Traditional Poster Round
Context: : Gastrostomy (G Tube) and gastrojejunostomy (GJ Tube) dislodgement is a frequent problem for enterally fed children. Management involves the insertion of a temporary tube into the tract to protect tract patency. Use of an improperly placed temporary tube can cause serious harm to patients. Contrast study is recommended to verify tube placement if uncertain. However, ordering a contrast study for every patient with a dislodged tube will result in over testing and unnecessary waste of resources. Over the last few years, multiple safety events involving G and GJ tubes have occurred at The Hospital for Sick Children. Tube dislodgement protocols have varied depending on the service that inserts the original tube. The development of an algorithm to manage G and GJ tube dislodgements will decrease safety events within the organization. The aim of this project is to standardize the care of G and GJ Tube dislodgement at The Hospital for Sick Children by developing a unified algorithm that can be used in all areas and to test it with simulation prior to implementation.
Description: : The Model for Improvement was used to develop and test a new G and GJ Tube dislodgement algorithm. Several Plan-Do-Study-Act cycles initially focused on developing the algorithm. The subsequent cycles focused on testing the algorithm by using in-hospital simulations. Front-line stakeholders, quality improvement experts and SickKids Learning Institute were engaged. Clinicians who manage or at risk of managing G and GJ tube dislodgement were recruited on different inpatient units across the hospital. Three clinical scenarios were created and based on the serious safety events. The three arms of the algorithm were tested. Each simulation included utilizing the algorithm through a clinical scenario followed by a debriefing session and a small participant survey. The G and GJ Tube algorithm was revised with each simulation, based on observations and participant feedback. The newer draft version was utilized for the subsequent simulation. Qualitative data were analyzed. A T chart was used to analyze baseline safety events.
Observation/Evaluation: : Subject matter experts, front-line stakeholders and quality experts developed the G and GJ tube dislodgement algorithm. A total of 19 simulations were done across multiple units at The Hospital for Sick Children. Participants included 12 nurses, 4 nurse practitioners, 3 trainees and 2 physicians. Most of the participants worked in General Paediatrics (38%). Through simulations, a strong culture of urgent Foley reinsertion to preserve the stoma was observed, no matter the type of device. Identification of the type of device and the date of primary insertion was difficult for several participants. Participants commented on the complex appearance of the algorithm's first version. The algorithm was revised based on observations and feedback from participants. Participants gave a score of 86% for realism of the scenarios, 83% for appreciation of the algorithm and 91% for its usefulness. Suggestions to implement the G and GJ tube dislodgement algorithm were obtained.
Discussion: : An algorithm to standardize the management of dislodged G and GJ tubes, and the tube placement verification was developed and then tested through simulations. Simulation helped to identify the strengths and weaknesses of the algorithm, facilitating improvement and ensuring it is user friendly for clinicians. Use of simulation was a valuable tool that helped our organization to optimize the quality of an algorithm before implementing it as a new policy.