Journal of Pediatric Surgery 49 (2014) 1598–1601
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Resource utilization after gastrostomy tube placement: Defining areas of improvement for future quality improvement projects☆ Jesus A. Correa a, Sara C. Fallon a, Kathleen M. Murphy a, Veronica A. Victorian a, George S. Bisset b, Sanjeev A. Vasudevan a, Monica E. Lopez a, Mary L. Brandt a, Darrell L. Cass a, J. Ruben Rodriguez a, David E. Wesson a, Timothy C. Lee a,⁎ a b
Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX
a r t i c l e
i n f o
Article history: Received 21 February 2014 Received in revised form 22 June 2014 Accepted 25 June 2014 Key words: Gastrostomy Pediatrics Quality improvement
a b s t r a c t Background: Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care children's hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis. Methods: We reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30 days after discharge and 30–365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. Results: During the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3 months (range 0.03 months–22 years). Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31–365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%). Conclusions: Few studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge. © 2014 Elsevier Inc. All rights reserved.
1. Background Gastrostomy tube (GT) placement in the pediatric population plays an important role in the care of high-risk patients with neurologic disease and feeding difficulties. In 2006, an estimated 11,000 gastrostomy tubes were placed in patients less than 18 years of age in the US [1]. Complications related to the procedure can range from minor (granulation tissue) to serious (gastric outlet obstruction, bowel perforation, intraperitoneal leak). Fortunately, significant
☆ Disclosures: The authors have no sources of support or disclosures regarding the preparation of this manuscript. ⁎ Corresponding author at: 6701 Fannin Suite 1210, Houston, TX 77030. Tel.: +1 832 822 3135; fax: +1 832 825 3141. E-mail address: [email protected] (T.C. Lee). http://dx.doi.org/10.1016/j.jpedsurg.2014.06.015 0022-3468/© 2014 Elsevier Inc. All rights reserved.
complications are very rare (b1%), particularly with the Stamm gastrostomy technique [2]. Minor complications occur more frequently and result in a higher relative burden on the health care system. One cross-sectional study of ER visits related to gastrostomy complications found that 62% of patients presented to the ER with dislodgement concerns [3]. Another study of 159 pediatric patients with gastrostomy placement found the majority of ER visits were related to granulation tissue (58%) and tube dislodgement (28%), with 93% of patients being discharged from the emergency department [4]. If these numbers were extrapolated to the 11,000 patients necessitating this procedure annually, this would result in 6918 ER visits a year with only 484 complications requiring admission to the hospital. The cost of these unnecessary visits cannot be ignored. In one adult study examining ER visits in patients with gastrostomy tubes, 33 patients visited the ED 138 times over a two
J.A. Correa et al. / Journal of Pediatric Surgery 49 (2014) 1598–1601
year period with the majority of complaints related to dislodgement; the estimated cost of each visit was approximately $1000 [5]. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. As we perform approximately 150 new tube insertions per year, this volume of ER visit represents an area of significant resource utilization. The purpose of this study was to evaluate the incidence and indications for these ER visits so that a patient-directed educational program could be developed to decrease these visits and improve the quality of their care. 2. Methods 2.1. Study design After IRB-approval, the medical records of all patients at who had undergone gastrostomy placement by the surgery service at a tertiary care referral center from January 2011 to September 2012 were reviewed. Patients who went to the operating room during this time frame for a revision of a previously placed gastrostomy were excluded. Patients received an open Stamm gastrostomy, a laparoscopic gastrostomy, or rarely, a percutaneous endoscopic gastrostomy (PEG). Patients who had a PEG placed by the interventional radiology or gastroenterology departments were not included. Data collected included patient demographics, the indication for placement, operative technique, and postoperative outcomes. Data analysis was descriptive; all data are reported as a mean (standard deviation) or a median (range). 