Impact of nurse practitioner navigation on access to care for patients with refractory gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common digestive complaint that can negatively affect patients' quality of life and have serious complications if inadequately treated.

LOCAL PROBLEM

Facilitating prompt and efficient access to digestive care is imperative especially given the current burden of gastrointestinal diseases such as GERD.

METHODS

A clinical team conducted a quality improvement study in which a nurse practitioner (NP) navigator performed a preconsultation chart review for patients with refractory GERD referred to an Esophagus Center between August and December 2018.

INTERVENTIONS

Based on preconsultation chart review, the NP navigator arranged for diagnostic testing and follow-up. Days from consultation to testing completion and establishment of plan were tracked and compared with historic controls. The NP navigator documented time spent for chart review and care coordination.

RESULTS

The median number of days from consultation to testing completion for patients who underwent NP navigation and required diagnostic testing (n = 26) was 33.5 as compared with 64.5 for historic controls who required testing but received usual care (n = 28) (p = .005). The median number of days from consultation to establishment of a management plan was 52 for patients who underwent NP navigation as compared with 97 for historic controls who did not (p = .005). The mean amount of time spent by the NP navigator for chart review and care coordination was 17.5 min (n = 30).

CONCLUSIONS

Incorporation of NP navigators into gastroenterology practices offers a potential solution for timelier patient care delivery.

Nutrition for full-term and preterm infants

Providing adequate nutrition for the healthy full-term newborn is relatively easy; breast milk or formula is sufficient for the first six months of life. Although the full-term infant's organ systems are relatively mature, the gastrointestinal tract is often stressed by the demands of rapid growth, and feeding difficulties, such as gastroesophageal reflux, colic, milk allergy, and constipation, may occur that necessitate special handling. The small preterm infant, however, has many urgent nutritional needs; management is usually complicated by the fact that the infant's immature organs may be unable to cope with enteral feedings. Thus, total parenteral nutrition is necessary, with extensive laboratory monitoring of metabolic functions and precise attention to detail to avoid a prolonged period of partial starvation.

Gord

Essential facts Bringing up food after eating is a normal process that can occur in healthy infants, children and young people. Gastro-oesophageal reflux (GOR) is most common in babies, affecting four in ten infants. Gastro-oesophageal reflux disease (GORD) is reflux that is so severe medical treatment is required. Differentiating between GOR and GORD is difficult because the terms are often used interchangeably.

A review of nonsurgical treatment for the symptom of irritability in infants with GERD

PURPOSE

The purpose of this review was to assess effectiveness of nonsurgical treatment on irritable behavior of infants with gastroesophageal reflux disease.

DESIGN AND METHODS

A systematic literature review was conducted.

RESULTS

Research targeted treatment for irritability in infants with gastroesophageal reflux disease. All interventions including placebo were similar in reducing irritability. Which specific intervention is best for which infant is not yet known. Minor adverse effects that could increase discomfort in infants were found with pharmacologic treatments.

PRACTICE IMPLICATIONS

Knowledge of the effects of treatment on irritability and regurgitation can assist the nurse to work with other care providers in deciding how best to treat an individual infant.

The role of the pediatric home healthcare nurse

The acuity and number of children with life-threatening, life-limiting, and chronic conditions has increased dramatically over the past decade. The pediatric home care nurse needs a special body of knowledge and repertoire of tools to accurately assess, intervene, manage, evaluate, and provide resources to this most vulnerable population. Inherent in caring for these children is the need to support the family, nurturing the parents who care for chronically ill children at home.

Simultaneous development of the Pediatric GERD Caregiver Impact Questionnaire (PGCIQ) in American English and American Spanish

Background

The objective of this study was to develop simultaneously a new questionnaire, the Pediatric GERD Caregiver Impact Questionnaire (PGCIQ), in American English and American Spanish in order to elucidate the impact of caring for a child with GERD.

Methods

Two focus group discussions were conducted in American English and American Spanish to develop a relevant conceptual model. Focus group participants were the primary caregivers of children with GERD (newborn through 12 years of age). Participant responses were qualitatively analyzed to identify potential differences in caregiver perspectives by the caregiver's language, socio-economic status and demographic profile as well as the child's age and disease severity level. Items in the PGCIQ were generated simultaneously in English and Spanish by reviewing results of qualitative analysis from focus groups in each language. The PGCIQ was finalized in both languages after testing content validity and conducting an in-depth translatability assessment.

