Fellows journal Club
Article: McSweeney ME, Meleedy-Rey P, Kerr J, Chan Yuen J, Fournier G, Norris K, et al. A Quality Improvement Initiative to Reduce Gastrostomy Tube Placement in Aspirating Patients. Pediatrics. 2020;145(2).
Fellow: Mary Katherine Hood MD, Le Bonheur Children’s Hospital (University of Tennessee Health Science Center)
Summary: In infants and children, oropharyngeal dysphagia with aspiration can be treated with adjustments in the oral feeding regimen through thickening of feeds or with placement of a gastrostomy tube. There is variability among providers with when to recommend gastrostomy tube placement. Previous data shows that patients with gastrostomy tubes have twice the number of hospitalizations when compared to those with thickened oral feeds, and oral feeding can improve neurologic outcomes and weight gain as well. Using an evidence-based guideline, this study aimed to standardize the approach to these patients and decrease the rate of gastrostomy tube placement. The primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within one year of implementing the evidence-based guideline, with balancing measures of total hospital readmissions or emergency department visits within 6 months of the abnormal videofluoroscopic swallow study (VFSS). Out of 6125 patients less than 2 years of age who had completed a VFSS, 1668 (27.2%) had aspiration or penetration noted on initial VFSS. The mean gastrostomy tube placement fell from 10.9% to 5.2% after evidence-based guideline initiation, which was sustained for 3 years.
Key Strengths: Using rigorous QI methodology, there was a significant decrease in the rate of gastrostomy tube placement, which was sustained for 3 years. Additionally, they created a multi-disciplinary team to educate physicians on providing oral feeds when possible and receiving support from aerodigestive sub-specialists when needed.
Limitations/Flaws: This project would be more difficult to initiate at an institution that does not have an aerodigestive center which could provide outpatient monitoring of nasogastric tubes. The primary outcome of gastrostomy tube placement within 6 months of the initial abnormal VFSS was used, so it is unknown whether there are some patients who had a gastrostomy tube placed after that time period.
Takeaway Message: Standardizing the approach to evaluation and management of infants or young children with dysphagia successfully decreased the need for gastrostomy tube placement but did not increase hospitalizations or ED visits. In fact, promoting oral feedings decreases the number of emergency department visits, and gastrostomy tube patients had twice the number of hospitalizations within the year.
Practice Impact: Physicians should consider oral feedings or NGT feedings (when oral feedings are not safe due to aspiration) prior to placing a gastrostomy tube, which has been shown to have higher associated costs and hospitalizations, especially since dysphagia can improve over time in young children.
Fellow: Mary Katherine Hood MD, Le Bonheur Children’s Hospital (University of Tennessee Health Science Center)
Summary: In infants and children, oropharyngeal dysphagia with aspiration can be treated with adjustments in the oral feeding regimen through thickening of feeds or with placement of a gastrostomy tube. There is variability among providers with when to recommend gastrostomy tube placement. Previous data shows that patients with gastrostomy tubes have twice the number of hospitalizations when compared to those with thickened oral feeds, and oral feeding can improve neurologic outcomes and weight gain as well. Using an evidence-based guideline, this study aimed to standardize the approach to these patients and decrease the rate of gastrostomy tube placement. The primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within one year of implementing the evidence-based guideline, with balancing measures of total hospital readmissions or emergency department visits within 6 months of the abnormal videofluoroscopic swallow study (VFSS). Out of 6125 patients less than 2 years of age who had completed a VFSS, 1668 (27.2%) had aspiration or penetration noted on initial VFSS. The mean gastrostomy tube placement fell from 10.9% to 5.2% after evidence-based guideline initiation, which was sustained for 3 years.
Key Strengths: Using rigorous QI methodology, there was a significant decrease in the rate of gastrostomy tube placement, which was sustained for 3 years. Additionally, they created a multi-disciplinary team to educate physicians on providing oral feeds when possible and receiving support from aerodigestive sub-specialists when needed.
Limitations/Flaws: This project would be more difficult to initiate at an institution that does not have an aerodigestive center which could provide outpatient monitoring of nasogastric tubes. The primary outcome of gastrostomy tube placement within 6 months of the initial abnormal VFSS was used, so it is unknown whether there are some patients who had a gastrostomy tube placed after that time period.
Takeaway Message: Standardizing the approach to evaluation and management of infants or young children with dysphagia successfully decreased the need for gastrostomy tube placement but did not increase hospitalizations or ED visits. In fact, promoting oral feedings decreases the number of emergency department visits, and gastrostomy tube patients had twice the number of hospitalizations within the year.
Practice Impact: Physicians should consider oral feedings or NGT feedings (when oral feedings are not safe due to aspiration) prior to placing a gastrostomy tube, which has been shown to have higher associated costs and hospitalizations, especially since dysphagia can improve over time in young children.
Fellow: Mary Katherine Hood MD, Le Bonheur Children’s Hospital (University of Tennessee Health Science Center)
Current Research: In residency, I realized that hospitalization serves as an opportunity to address issues that are not directly related to the hospitalization but affect the patients’ overall quality of life. During that time, I designed and implemented a quality improvement project which improved resident documentation of sexual history and subsequent screening for sexually transmitted infections by 20%. In fellowship, I have completed a retrospective cohort study of hospitalized pediatric patients to identify the rate of obesity recognition in a large multicenter inpatient database, since this is an issue that is affecting children’s health not only now, but for years to come. After obtaining the national data, I designed a quality improvement project for my institution to improve recognition of pediatric obesity in the inpatient setting, with the aim of improving inpatient dietician consults, documentation of obesity, obesity screening labs, and appropriate obesity follow up by 20%.
Future Plans: I have a passion for providing high-value, high-acuity care to underserved patient populations. I plan on continuing my career as a clinician educator at an academic institution and utilizing resident and patient education to improve longitudinal health for underserved communities.
Fun Fact: In my free time I enjoy painting, whether that may be giving old furniture a new look or painting a canvas to brighten up a room.
Current Research: In residency, I realized that hospitalization serves as an opportunity to address issues that are not directly related to the hospitalization but affect the patients’ overall quality of life. During that time, I designed and implemented a quality improvement project which improved resident documentation of sexual history and subsequent screening for sexually transmitted infections by 20%. In fellowship, I have completed a retrospective cohort study of hospitalized pediatric patients to identify the rate of obesity recognition in a large multicenter inpatient database, since this is an issue that is affecting children’s health not only now, but for years to come. After obtaining the national data, I designed a quality improvement project for my institution to improve recognition of pediatric obesity in the inpatient setting, with the aim of improving inpatient dietician consults, documentation of obesity, obesity screening labs, and appropriate obesity follow up by 20%.
Future Plans: I have a passion for providing high-value, high-acuity care to underserved patient populations. I plan on continuing my career as a clinician educator at an academic institution and utilizing resident and patient education to improve longitudinal health for underserved communities.
Fun Fact: In my free time I enjoy painting, whether that may be giving old furniture a new look or painting a canvas to brighten up a room.
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