2.2. Measured clinical and resource utilization outcomes In order to quantify our resource utilization in these patients, we evaluated: ER visits less than 30 days after discharge, ER visits 30–365 days after discharge, and unplanned clinic visits related to gastrostomy tube concerns. The purpose for the ER or clinic visit was categorized as either a mechanical or a wound concern. Mechanical concerns included dislodgment, clog, or leak. Wound concerns were categorized as infectious (cellulitis, abscess) or noninfectious (granulation tissue, skin breakdown, bleeding). Essential visits were defined as those involving a problem that required urgent medical attention or could not be reasonably addressed at home. Examples include dislodgement in the 30 day postoperative period, concern for infection, signs of obstruction, or an acute change in the mechanical functioning of the tube. Avoidable visits were defined as those involving a preventable problem or problem that could be addressed by the caretaker at home. Examples include granulation tissue, leaking, or minor clogs that did not interfere with the overall tube functioning. For instances where the nature of the ER visit was considered difficult to categorize based on these a priori definitions, the case was reviewed by a resident and a staff surgeon, and a consensus was reached after a discussion of the case. Visits related to a subsequently placed gastrojejunostomy tube were not included in this review. Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. The average cost related to ER visits for gastrostomy concerns was calculated. 3. Results
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Table 1 Variable Median age at surgery
15.3 months (range 0.03–264)
Median BMI at the time of surgery Gender Indications Neurologic dysfunction Congenital heart disease Metabolic disorder Surgical GI anatomic abnormality Cystic fibrosis with pancreatic insufficiency Other indication (BPD, muscular dystrophy, facial deformity) Operation Open Stamm gastrostomy Laparoscopic gastrostomy PEG Gastrostomy device Primary tube Primary button
15.3 kg/m2 (range 10.5–35.5) 131 females (53%) 116 males (47%) 120 (49%) 19 (7.7%) 18 (7.2%) 14 (5.7%) 11 (4.5%) 65 (26.3%)
181 (73%) 60 (24%) 6 (3%) 141 (57%) 106 (43%)
gastrostomy. Pezzer or Malecot tubes were placed in 141 patients (57%), 90 (36%) received primary balloon buttons, and 16 (7%) received non-balloon buttons. 3.2. Patient clinical outcomes Postoperative complications prior to discharge were minimal. Ten patients had adverse events including 6 wound infections, 2 dislodgements where a tube was replaced with a Foley catheter, 1 dislodgment that required a repeat operation for replacement, and 1 dislodgement into the subcutaneous space that was corrected by readjusting the catheter. 3.3. Gastrostomy device As previously stated, the majority of patients received a gastrostomy tube initially. These patients had a rate of ER visit N30 days after discharge of 20% (Table 2). The majority of visits were related to mechanical concerns (13%). Similarly, those who had an initial balloon button had an ER visit rate of 20%, with the majority related to wound concerns (13%). Those with a nonballoon button had a visit rate of 13%. 3.4. Emergency room visits Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their tube. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17 (44%). Conversely, 61% presented with essential visits to the ER with concerns for tube dislodgment less than 30 days after placement or infection of the wound (Fig. 1). The mean ER visit length of stay was 5.4 hours (±3.8). The majority of these visits were related to mechanical concerns (60%, Fig. 2). An additional 40 patients (16%) presented to the ER a total of 71 times greater than 30 days but less than 1 year after discharge from
3.1. Patient demographics During the study period, 247 patients had a GT placed at our institution. Demographics and surgical procedural data are presented in Table 1. The median age at initial placement was 15.3 months (range 0.03 months–22 years). The most common indication for gastrostomy placement was neurologic dysfunction (49%). Open procedures were performed in 181 (73%) patients, laparoscopic placement in 60 (24%), and 6 (3%) had a percutaneous endoscopic
Table 2 ER visit rate by type of gastrostomy device, b30 days.