Results

Analysis of focus group comments resulted in the development of a first draft questionnaire consisting of 58 items in 10 domains. Content validity testing and an in-depth translatability assessment resulted in wording modification of 37 items, deletion of 14 items and the addition of a domain with five items. Feedback from the content validity testing interviews indicated that the instrument is conceptually relevant in both American English and American Spanish, clear, comprehensive and easy to complete within 10 minutes. The final version of the PGCIQ contains 49 items assessing ten domains. An optional module with nine items is available for investigative research purposes and for use only at baseline.

Conclusion

The PGCIQ was developed using simultaneous item generation, a process that allows for consideration of concept relevance in all stages of development and in all languages being developed. The PGCIQ is the first questionnaire to document the multidimensional impact of caring for an infant or young child with GERD. Linguistic adaptation of the PGCIQ in multiple languages is ongoing. A validation study of the PGCIQ is needed to examine its psychometric properties, further refine the items and develop an appropriate scoring model.

Discerning differences: gastroesophageal reflux and gastroesophageal reflux disease in infants

Gastroesophageal reflux (GER) is a frequently encountered problem in infancy; it commonly resolves spontaneously by 12 months of age. Caregivers are challenged to discriminate between physiologic GER and the much less common and more serious condition of pathologic gastroesophageal reflux disease (GERD). Pathologic GERD may require more extensive clinical evaluation and necessitate treatment. GERD may be primary or secondary; secondary GERD is associated with a number of genetic syndromes, chromosomal abnormalities, birth defects, or a host of neurologic conditions frequently seen in the newborn intensive care unit. This article reviews the unique anatomic, physiologic, developmental, and nutritional vulnerabilities of infants that make them susceptible to GER and GERD. The North American Society of Pediatric Gastroenterology and Nutrition have recently developed a comprehensive evidence-based clinical practice guideline that structures the diagnostic approach and treatment option in infants with suspected and confirmed GERD. These guidelines provide clear definitions of GER and GERD to aid the clinician in distinguishing between the 2 conditions. They emphasize the use of history and physical examination and discuss the indications for the use of other diagnostic procedures, such as upper gastrointestinal studies, nuclear medicine scintiscan, esophagogastroduodenoscopy with biopsy, and esophageal pH probe monitoring. Management of GERD begins with a nonpharmacologic approach; the emphasis is on positioning, a trial of a hypoallergenic formula, and thickening of feedings. When these measures fail to control symptoms, a trial of either histamine(2) antagonists or a proton pump inhibitor may be indicated. Finally, surgical treatment may be needed if all other management measures fail. New sleep recommendations for infants with GERD are now consistent with the American Academy of Pediatrics' standard recommendations. Prone sleep positioning is only considered in unusual cases, where the risk of death and complications from GERD outweighs the potential increased risk of sudden infant death syndrome (SIDS). The nursing care of infants with GER and GERD, as well as relevant issues for parent education and support, are reviewed and are essential elements in managing this common condition.

