Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA.
Department of Surgery, Nemours AI duPont Hospital for Children, Wilmington, DE.
J Pediatr Surg. 2020 Jun;55(6):1013-1022. doi: 10.1016/j.jpedsurg.2020.02.033. Epub 2020 Feb 27.
Children requiring gastrostomy tubes (GT) have high resource utilization. In addition, wide variation exists in the decision to perform concurrent fundoplication, which can increase the morbidity of enteral access surgery. We implemented a hospital-wide standardized pathway for GT placement.
The standardized pathway included mandatory preoperative nasogastric feeding tube (FT) trial, identification of FT medical home, and standardized postoperative order set, including feeding regimen and parent education. An algorithm to determine whether concurrent fundoplication was indicated was also created. We identified children referred for GT placement from 2015 to 2018 and compared concurrent fundoplication rates and outcomes pre- and postimplementation.
We identified 332 patients who were referred for GT. Of these, 15 avoided placement. Concurrent fundoplication decreased postpathway (48% vs 22%, p < 0.0001). After adjusting for reflux and cardiac disease, prepathway patients were 3.5 times more likely to undergo concurrent fundoplication. ED visits (46% vs 27%, p = 0.001) and postoperative LOS (median (IQR) 10 days (5-36) to 5.5 days (1-19), p = 0.0002) decreased.
A standardized pathway for GT placement prevented unnecessary GT placement and fundoplication with reduction in postoperative LOS and ED visits. This approach can significantly reduce resource utilization while improving outcomes.
Prognosis study.
Level II.
需要胃造口管（GT）的儿童资源利用率高。此外，同时进行胃底折叠术的决策存在很大差异，这会增加肠内通路手术的发病率。我们实施了一项全院范围的 GT 放置标准化途径。
标准化途径包括强制性术前鼻胃管（FT）试验、确定 FT 的医疗之家以及标准化的术后医嘱集，包括喂养方案和家长教育。还创建了一个确定是否需要同时进行胃底折叠术的算法。我们确定了从 2015 年到 2018 年因 GT 放置而转介的儿童，并比较了实施前后同时进行胃底折叠术的比率和结果。
我们确定了 332 名因 GT 而转介的患者。其中 15 人避免了放置。实施途径后，同时进行胃底折叠术的比例降低（48%比 22%，p<0.0001）。在调整了反流和心脏病后，途径前的患者进行同时胃底折叠术的可能性是其 3.5 倍。急诊就诊（46%比 27%，p=0.001）和术后住院时间（中位数（IQR）10 天（5-36）至 5.5 天（1-19），p=0.0002）减少。
GT 放置的标准化途径可防止不必要的 GT 放置和胃底折叠术，同时减少术后住院时间和急诊就诊次数。这种方法可以在改善结果的同时显著减少资源利用。
预后研究。
二级。
