Process Improvement Project for PEG Tube Insertion in Oncology Patients

Background: As a member of the Cancer Care Committee at a community hospital, the thoracic oncology nurse navigator (ONN) recognized the need for a quality study investigating the process for cancer patients receiving PEG tube placement. Studies have shown that PEG tube placement enhances supportive care for cancer patients who are unable to swallow or eat due to their cancer or the side effects of their prescribed cancer treatment regimen. The Cancer Care Committee voted to pursue this study for one of the 2019 Quality Studies as outlined in the Commission on Cancer Standard 4.7 Studies of Quality. A small committee was formed to examine the issues.

Objectives: To identify gaps and barriers, if any, to cancer patients following the desired pathway prior to PEG tube placement. The desired pathway includes referrals for the following: (1) preop PEG tube assessment by dietitian, (2) referral to home enteral supply company for durable medical supplies, and (3) referral to home health agency for nursing support post PEG tube insertion. Improve process for PEG tube placement and ensure patients have appropriate referrals.

Methods: Quality coordinator and committee completed FOCUS (Find-Organize-Clarify-Understand-Select) worksheet. Committee findings were: (1) no standardized pre- or post-PEG placement order sets, (2) some medical oncology offices would order and schedule PEG tube placement but would not order dietitian assessment, feeding supplies, or home health nursing. The committee understood the problem to be lack of education in MD offices for the recommended pathway. PDCA (Plan-Do-Check-Act) phase entailed: (1) develop checklist for schedulers in medical oncology offices to ensure proper referrals were made, (2) determine who would educate office schedulers, (3) add a query to hospital central scheduling for them to ask when scheduling the PEG placement (4) create letter to physicians and their schedulers to enhance education by the oncology dietitian.

Results: The committee recognized that a problem did exist and identified gaps in the care cancer patients were receiving when a PEG tube was ordered. As a result, education was provided along with a checklist and letter to physician offices targeting their schedulers. The ongoing monitoring of PEG tube placement and outcomes of patients are reported to the Cancer Care Committee by the quality improvement coordinator at the quarterly Cancer Care Committee meetings. Continued monitoring and reassessment occur.

Conclusions: The ONN’s role is to remove barriers to care for patients by ensuring they have the resources to adhere to the treatment plans. This cannot be accomplished without a multidisciplinary approach to care. This thoracic ONN was able to identify an issue impeding cancer patients’ care and outcomes. With a multidisciplinary team approach, a process improvement plan was established to improve PEG tube education and coordination of care for cancer patients. From August 2019 to September 2019 all 3 PEG tubes ordered followed the pathway. Ongoing monitoring and assessment occur to ensure the process is followed.

Sources

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Moreland SS. Nutrition screening and counseling in adults with lung cancer: a systematic review of the evidence. Clin J Oncol Nurs. 2010;14:609-614.

Muñoz R, Farshidpour L, Chaudhary UB, Fathi AH. Multidisciplinary cancer care model: a positive association between oncology nurse navigation and improved outcomes for patients with cancer. Clin J Oncol Nurs. 2018;22:E141-E145.