Gastroesophageal reflux in infants: a primary care perspective

This clinical paper discusses the role of the pediatric nurse in the evaluation and management of gastroesophageal reflux (GER) in infants. During an infant's first year of life, GER is a common occurrence and concern of families. The infant with uncomplicated GER may be managed conservatively with feeding schedule modifications, thickened feeds, changes in positioning, or a trial of formula change. Gastroesophageal reflux disease (GERD) is a pathological process in infants manifested by poor weight gain, signs of esophagitis, persistent respiratory symptoms or complications, and changes in neurobehavior. Management of the infant with GERD, in addition to non-pharmacological interventions, involves further diagnostic evaluation and pharmacologic therapy, depending upon the child's history and clinical presentation. While most cases of GER are self-limiting, complications include esophagitis, bronchospasm, apnea, aspiration pneumonia and other otolaryngologic disorders. The pediatric health care provider should offer an ongoing, comprehensive clinical approach to the family based on considerations of growth and development, and the quality of interactions between the caregivers and child.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is generally a lifelong illness that affects many people, but its significance is often underestimated. Chronic abnormal gastric reflux results in erosive esophagitis in up to 60% of patients with GERD. Esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma are the most serious complications of GERD. Although heartburn and acid regurgitation are the most common complaints, extraesophageal symptoms such as noncardiac chest pain, laryngitis, coughing, and wheezing can be manifestations of GERD. Unfortunately, the severity of symptoms is not a reliable indicator of the severity of erosive esophagitis. Endoscopy is the preferred method to diagnose and grade erosive esophagitis, and various classification systems are used to grade disease severity. The Los Angeles Classification is a valid and widely accepted system to evaluate the severity of erosive esophagitis. The immediate goals of treatment are to provide effective symptomatic relief and to achieve healing in patients with esophageal damage. The treatment regimen often begins by prescribing a therapy to reduce gastric acid secretion. A proton pump inhibitor is the preferred agent for many patients. Because GERD is a chronic, relapsing disease, long-term maintenance therapy is usually necessary to relieve symptoms, prevent complications, and improve the quality of life in patients with GERD.

An Overview of Proton Pump Inhibitors

SUMMARY

Proton pump inhibitors are the standard of treatment for acid-related disorders. These disorders include gastroesophageal reflux disease and its complications (i.e., erosive esophagitis and Barrett's esophagus), peptic ulcer disease, Zollinger-Ellison syndrome, and idiopathic hypersecretion. Proton pump inhibitors are also successfully used for the treatment of Helicobacter pylori infection and upper gastrointestinal bleeding. There are currently five proton pump inhibitors approved by the Food and Drug Administration and available in the United States. These are omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). This review discusses the history of proton pump inhibitors and compares and evaluates the pharmacology including mechanism of action, pharmacokinetics, pharmacodynamics, administration, dosage, and drug interactions. Information regarding therapeutic indications, clinical efficacy, short- and long-term side effects, and cost is also presented. A case presentation offers an analysis of the use of proton pump inhibitors in individualized patient care.

Gastro-oesophageal reflux in infants: an evidence-based approach

Gastro-oesophageal reflux (GOR) is present in most infants, but is usually a benign condition that resolves by the age of 6 to 12 months as the gastrointestinal tract develops. While it lasts, however, reflux symptoms can be very worrying for parents, and community nurses are well placed to provide them with reassurance, support and advice on practical measures that will improve symptoms in most cases. Nurses also have an essential role in monitoring infants for possible progression of symptoms to complicated GOR or gastro-oesophageal reflux disease (GORD), and in ensuring that such babies, and those with a possible underlying abnormality, receive appropriate referral for further investigation and medical or surgical treatment.

Care modes for the older adult with gastroesophageal reflux disease

Gastroesophageal reflux disease is a common chronic disease in the older population. Because of the cumulative effects of acid reflux and delayed gastric emptying, the older adult is at risk for such complications as peptic strictures, esophagitis, and Barrett's esophagus. Providing information on the current care modes (lifestyle, dietary, pharmacologic, and surgical interventions) will help identify relevant solutions and help the older adult generate alternative safe and effective solutions to manage the disease. Many people struggle to change their lives and may need assistance to break old habits.

Outpatient laparoscopic Nissen fundoplication

Gastroesophageal reflux disease affects more than 40% of Americans, causing heartburn and reflux of gastric contents into the esophagus when bending or lying down. Lifestyle modification, such as weight loss and a diet rich in protein and low in fat and glucose, should increase the patient's resting lower esophageal sphincter pressure. Avoiding exacerbating substances, such as mint, chocolate, alcohol, and tobacco, also may reduce symptoms. Medications may be prescribed to reduce persistent symptoms, although no medication currently available cures the disease process. Patients who need antireflux medication regularly for four to six weeks or more may be candidates for laparoscopic Nissen fundoplication. Patients who do not want to take antireflux medication for the rest of their lives, cannot afford the medication for an extended period of time, or suffer significant side effects from the medication also are candidates. This article describes performing Nissen fundoplication laparoscopically on an outpatient basis. The average length of hospital stay has been decreased to two to three hours when performed laparoscopically on an outpatient basis from 10 days for the open procedure and two to three days when performed laparoscopically on an inpatient basis. The incidence of recurrent heartburn is less than 2% when the procedure is performed laparoscopically and does not appear to be clinically significant.

