness week, and vice versa with nursing leadership).
After starting the G-tube Peer Support Group, it became challenging to stay organized. Multiple different providers were doing different program-related administrative tasks to decrease the burden on any one provider. Unfortunately, this system creates some confusion. Hiring program coordinators has helped streamline the program. More children are enrolled in a timely fashion and more work gets done between meetings due to improved transparency and accountability.
End-of-Project Decision-Making
Future Actions
Our team continues our efforts to improve care for children with G-tubes. We are working to make our G-tube Peer Support program more sustainable. We are interested in working with other hospitals who are interested in quality improvement after gastrostomy insertion and/or developing a peer support program of their own.
Post-Project Plan
We are considering broadening our Peer Support Program to children and their caregivers discharge home with feeding NG tubes. In this way, we hope to engage these families earlier to further improve the G-tube community.
