Home enteral feed dietitians save unnecessary hospital admissions of patients with percutaneous endoscopic gastrostomy (PEG)

Abstract

Having shown that PEG-related complications are a common cause of hospital readmission (1) , two home-enteral-feed (HEF) dietitians were appointed to provide patient support in the community by regular dietetic monitoring and having the ability to respond to gastrostomy-related problems efficiently to prevent hospital re-admission. They also provide training to patients, carers and other health care professionals on how to deal with tube complications including displacement. All patients were discharged with an aftercare protocol including advice and contact numbers in the event of problems. Data for the year ending February 2007 were collected prospectively using the Infoflex PEG database. The caseload at the year end was 180 patients. Over this period, a total of 245 individual patients were home-enterally-fed at some point. Seventy-nine of these were new patients of whom 91 % were seen within 5 working days (mean 2.9 d) of hospital discharge. There were 1514 follow-up contacts (home, n 825; nursing or residential home, n 392; telephone, n 303; outpatients , n 3 and hospital inpatients, n 2). A total of 545 PEG-related complications were dealt with (over-granulated stoma, n 98; broken Y adaptor, n 88; broken clamp, n 50; leaking stoma, n 47; fixation device too tight, n 23; damaged tube, n 15 and other, n 123). A total of 101 patients required new balloon retained gastrostomies (seventy-one balloon gastrostomies and thirty low profile gastrostomies), fifty-eight as emergency procedures (following PEG displacement, tube damage or blockage) and forty-three planned, with no complications. Although sixty-nine patients were admitted during this year, only fifteen (21 %) were for PEG problems and all occurred at times of non-availability of staff at weekends or holidays or failure of carers to adhere to the written aftercare protocol. Hospital admissions were avoided in all fifty-eight instances (thirty patients, 12 % of the total cohort of 245 patients) of PEG displacement, damage or blockage by emergency replacement by the HEF dietitians. However, it is likely that the early diagnosis and treatment of less urgent complications, and the training of patients, carers and other health care professionals will have avoided many further admissions.

A scoping review of best practices in home enteral tube feeding

“…Many common tube-related issues such as blockages or dislodgement may be dealt with at a lesser cost by having a specialist service. Furthermore, early recognition and treatment of non-urgent complications can save costs and hospital admissions (White et al, 2008). In addition to providing practical support around the feeding regimen and ET, a HEN dietitian may provide reassurance for patients, particularly in the initial stages of adaptation to HEN.…”

“…Another (White et al, 2011) found that 343 PEG-related complications were handled by the HEN team during a one-year period, and 228 hospital admissions were avoided due to direct actions taken by the HEN team. Finally, 545 PEG-related complications were dealt with by the HEN team, and hospital admissions were avoided in all fifty-eight instances of PEG displacement, damage, or blockage by emergency replacement by the HEN dietitians (White et al, 2008).…”

High costs and limited dietitian services for home enteral nutrition users: A Canadian study

“…Previous findings demonstrate that patients who have timely access to community RD services and multidisciplinary teams have reduced number of hospital-related visits. 3,4,20,21 This lack of coordinated community care may explain the higher number of hospital visits given the top 3 complications (gastrointestinal, pneumonia, and metabolic complications) are best managed by a multidisciplinary team. It could also be theorized that those who were acutely ill and experiencing HEN complications were more tenacious in trying to resolve their issues by seeing a community RD but, in turn, also had more visits to the emergency room and hospital.…”

Hospital Inpatient Admissions With Dehydration and/or Malnutrition in Medicare Beneficiaries Receiving Enteral Nutrition: A Cohort Study

“…Patients with an HHV who were admitted were more likely to be eligible for Medicaid, compared with those who were not admitted. Previous work demonstrates that support from home EN dietitians can reduce unnecessary hospital admission of patients receiving home EN . This suggests it is helpful for clinicians to be aware of the Medicaid‐eligible status of their EN patients and that support from home EN dietitians may be particularly effective for reducing acute care hospital admissions in this population.…”