Endoluminal gastroplication. A new therapeutic endoscopic procedure for gastroesophageal reflux disease

It is estimated that more than 15 million Americans suffer daily from gastroesophageal reflux disease (GERD) (De Vault, 1995). The spectrum of symptoms for GERD ranges from simple heartburn and regurgitation to persistent esophageal tissue damage with subsequent development of serious complications. The frequent occurrence and intensity of GERD symptoms can severely impact a person's quality of life (Behar, 1990). Until recently, treatment options included a lifetime of drug therapy, disagreeable daily lifestyle changes, and the possibility of invasive surgery. In 2000, the Food and Drug Administration cleared a new endoscopic tool called the EndoCinch, a device that enables endoscopic endoluminal gastroplication as an outpatient procedure for the treatment of GERD. Endoscopic endoluminal gastroplication has been shown to be a safe and effective therapeutic outpatient procedure offering sustainable clinical benefits and cost savings to patients suffering with GERD (Patel, 2001; Raijman, 2001; Weiland, 2001). The purpose of this article is to present an overview of GERD with a particular focus on management of the disease using this new procedure.

Care of the laparoscopic Nissen fundoplication patient

Gastroesophageal reflux disease can usually be successfully managed with conservative medical treatment. Anti-reflux surgery is a safe alternative when treatment fails or patients desire a more definitive treatment option. Through a case study approach, this article describes the indications for surgery, the essentials of the authors' multi-disciplinary approach to care and the components of a well-designed education plan for a patient undergoing laparoscopic Nissen fundoplication. Although most patients do well after surgery, diligent nursing care is required before and after surgery to prevent or manage complications and ensure patients have a rapid recovery and successful outcome.

Applying clinical practice guidelines to a patient with complicated gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a complex, often misunderstood disease that requires comprehensive medical and nursing care. Recently published clinical practice guidelines provide new direction with regard to the causes, diagnosis, treatment, and nursing care of patients with GERD. Using a case study approach, this article outlines the most recent evidence-based treatment options and patient education guidelines for a patient suffering from a complicated case of GERD.

Gastroesophageal reflux in children: a guide for the advanced practice nurse

Gastroesophageal reflux (GER) is one of the most common gastrointestinal problems in infants and children. Unfortunately, the diagnosis of GER is often made after development of serious complications, placing the child at medical and developmental risk. Early recognition by primary care providers is essential in preventing these serious, sometimes life-threatening complications of untreated GER. This article reviews the pathophysiology, clinical manifestations, diagnostics, and treatment modalities of GER along with developmental considerations. As a health care provider, the advanced practice nurse is in an ideal position to provide a complete assessment, develop a realistic plan of care, coordinate interventions, assess outcomes, and offer support to the family of the child with GER.

Gastroesophageal reflux disease

In this age of fast food, overeating, and busy schedules, many people frequently complain of heartburn or indigestion. Meal times are rarely consistent, so meal planning appears out of the question. What are the consequences of this lifestyle? Gastroesophageal reflux disease (GERD) is a common disorder that affects every population. This article defines this condition and provides a history, literature review, and pathophysiology for the disorder. Recommendations for diagnosis and guidelines for treatment and nursing care interventions also are given.

The role of laparoscopic Nissen fundoplication in gastroesophageal reflux disease

Gastroesophageal reflux is a highly prevalent condition that usually requires long-term medical therapy. Although symptom management still remains satisfactory for the majority of patients, laparoscopic Nissen fundoplication is proving to be an effective alternative in treating complications of gastroesophageal reflux disease.

Diagnosis and management of gastroesophageal reflux in infants and children

Use of histamine blockers, proton pump inhibitors, and prokinetic drugs, along with traditional antacids, has become standard therapy for gastroesophageal reflux (GER) in symptomatic adults. Response to this therapy is assessed to confirm the diagnosis of GER, and is often advocated as the best way to establish the causes and effects of the disease. It is well documented that reflux occurs throughout the life span. However, the incidence in children is difficult to estimate, requiring interpretation of behavior and symptoms in nonverbal and atypical presentations. Unfortunately, the diagnosis of GER in children is often made after the development of complications such as aspiration pneumonia, esophagitis, or ulcers. Early recognition and intervention by primary care providers is necessary to prevent such serious complications of untreated GER. This article presents the pathophysiology and clinical manifestations of GER. Diagnosis in children is discussed, and recommendations for empiric therapy, including conservative measures and drug therapies, are presented.

