Universal Outpatient Management of Pediatric Nasogastric Tubes by the Pediatric Gastroenterology Division Did Not Significantly Reduce Emergency Department Utilization for Tube Evaluation at a Tertiary Care Children's Hospital

ABSTRACT

Background: Enteral tubes, including nasogastric (NG) tubes, are an important tool in managing multiple medical conditions in which oral feeding cannot be successfully accomplished due to feeding ability or safety, and these devices are commonly employed at children's hospitals worldwide. While these devices are life-saving, they can develop are a significant burden on families and the healthcare system. There is relatively little published data on the practices of pediatric enteral tube outpatient management, including whether primary outpatient management is undertaken by pediatric gastroenterologists or other medical practitioners (e.g. primary care providers and other pediatric subspecialists), and if a primary management team would affect overall clinical outcomes. In the late fall of 2019, at the American Family Children's Hospital (AFCH), a tertiary care children's hospital, pediatric outpatient enteral tube management, with the exception of tubes in patients under the primary care of Pediatric Hematology/Oncology (PHO), was fully assumed by the Pediatric Gastroenterology (PGI) division, with previous management divided or shared among the PGI division, primary care providers, and other pediatric subspecialists. Due to the division having subspecialty nurses, nurse practitioners, and physicians who had expertise managing enteral tubes on an inpatient and outpatient basis, we hypothesized that primary outpatient management by Pediatric GI would reduce ED utilization for nasogastric tube evaluation. Method(s) We performed a retrospective chart review of all patients discharged from AFCH with a nasogastric tube in place from March 1 2018 to October 31 2019 and June 1 2020 to January 31 2022. The study was reviewed by the University of Wisconsin-Madison Minimal Risk Research Institutional Review Board and met criteria for exempt human subjects. We left a 7-month temporal gap to allow for complete implementation of the policy of pediatric GI management to be uniformly practiced within the hospital, and to account for the beginning of the COVID-19 pandemic, when outpatient clinics were closed and ED evaluation was required for all hands-on non-inpatient medical care at our institution. Patients were grouped and analyzed according to being pre-intervention or post-intervention, and they were followed until either their NG tube was permanently removed, or until their NG tube was replaced with a gastrostomy tube. Patients were excluded if they were primarily managed by PHO, lost to followup, still had NG tube in place at time of data analysis, died during the study period, or had their tube converted to a postpyloric tube. Our primary outcome was the incidence rate of ED visits for nasogastric tube evaluation per patient-weeks between the pre- and post-intervention groups. Patient demographics and diagnoses were also recorded and analyzed. Statistical analysis was conducted. Result(s) There were 130 patients identified after applying inclusion and exclusion criteria, with 56 in the pre-intervention group and 74 in the post-intervention group. The median chronological age of patients in the pre-intervention group was 5 months, and it was 6 months for the post-intervention group. The mean time from initial hospital discharge to either NG tube removal or conversion to gastrostomy tube was 6.2 weeks in the pre-intervention group and 8.8 weeks in the post-intervention group. In the pre-intervention group, the incidence rate of ED visits for NG tube evaluation was 15.6 visits per 100 patient-weeks (95% Confidence Intervals (CI) 11.7-20.3), and in the post-intervention group, the rate was 9.7 visits per 100 patient-weeks (95% CI 7.4-12.4). Discussion(s) This study demonstrated that at our institution, there appeared to be a decrease in ED utilization for nasogastric tube evaluation after outpatient tube management was assumed by the PGI division, but this decrease was not quite enough to reach statistical significance. This study is limited by multiple factors including the retrospective nature of the study, modest sample size limiting statistical power, and, potentially, lingering effects of the COVID-19 pandemic affecting patient care decisions. Identifying balancing measures from this intervention, as well as identifying alternative changes that could further decrease ED evaluation rates, can be explored in future quality improvement initiatives.