Alfred Health PEG Credentialing Program

Lisa Murnane

Senior Dietitian, Alfred Health

Management of Gastrostomy Feeding Tube’s in Adults

Friday 11th December, 2015

Acknowledgements

• A/Prof Ibolya Nyulasi; Manager, Nutrition Services, Alfred Health

• Professor Stuart Roberts; Director Hepatology & PEG service, The Alfred

• Vanessa Carter & Allison Lauder; Founding Dietitians, Formerly The Alfred

• Georgina Calder; Senior Nurse Clinician, MATS Gastrostomy service

• Dr Eva Kipen; Geriatrician, Aged Care Service, The Alfred

• Kathryn Collins & Lorraine Gaffney; former Enteral Nutrition Portfolio Leads

Presentation Overview

• Background – Alfred Health

– Gastrostomy feeding tubes

– Home enteral nutrition (HEN) patient management

– Alfred Health HEN Service profile

• Extended Scope of Practice (ESoP) program – Gastrostomy tube credentialing program overview

– Brief history of the credentialing program’s development

– Who can be credentialed?

– Credentialing Process

– Competency & clinical governance

• Measures of success – Key Performance Measures

– How does this ESoP program enhance the ED?

– Why the model works

Southern

Eastern

0 10 20

Kilometres

North and West

Broadmeadows Health Service

Bundoora Extended Care Centre

Heidelberg Repatriation HospitalSunshine Hospital

Western Hospital

Healesville & District Hospital

The Peter James CentreWilliamstown Hospital

Mercy Werribee Caulfield General Medical CentreAngliss Hospital

Monash Medical Centre, Moorabbin Monash Medical Centre, ClaytonHampton Rehabilitation Hospital

Sandringham & District Hospital Kingston Centre

Queen Elizabeth Centre Dandenong Hospital

Frankston Hospital

Rosebud Hospital

The Northern Hospital

Cranbourne Integrated Care Centre

Casey Hospital

Rosebud Rehabilitation Unitp

The Mornington Centre

Golf Links Road Rehabilitation and PCUp

pYarra Ranges Health

O'Connell Family Centre (Grey Sisters) Inc.

Melton Health

Craigieburn Health Service

Wantirna Health

Sunbury Day Hospital

Austin Hospital andMercy Hospital for Women

Royal Melbourne Hospital, Royal Park

Tweedle Child & Family Health CentreRoyal Talbot Rehablilitation Centre

Maroondah Hospital

Calvary Health Care Bethlehem Ltd

The Alfred

Box Hill Hospital

St George's Health Service

Hospitals current as at 1 June 2011

Southern

Eastern

0 10 20

Kilometres

North and West

Broadmeadows Health Service

Bundoora Extended Care Centre

Heidelberg Repatriation HospitalSunshine Hospital

Western Hospital

Healesville & District Hospital

The Peter James CentreWilliamstown Hospital

Mercy Werribee Caulfield General Medical CentreAngliss Hospital

Monash Medical Centre, Moorabbin Monash Medical Centre, ClaytonHampton Rehabilitation Hospital

Sandringham & District Hospital Kingston Centre

Queen Elizabeth Centre Dandenong Hospital

Frankston Hospital

Rosebud Hospital

The Northern Hospital

Cranbourne Integrated Care Centre

Casey Hospital

Rosebud Rehabilitation Unitp

The Mornington Centre

Golf Links Road Rehabilitation and PCUp

pYarra Ranges Health

O'Connell Family Centre (Grey Sisters) Inc.

