Optimizing Cost and Workflow: A Quality Improvement Initiative in Outpatient Placement of Gastrostomy Tubes
22 March 2018 (online)
Purpose The current practice for outpatient placement of percutaneous gastrostomy tubes (g-tubes) by interventional radiology (IR) at our institution is overnight admission and fluoroscopic g-tube check the next morning, prior to initiation of enteral feeding. Our primary objective is to examine the clinical need for routine admission and g-tube check after. Secondarily, we aim to quantify the potential cost savings of a policy change.
Materials and Methods There are both IR and gastroenterology (GI) data, which shows no significant difference in complication rates between the same day discharge versus admission and also show safety in early enteral use of the g-tube in properly selected patients. While they are admitted, there should be a nutrition consult for not only teaching and use information, but also evaluating for risk of re-feeding syndrome in those patients who will be predominantly dependent on their g-tube for enteral nutrition. We questioned the need for routine admissions and fluoroscopic checks of the newly placed g-tubes on all patients.
Results Ninety-three outpatients who underwent new g-tube placement from 2011 to 2016 were included. All the next day, fluoroscopic g-tube examinations were normal. Median and mean length of stay (LOS) were 1.0 and 1.6 days, respectively. Twenty-six percent had a LOS >1 day: 11 related to nutrition and 7 of 11 based on high risk of re-feeding syndrome (RFS) or laboratory evidence of RFS. Excluding patients with a LOS >1 day, the mean and median cost of visit was $8,524.89 and $6,104.35, respectively.
Conclusion We found no indication for post-procedure g-tube checks or routine admission of all patients overnight. There were no changes in patient management based on normal results of g-tube check in 100% of patients. Regarding admission, those 7.5% of patients who were deemed high risk or developed RFS benefited from a planned admission. One change we propose is a nutrition consultation concurrent with a pre-procedure clinic visit to identify patients at risk for RFS that would benefit from a planned admission. The potential average cost savings in eliminating all post-procedure g-tube checks as well as routine admissions in low-risk patients would be $5,470 per patient in our population. This is based on an estimated average cost of medical supplies, procedure, and fluoroscopy suite time from a representative sampling of cost data. Our results are concordant with other data from both the IR and GI literature concluding that routine admission of all outpatient placements is not indicated.