What Is Known
- Enteral feeding is commonly used in children with neurologic or gastrointestinal disorders.
- Image-guided gastrojejunostomy tube placement is less invasive than surgery, but may be more prone to complications.
- There is a lack of consensus on how to best manage gastrojejunostomy tube complications.
What Is New
- The expected course of management for gastrojejunostomy tube complications can be effectively communicated in the radiology procedure note.
- Improved communication likely reduces the number of patients presenting after hours for gastrojejunostomy tube complications.
- Improved communication likely improves patient, caregiver, and clinician satisfaction while reducing healthcare costs.
Transpyloric enteral feeding is a commonly used strategy for long-term nutrition in children with neurologic disorders and other conditions predisposing to aspiration or severe gastroesophageal reflux. Traditional options for enteral feeding include surgical jejunostomy and percutaneous gastrojejunostomy (GJ) tubes, which may be placed under endoscopic or fluoroscopic guidance. Although initially less invasive than surgical jejunostomy, GJ tubes are prone to mechanical complications and require frequent replacement (1). Given the implications for feeding and medication administration, GJ tube malfunction is often perceived as an emergency, prompting requests for after-hours replacement under image guidance. This practice is not always appropriate and can place a burden on limited resources, but may be encouraged by the lack of a documented “plan” for tube-related complications in the patient's medical record. The present study was designed to assess whether including a patient-specific plan and recommendations at the end of each radiology GJ tube procedure note that is available in the electronic medical record (EMR) reduces after-hour resource utilization in patients who could otherwise have their tubes replaced during standard operating hours with image guidance.
MATERIALS AND METHODS
The present study was approved by the institutional review board of the Children's Hospital of Wisconsin. The Health Insurance Portability and Accountability Act requirement to obtain informed consent was waived.
The following GJ tubes were placed by the pediatric interventional radiology (PIR) service at our institution during this study: MIC-KEY low-profile transgastric-jejunal feeding tube (Kimberly-Clark, Dallas, TX), MIC-KEY long transgastric-jejunal feeding tube (Kimberly-Clark), AMT G-Jet low-profile transgastric-jejunal feeding tube (Applied Medical Technology, Inc, Brecksville, OH), and 16-French Corflo-Max PEG tube (CORPAK MedSystems, Inc, Buffalo Grove, IL). The Corflo PEG is paired with either an 8-French Frederick Miller feeding tube Cook, Inc, Bloomington, IN) or 8.5-French Marx Cope jejunostomy catheter (Cook, Inc) to make it a complete GJ system.
GJ tube replacement procedures performed by the PIR service from 11/2012 to 4/2013 were analyzed and served as the traditional baseline. This was compared to the period from 11/2013 to 4/2014 during which a specific plan in the event of GJ tube dysfunction was embedded into the postprocedure radiology report. The comparison period was chosen to allow for a reasonable transition period to the new reporting policy and to eliminate any seasonal variability in the results. These plans were made in collaboration with the patient's feeding team or medical team based upon nutrition and medication requirements. Each plan included the time frame and urgency of GJ tube replacement in the event of dysfunction. The radiology procedure report and plans were made accessible to all providers within each patient's EMR and the Radiology Information system. Standard operating hours for GJ tube replacement procedures were defined as 7:00 am to 5:00 pm Monday through Friday. GJ tube replacement procedures performed outside of these hours were considered after-hours. Data were collected for procedure timing (standard hours vs after-hours), patient sex, age, and weight.
Additional cost incurred by the organization for after-hours nursing and technical staff compensation was also considered. No added costs were incurred for materials, facility, or professional charges because these are fixed costs regardless of procedure timing.
Fisher exact tests were used to examine the relation of categorical variables. A Mann-Whitney test was used to compare continuous variables. A generalized estimating equation model was used to examine further the relation of differences in after-hours encounters (after-hours = 1, standard hours = 0) between the 2 data collection periods; the variable “encounters” was the outcome, “year” was a predictor along with sex, weight in kilograms, age in years, and their interaction with “year.” A compound symmetry assumption was used for the covariance structure. Backward elimination with a stay and enter of 0.05 was used. Significance was defined as a P value of <0.05.
