The cirrhosis care Alberta (CCAB) protocol: implementing an evidence-based best practice order set for the management of liver cirrhosis - a hybrid type I effectiveness-implementation trial.

BACKGROUND: Liver cirrhosis is a leading cause of morbidity, premature mortality and acute care utilization in patients with digestive disease. In the province of Alberta, hospital readmission rates for patients with cirrhosis are estimated at 44% at 90 days. For hospitalized patients, multiple care gaps exist, the most notable stemming from i) the lack of a structured approach to best practice care for cirrhosis complications, ii) the lack of a structured approach to broader health needs and iii) suboptimal preparation for transition of care into the community. Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial which aims to address these gaps. The proposed intervention is initiated at the time of hospitalization through implementation of a clinical information system embedded electronic order set for delivering evidence-based best practices under real-world conditions. The overarching objective of the CCAB trial is to demonstrate effectiveness and implementation feasibility for use of the order set in routine patient care within eight hospital sites in Alberta. METHODS: A mixed methods hybrid type I effectiveness-implementation design will be used to evaluate the effectiveness of the order set intervention. The primary outcome is a reduction in 90-day cumulative length of stay. Implementation outcomes such as reach, adoption, fidelity and maintenance will also be evaluated alongside other patient and service outcomes such as readmission rates, quality of care and cost-effectiveness. This theory-based trial will be guided by Normalization Process Theory, Consolidated Framework on Implementation Research (CFIR) and the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Framework. DISCUSSION: The CCAB project is unique in its breadth, both in the comprehensiveness of the multi-component order set and also for the breadth of its roll-out. Lessons learned will ultimately inform the feasibility and effectiveness of this approach in "real-world" conditions as well as adoption and adaptation of these best practices within the rest of Alberta, other provinces in Canada, and beyond. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04149223, November 4, 2019.

Comparison of complication rates, types, and average tube patency between jejunostomy tubes and percutaneous gastrostomy tubes in a regional home enteral nutrition support program.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are common enteral access devices for long-term enteral nutrition. Jejunostomy tubes (J-tubes) are able to provide postpyloric enteral access in patients who are not PEG tube candidates. There is a scarcity of literature comparing complication rates of J-tubes to PEG tubes. OBJECTIVE: To compare and characterize J-tube and PEG tube complications requiring tube replacement. METHODS: A retrospective chart review was performed on 560 patients discharged from the Northern Alberta Home Enteral Nutrition Support Program (NAHENSP) from January 2010 to December 2011. Patients were followed for 3 years from initial tube insertion or until discharge from the NAHENSP, whichever was earliest. Comparisons were made in terms of complications requiring tube replacement, tube patency to first replacement, and indications for tube replacement. RESULTS: A total of 64 J-tube patients were identified and compared with 65 PEG tube patients. Tube replacement rates for the J-tube group included 3.2 cases per 1000 patient days compared with 0.86 cases per 1000 patient days in the PEG group (P < .001). The mean ± SEM duration to first tube replacement for J-tube and PEG tube patients was 160 ± 26.3 days and 331 ± 53.6 days, respectively (P = .010). The most common causes for tube replacement in J-tube patients were dislodgement (35.6%) and obstruction (22.2%) compared with routine replacement (54.5%) and dislodgement (27.2%) in the PEG tube group. CONCLUSION: J-tubes are associated with higher complication rates requiring tube replacement compared with PEG tubes. The main causes of J-tube replacement are dislodgement and obstruction.