Melton Health

Craigieburn Health Service

Wantirna Health

Sunbury Day Hospital

Austin Hospital andMercy Hospital for Women

Royal Melbourne Hospital, Royal Park

Tweedle Child & Family Health CentreRoyal Talbot Rehablilitation Centre

Maroondah Hospital

Calvary Health Care Bethlehem Ltd

The Alfred

Box Hill Hospital

St George's Health Service

Inner South Inner East

North East

Hume Whittlesea

HealthWest

Inner North WestOuter East

Kingston-Bayside

South East

Frankston-Mornington

Moonee Val l ey - Mel bour ne

Inner EastHealthWestCaritas Christi Hospice

Dental Health Services VictoriaRoyal Women's HospitalRoyal Children's Hospital

Royal Melbourne Hospital, City

St Vincent's Hospital Royal Victorian Eye & Ear Hospital

Peter MacCallum Cancer Centre INSETINSET0 500

Metres

1000

Department of Health regional boundariesPrimary Care Partnership

Metropolitan Melbourne public hospitals

Kingston – North (S)

Kingston – South (S)

Glen Eira – South (S)

Bayside – South (P)

Bayside – Brighton (P)

Glen Eira – Caulfield (P)

Port Phillip – St Kilda (P)

Port Phillip – West (P)

Stonnington

- Prahran (P)

Stonnington

- Malvern (P)

Melbourne – Inner (S)

Melbourne

– S’bank

- D’lands (S)

Melbourne –

Remainder (S)

•

•

•The Alfred

Caulfield Hospital

Sandringham Hospital

Kingston – North (S)

Kingston – South (S)

Glen Eira – South (S)

Bayside – South (P)

Bayside – Brighton (P)

Glen Eira – Caulfield (P)

Port Phillip – St Kilda (P)

Port Phillip – West (P)

Stonnington

- Prahran (P)

Stonnington

- Malvern (P)

Melbourne – Inner (S)

Melbourne

– S’bank

- D’lands (S)

Melbourne –

Remainder (S)

•

•

•The Alfred

Caulfield Hospital

Sandringham Hospital

Alfred Health inpatient sites

The Alfred Caulfield

Hospital

Sandringham

Hospital

Hospital type Acute Sub-acute Acute (community)

Bed # ~470 ~255 ~45

Dietetic EFT 26 6 1

Services include Tertiary referral

hospital

Specialist services:

Trauma / Burns,

Emergency & ICU,

Cancer, Respiratory

including CF, HIV,

Heart / Lung

transplant, Bariatric

surgery

Aged care, rehab

(including ABI) &

residential care

Surgery, acute aged

care, emergency &

maternity

Alfred Health HEN Service Profile

• Insert ~130 Gastrostomy tubes per year

• ~80 HEN clients currently

• All HEN patients reviewed in-person every 3 months by the Dietitian via:

– PEG clinic

OR

– Mobile PEG service

• Nutrition Service holds HEN budget including formula, equipment & replacement feeding tubes

Stroke 23%

Head & Neck Ca

26% Trauma 25%

Neuromusc Disease/ Dementia

10%

HIV 3%

Cystic Fibrosis

3%

Other 10%

Gastrostomy tube Credentialing Program

• Extended scope of practice program for Dietitians & RNs

• Advanced role: independently manage patients with Gastrostomy feeding tubes including tube replacement

• Includes inpatients & those living in the community

• Developed collaboratively by: – The Alfred Gastroenterology Unit

– Alfred Health Nutrition Service

– The Alfred Mobile assessment & treatment service (MATS)

• Commonly Medical practitioner role

(stomal therapist/outreach RN in some organisations)

Gastrostomy ‘PEG’ Clinic established

Problem Identification

ED presentations

16 week waiting list for PEG clinic

Residential care patients: distress & transport difficulties

Mobile Gastrostomy Service established

Approval of credentialing program by:

Clinical Risk Committee

Legal Counsel

Hospital insurers

Alfred Health Executive

Model of care for Mobile Gastrostomy service &

Gastrostomy tube Credentialing program developed

Gastrostomy Credentialing Program commenced

1997

2002

2004

2005

Process of Credentialing Program Development

Who can be credentialed?

