Introduction Percutaneous endoscopic gastrostomy (PEG) tubes are associated with complications and excess mortality if mistimed or inserted inappropriately. A 2008 anonymised NCEPOD review highlighted a very high mortality rate of 43% at one week post-insertion.1 The aim of this study was to see if the introduction of a new pathway, featuring the use of nasal bridles, could improve PEG related outcomes amongst inpatients at SRH - a hospital where >25% of inpatients are over 75.
Methods Nasal bridles for nasogastric (NG) tubes and a new multi-disciplinary pathway were introduced at SRH: May-Sept 2014. In Dec-2015 the notes for all inpatients receiving a PEG tube were reviewed. Group 1 – patients receiving PEG tube the year before the changes: [May 2013 – May 2014]. Group 2, the year after: [Sept 2014 – Sept 2015]. Prior modes of feeding and outcomes were analysed: 1outcome: 30 day mortality. 2outcomes: major complications; length of stay.
Results 58 inpatients received a PEG tube during the study period. Full records were unavailable for 2 from each group. Of the 54 remaining: 27 were male, 27 female; mean age: 76 (range: 34–95). Group 1: 29 patients (53.7%); None received a bridle or parenteral nutrition. 27.6% of patients multiply failed conventional NG progressing straight to PEG - mean age of subgroup: 85 (range: 76–93). 1outcome:30 day mortality - 27.6%. 2outcomes: two suffered a major complication (intra-abdominal sepsis); mean length of stay was 61 days. Group 2: 25 patients (46.3%); No patients received parenteral nutrition but 36% of patients received a nasal bridle prior to PEG - the mean age of this sub-group was 82 (range: 78–95). The mean delay from placement of bridle to PEG tube insertion was 26.5 days. 1outcome outcomes: 30 day mortality - 12%. 2outcomes: there were no major complications and the mean length of stay was 51 days.
Conclusion Decisions regarding the timing of PEG tube insertion are fraught with difficulty. The changes have greatly improved outcomes following PEG tube insertion locally. We, the authors, feel this is primarily because: 1) amongst a very elderly subgroup, nasal bridles helped to appropriately delay PEG tube insertion until nutrition was optimised; 2) the protocol served to improve communication between healthcare professionals preventing inappropriate PEG insertion. The changes were inexpensive but also contributed to saving the hospital up to 250 excess bed days, worth over £70,000.
Reference 1 Johnston SD, et al. Death after PEG: results of the national confidential enquiry into patient outcome and death. Gastrointest Endosc. 2008 Aug;68:223–7.
Disclosure of Interest None Declared
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