The Pediatric Emergency Department Nurse and Gastrostomy Tube Replacement: How Safe Is it?

AIM: To review the outcomes of a nurse-only guideline for replacement of gastrostomy tubes (g-tubes) in a pediatric emergency department (ED) and compare rates of success, failure, length of stay (LOS), and return visits with that of ED physicians. DESIGN: Nursing g-tube guidelines, created by a nurse educator and nursing council, were instigated on January 31, 2018. Variables examined included LOS, age at visit, return visit within 72 hours, reason for replacement, and any postplacement complications. REVIEW METHODS: Data of g-tube placement by nurses and physicians were compared using t test or χ 2 analysis (IBM-SPSS version 20, New Orchard Road, Armonk, NY). The institutional review board determined the study to be exempt from human subjects. The STROBE checklist was used and completed accordingly. DATA SOURCES: Chart abstraction and data were collected from January 1, 2011 through April 13, 2020, and medical records were obtained using International Classification of Diseases, Tenth Revision (ICD-10) codes for g-tubes: Z93.1, K94.23. RESULTS: A total of 110 patients were included in our study. Fifty-eight underwent nursing-only replacements; 52 were replaced by physicians. Nurse replacement success rate was 98.3% with an average stay of 22 minutes. Physician success rate was 100% with an average stay of 86 minutes. The difference between nursing and physician LOS was 64.6 minutes. No patient in either group experienced postreplacement complications. CONCLUSIONS: The initiation of nurse-only management of dislodged g-tubes was successful, safe, and had a shorter LOS when compared with physicians in the pediatric ED. IMPACT: Our study determined the implications of nurse-only replacement of g-tubes in a pediatric ED. We found that nurses replacing g-tubes was equally safe and effective as physician counterparts. In addition, we found that it significantly reduced the LOS for patients, which has consequences on patient satisfaction and billing. PATIENT/PUBLIC CONTRIBUTION: Nursing staff were trained in g-tube replacement using guidelines created by a nurse educator and nursing council. Patients either had their dislodged g-tubes replaced by the trained nurse or a physician and comparisons on the outcomes were made. Patients were aware of the study and consented to have their medical records accessed to make the data comparisons. RELEVANCE TO CLINICAL PRACTICE: With more than 189,000 children in the United States relying on g-tubes, nursing staff will inevitably be involved in the care of patients with such a device. In addition, as pediatric EDs continue to develop longer and longer waiting times, we must learn how to better use our nursing staff for procedures within their scope and minimize LOS. Our research demonstrates the safety, feasibility, and general benefits of having the pediatric nursing staff replace g-tubes in the ED, and it is hoped that this will lead to beneficial policy changes. WHAT DOES THIS ARTICLE CONTRIBUTE TO THE WIDER GLOBAL COMMUNITY: - Demonstrates the safety and effectiveness of nurse-only g-tube replacement- Reports on the statistically significant difference in LOS between physician and nurse replacement of g-tubes in a pediatric ED- Has the ability to lead to policy change in the pediatric ED that will allow for greater patient satisfaction and decrease patient cost.

The Use of a Triage-Based Protocol for Oral Rehydration in a Pediatric Emergency Department.

BACKGROUND: Guidelines recommend oral rehydration therapy (ORT) and avoidance of laboratory tests and intravenous fluids for mild to moderate dehydration in children with gastroenteritis; oral ondansetron has been shown to be an effective adjunct. OBJECTIVES: The aim of this study was to determine if a triage-based, nurse-initiated protocol for early provision of ondansetron and ORT could safely improve the care of pediatric emergency department (ED) patients with symptoms of gastroenteritis. METHODS: This study evaluated a protocol prompting triage nurses to assess dehydration in gastroenteritis patients and initiate ondansetron and ORT if indicated. Otherwise well patients aged 6 months to 5 years with symptoms of gastroenteritis were eligible. Prospective postintervention data were compared with retrospective, preintervention control subjects. RESULTS: One hundred twenty-eight (81 postintervention and 47 preintervention) patients were analyzed; average age was 2.1 years. Ondansetron use increased from 36% to 75% (P < 0.001). Time to ondansetron decreased from 60 minutes to 30 minutes (P = 0.004). Documented ORT increased from 51% to 100% (P < 0.001). Blood testing decreased from 37% to 21% (P = 0.007); intravenous fluid decreased from 23% to 9% (P = 0.03). Fifty-two percent of postintervention patients were discharged with prescriptions for ondansetron. There were no significant changes in ED length of stay, admissions, or unscheduled return to care. CONCLUSIONS: A triage nurse-initiated protocol for early use of oral ondansetron and ORT in children with evidence of gastroenteritis is associated with increased and earlier use of ondansetron and ORT and decreased use of IV fluids and blood testing without lengthening ED stays or increasing rates of admission or unscheduled return to care.

Electrocardiographic practices: the current report of monitoring and education in Veterans Affairs facilities.

In 2004, practice standards for electrocardiographic (ECG) monitoring were published to address the need for an expanded use of ECG monitoring beyond heart rate and basic rhythm determination. This article reports the data collected from a survey distributed throughout the Veterans Healthcare Administration hospitals to determine the extent to which practice standards have been adopted. Survey data were used to identify the differences between actual practice and evidence-based standards. The results were divided into ECG electrode application, lead selection, alarm limits, monitoring capabilities, monitoring during patient transport, and education and competencies. The results confirm the need for improvement, including a thorough evaluation of facility practices and education. The data demonstrate the differences among actual practice and evidence-based recommendations.