• Required professional qualifications:

- Dietitian: minimum 3yrs experience with enteral nutrition

OR

- Registered Nurse working in the AH MATS program

• Must be an Alfred Health employee

• Dietitian with high HEN caseload credentialed as a priority

e.g. Head & neck cancer, CF, stroke, trauma

Credentialing process Part 1: Experience

• The trainee must attend a minimum of 10 Alfred PEG clinics (or have equivalent

experience) and be able to:

– Identify current feeding tubes used across AH including removal method(s)

– Identify possible risks / complications associated with tube removal / replacement and be

competent to manage these if they arise

– Identify situations where it is not appropriate to manage the patient in the community &

when escalation to Gastro team required

– Identify when it is clinically appropriate to order a PEG-o-gram via the AH Radiology

Credentialing process Part 2: Supervised practice

• The trainee must complete:

– 5 supervised BALLOON gastrostomy tube

replacements including: > 3 supervised by the Consultant Gastroenterologist (minimum)

> 2 supervised by Credentialed Dietitian or RN who is an

approved supervisor

– 5 supervised EXTERNAL-TRACTION gastrostomy

tube removals with balloon replacement

(supervision as above)

Note: An ‘approved supervisor’ is a Dietitian or RN who has significant experience in independent / safe tube replacement (minimum 25

replacements) & has written approval to supervise from the Consultant Gastroenterologist

Credentialing process Part 3: Infection prevention

• The trainee must:

– Read & understand the AH Infection Control guideline on ‘Standard

precautions’

– Completed AH eLearning package on ‘aseptic technique’

Competency & Clinical Governance

• Prior to independent practice, the trainee must:

– deem themselves competent

– be deemed competent (in writing) by the Consultant Gastroenterologist

• Annual re-evaluation of competency occurs by the Consultant Gastroenterologist via:

– Completion of independent practice for the past 12 months,

– May require supervised Gastrostomy replacement(s) at the discretion of the

Consultant Gastroenterologist

• Development & review of the competency standards are the responsibility of the

Gastro Unit

• Credentialing/re-credentialing of staff & ongoing management of the credentialing

program is the joint responsibility of Gastro Unit and Nutrition Service

Key Performance Measures Pre-credentialing Program Currently

Credentialed Staff None ~19 Dietitians

(6 employed currently)

8 MATS RNs

(4 employed currently)

ED admissions > 1 per month ~1 every 6 months

PEG Clinic waiting list 16 weeks 1 weeks

Mobile Gastrostomy Service

Dietitian FTE

0.1 FTE Senior Dietitian 0.2 FTE Senior Dietitian

NB: nil other dedicated FTE

Clinical incidents relating to

tube replacements

Unknown Nil to date

How does this ESoP program

‘enhance’ the ED?

1. Reduction in ED presentations

• Minimum 3 monthly tube reviews via PEG clinic OR MATS PEG service (including

proactive tube replacement where indicated)

• Systems to prevent ED presentation if tube dislodges or concerns with tube / stoma:

– 24 hour on-call service for patients on the MATS PEG program (7 day service for

emergency tube replacements / review)

– ‘on-call’ PEG Dietitian available during business hours for drop-in service where required

– Dietitian able to troubleshoot non-urgent issues over the phone

• Training & education of local aged care facilities have

improved their capacity to manage residents with

Gastrostomy feeding tube with less reliance on ED

2. ED consultation by credentialed staff

Excerpt from TAH

E&TC’s Gastrostomy

tube dislodgement

guideline (Oct 2011)

Dietitian able to

managed

all aspects of

HEN care

Wide

organisational

support

Primarily utilises

existing FTE

Enhanced Dietetic

profession

Clear,

thorough

& well

governed

Patient-centered

Why the

model works

Why consider this ESoP program elsewhere?

• Patients come first!

• Utilises existing resources

• Sustainable

• Shares workload

• Improved recognition of dietetic profession

Thankyou.

l.murnane@alfred.org.au