title: Resource utilization after gastrostomy tube placement: defining areas of improvement for future quality improvement projects.
abstract: BACKGROUND
  Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care children's hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis.
  
  
  METHODS
  We reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30 days after discharge and 30-365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies.
  
  
  RESULTS
  During the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3 months (range 0.03 months-22 years). Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31-365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%).
  
  
  CONCLUSIONS
  Few studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge.
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Jesus A
authors.initials: JA
authors.lastname: Correa
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Sara C
authors.initials: SC
authors.lastname: Fallon
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Murphy
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Veronica A
authors.initials: VA
authors.lastname: Victorian
authors.affiliation: Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX.
authors.forename: George S
authors.initials: GS
authors.lastname: Bisset
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Sanjeev A
authors.initials: SA
authors.lastname: Vasudevan
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Monica E
authors.initials: ME
authors.lastname: Lopez
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Mary L
authors.initials: ML
authors.lastname: Brandt
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Darrell L
authors.initials: DL
authors.lastname: Cass
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: J Ruben
authors.initials: JR
authors.lastname: Rodriguez
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: David E
authors.initials: DE
authors.lastname: Wesson
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX. Electronic address: tclee@texaschildrens.org.
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Lee
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D005774:Gastrostomy / Q000295:instrumentation*; D006295:Health Resources / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D058996:Quality Improvement; D012189:Retrospective Studies; D055815:Young Adult
keywords: Gastrostomy; Pediatrics; Quality improvement