ER Visits b30 days from discharge Mechanical concerns Wound concerns
Tube n = 141
Balloon button n = 60
Nonballoon button n = 16
28 (20%)
12 (20%)
2 (13%)
19 (13%) 9 (6%)
4 (7%) 8 (13%)
2 (13%)
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J.A. Correa et al. / Journal of Pediatric Surgery 49 (2014) 1598–1601
Fig. 1. Potentially avoidable visits related to gastrostomy tube concerns.
the hospital. Fifty-nine (83%) of these visits were related to tube dislodgements, clogs, leaking, and granulation tissue and were potentially avoidable. Twelve patients (17%) returned to the ER for essential visits related to infection, gastrostomy site closure, gastric outlet obstruction, and balloon rupture. A greater proportion of visits to the ER were related to mechanical concerns (86%). 3.5. Unplanned clinic visits Sixty-four (26%) patients returned to our clinic for 89 unplanned visits (some patients had multiple concerns). There were 47 visits related to mechanical issues, including 14 dislodgements, 19 persistent leaks, and 11 malfunctions or broken tube, and 3 clogs. Patients presented with noninfectious wound concerns consisting of 21 cases of granulation tissue, 10 site irritations/excoriations, and 2 granulomas. Eleven patients presented with wound concerns and were treated with antibiotics. Three patients had nonspecific gastrointestinal symptoms. During the first postoperative year, 77 (31%) patients were treated for granulation tissue either during their regularly scheduled clinic visit or an unplanned trip to the clinic. Up to 1/3 of these unplanned clinic visits could have been avoided with additional educational efforts on tube replacement and basic wound care.
Readmission rates related to the gastrostomy tube were low (4%) at a median time of 100 days (range 5–365). Reasons for readmission included infection (n = 8), and dislodgement requiring monitoring or revision (n = 3). A total of 22 (9%) patients went to the operating room for a revision, and 19 (8%) patients required a conversion to a GJ tube by interventional radiology for continued feeding difficulties at a median of 110 days (range = 15–351) from gastrostomy. Over 1/3 of the patients received a gastrostomy tube contrast study (n = 76, with a total of 125 studies) for evaluation of tube placement or possible obstruction. The average variable direct cost of an ER visit related to gastrostomy concerns was 528 USD (±762). Including an average ER provider consultation rate of 700 USD in addition to the variable direct cost, an estimated mean cost of each ER visit was approximately 1200 USD. 4. Discussion Gastrostomy placement is a common, essential surgical procedure in children with a variety of indications for supplemental feeding. Unfortunately, the postoperative care of these tubes and buttons requires significant effort on the part of both the caregiver and the health care provider. The majority of postoperative issues related to the device are generally not serious. In one series comparing PEG to
Fig. 2. Distribution of patient concerns during ER and unplanned clinic visits.
J.A. Correa et al. / Journal of Pediatric Surgery 49 (2014) 1598–1601
laparoscopic tube placement, the postoperative complication rate was 6%, compared to a minor maintenance issue rate of 61% [6]. A similar study found a major postoperative complication rate of 10% and a minor rate of 45% [7]. Our study had similar findings, with a low readmission rate (4%) with few serious complications identified (and no intraoperative complications). While continued examination of operative technique (PEG vs. laparoscopic vs. open) may identify a superior method for decreasing major complications, the more frequent minor complications are likely independent of operative technique. Therefore, interventions aimed at reducing the incidence and resources devoted to the treatment of these minor problems should be focused on education at the caregiver level. In our own study, we discovered a rather high rate (20%) of 30-day post discharge ER visits related to the gastrostomy. A significant percentage of these visits were owing to issues that could have been avoided with a dedicated educational program, as granulation tissue, tube clogs, and leaking are all treatable by the caregiver at home or with a standard clinic visit. We included dislodgements within 30 days as essential visits, as theoretically these patients do not yet have a well-formed gastrostomy tract and likely require physician assessment of proper replacement into the stomach lumen. However, some of these dislodgements could have been avoided with improved caregiver education on proper gastrostomy handling. In one study of pediatric emergency room visits related to gastrostomy tubes, the most common complaint was