Streamlining Outpatient Gastrostomy Tube Placement: A Collaboration between Pediatric General Surgery, Pediatric Gastroenterology, and Outpatient Community Services

General Information

Institution Name: Mary Bridge Children’s Hospital, MultiCare Health Systems

Primary Author & Title: Stephanie Acierno, MD, Pediatric Surgeon and ACS NSQIP Pediatric Surgical Champion, and Kate Callaham RN, BSN, Quality Outcomes Project Manager and ACS NSQIP Pediatric SCR

Co-Authors & Titles:

Pediatric Gastroenterology—Melawati Yuwono, MD; Rohit Gupta, MD; Lisa Philichi, ARNP; Rebecca Miller, RN; and Jennelle McClaughry, RN 

Pediatric Surgery—Mauricio A. (Tony) Escobar, Jr., MD; Randall Holland, MD; Meade Barlow, MD; Elizabeth Berdan, MD; Oliver Lao, MD; 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—Phuong Tran, RD 

Mary Bridge Community Services—Erin Summa and Peggy Norman 

Name of the Case Study:Streamlining Outpatient Gastrostomy Tube Placement: A Collaboration between Pediatric General Surgery, Pediatric Gastroenterology, and Outpatient Community Services

What Was Done?

Global Problem Addressed

Gastrostomy tube (colloquially referred to as “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, but there often exists no uniform approach to patient counseling and postoperative management.

Families often agonize about 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. Lengths of stay (LOS) and feeding advancements vary between different centers and different providers.¹ All these factors impact 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 length of stay postoperatively and decreased ED visits.² Appropriate preoperative family education is necessary to understand the surgery, but perhaps more importantly, to prepare them for what to expect once their child has a G-Tube. Video skill clips for caregiver education can be an easily accessible and efficient tool to help improve confidence levels, particularly for families with low literacy levels.³

Identification of Local Problem

Gastrostomy tube referrals at our institution prior to this intervention were a point of frustration for caregivers, providers, and the nursing staff. There was often confusion on the parts of the caregivers, missing or incomplete preoperative work up or education, delays in scheduling, conflicting instructions on postoperative feeding plans, and frequent ED visits due to dislodgements, feeding intolerance, and conflicting patient education. There was wide variation among surgeons on postoperative feeding advancements and length of stays, particularly on the weekends due to 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 ACS NSQIP-P process, we learned through discussion with other centers that our length of stay was longer than other comparable hospitals.

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

Context of the QI Activity

Mary Bridge Children’s Hospital is a community-based, 82-bed, Level II trauma center, children’s hospital within a hospital as 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 provide care to more than 330,000 children per year. The Leapfrog Group named Mary Bridge Children’s Hospital as one of the 2018 and 2019 “Top Children’s Hospitals.”

Planning and Development Process

Patients requiring outpatient gastrostomy tube placements were noted to have wide variations in pre-consultation education, family preparedness, and completion of necessary diagnostic procedures. These variations resulted in longer clinic visits and delays in surgical scheduling. This was leading to family and provider dissatisfaction. In addition, variation was noted among the pediatric surgeons regarding postoperative education, feeding plans, and length of stay. Upon joining ACS NSQIP-P, we learned when conferring with other hospitals within ACS NSQIP-P our postoperative LOS was higher than other institutions. Having previously completed a very successful Kaizen to standardize appendectomy care with improved patient satisfaction and LOS, the pediatric surgeons turned their attention to outpatient gastrostomy tube placements as their next quality improvement focus.

Pediatric surgery teamed with another key stakeholder, pediatric gastroenterology, to decrease cost within the clinic, the number of unnecessary patient visits, and returns to the emergency room. The pediatric surgeons and pediatric gastroenterologists formed a task force to analyze current state for outpatient gastrostomy tube placements. Multidisciplinary teams comprised of physicians, advance practice providers (APPs), nursing staff, clinic medical assistants, and registered dieticians, were developed to review steps in the process and identify potential areas of improvement. The Pediatric ACS NSQIP Surgical Champion filled the role of Project Manager, leading the task force.

