Enhancing gastrostomy tube care: A qualitative insight into G-tube safety and related policy dissemination at a large academic tertiary care center

From the 2023 HVPA National Conference

Xiyu Zhao, Undergraduate (Johns Hopkins School of Medicine), Danna Lamont, Undergraduate (Johns Hopkins University School of Nursing), Sarah Osorio, Undergraduate, Jacob Blum, Undergraduate, Carolyn Im, Undergraduate, Siam Muquit, Undergraduate, Ariel Leong, Undergraduate, Oren Wei, Undergraduate, Aaron Bao, Undergraduate, Shreya Sriram, Undergraduate, Setu Mehta, Undergraduate, Renee Blanding

Background:
Gastrostomy tube (G-tube) placement is a standard procedure for patients requiring long-term enteral access. Techniques include percutaneous endoscopic gastrostomy (PEG), fluoroscopy-guided gastrostomy, and open or laparoscopic gastrostomy. Recognizing adverse events and understanding mortality rates are crucial for patient care. Tube dislodgment is a significant complication, prompting new hospital-wide enteral nutrition policies.

Objectives:
This study aims to assess current gastrostomy tube practices and policy dissemination at a large academic tertiary care center, providing recommendations for safer G-tube placement and maintenance.

Methods:
Hour-long qualitative interviews were conducted with physicians and nurses involved in G-tube placement and maintenance. Content and thematic analyses were performed using NVivo 1.0.

Results:
Nine stakeholders participated in this study. Assessment of current policy dissemination methods revealed a fragmented process necessitating individuals to independently seek out and read new policy changes.. Existing channels include email, in-person training, policy manuals, online resources, and hospital flyers. Of the nursing staff, 57.1% (n=4) reported not thoroughly reading email notifications due to their volume and length. Different units reported various methods of learning about new policies.

Several patient-related, device-related, and system-related factors contributing to g-tube dislodgment were identified (Figure 1). To address shortcomings in policy dissemination and identified risk factors, we propose implementation strategies and a new patient workflow for g-tubes (Figure 2). The current workflow includes assessment, preparation, consent, insertion, management, and removal. We recommend incorporating a risk stratification process before tube insertion to guide patient management. Primary providers should examine identified risk factors and develop tailored g-tube maintenance plans based on dislodgment likelihood. For high-risk patients, interventions like frequent monitoring and prophylactic mittens can prevent dislodgment.

For policy dissemination, we propose using brief, targeted communication, identifying the most relevant units and departments, and sending concise key takeaways to those units. We recommend designating a policy educator role to the charge nurse and/or educational council for improved clarity, understanding, and implementation of new policies.

Conclusions:
This study emphasizes the need for improved gastrostomy tube care and effective policy dissemination methods at a large academic tertiary care center. Incorporating risk stratification into the g-tube workflow and tailoring maintenance plans based on dislodgment likelihood can enhance patient safety and mitigate complications. Adopting brief, targeted communication strategies and designating a policy educator role within hospital units can improve policy dissemination and understanding, leading to better patient outcomes. Further research is needed to evaluate the effectiveness of these proposed changes and explore standardized scoring models for assessing patient safety concerning gastrostomy tubes.

Clinical Implications:
This educational program can advance participants’ practice in gastrostomy tube care and policy dissemination, improving care value. Incorporating risk stratification and creating tailored maintenance plans can effectively prevent complications such as tube dislodgment, enhancing patient safety and reducing treatment costs. The program’s emphasis on targeted communication strategies and designating a policy educator role addresses policy dissemination challenges, ensuring medical professionals are consistently informed, resulting in better adherence, understanding, and implementation.

The clinical implications extend beyond gastrostomy tube care, as the proposed strategies for policy dissemination and risk management can apply to other healthcare practices, optimizing patient care and safety across various medical disciplines.

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