tube dislodgement, and the majority were treated easily in the ER (97%) [3]. Regardless of the indication for the visit, a 20% ER rate within 30 days of discharge represents an opportunity for improvement, benefiting both the patient caregiver and the surgical provider. Our late visit rate (30 days–1 year) postdischarge was also significant at 16%. The overwhelming majority of trips were not related to emergent concerns (83%), particularly related to late tube dislodgement, clogs, and granulation tissue. Whether this rate of late ER visits is secondary to a lack of accessibility to our outpatient clinics, a need for continued education after discharge, or both is difficult to determine. At our own institution, we have a dedicated nurse at an outpatient clinic that provides treatment and education for postoperative patients, which might explain the relative decrease in the volume of visits over time to the ER. Identifying and removing barriers to patient access to this resource may help reduce the volume of ER visits in this patient group. While in general we would prefer that nonessential health care visits are made in the outpatient clinic setting as opposed to the emergency room, up to 1/3 of our patients came to the clinic with concerns that could have easily been addressed over the phone or by the caregiver. These visits recorded were not part of the routine postoperative care of the gastrostomy, so the overall volume of clinic time devoted to gastrostomies in their entirety is underestimated in this calculation. Again, reductions in this rate of clinic visitation, which would certainly help the caregivers of those with gastrostomies and relieve the high volume of patient flow to the extremely busy clinic, could be achieved with formalized educational efforts in gastrostomy care. Inherent in this discussion of ER and clinic visits related to the care of these gastrostomies are the resources utilized in their care and management. At a mean cost of 1200 USD per ER visit and time in the ER of 5 hours for basic gastrostomy maintenance, there exists the potential for an increasing cost burden to the family and the hospital over the course of the patient's lifetime, particularly if the primary provider is unable to troubleshoot GT issues independently. Of additional concern is the number of gastrostomy tube studies performed for confirmation of placement and positioning. More
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than 30% of our patients had a contrast study performed for a variety of indications, while only 2 had an abnormal finding related to obstruction and none with intraperitoneal extravasation. This trend was similarly observed in another study of confirmatory imaging after gastrostomy replacement in the ER, reporting only 1 finding of gastric outlet obstruction in 84 studies [8]. Further educational efforts for both the patients on tube maintenance and the ER and surgical staff on appropriate indications for contrast studies should help to decrease overall costs associated with gastrostomy care. There are limitations to this study. This is a retrospective review of data, and is subject to certain biases related to this type of data collection compared to prospectively obtained data. As patients may go to other hospitals for postoperative care, our results may underestimate the true ER visit rate and resources dedicated to the care of these devices. In our cost analysis, the true costs associated with managing these tubes are likely under estimated, as we were unable to calculate the cost to the caregiver for lost wages when missing work for hospital visits and the time spent by the surgical staff and residents fielding consultations. In general, the limitations of our study appear to underestimate the true amount of postoperative care required for these devices, and underscore the need for improved educational efforts.
5. Conclusion Few studies have attempted to quantify the amount of resources utilized postgastrostomy placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge. These educational materials are directed to address the indications for return to the ER that have been noted in this study. For example, patients with tubes would benefit from education that emphasizes issues related to dislodgement, while those with balloon buttons likely need additional education with regards to wound care. We will continue tracking our ER visit rates postgastrostomy placement after implementation to see if these interventions decrease the overall health care resource utilization. Hopefully the findings from this prospective study can demonstrate the cost benefit to the hospital of hiring dedicated surgical educators, with replication of this process in other disease processes.
