Implementation of dietitian led feeding tube change care pathway in the Emergency Department

Patients who present to the emergency department with a dislodged, broken or blocked feeding tube required an admission to access endoscopy or interventional radiology services to replace their feeding tube in the past. In April 2023, our emergency department clinical specialist dietitian introduced a care pathway whereby these tubes were replaced in the emergency department thereby avoiding hospital admission. This pilot study aimed to assess the feasibility of replacing feeding tubes in the emergency department and quantify the number of patients who would avoid hospital admission for same. A pilot project was conducted between June and October 2023 in a tertiary emergency department which has 53,000 annual presentations. Patients who presented to the ED with a dislodged, broken or blocked feeding tube as their presenting complaint were included in the study. In the initial PDSA (Plan, Do, Study, Act) cycle, feeding tubes were replaced by the ED clinical specialist dietician. Eighteen patients presented to the ED with feeding tubes as their primary presenting issue during the time period between June and October 2023. Seventeen patients had feeding tubes replaced, repaired or unblocked and were discharged directly from the ED with community care follow-up. The mean age of the study population was 56 years old and of whom 64% were male. Half of these patients had oesophageal and oral cancer diagnosis with the other half having a variety of diagnosis including cerebral palsy, Huntington’s disease and rare metabolic disorders. By replacing, repairing or unblocking these tubes in ED, unnecessary admission to hospital was avoided which equates to approximately 90 bed days saved. Patients and their carers reported that they were extremely satisfied with the efficiency of this service and the quality of care provided. Staff reported that their knowledge and confidence had increased significantly post training. The introduction of an ED clinical specialist dietitian led feeding tube change care pathway in our ED has ensured significant hospital admission avoidance rates in patients presenting with feeding tube issues and cost savings. The aim of the next PDSA cycle is to expand the skillset and knowledge of the ED medical and nursing clinicians regarding feeding tube management. Upskilling doctors will ensure that feeding tube replacement can be done outside working hours. To achieve these aims, the policies, procedures, protocols and guidelines (PPPG’s) on “Management of gastrostomy tube related issues in the emergency department” have been developed to give guidance to all health care professionals on this pathway. Furthermore, a clinical skills tube training workshop is being rolled out to all medical staff to provide this service out of hours when the dietitian is off duty. A nationwide training module is currently in development which will be available to all healthcare staff on the national health service e-learning platform (HSEland). Implementation of the feeding tube change care pathway in the Emergency Department enhances hospital avoidance, patient experience and reduces cost.