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

Description of the Quality Improvement Activity

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

Preoperative Referrals and Scheduling

• GI Clinic Referral Process
  • The team consisted of a pediatric gastroenterologist, pediatric surgeon, surgery clinic registered nurse, and gastroenterology clinic registered nurse.
  • This team developed best practices for referrals and coordination between clinics, including the completion of a fluoroscopic upper gastrointestinal (upper GI) series prior to appointment in the surgery clinic.
• Surgery Clinic Scheduling and Preoperative Visit
  • The team consisted of 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 surgery to be scheduled prior to clinic discharge, including postoperative two- and six-week follow-up visits.

Patient Education

• Gastrostomy Tube Education Video
  • Standardization of patient education was a key component to process improvement. The task force created a patient education video to be viewed by caregivers preoperatively. The video was written 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 participated by sharing their stories.
  • The video was made available online or as a disc checked out from clinic
  • In addition to the creation of the video, caregiver education handouts, and a post-test were created to ensure comprehension of the materials.
  • Since completion of our project, the video was translated into Spanish.
  • A post-test was used to identify families who needed additional education which was provided by the GI clinic nursing team either over the phone or in the clinic.
• Bedside Nursing Education
  • A gastrostomy tube “Pathway to Home” flyer was created to educate inpatient nursing on postoperative and discharge teaching for caregivers.
  • Surgery clinic APPs conducted classes during the yearly Surgery Super User pediatric surgical skills nursing and in the RN Residency Program. These classes continue currently.

• Standardized Discharge Instructions
  • This team consisted of surgery clinic APPs.
  • Handouts and an electronic medical record (EMR, in this case EPIC) smart phrase were created for gastrostomy care discharge instructions
  • This included information on-site care, looping and taping of the extension tubing, bathing instructions, and feeding instructions for the first postoperative week.

Postoperative Management

• Standardization of Postoperative Order Set
  • This team consisted of a pediatric surgeon and surgical ARNP.
  • This team worked on developing 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 dietician consultation.
• Postoperative Nutrition
  • Pediatric gastroenterology and a registered dietician were assigned to this part of the process.
  • This team created post-placement feeding recommendations and goals for the immediate postoperative nutritional plan.
  • Hydration goal was the criteria for discharge with nutritive goal being achieved within one to two weeks postoperatively.
• Standardized Discharge Criteria Development
  • ° The pediatric surgeons developed standardized discharge criteria, which included:
    • − Afebrile <100.5;
      • Pain well controlled;
      • Typically obtained with acetaminophen and/or ibuprofen;
    • − Minimize discharge with oxycodone;
    • − Tolerating feeds at hydration goal;
    • − Ambulating at baseline function; and
    • − Caregiver completion of the “Pathway to Home” with demonstration of skills competency and comfort with tube care.

During the quality improvement process, some team members began implementing pieces of the process as they were developed throughout 2016 and 2017. Our adaptation of all the improvements began in 2018.

Resources Used and Skills Needed

Staff

This project was a joint effort on the part of the Mary Bridge Pediatric Surgery and Gastreonterology Departments. This involved six pediatric surgeons, two pediatric gastroenterologists, one registered dietician, five APPs, four clinic RNs, two medical assistants, and two members of our Community Services – Health Promotion team, as well as a contracted producer for the video. Due to the comprehensive overhaul of our process, each component was assigned to members of the surgery and GI teams to dedicate focus on that segment.

Costs

The only additional cost accrued was the cost of the video production. The use of the outside contractor cost $5,000. After the conclusion of the initial project, the video was translated into Spanish for an additional cost of $2,500.

Funding Sources

We received a personal grant of $5,000 by Dr. Amin Tjota and a $2,500 grant by the Mary Bridge Brigade, our philanthropic foundation, which funded our additional costs.

What Were the Results?