References [1] Goldberg E, Barton S, Xanthopoulos MS, et al. A descriptive study of complications of gastrostomy tubes in children. J Pediatr Nurs 2010;25:72–80. [2] Conlon SJ, Janik TA, Janik JS, et al. Gastrostomy revision: incidence and indications. J Pediatr Surg 2004;39:1390–5. [3] Saavedra H, Losek JD, Shanley L, et al. Gastrostomy tube-related complaints in the pediatric emergency department: identifying opportunities for improvement. Pediatr Emerg Care 2009;25:728–32. [4] Naiditch JA, Lautz T, Barsness KA. Postoperative complications in children undergoing gastrostomy tube placement. J Laparoendosc Adv Surg Tech A 2010;20:781–5. [5] Odom SR, Barone JE, Docimo S, et al. Emergency department visits by demented patients with malfunctioning feeding tubes. Surg Endosc 2003;17:651–3. [6] Akay B, Capizzani TR, Lee AM, et al. Gastrostomy tube placement in infants and children: is there a preferred technique? J Pediatr Surg 2010;45:1147–52. [7] Wragg RC, Salminen H, Pachl M, et al. Gastrostomy insertion in the 21st century: PEG or laparoscopic? Report from a large single-centre series. Pediatr Surg Int 2012;28:443–8. [8] Showalter CD, Kerrey B, Spellman-Kennebeck S, et al. Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging. Am J Emerg Med 2012;30:1501–6.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Resource utilization after gastrostomy tube placement: Defining areas of improvement for future quality improvement projects☆ Jesus A. Correa a, Sara C. Fallon a, Kathleen M. Murphy a, Veronica A. Victorian a, George S. Bisset b, Sanjeev A. Vasudevan a, Monica E. Lopez a, Mary L. Brandt a, Darrell L. Cass a, J. Ruben Rodriguez a, David E. Wesson a, Timothy C. Lee a,⁎ a b
Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX
a r t i c l e
i n f o
Article history: Received 21 February 2014 Received in revised form 22 June 2014 Accepted 25 June 2014 Key words: Gastrostomy Pediatrics Quality improvement
a b s t r a c t Background: Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care children's hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis. Methods: We reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30 days after discharge and 30–365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. Results: During the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3 months (range 0.03 months–22 years). Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31–365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%). Conclusions: Few studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge. © 2014 Elsevier Inc. All rights reserved.
1. Background Gastrostomy tube (GT) placement in the pediatric population plays an important role in the care of high-risk patients with neurologic disease and feeding difficulties. In 2006, an estimated 11,000 gastrostomy tubes were placed in patients less than 18 years of age in the US [1]. Complications related to the procedure can range from minor (granulation tissue) to serious (gastric outlet obstruction, bowel perforation, intraperitoneal leak). Fortunately, significant
☆ Disclosures: The authors have no sources of support or disclosures regarding the preparation of this manuscript. ⁎ Corresponding author at: 6701 Fannin Suite 1210, Houston, TX 77030. Tel.: +1 832 822 3135; fax: +1 832 825 3141. E-mail address: [email protected] (T.C. Lee). http://dx.doi.org/10.1016/j.jpedsurg.2014.06.015 0022-3468/© 2014 Elsevier Inc. All rights reserved.
complications are very rare (b1%), particularly with the Stamm gastrostomy technique [2]. Minor complications occur more frequently and result in a higher relative burden on the health care system. One cross-sectional study of ER visits related to gastrostomy complications found that 62% of patients presented to the ER with dislodgement concerns [3]. Another study of 159 pediatric patients with gastrostomy placement found the majority of ER visits were related to granulation tissue (58%) and tube dislodgement (28%), with 93% of patients being discharged from the emergency department [4]. If these numbers were extrapolated to the 11,000 patients necessitating this procedure annually, this would result in 6918 ER visits a year with only 484 complications requiring admission to the hospital. The cost of these unnecessary visits cannot be ignored. In one adult study examining ER visits in patients with gastrostomy tubes, 33 patients visited the ED 138 times over a two
J.A. Correa et al. / Journal of Pediatric Surgery 49 (2014) 1598–1601
