392 - The Emergency Department Nurse and Gastrostomy Tube Replacement at Triage: How Safe is it?

Poster Number: 392
Publication Number: 392.314

Katlin VanDerhoef, IHS - Pediatric Resident, Minneapolis, MN, United States; Czarina Jimenez, University of Minnesota Masonic Children's Hospital, Otsego, MN, United States; Jonathan Strutt, The University of Minnesota, Edina, MN, United States; Iluonose Amoni, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States; Jeffrey Louie, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States

Background: Complications of gastrostomy tubes (GT) often present to the Emergency Department (ED) and may include site infections, clogged GT, dislodgement or balloon rupture requiring replacement. Likely a physician or nurse practitioner replaces the GT as compared to a nurse.

Objective: We introduced a nurse-only guideline to replace a GT in triage. This retrospective study will describe successes, failures, and return visits within 72 hours after replacement and compares physician versus nurse replacement data.

Design/Methods: Data was collected from January 1, 2011 through April 13, 2020. MRNs were obtained using ICD-10 codes for gastrostomy tube: Z93.1, K94.23. The RN GT guidelines were initiated on January 31, 2018. The RNs were trained to replace a GT but only under strict conditions: the GT was at least post-op day 90 and the first GT replacement after surgical placement was by either gastroenterology or surgery; any dislodged GT had to be less than 24 hours; and replacement of GT was identical in size and length. GT was confirmed with aspiration of gastric fluid. Variables collected were: age at visit, return visit within 72 hours, and reason for replacement. For comparison, data was collected for MD visits for GT replacement that did not require dilation, consultation, or sedation.

Results: A total of 58 encounters, of which 57 (98.3%) GT were successfully replaced by ED RN. MD replaced 87 GT (excluded were patients who required dilatation, a surgery consult, or sedation) and no cases returned within 72 hours. The mean length of stay for RN-only GT replacement (N, 57) was 22 minutes (SD 16.7 minutes), while MD visits was 86 minutes (SD 63.3 minutes), a difference of 64.6 minutes, (P < 0.0001). One (1/58, 1.7%) GT replaced by RN returned to ED < 72 hours (Table 1).Conclusion(s): Using a strict protocol, ED RNs can successfully replace a GT without MD supervision and length of stay was significantly shorter for RN encounters. The protocol allowed an RN to confirm GT by aspiration of gastric fluid without exposure to radiation via radiographs or other studies. No child returned with an intra-abdominal infection or GT failure. It may appear that the initiation of RN only visits to manage dislodged or clogged GT was successful and safe.
Table 1. Description of the Child Who Returned to ED after G-Tube Replacement by RNOnly one child returned to the ED after replacement by RN or MD