Standardization Improves Discharge Care Coordination for Children with Nasogastric Tubes

Abstract

Introduction: Discharging patients with new nasogastric tubes (NGTs) for enteral nutrition at home is complex and requires intricate care coordination and education from a multidisciplinary team. We designed a quality improvement (QI) initiative to improve efficiency and decrease variation in care coordination for patients discharged with a new NGT. Our objective was to reduce mean modified hospital length of stay (mLOS) by 10% from baseline within 6 months and sustain improvement for 12 months.

Methods: Applying the Model for Improvement, we used plan-do-study-act cycles to improve NGT discharge care coordination using a multidisciplinary team. Primary interventions rooted in Lean methodology included creating a standardized discharge algorithm, utilizing nurse practitioners as care coordination champions, routine consultation of an enteral tube service (ETS), and implementing a formula substitution guide. The primary outcome measure was mean mLOS. The process measure was the time from NGT placement to ETS consult. Balancing measures were ETS consult volume and 30-day healthcare reutilization. Statistical process control charts measured the impact of interventions.

Results: Baseline mLOS decreased from 8.2 to 7.4 days with a sustained reduction in process variability over time. Time from NGT placement to ETS consult decreased from 4.1 to 3.0 days. There were no changes in 30-day healthcare reutilization or ETS consult volume over time.

Conclusions: A multidisciplinary quality improvement initiative effectively improved complex NGT transitional care planning and was sustained over time.

Fig. 1.

Key driver diagram for home NGT discharge optimization. Driver diagram depicting the relationship between project aim, primary drivers, secondary drivers, and associated change strategies. DME,: durable medical equipment.

Fig. 2.

Process map. The process flow map outlines the revised workflow created during the improvement project to guide medical providers through the care coordination process for patients being discharged home with new NGTs.

Fig. 3.

Statistical process control individuals chart (I-MR chart) of modified hospital length of stay for children discharged with NGTs for home nutrition. The I-MR chart shows a change in mLOS. Each point represents individual patient measurements in chronological order throughout the improvement project. A solid black line represents the mean centerline for mLOS. The solid blue line is the target improvement goal. Dotted lines denote the statistical upper and lower control limits. There is a downward arrow indicating the direction of intended improvement. The MR panel shows the absolute difference between the values in consecutively charted points in the control chart. The center line is the average of all MR values. LCL, lower control limit; MR, moving range; UCL, upper control limit.

Fig. 4.

Statistical process control individuals chart (I-MR chart) of time from NGT insertion to enteral tube service consult. The I-MR chart shows a change in time from NGT insertion to enteral tube service consultation. Each point represents individual patient measurements in chronological order throughout the improvement project. A solid black line represents the mean centerline for mLOS. The solid blue line is the target improvement goal. Dotted lines denote the statistical upper and lower control limits. There is a downward arrow indicating the direction of intended improvement. The MR panel shows the absolute difference between the values in consecutively charted points in the control chart. The center line is the average of all MR values. LCL, lower control limit; MR, moving range; UCL, upper control limit.