year period with the majority of complaints related to dislodgement; the estimated cost of each visit was approximately $1000 [5]. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. As we perform approximately 150 new tube insertions per year, this volume of ER visit represents an area of significant resource utilization. The purpose of this study was to evaluate the incidence and indications for these ER visits so that a patient-directed educational program could be developed to decrease these visits and improve the quality of their care. 2. Methods 2.1. Study design After IRB-approval, the medical records of all patients at who had undergone gastrostomy placement by the surgery service at a tertiary care referral center from January 2011 to September 2012 were reviewed. Patients who went to the operating room during this time frame for a revision of a previously placed gastrostomy were excluded. Patients received an open Stamm gastrostomy, a laparoscopic gastrostomy, or rarely, a percutaneous endoscopic gastrostomy (PEG). Patients who had a PEG placed by the interventional radiology or gastroenterology departments were not included. Data collected included patient demographics, the indication for placement, operative technique, and postoperative outcomes. Data analysis was descriptive; all data are reported as a mean (standard deviation) or a median (range). 2.2. Measured clinical and resource utilization outcomes In order to quantify our resource utilization in these patients, we evaluated: ER visits less than 30 days after discharge, ER visits 30–365 days after discharge, and unplanned clinic visits related to gastrostomy tube concerns. The purpose for the ER or clinic visit was categorized as either a mechanical or a wound concern. Mechanical concerns included dislodgment, clog, or leak. Wound concerns were categorized as infectious (cellulitis, abscess) or noninfectious (granulation tissue, skin breakdown, bleeding). Essential visits were defined as those involving a problem that required urgent medical attention or could not be reasonably addressed at home. Examples include dislodgement in the 30 day postoperative period, concern for infection, signs of obstruction, or an acute change in the mechanical functioning of the tube. Avoidable visits were defined as those involving a preventable problem or problem that could be addressed by the caretaker at home. Examples include granulation tissue, leaking, or minor clogs that did not interfere with the overall tube functioning. For instances where the nature of the ER visit was considered difficult to categorize based on these a priori definitions, the case was reviewed by a resident and a staff surgeon, and a consensus was reached after a discussion of the case. Visits related to a subsequently placed gastrojejunostomy tube were not included in this review. Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. The average cost related to ER visits for gastrostomy concerns was calculated. 3. Results
1599
Table 1 Variable Median age at surgery
15.3 months (range 0.03–264)
Median BMI at the time of surgery Gender Indications Neurologic dysfunction Congenital heart disease Metabolic disorder Surgical GI anatomic abnormality Cystic fibrosis with pancreatic insufficiency Other indication (BPD, muscular dystrophy, facial deformity) Operation Open Stamm gastrostomy Laparoscopic gastrostomy PEG Gastrostomy device Primary tube Primary button
15.3 kg/m2 (range 10.5–35.5) 131 females (53%) 116 males (47%) 120 (49%) 19 (7.7%) 18 (7.2%) 14 (5.7%) 11 (4.5%) 65 (26.3%)
181 (73%) 60 (24%) 6 (3%) 141 (57%) 106 (43%)
gastrostomy. Pezzer or Malecot tubes were placed in 141 patients (57%), 90 (36%) received primary balloon buttons, and 16 (7%) received non-balloon buttons. 3.2. Patient clinical outcomes Postoperative complications prior to discharge were minimal. Ten patients had adverse events including 6 wound infections, 2 dislodgements where a tube was replaced with a Foley catheter, 1 dislodgment that required a repeat operation for replacement, and 1 dislodgement into the subcutaneous space that was corrected by readjusting the catheter. 3.3. Gastrostomy device As previously stated, the majority of patients received a gastrostomy tube initially. These patients had a rate of ER visit N30 days after discharge of 20% (Table 2). The majority of visits were related to mechanical concerns (13%). Similarly, those who had an initial balloon button had an ER visit rate of 20%, with the majority related to wound concerns (13%). Those with a nonballoon button had a visit rate of 13%. 3.4. Emergency room visits Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their tube. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17 (44%). Conversely, 61% presented with essential visits to the ER with concerns for tube dislodgment less than 30 days after placement or infection of the wound (Fig. 1). The mean ER visit length of stay was 5.4 hours (±3.8). The majority of these visits were related to mechanical concerns (60%, Fig. 2). An additional 40 patients (16%) presented to the ER a total of 71 times greater than 30 days but less than 1 year after discharge from
3.1. Patient demographics During the study period, 247 patients had a GT placed at our institution. Demographics and surgical procedural data are presented in Table 1. The median age at initial placement was 15.3 months (range 0.03 months–22 years). The most common indication for gastrostomy placement was neurologic dysfunction (49%). Open procedures were performed in 181 (73%) patients, laparoscopic placement in 60 (24%), and 6 (3%) had a percutaneous endoscopic
Table 2 ER visit rate by type of gastrostomy device, b30 days.
