Introduction Careful patient selection is key in the success of percutaneous endoscopic gastrostomy (PEG) procedures1. The 30 day mortality rate post insertion is an indicator of appropriate selection in those who are chosen for PEG, but reveals nothing about the patients judged unsuitable for PEG. We evaluated our decision making behind patient selection based on outcomes in those with a PEG inserted and those without.
Methods The study identified all patients referred for specialist nurse-led PEG assessment between Jan 2007 – Dec 2011 within our centre. Data regarding age, sex, diagnosis, indication for PEG, date of referral, reason for non-insertion and RIG referrals were stored prospectively on a clinical database and analysed retrospectively. Patients were stratified into groups and mortality in each examined. Further information regarding cause of death and alternative feeding methods were obtained for selected patients from paper and electronic patient notes.
Results A total of 555 PEG referrals were received with 38% of all referrals to the PEG team resulting in PEG non-insertion. The 30 day mortality rate following PEG insertion was on average 6.1%; this reduced from 8.6% in 2007 to 2.2% in 2011. 50% of all patients in the non-insertion group had a CVA as their diagnosis. 47% of all non-insertion patients and 83% of insertion patients were alive 120 days after referral. Reasons for non-insertion were grouped into unfit (n = 98, 46% of total), improved (n = 44, 21%), contraindicated (n = 34, 16%) and refused (n = 26, 12%). 74% of those deemed unfit died within 30 days of referral, and 93% of those judged to be improving were alive at 4 months post-referral. RIG referrals were arranged in 19 of 34 patients contraindicated against a PEG procedure. Patient or family refusal was the main reason for non-insertion in 12% of the non-insertion group. 12 notes were examined in patients who died in 60–180 days following PEG referral: 9 had evidence of NG feeding and 3 received RIGs. Extensive MDT input was evident. 4 patients were re-referred to the service for a second assessment if the best option was unclear.
Conclusion Patient selection for PEG will continue to be complex. The nurse-led PEG assessment team, in conjunction with other MDT members, make well-informed and justifiable decisions, based on the low 30 day mortality rate post insertion, and that reasons against insertion correlate with how patient condition progresses. Alternative feeding methods are employed in the non-insertion group to combat ongoing nutritional needs. Lack of information on quality of life is the main limitation to the conclusion.
Disclosure of Interest None Declared.
Kurien M, McAlindon ME, Westaby D, Sanders DS. Percutaneous endoscopic gastrostomy (PEG) feeding. Bmj. 2010 May 7; 340(may07 2):c2414–c2414.