St Vincent’s Hospital Sydney (SVHS) improved patient information, treatment procedures and staff education, to ensure the placement of gastronomy feeding tubes aligned with best practice and Agency for Clinical Innovation (ACI) guidelines.
Aim
To ensure 100 per cent of patients referred for a gastronomy feeding tube on Ward 8 South in SVHS have a holistic nutrition plan in place prior to and following tube insertion, within 12 months.
Benefits
- Provides integrated and standardised care for patients who need gastrostomy tubes and devices.
- Improves clinical pathways at every stage of the patient journey, including the needs assessment, insertion of gastronomy tubes and devices, and ongoing care.
- Provides a clearly defined journey for patients to follow when using a gastrostomy tube or device.
- Improves knowledge across the emergency department and surgical wards about gastronomy feeding tubes and devices.
- Enhances the patient experience and quality of care delivered to those who need gastronomy tubes and devices.
Background
Gastrostomy tubes and devices are an established means of providing long-term enteral nutrition. A gastrostomy tube or device is inserted into the stomach through the abdominal wall, so that liquid nutrition, fluids and medication can be given1. However, a review by the ACI’s Gastroenterology and Nutrition Networks in 2012 found there were no statewide guidelines in place for the management and care of people who require gastronomy feeding.
The ACI published its statewide Gastronomy Guidelines in November 2014 and conducted a baseline audit of hospitals in 2015, asking them to compare their practices with the new guidelines. SVHS performed poorly in this audit and, during the auditing process, discovered that staff were not following best practice in terms of which patients were offered gastronomy feeding during their treatment for certain types of head and neck cancers.
A review of critical incidents and a retrospective audit of medical records from 2012-2014 also highlighted the need to reduce clinical variation when recommending and providing gastrostomy feeding to patients. Anecdotally, there was frustration among doctors about the lack of standardised patient journeys and potential for patients to receive less than appropriate care.
Implementation
- A multidisciplinary team of key stakeholders (including a patient representative, medical staff, dietitians, nurses, speech pathologists and pharmacists) was established to map the patient journey and extend the retrospective medical record audit to include 2014-16, benchmarking results against ACI guidelines.
- Written patient education materials used by dietitians, stomal therapists and pharmacists were updated to reflect ACI guidelines and standardised to meet SVHS policy requirements, such as use of simple language and approved logos.
- The ACI guidelines document was implemented as an official policy for SVHS and made available on the hospital intranet. A screen saver was developed for all hospital computers to notify staff of the change.
- As the ACI guidelines are long and complex, a Caring for People with Gastronomy Tubes and Devices Procedure was developed, to provide staff with a guide for each step in the referral, placement and management process when caring for patients with gastronomy tubes and devices at SVHS. This procedure is currently in the draft stage and has been provided to key hospital stakeholders for comment, including the Stroke Unit, Endoscopy Unit, upper GI surgical team, and head and neck cancer team.
- Nursing and allied health staff received a one-hour face-to-face group education program delivered by a stomal therapist, on the topic of pre and post-insertion care of gastronomy tubes and devices. The ACI guidelines and results from the retrospective audit were used to inform the content, which was developed by a stomal therapist in conjunction with the Nursing Education Unit. A pre and post-education knowledge and confidence questionnaire was provided to all participants.
- Patients often did not know or forgot about the details of their gastronomy tube which was placed during admission. This sometimes led to delays in appropriate post-insertion management in doctor’s clinics and emergency departments. To improve communication between healthcare teams following discharge, a wallet-sized information card was developed for patients to keep. This card contained information on the type of tube, its placement details and contact details of the hospital.
- A standardised electronic referral form for gastroenterologists and ear, nose and throat surgeons was developed for medical and surgical teams who required gastronomy tubes for their patients. Previously, there was no formal process for this referral, with requests written in the notes without details regarding reasons for placement. This led to an increased length of stay, delays in the referral process and more time spent without an appropriate feeding tube for the patient. The new referral form contains all the information required by surgeons to triage the patient and make the booking.
- The initial audit identified that patients were not receiving quality information about potential complications and risks of gastronomy tube feeding and as a result, were not able to understand the risks and provide informed consent. A one-page brochure was developed that contains all the relevant information, which is signed by the doctor and patient or carer and kept by the patient or carer. This complemented the new patient education materials developed.
- A sticker was developed, which is placed in the patient’s medical record and used to record the details of their gastronomy tube insertion procedure. While it does not replace theatre notes, the sticker is large, bright and easily noticeable to anyone going through the medical record. The sticker also acts as a reminder to doctors and nurses about the new post-insertion management guidelines.
Status
Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.
Dates
June 2016 – June 2018
Implementation Sites
St Vincent’s Hospital Sydney, SLHD
Partnerships
- Clinical Leadership Program
- ACI Nutrition Network
Evaluation or Results
A full evaluation will be conducted in June 2018, once all solutions are implemented. This will include measurement of:
- number of patients referred for a gastronomy feeding tube with a holistic nutrition plan in place prior to and following tube insertion
- compliance with the new policy and procedure once it has been implemented for 12 months
- compliance with electronic referral forms for gastroenterologists and ear, nose and throat surgeons
- staff knowledge and confidence in the management of gastronomy tubes and devices, following education
- feedback from patients and carers on the content, layout and readability of patient education materials, the one-page brochure and wallet-sized information card.
As of August 2017, staff knowledge and confidence in the management of gastronomy tubes and devices has improved significantly following education sessions. Moving forward, a Gastrostomy Support Team will be established to identify patients who need gastronomy feeding, as well as provide expert advice and support for doctors during the patient’s hospital stay and beyond. This team will be led by an oncology senior dietitian and include representatives from gastroenterology, nursing, speech pathology and pharmacy teams, to regularly monitor and review gastrostomy feeding practices throughout SVHS.
Lessons Learnt
Key Learnings
- It is important to engage key stakeholders across disciplines and ensure that all team members have a desire for change.
- Undertaking a full diagnostic evaluation of current processes is essential before planning solutions.
- Consumer involvement allowed the team to stay focused on patient outcomes.
- Support from the Patient Quality and Safety Unit representative was essential, especially when writing new policies and procedures.
- It is a good idea to start with a small project team and only expand membership if and when required.
Key Challenges
- The scope of the project was huge and difficult to achieve in a 12-month timeframe.
- Once clinical variation is identified, it can be difficult to get some doctors to agree on priorities for change and actions to make them happen. There is also a power gradient between non-medical staff and medical staff which makes challenging the variations in medical practice by non-medical staff difficult. By having medical staff on our team, we were able to build a trusting relationship which made this process easier.
- Getting financial support for a proposed Gastronomy Support Team was a challenge, as not all staff have the time to add more responsibilities to their role and its value needed to be clearly articulated for funding purposes.
- Some problems cannot be solved at the present time, as they rely on additional funding and departments.
- Standardising documentation is a challenge. This was addressed through the development of the new referral form and sticker.
- Partnering with consumers is important, but the consumer’s wellbeing needs to be carefully monitored, to make sure they are coping with the frank discussions that will occur when attempting to fix practices that are not working well.
References
- NSW Agency for Clinical Innovation (ACI). A Clinician’s Guide: Caring for people with gastrostomy tubes and devices. From pre-insertion to ongoing care and removal. Chatswood, NSW: ACI; 2014.
Further Reading
Rob’s Story (video about living with a permanent gastrostomy feeding tube)
Contact
Melissa Armstrong
Manager, Nutrition and Dietetic Services
St Vincent’s Hospital Sydney, SLHD
Phone: 02 8382 2654
Email: melissa.armstrong@svha.org.au