ER Visits b30 days from discharge Mechanical concerns Wound concerns
Tube n = 141
Balloon button n = 60
Nonballoon button n = 16
28 (20%)
12 (20%)
2 (13%)
19 (13%) 9 (6%)
4 (7%) 8 (13%)
2 (13%)
1600
J.A. Correa et al. / Journal of Pediatric Surgery 49 (2014) 1598–1601
Fig. 1. Potentially avoidable visits related to gastrostomy tube concerns.
the hospital. Fifty-nine (83%) of these visits were related to tube dislodgements, clogs, leaking, and granulation tissue and were potentially avoidable. Twelve patients (17%) returned to the ER for essential visits related to infection, gastrostomy site closure, gastric outlet obstruction, and balloon rupture. A greater proportion of visits to the ER were related to mechanical concerns (86%). 3.5. Unplanned clinic visits Sixty-four (26%) patients returned to our clinic for 89 unplanned visits (some patients had multiple concerns). There were 47 visits related to mechanical issues, including 14 dislodgements, 19 persistent leaks, and 11 malfunctions or broken tube, and 3 clogs. Patients presented with noninfectious wound concerns consisting of 21 cases of granulation tissue, 10 site irritations/excoriations, and 2 granulomas. Eleven patients presented with wound concerns and were treated with antibiotics. Three patients had nonspecific gastrointestinal symptoms. During the first postoperative year, 77 (31%) patients were treated for granulation tissue either during their regularly scheduled clinic visit or an unplanned trip to the clinic. Up to 1/3 of these unplanned clinic visits could have been avoided with additional educational efforts on tube replacement and basic wound care.
Readmission rates related to the gastrostomy tube were low (4%) at a median time of 100 days (range 5–365). Reasons for readmission included infection (n = 8), and dislodgement requiring monitoring or revision (n = 3). A total of 22 (9%) patients went to the operating room for a revision, and 19 (8%) patients required a conversion to a GJ tube by interventional radiology for continued feeding difficulties at a median of 110 days (range = 15–351) from gastrostomy. Over 1/3 of the patients received a gastrostomy tube contrast study (n = 76, with a total of 125 studies) for evaluation of tube placement or possible obstruction. The average variable direct cost of an ER visit related to gastrostomy concerns was 528 USD (±762). Including an average ER provider consultation rate of 700 USD in addition to the variable direct cost, an estimated mean cost of each ER visit was approximately 1200 USD. 4. Discussion Gastrostomy placement is a common, essential surgical procedure in children with a variety of indications for supplemental feeding. Unfortunately, the postoperative care of these tubes and buttons requires significant effort on the part of both the caregiver and the health care provider. The majority of postoperative issues related to the device are generally not serious. In one series comparing PEG to
Fig. 2. Distribution of patient concerns during ER and unplanned clinic visits.