Persistent failure-to-thrive: a case study

The inability to successfully feed a young infant or child is as worrisome to parents as it is to the health care provider. Early growth failures are likely to reflect difficulty with infant homeostasis and often respond to medical management of the physical problem that is temporarily interfering with the infant's ability to feed by mouth. In addition to medical management, however, treatment also necessitates investigation and management of behavioral problems that so universally accompany growth failure. This article presents a case study of a child who presented with poor growth and respiratory symptoms associated with nonregurgitant gastroesophageal reflux, a clinical entity that can be difficult to recognize. Although surgical management of this condition was successful, persistent failure-to-thrive continued and was seemingly recalcitrant to treatment. The use of cyproheptadine as an appetite stimulant to promote weight gain in this child is discussed with a review of the current literature regarding this pharmacologic approach to poor weight gain. A behavioral-based treatment plan is described as an alternate management method, avoiding the use of pharmacologic agents in general.

Gastroesophageal reflux in infants

Spitting is a common occurrence in infants and is usually of no consequence. When regurgitation is accompanied by the return of gastric acids into the esophagus, however, it is considered to be gastroesophageal reflux. Failure to thrive, esophagitis, aspiration, chronic respiratory disease, and apnea can all be associated with pathologic gastroesophageal reflux. This paper discusses the causes, symptoms, and treatment modalities for pathologic gastroesophageal reflux. Health care practitioners can play a major role in providing direct care as well as coordinating and evaluating treatment interventions for infants with gastroesophageal reflux. In addition, health care providers can supply the families of these infants with the necessary education and emotional support required to care for their infant.

A case of feet

Gastric reflux with regurgitation is not an uncommon feeding problem in the young child. It can cause acute distress for both the child and parents, as well as major disruptions to the family functioning. Reflux is commonly managed with a variety of strategies, including feeding management, practical techniques and medication. Resolution is quickly achieved in some instances, but in others, or where these strategies are not seen as desirable, there may be a need to consider alternatives.

Home care of the infant with gastroesophageal reflux and respiratory disease

An increasing number of infant's with gastroesophageal reflux (GER) and respiratory disease and are being cared for at home. These infants have a chronic disease requiring long-term medical care. However, once the infant's condition stabilizes, home care is preferable to prolonged hospitalization. Nursing care of the infant with GER and respiratory disease is a challenging process that is complicated by the severity of GER and the degree of respiratory compromise. An understanding of disease process, family process, and skills of assessment are essential in planning care for these infants and their families.

Mothers' internal working models with infants with gastroesophageal reflux

Gastroesophageal reflux (GER) places infants both at biological risk and developmental risk. Care of an infant with GER requires an integration of the physiologic and developmental needs of the infant. The author explores the physiologic bases for GER, current treatment modalities impacting caregiver problem solving, and the potential impact of GER on infants' development of self-regulatory processes. The concept of internal working models is presented as a framework for nurses to use to individualize anticipatory guidance for parents of infants with GER.

Home management related to medical treatment for childhood gastroesophageal reflux

Parents caring for a child with gastroesophageal reflux are at risk for impaired home maintenance management because of the challenges they face such as the emotional impact, financial concerns, and difficulty maintaining the strict regime. Nursing interventions related to family education and support assist the families in becoming knowledgeable and compliant while fostering normal growth and development.

Gastroesophageal reflux in infancy: review and update

Gastroesophageal reflux is a common occurrence in infancy. The purpose of this article is to describe gastroesophageal reflux and differentiate among its three categories. Initial evaluation includes an accurate history and growth assessment. Continued monitoring of growth is important to determine when and if intervention is necessary. The nurse practitioner will be able to make referrals or prescribe treatment based on the guidelines presented. Having knowledge of the various aspects of this problem will enable the nurse practitioner to assess and monitor the infant and reassure parents.