Over a 6-month period before the inclusion of a patient-specific plan, there were 242 total GJ tube changes performed on 129 unique patients by the PIR service under image guidance (Table 1). Of the 242 GJ tube replacement procedures 26 (10.7%) were performed after-hours on 19 unique patients. Of these 26 GJ tube replacement procedures 6 were performed for children seeking care in the emergency department (ED), 8 of 26 for children on inpatient services, and 12 of 26 for children in whom the patient or their caregiver directly contacted the on-call interventional radiology service. Of the 8 inpatients, 3 were admitted from the ED expressly for tube replacement.
Data were again collected for 6 months following inclusion of a patient-specific plan. During this period, 240 total image-guided tube changes were performed on 118 unique patients (Table 1). Fifteen of 240 (6.3%) were performed after-hours on 13 unique patients: 2 of 15 procedures were performed for children in the ED, 4 of 15 for inpatients, and 9 of 15 for children in whom the patient or their caregiver directly contacted the on-call interventional radiology service. No patients were admitted for GJ tube replacement procedures after implementation of the enhanced reporting policy.
These data indicate a reduction in after-hours GJ tube replacement requests by the ED (23.1%–13.3.%), inpatient service (30.8%– 26.7%), and all patients (14.7%–11%). Statistical analysis confirms a trend toward fewer total after-hours procedures (P = 0.123) and toward fewer unique patients undergoing after-hours procedures (P = 0.104). There were no significant differences in weight, sex, or age (P > 0.29), between the 2 groups. Fewer after-hours GJ tube changes necessarily reduced cost by proportionately reducing hourly compensation for interventional radiology nurses and technicians.
Enteral feeding, by definition, involves nutrition and/or medication administration via the gastrointestinal tract. Common sites of enteral access include the esophagus, stomach, small intestine, and large intestine. This contrasts with parenteral feeding, which refers to food or drug administration by any non-gastrointestinal route (ie, intravenous, etc). Enteral feeding is necessitated by inadequate oral intake, most commonly in the setting of neurologic impairment, intractable gastroesophageal reflux, tracheoesophageal fistula, or failed Nissen fundoplication.
Historically, a common strategy of enteral feeding has required a surgical jejunostomy. Enteral access may also be achieved by endoscopic or image-guided percutaneous methods. Endoscopically and fluoroscopically guided gastrostomies allow the installation of a long, flexible conduit that terminates in the proximal jejunum. Known as a GJ tube, this device (usually polyurethane or silicone) permits nutrition and/or medication delivery to the stomach, jejunum, or both. This technique has the advantage of establishing postpyloric access in a minimally invasive fashion, avoiding a surgical procedure. Unfortunately, GJ tubes have several disadvantages when used for long-term enteral nutrition. A variety of mechanical complications have been described, such as clogging, cracking, deterioration, and dislodgement (1). All of these dysfunctions require tube replacement, frequently utilizing fluoroscopic image guidance by the interventional radiology service.
We are not aware of any prior studies assessing the affect of improved communication on image-guided procedure utilization, particularly enteral tube manipulation. Existing literature is focused on techniques for enteral feeding tube placement, reporting of complications, and nutritional strategies. Showalter et al concluded that most pediatric gastrostomy tubes are safely replaced in the ED without confirmatory imaging and that imaging was associated with a considerably longer length of stay (3). That study was limited to gastrostomy tubes, however, and did not evaluate these parameters in patients with GJ tubes. In our experience, the additional length and the presence of a second (jejunal) port for feeding or medication administration add sufficient complexity to dissuade ED clinicians from manipulating GJ tubes. Raval and Phillips (4) compared the long-term outcomes of surgical jejunostomy to image-guided GJ tubes in children, concluding that the latter are associated with greater maintenance, complications, and hospitalizations. Crosby and Duerksen (5,6) reported similar findings in both retrospective and prospective analyses of tube-related complications in patients requiring long-term home enteral nutrition, with emphasis on associated health care costs. Our study was designed to address this issue at our center, where after-hours GJ tube changes have been identified as a potential source of suboptimal resource utilization.