Overall Results

All outpatient gastrostomy tubes were reviewed for the year 2018. Exclusions were applied to patients who were in the neonatal intensive care unit (NICU), inpatient consultations, concurrent procedures, postoperative admission to non-surgical 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 EMR, and caregiver surveys to review the improvement implementation.

Upper GI Performed Prior to Surgical Clinic Visit

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

Use of Standardization of Postoperative Order Set

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.

Length of Stay

Average LOS in 2015 was 70.88 hours. In 2016, due to 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 YTD, our LOS has remained consistently below our initial goal at 39.4 and 40.1 hours respectively.

Comfort with Care of G-Tube at Time of Discharge

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

Setbacks

One delay in implementation of our process was the construction of the standardized Post Op Gastrostomy Tube Order Set in our EMR (EPIC). While the provider team came to consensus on its design quickly using our Post Op Appendectomy Order Set as a model, the build team was delayed due to demands created by a system-wide EPIC upgrade. This resulted in the order set not being 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 by hand. We have solved this for future projects by planning such EPIC builds far in advance to avoid such delays.

Due to turnover in both our quality and information technology teams, we had significant issues with being able to review compliance with the protocols and identifying cases for review via EPIC. This resulted in the need for 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 utilizing ACS NSQIP-P for our G-Tube abstraction granting us concurrent access to the data.

We had significant “contamination” of our baseline data due to providers implementing various aspects of the protocol once approved by our task force rather waiting for the implementation phase. Because of this early implementation, the decision was made to use 2015 as our baseline due to providers starting to migrate their practice as early as 2016 as we were beginning our design phase. However, this “staged” introduction allowed the providers, nursing staff, and care teams to adjust in smaller increments at a time and made the unveiling of the new process less intimidating. The providers’ engagement in the process was further encouraged as we saw our length of stay gradually decrease with each new component coming online.

Lastly, during the time of our implementation, several of our GI providers relocated resulting in long referral delays. This resulted in several patients who would have been outpatient referrals becoming inpatient referrals. These patients were not included in the evaluation, but as we educated referring providers these patients received the same preoperative education and postoperative management when able. As understanding grew among other services of our protocol, the frequency of gastroenterology consultation prior to surgical consultation increased.

Cost Savings

Prior to the implementation of the new education video and process, the cost of G-Tube teaching by a Registered Nurse was $11,592 per year. By implementing the video, the estimated cost saving over a 5-year period is $52,460.

Tips for Others

Getting Started

We began this project using the lessons learned during our prior Kaizen experience for postoperative appendectomy pathways. Our guiding principle was making the process easier and more efficient for the families. Education beginning at the first encounter with a consistent messaging was important. The video allowed families to do the education in their own homes at their own pace resulting in improve retention. Having involved members of the team working together on each phase helped build a sustainable plan. Standardized order sets were very 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.

How to Sustain the Activity

One of our keys to sustaining the improvements was frequent feedback, particularly sharing the results in reduction of LOS periodically during our implementation period. The standardized order set made it easier to follow the protocol than to deviate.

The frequent vocal reports of caregivers about “how (the process) was so much easier than they thought it would be” reinforced the care teams desire to continue. This feedback was shared back with the involved providers.

Other Tips and Considerations

• The ACS does have a video available for Pediatric Gastrostomy Education, which could be used to avoid the video production costs. We wished to create one that more closely mimicked the teaching done in our prior 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 prior to proceeding. Depending on the knowledge gaps, this was either done over the phone or at an in-person visit.
• While our initial post G-Tube feeding advancement plan was moderate (six hours NPO, six hours Pedialyte continuous, then formula advancement, either continuous or bolus, achieving hydration goal within 24 hours), we have migrated to a more aggressive advancement as the team members became more comfortable.

References

1. Goldin AB, Heiss KF, Hall M, et al. Emergency department visits and readmissions among children after gastrostomy tube J Pediatr. 2016;174:139-145.
2. Devin CL, Linden AF, Sagalow E, et al. Standardized pathway for feeding tube placement reduces unnecessary surgery and improves value of care. J Ped Surg. 2020:1013-1022.
3. 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;5:287.