Introduction Percutaneous Endoscopic Gastrostomy (PEG) is usually the preferred method of providing enteral nutrition in those patients whereby oral nutrition is contraindicated or inadequate for more than four to six weeks. Yet it is an invasive procedure and not without complications. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2004) found (19%) of PEG procedures were futile or not indicated at all. Furthermore 30 days PEG related mortality was reported to be between 2% to 26%. It was therefore advised that clinicians need to ensure appropriateness of its usage and that patient selection is paramount.
At our trust a Nutrition Nurse Specialist (NNS) assesses all adult patients referred for a gastrostomy. Complex patients are discussed with a Consultant Gastroenterologist or Gastroenterology Registrar. In the absence of the NNS a Gastroenterology Registrar reviews patients.
Methods Data was collected prospectively, by the NNSs, on both inpatients and outpatients referred for gastrostomy between 1 April 2010 and 1 April 2015. Information recorded included indication for and source of referral, time to procedure, morbidity and 30 day mortality.
ResultsTable 1 above shows the numbers of PEG, RIG (Radiologically Inserted Gastrostomy) and jejunostomy insertion, changes and removals.
During this period there were 5 infections at the tube site confirmed by positive culture (0.9%, reduced from 12.5% pre current NNS)
3 leakages resulting in peritonitis (0.5%)
1 bleeding post procedure -anticoagulation not held as per advice (0.2%)
Mortality Overall 30 day mortality from any cause following gastrostomy was 5.6% (n = 31). 3.8% (n = 21) were in the RIG group and 2% (n = 11) were in the PEG group.
193 (35%) patients were referred for gastrostomy but did not go ahead with the procedure or had it deferred. With the cost of gastrostomy insertion of approximately £2000 (PEG/RIG) this has resulted in a cost saving to the trust of £386,000.
Despite on-going training indication for gastrostomy insertion is still not understood by referring teams.
A NNS led service can reduce morbidity, mortality and procedure failure rate.
Comparing data to pre current NNS appointment the total number of tube insertions has doubled however deferral rates remain the same. There was a 15% failure rate which has since decreased to 3%.
Infection rate reduction, may be linked to the development of an education programme, development of nutrition link nurse role, competencies and policy.
Improve knowledge on procedure and complications to reduce the number of inappropriate referrals.
Disclosure of Interest None Declared