Practice Safety Alerts

Early detection of complications after gastrostomy: summary of a safety report from the National Patient Safety Agency

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2160 (Published 04 May 2010) Cite this as: BMJ 2010;340:c2160
  1. Frances Healey, head of patient safety for medical specialties1,
  2. David S Sanders, consultant gastroenterologist2,
  3. Tara Lamont, head of response1,
  4. John Scarpello, deputy medical director1,
  5. Taofikat Agbabiaka, research associate1
  1. 1National Reporting and Learning Service, National Patient Safety Agency, London W1T 5HD
  2. 2Department of Gastroenterology, Royal Hallamshire Hospital and the University of Sheffield, Sheffield
  1. Correspondence to: F Healey frances.healey{at}npsa.nhs.uk

    Why read this summary?

    Gastrostomies are used as a medium to long term feeding strategy for children and adults with additional dietary needs or an inability to swallow, and they may be inserted surgically, endoscopically, or under radiological guidance. About 15 000 gastrostomies are inserted annually in the United Kingdom.1 Complications include chemical peritonitis, infection, bowel perforation, haemorrhage, and aspiration pneumonia. But early recognition and prompt action reduces the risk of serious harm or death.2 Over six years (October 2003 to January 2010) the National Patient Safety Agency (NPSA) received 22 reports (including five incidents in children) from clinical staff of harm from delayed response to serious complications after gastrostomy insertion. Eleven patients died and 11 became critically ill. Reported complications included nine cases of leakage of feed into the peritoneal cavity and/or peritonitis, three colonic punctures, and two complications related to haemorrhage; under-reporting is likely.3

    Incidents were reported from settings that included general medical, surgical, and elderly care wards after gastrostomy insertion in an endoscopy or radiology unit; patients whose gastrostomy had been inserted in a day case unit sometimes returned to the unit or presented at emergency departments. A typical incident report reads: “Gastrostomy undertaken as planned within the Endoscopy Unit on [Friday]. Limited post-procedure vital sign recordings were undertaken on [Friday to Sunday], the patient was escalated to the on-call SHO on [Sunday] at 23:00 hours due to a raised CRP [C reactive protein] . . . the most likely cause was considered to be dehydration . . . on [Monday] the patient was noted to be less responsive . . . on-call SHO was of the opinion that this was due to the patients controlled drugs. She was seen on the [Tuesday] by the specialist who requested radiological investigations to rule out any perforation. The CT abdomen confirmed perforation . . . ”

    This summary is based on a safety report (known as a “rapid response report” or “RRR”) on early detection of complications after gastrostomy, with key actions for staff, issued by the NPSA in March 2010.1

    What can we do?

    For clinical staff caring for patients in the first three days after gastrostomy insertion (including those staff working in hospital wards, care homes, or the community (general practitioners and those working for out of hours services)), the NPSA recommends the following actions.

    • In the immediate recovery period, ensure regular observations of temperature, blood pressure, pulse respirations, and pain score (to detect general complications such as haemorrhage, aspiration pneumonia, or sepsis).

    • Ensure review by a senior member of staff before discharge.

    • Be aware of “red flag” symptoms specific to gastrostomy, including pain on feeding, prolonged or severe pain after the gastrostomy, or external leakage of gastric contents (which could indicate internal leakage into peritoneum; incident data suggested such leakage was often treated instead as a minor skin care problem).

    • If pain occurs on feeding, stop feeding immediately. Obtain advice from a senior colleague and consider computed tomography, a contrast study, or surgical review (as the incident review showed that staff did not consider the possibility of internal leakage of gastric contents but responded instead with pain relief or change of feeding speed).

    • Tell patients and their carers about signs of complications and give them a contact number for urgent advice (data suggested carers did not know whom to call). The NPSA alert provides warning labels for local use.

    The RRR does not give detailed advice on investigating and managing complications as this will vary with patients’ circumstances and local service provision, and between adults and children.

    What else do we need to know?

    The fatal and serious outcomes of the cases highlighted in the RRR reinforce the need for careful consideration when making decisions to feed a patient via a gastrostomy, also the subject of recent guidance from the Royal College of Physicians.4 The benefits of gastrostomy feeding in patients with dementia are also contentious.5 Careful counselling and a multidisciplinary approach are essential; patients (if cognisant) and carers should be given enough information to make an informed decision.

    How will we know when practice has become safer?

    The NPSA will monitor reports it receives, especially for any that describe earlier recognition of complications and action taken to treat their causes. NHS organisations will also report on their compliance with the actions required by the RRR through the Department of Health’s Central Alerting System. National organisations with an interest in gastrostomy insertion may consider future audits of the prevalence of complications and overall mortality incurred by gastrostomy insertion, building on previous national mortality audits.2

    Notes

    Cite this as: BMJ 2010;340:c2160

    Footnotes

    • This is one of a series of BMJ summaries of recommendations to improve patients’ safety, based on reports of safety concerns, incident analysis, and other evidence. The articles highlight the risks of incidents that have the potential for serious harm and are not well known, and for which clear preventive actions are available.

    • To report adverse events to the National Patient Safety Agency, go to www.nrls.npsa.nhs.uk/

    • Contributors: FH wrote the first draft, based on work led by DSS, TA, FH, TL, and others at NPSA (with input from JS). All authors reviewed the draft. FH is the guarantor.

    • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author and declare (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

    References