Development and Implementation of the MED4TUBE Evidence-Based Care Bundle to Reduce Medication Errors in Enteral Feeding Tubes: A Quality Improvement Study.

PEG remains the standard for durable enteral access in patients unable to swallow safely or meet nutritional needs orally, placed by the pull (Gauderer-Ponsky) technique, and ASGE 2024 now suggests PEG over IR-guided gastrostomy for initial placement in normal foregut anatomy. A single prophylactic IV dose of a beta-lactam antibiotic (e.g., cefazolin) is given before placement. Post-procedure bowel rest is no longer recommended: feeding may start within 3-4 hours of uncomplicated placement (ESGE 2021, strong/high-quality; ASGE 2024, strong/moderate), medications may be given immediately, and routine gastric residual volume checks are not indicated. Buried bumper prophylaxis is daily site care with DAILY inward tube mobilization and a loose external bumper kept 1-2 cm from the abdominal wall (ESGE 2021), not weekly rotation. Antiplatelet agents, including dual antiplatelet therapy, need not be routinely withheld for PEG; anticoagulant management is individualized by multidisciplinary discussion of bleeding versus thrombotic risk. In malignant dysphagia, either transoral pull PEG or direct (introducer) PEG is acceptable with counseling about implantation metastasis and periodic site examination. Device selection among PEG, PEG-J, DPEJ, surgical gastrostomy, and parenteral nutrition remains multidisciplinary, and a goals-of-care discussion before placement, including avoiding routine PEG in advanced dementia in favor of careful hand feeding (AGA 2020 / Choosing Wisely), is unchanged.