As suggested by Raval and Phillips, complications are a major source of cost and patient/caregiver dissatisfaction with GJ tubes. Most mechanical complications can be avoided by regularly scheduled tube exchanges, with many authors recommending intervals between 3 and 8 months (1,3). Tube dislodgement, however, is less predictable and occurs in 65% of patients within 5 years (2). Regardless of type, tube complications can occur during times of reduced access to medical resources—evenings, weekends, and holidays. Many patients, therefore, present to EDs with the expectation of GJ tube manipulation (de-clog, replacement, etc). This scenario is often complicated by the absence of a documented plan for tube-related complications in the medical record. Surgery, gastroenterology, and radiology procedure notes have historically lacked such information, serving instead to document the technical execution of GJ tube manipulation procedures. This is an important source of clinical uncertainty, because tube-fed patients vary in their ability to tolerate interrupted nutrition, missed medications, and gastric administration thereof. GJ tube malfunction or dislodgement may, therefore, constitute an urgent matter in some patients but not in others (Table 2). For those in the latter group, emergent tube manipulations, especially those performed with image guidance, represent a source of unnecessary added medical costs. Improving communication of patient-specific recommendations between health care providers, therefore, has the potential to facilitate significant cost savings while enhancing the care experience for patients and their families.
A plan for GJ tube–related complications is ideally succinct, clear, and up to date. In our practice, all recommendations are generated in consultation with the referring clinician, typically a gastroenterologist and/or nutritionist (Fig. 1). In their 2009 review of pediatric ED G-tube management, Saavedra et al (7) suggested that tube management protocols and thorough documentation are likely to improve patient care. When asked what resources would be valuable in caring for feeding tube–dependent children, primary caregivers in Crosby and Duerksen's 2005 survey cited education and a documented care plan: “Literature on the kinds of problems we can expect and doctors informing us of the types of problems to expect in advance because of the additional problems related to tube feeding that don’t have anything to do with the disease”(5). These findings suggest that a predetermined, well-documented plan of action in the event of tube dysfunction is cost-effective, helpful to providers, and reassuring to caregivers.
Our study showed that patient-specific instructions at the end of radiology GJ tube procedure notes are associated with fewer after-hours requests for tube replacement. This effect was observed in patients seen in the ED, inpatients, and all patients collectively. Access to the enhanced procedure report in the EMR presumably accounts for decreased requests by providers. Decreased family/caregiver requests are likely an effect of our policy to discuss the plan and provide detailed written instructions before discharge from the radiology department. This observation suggests that simple education alone has the potential to modify the requesting behaviors of families and caregivers. It may be informative to evaluate whether access to a reference copy of the procedure note, printed or electronic, further reinforces the desired effect.
In our experience, fewer after-hours procedures resulted in reduced technical support costs. This reflects the fact that, at our institution, after-hours procedures involve interventional radiology nurses and technicians who are compensated on an hourly or per-procedure basis. Cost savings related to improved ED workflow and throughput are difficult to quantify, but likely significant. Avoided unnecessary admissions are presumably the greatest source of savings, but also difficult to quantify.
Before inclusion of a patient-specific plan, after-hours procedures were requested for 3 patients being admitted exclusively for that purpose. These cases involved patients who presented to the ED with nonemergent tube complications after traveling a significant distance. A nonemergent complication, combined with caregiver resistance to returning the following day due to prolonged travel, resulted in the admission of each patient. No GJ tube–related admissions occurred during the postintervention period, likely reflecting a combination of factors: decreased likelihood of distant-living patients/caregivers to report to the ED and decreased likelihood of ED physicians to offer admission to these patients. Both factors indicate that discussion and/or documentation of a patient-specific care plan improves understanding of complication acuity (ie, emergent vs nonemergent).
The present study is limited by its single-center retrospective nature, lack of randomization, and relatively small sample size. Also, the various types of GJ tubes used may have affected complication rates. Future studies should be designed to address these limitations. Additional opportunities exist to more comprehensively quantify savings and to assess the effect of this intervention on patient/caregiver satisfaction.
Our single-center data show a trend toward decreased after-hours resource utilization following the inclusion of patient-specific recommendations at the end of each radiology GJ tube procedure note. These recommendations are ideally generated in consultation with the managing provider, discussed with the patient/caregiver, and readily accessible via the EMR. Avoidance of tube-related admissions is likely the greatest source of cost savings, followed by lower radiology technical support costs. Cost savings related to improved ED workflow and reduced patient/caregiver anxiety are difficult to quantify, but likely significant.
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