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A PEG service with nurses at its heart

VOL: 96, ISSUE: 39, PAGE NO: 39

Cris Pollard, BA, RGN, is upper gastrointestinal nurse specialist, Department of Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust

Percutaneous endoscopic gastrostomy (PEG) placement, traditionally provided by medical staff at Leicester General Hospital, was frequently scheduled between other clinical commitments. The ad hoc nature of the service often resulted in patients waiting longer than necessary and frequently being cancelled from scheduled operating lists.

Percutaneous endoscopic gastrostomy (PEG) placement, traditionally provided by medical staff at Leicester General Hospital, was frequently scheduled between other clinical commitments. The ad hoc nature of the service often resulted in patients waiting longer than necessary and frequently being cancelled from scheduled operating lists.

Preoperative visits were not routine, which meant patients' suitability was not adequately assessed before the procedure was attempted. Following the placement of a PEG device, the ward and community nursing staff were given no clear guidance on how to manage it properly. A definite need for improvement was identified and the nurse-led PEG service was created.

When to use PEG
For patients who will not or cannot swallow, safe access into the gastrointestinal (GI) tract is of paramount importance to maintain nutritional requirements. Some may only be faced with the insertion of a PEG device as a short-term measure - for example, those who have temporarily lost the ability to swallow due to stroke. However, an increasing number will require the insertion of a PEG device as a long-term solution.

PEG, has now become established as a means of maintaining long-term access to the GI tract. The procedure has managed to overcome many earlier prejudices relating to invasiveness, and contra-indications of the procedure are rare (see Box 1).

Alternative methods such as nasogastric or nasojejunal feeding are still employed under some circumstances and can provide access for short periods (generally less than four weeks). There are, however, several possible complications with these procedures, including poor tolerance, increased susceptibility to chest infections, displacement of nasojejunal tubes, clogging of the tubes due to their fine calibre and, occasionally in confused patients, repeated self-extubation (Chowdhury et al, 1996). This increases the risk of pulmonary aspiration and its subsequent complications, such as 'aspiration pneumonia'.

Towards a nurse-led service
Following the introduction of PEG feeding, prospective comparisons were made against nasogastric (NG) feeding, which had previously been the accepted means of treatment. Due to the interrupted nature of NG feeding as a result of tube displacement. Park (1992) found that a greater proportion of prescribed feeds and supplements were successfully received via the PEG route and that this resulted in a significant advantage in weight gain.

This recognition has led to an increased demand for PEG device placements which has, in many ways, paralleled the increased interest and requirement for wider nursing roles. Maule (1994) demonstrated unequivocally that nurses could develop the necessary skills to perform endoscopy and ultimately provide an endoscopy service.

Since 1994, a significant number of nurse practitioners have been trained in a wide variety of endoscopic techniques, both in the UK and the USA (BSG, 1994; Maule, 1994). More recently, there have been reports of nurses taking on the role of first assistant in the placement of PEG tubes (McPhilips et al, 1996; Patrick et. al, 1996).

Taking these facts into consideration, it was decided to combine the skills of the GI clinical nurse specialist and a nurse endoscopist at Leicester General Hospital to develop a nurse-led PEG service. The service aimed to:

- Reduce waiting times for patients requiring PEG device placement;

- Increase the quality of the service offered, particularly the continuity of care;

- Act as a resource when problems occur;

- Provide pre-assessment for every patient;

- Provide verbal and written guidelines;

- Monitor progress and effectiveness by auditing.

The training programme
In line with the UKCC's revised Code of Professional Conduct and Scope of Professional Practice, and following discussion with the lead consultant and director of nursing, a teaching protocol on the insertion of PEGs was devised for the nurse endoscopist and the GI clinical nurse specialist at the hospital. A clinician was appointed to train both practitioners.

Detailed information regarding the anatomy, physiology and pathology of the GI tract, and its relation to GI disease, is required. This was incorporated into training, along with legal and moral issues that can arise relating to PEG insertion. Practical training was carried out under the direct supervision of a consultant surgeon specialising in GI surgery (Box 2).

PEG placement technique
A gastroscopy is performed under sedation following the administration of local anaesthetic throat spray. The patient receives oxygen via a nasal cannula, and oxygenation is monitored by pulse oximetry. PEG placement is preceded by skin preparation with chlorhexidine

The nurse endoscopist advances a gastroscope into the stomach to inspect the interior. The stomach is then inflated with air which allows the anterior stomach wall to meet the abdominal wall.

The clinical nurse specialist performing the PEG placement digitally compresses the abdominal wall to identify an appropriate location. The skin, muscle, peritoneum and stomach wall are infiltrated with local anaesthetic (1% lignocaine) and a 12-gauge needle is inserted at the chosen site. Once satisfied with position, a small incision is made in the skin before the insertion of the PEG trocar. This allows introduction of a guidewire into the stomach. The latter is grasped with a snare. The guidewire, snare and endoscope are withdrawn through the oesophagus and out the mouth. The PEG tube is attached to the guidewire, which is pulled down the oesophagus, through the stomach and abdominal wall. The PEG is then secured on to the abdominal wall with a locking disc.

Discussion
The implementation of this service has led to a greater continuity of nursing care for patients. Patients are assessed and counselled preoperatively by the same nurse who conducts postoperative follow-up visits. As part of this procedure, routine medications are administered to patients by nursing staff according to a specially designed protocol. Continuous evaluation of the nurse-led PEG service is carried out by regular auditing. Data collected from the audits are collated yearly and used to produce a report submitted to the trust and circulated to all clinicians who have used the service. The first 50 patients audited have experienced no immediate complications during PEG placement.

Conclusion
An experienced endoscopist is necessary for safe insertion of PEGs, and it has now been recognised by the British Society of Gastroenterology that an opportunity exists for the training of nurse endoscopists.

The development of a nurse-led PEG service at Leicester General has been driven by the need to improve the quality of patient care. The service has demonstrated that, with the appropriate training, nurses can safely and competently perform endoscopy and insertion of a PEG. This increases the availability of the consultants and other medical staff in other areas and creates an opportunity for nurses to expand their role.

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