Reducing Unnecessary and Futile PEG Insertions Jane R. Cowan, M.D.

Reducing Unnecessary and Futile PEG Insertions Jane R. Cowan, M.D.

Nothing to disclose Disclosures

Scope of the problem Few, if any, New York area SNF, rehabilitation centers, or home health agencies accept patients with nasal feeding tubes. 1 Thus to prevent unnecessary delays in discharge, PEGs are often requested early in an admission, regardless of clinical indication or appropriateness.

PEG indications and contraindications PEGs are indicated in: - Head and neck cancer 2 - Dysphagia after stroke, after 2-3 weeks 3,16 - Neuromuscular dystrophy syndromes 2 - Gastric decompression 2 - Cystic Fibrosis 4 - Long term enteral access 5,6 PEGs are contraindicated in: - Dementia 7 - Dysphagia after stroke, for first 2-3 weeks or 30 days after discharge 2,3,16 - Cancer anorexia/cachexia 2,8,9 - Limited life expectancy 2

What benefits? PEGs have been shown to have no improvement in aspiration versus nasal tubes. 2,10,11 PEGs are associated with increased decubitus ulcers and decreased healing of ulcers. 12 Most conditions show no improvement in weight or nutritional status with PEG versus nasal tube. 13,14 Quality of life not improved by PEG in the elderly, and 70% patients with altered mental status are chemically or physically restrained to prevent removal of the tube. 10,15

Our data Eighty-two patients who received PEGs from ACS staff over one year, identified via billing code-directed chart review. Eleven percent of patients were cleared for an oral diet on their index admission after a PEG was placed; these PEGs were unnecessary. Ten percent of patients died on their index admission after a PEG was placed; these PEGs were futile. Oral diet on index admission 11% Oral diet within 30 days of discharge 21% Death on index admission 10% Death within 1 year 15% Complication rate 11% Admitted to an ICU when placed 84%

International Interventions In Israel, a moratorium on PEG placement for 30 days after discharge decreased PEG placement by half and 30 day mortality by 40%. 17 In the UK, instituting mandatory in-hospital 1-2 week waiting periods decreased in-hospital mortality by up to 50%. 18 Given our chronic bed shortage, neither approach is practical at our hospital.

Our intervention Consult Discharge PEG Previously, the average time from PEG placement by the ACS service to discharge was 21 days. We changed our practice to schedule PEG placements only when the patient was medically stable for discharge.

Hopeful trends Sample size of preliminary data as yet underpowered for analysis of change in futile and unnecessary PEGs. However, time from placement to discharge has decreased from 21 days to 11 days. Similarly, placement at the bedside in an ICU has dropped from to 51% to 22%, while placement in the endoscopy suite (a surrogate marker for stability) increased from 12% to 69%.

References 1. Seres, David et al. Coerced Gastrostomy Placement in Skilled Nursing Facilities: Using Concept Mapping to Develop Interventions to Build Capacity for Nasal Feeding Tube. Adv Nutr vol. 8: 16, 2017 2. Plonk Jr, William J. To PEG or Not To PEG. Practical Gastroenterology. July 2005 3. Dennies, MS et al. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet 2005 4. Van Biervliet, S et al. Percutaneous endoscopic gastrostomy in cystic fibrosis: patient acceptance and effect of overnight tube feeding on nutritional status. Acta Gastro. 67(3) 2004 5. Loser, Chr. Et al. ESPEN guidelines on artificial enteral nutrition Percutaneous endoscopic gastrostomy (PEG). Clinical Nutrition. Vol 24. 2005 6. American Society for Gastrointestinal Endoscopy. Guideline: The role of endoscopy in enteral feeding. Gastrointestinal Endoscopy. Vol 74, No 1, 2011 7. American Geriatrics Society Ethics Committee, Clinical Practice and Models of Care Committee American geriatrics society feeding tubes in advanced dementia position statement. Journal of the American Geriatrics Society, Vol 62, No 8, 2014 8. Klein S, Koretz RL. Nutrition support in patients with cancer: what do the data really show? Nutr Clin Pract, 1994;9:87-89 9. Moynihan, Timothy. To Feed or Not to Feed: Is That the Right Question? Journal of Clinical Oncology, 2005 10. Gomes CAR et al. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. The Cochrane Collaboration. 2015.11. Finucane 12. Teno, Joan et al. Feeding Tubes and the Prevention or Healing of Pressure Ulcers. Arch Intern Med. Vol 172, No 9. 2012 13. Kaw, Madhukar and Gail Sekas. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients. Digestive Diseases and Sciences. Vol 39, Issue 4, 1994 14. Angus, Floyd and Robert Burakoff. The Percutaneous Endoscopic Gastrostomy Tube: Medical and Ethical Issues in Placement. Am J Gastroenterology. 98, 2003 15. Weaver, JP et al. Evaluation of the benefits of gastric tube feeding in an elderly population. Arch Fam Med 2(9), 1993 16. Wirth, Rainer et al. Guideline clinical nutrition in patients with stroke. Experimental & Translational Stroke Medicine. Vol 5, issue 14. 2013 17. Abuksis, Galia et al. Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience. Clinical Nutrition. Vol 23, 2004 18. Kuran, Matthew and David S Sanders. Improving Outcomes following percutaneous endoscopic gastrostomy (PEG) a seven-day waiting policy is essential. Clin Med 14:211 August 2011