Standardized Surgical Approach to Gastrostomy Tube Placement: A Quality Improvement Initiative at a Multi-Hospital Children's Health Care System

BACKGROUND: Children who require gastrostomy tube (G-tube) placement often have multiple medical comorbidities and are typically high-utilizers of the healthcare system. Multiple interventions have been studied to understand how to streamline the process of gastrostomy tube insertion and reduce hospital length of stay (LOS).

LOCAL PROBLEM: Within our multi-hospital children's healthcare system, the pre-operative workup for gastrostomy tube insertion was variable between providers and between hospitals. Also, the timeframe for which enteral tube feeds were started was inconsistent and without standardization. We hypothesized that standardization would lead to reduced hospital length of stay, and we aimed to decrease postop LOS for patients undergoing G-tube placement by 25%.

INTERVENTIONS: We created a clinical pathway for all children undergoing gastrostomy tube insertion within our healthcare system. The pathway included utilization of a pre-operative checklist, which included: (1) establishing a medical home for the patient, (2) identifying a durable medical equipment company to supply equipment and formula, (3) consultation with nutrition to establish feeding goals, (4) consultation with speech-language pathologist, as indicated, (5) educating families about the surgical procedure and enteral feeding expectations, (6) consultation with social work to identify psychosocial barriers and assess family readiness, (7) ensuring the patient is able to tolerate bolus feeds via a nasogastric tube. The post-operative portion of the pathway included initiating enteral feeds 4 hours post-operatively.

RESULTS: After one year, pathway utilization across our enterprise was 71%. Enteral tube feeds beginning within the appropriate timeframe increased from a baseline of 4% to 40.1%. Length of stay for patients undergoing outpatient G-tube decreased from 2.1 to 1.4 days, but there has not been a decrease in LOS for inpatient G-tube placement. There was no increase in returns to system despite reductions in LOS.

CONCLUSIONS: Introduction of a standardized pathway for G-tube placement, which includes a pre-operative checklist and initiation of early enteral feeds, led to a decrease in hospital length of stay without increasing readmissions.