J.A. Correa et al. / Journal of Pediatric Surgery 49 (2014) 1598–1601
laparoscopic tube placement, the postoperative complication rate was 6%, compared to a minor maintenance issue rate of 61% [6]. A similar study found a major postoperative complication rate of 10% and a minor rate of 45% [7]. Our study had similar findings, with a low readmission rate (4%) with few serious complications identified (and no intraoperative complications). While continued examination of operative technique (PEG vs. laparoscopic vs. open) may identify a superior method for decreasing major complications, the more frequent minor complications are likely independent of operative technique. Therefore, interventions aimed at reducing the incidence and resources devoted to the treatment of these minor problems should be focused on education at the caregiver level. In our own study, we discovered a rather high rate (20%) of 30-day post discharge ER visits related to the gastrostomy. A significant percentage of these visits were owing to issues that could have been avoided with a dedicated educational program, as granulation tissue, tube clogs, and leaking are all treatable by the caregiver at home or with a standard clinic visit. We included dislodgements within 30 days as essential visits, as theoretically these patients do not yet have a well-formed gastrostomy tract and likely require physician assessment of proper replacement into the stomach lumen. However, some of these dislodgements could have been avoided with improved caregiver education on proper gastrostomy handling. In one study of pediatric emergency room visits related to gastrostomy tubes, the most common complaint was tube dislodgement, and the majority were treated easily in the ER (97%) [3]. Regardless of the indication for the visit, a 20% ER rate within 30 days of discharge represents an opportunity for improvement, benefiting both the patient caregiver and the surgical provider. Our late visit rate (30 days–1 year) postdischarge was also significant at 16%. The overwhelming majority of trips were not related to emergent concerns (83%), particularly related to late tube dislodgement, clogs, and granulation tissue. Whether this rate of late ER visits is secondary to a lack of accessibility to our outpatient clinics, a need for continued education after discharge, or both is difficult to determine. At our own institution, we have a dedicated nurse at an outpatient clinic that provides treatment and education for postoperative patients, which might explain the relative decrease in the volume of visits over time to the ER. Identifying and removing barriers to patient access to this resource may help reduce the volume of ER visits in this patient group. While in general we would prefer that nonessential health care visits are made in the outpatient clinic setting as opposed to the emergency room, up to 1/3 of our patients came to the clinic with concerns that could have easily been addressed over the phone or by the caregiver. These visits recorded were not part of the routine postoperative care of the gastrostomy, so the overall volume of clinic time devoted to gastrostomies in their entirety is underestimated in this calculation. Again, reductions in this rate of clinic visitation, which would certainly help the caregivers of those with gastrostomies and relieve the high volume of patient flow to the extremely busy clinic, could be achieved with formalized educational efforts in gastrostomy care. Inherent in this discussion of ER and clinic visits related to the care of these gastrostomies are the resources utilized in their care and management. At a mean cost of 1200 USD per ER visit and time in the ER of 5 hours for basic gastrostomy maintenance, there exists the potential for an increasing cost burden to the family and the hospital over the course of the patient's lifetime, particularly if the primary provider is unable to troubleshoot GT issues independently. Of additional concern is the number of gastrostomy tube studies performed for confirmation of placement and positioning. More
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than 30% of our patients had a contrast study performed for a variety of indications, while only 2 had an abnormal finding related to obstruction and none with intraperitoneal extravasation. This trend was similarly observed in another study of confirmatory imaging after gastrostomy replacement in the ER, reporting only 1 finding of gastric outlet obstruction in 84 studies [8]. Further educational efforts for both the patients on tube maintenance and the ER and surgical staff on appropriate indications for contrast studies should help to decrease overall costs associated with gastrostomy care. There are limitations to this study. This is a retrospective review of data, and is subject to certain biases related to this type of data collection compared to prospectively obtained data. As patients may go to other hospitals for postoperative care, our results may underestimate the true ER visit rate and resources dedicated to the care of these devices. In our cost analysis, the true costs associated with managing these tubes are likely under estimated, as we were unable to calculate the cost to the caregiver for lost wages when missing work for hospital visits and the time spent by the surgical staff and residents fielding consultations. In general, the limitations of our study appear to underestimate the true amount of postoperative care required for these devices, and underscore the need for improved educational efforts.
5. Conclusion Few studies have attempted to quantify the amount of resources utilized postgastrostomy placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge. These educational materials are directed to address the indications for return to the ER that have been noted in this study. For example, patients with tubes would benefit from education that emphasizes issues related to dislodgement, while those with balloon buttons likely need additional education with regards to wound care. We will continue tracking our ER visit rates postgastrostomy placement after implementation to see if these interventions decrease the overall health care resource utilization. Hopefully the findings from this prospective study can demonstrate the cost benefit to the hospital of hiring dedicated surgical educators, with replication of this process in other disease processes.
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