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Adherence to and outcomes of a University-Consortium gastroschisis pathway
Daniel A DeUgarte1, Kara L Calkins1, Yigit Guner2
1University of California - Los Angeles.
Insights
Implementing a standardized gastroschisis pathway reduced mechanical ventilation and antibiotic exposure in newborns. Bedside closure techniques supported adherence to this improved care protocol.
Area of Science:
- Neonatal surgery
- Pediatric surgery
- Clinical pathway implementation
Background:
- Gastroschisis care varied significantly across institutions.
- A multi-institutional consortium developed a standardized gastroschisis pathway in 2015.
- The pathway aimed to improve care by standardizing key interventions.
Purpose of the Study:
- To assess the feasibility and impact of a standardized gastroschisis clinical pathway.
- To compare outcomes of patients treated under the pathway with historical controls.
- To evaluate the role of bedside closure techniques in pathway adherence.
Main Methods:
- Prospective monitoring of adherence to the gastroschisis pathway.
- Comparison of outcomes between a contemporary cohort (2015-2018) and a historical cohort (2007-2012).
- Analysis of specific interventions like intubation, mechanical ventilation, antibiotic use, and feeding initiation.
Main Results:
- Good adherence was observed in 70 cases of uncomplicated gastroschisis.
- The contemporary cohort showed significantly fewer mechanical ventilator days (2 vs. 5) and antibiotic days (5.5 vs. 9).
- Earlier initiation of feeds (12 vs. 15 days) was noted, with no significant difference in length of stay.
Conclusions:
- Adherence to the gastroschisis clinical pathway is feasible across multiple facilities.
- The pathway effectively reduced patient exposure to mechanical ventilation and antibiotics.
- Bedside skin closure techniques appear to facilitate compliance with the clinical pathway.
Background:
Our multi-institutional university consortium implemented a gastroschisis pathway in 2015 to standardize and improve care by promoting avoidance of routine intubation and paralysis during silo placement, expeditious abdominal wall closure, discontinuation of antibiotics/narcotics within 48 h of closure, and early initiation/advancement of feeds.
Methods:
Adherence to the gastroschisis pathway was prospectively monitored. Outcomes for the contemporary cohort (2015-2018) were compared with a historical cohort (2007-2012).
Results:
Good adherence to the pathway was observed for 70 cases of inborn uncomplicated gastroschisis. The contemporary cohort had significantly lower median mechanical ventilator days (2 versus 5; p < 0.01) and antibiotic days (5.5 versus 9; p < 0.01) as well as earlier days to initiation of feeds (12 versus 15; p < 0.01). However, no differences were observed in length of stay (28 versus 29 days; p = 0.70). A skin closure technique was performed in 66% of the patients, of which 46% were performed at bedside without intubation, the assistance of an operating-room team, or general anesthesia.
Conclusion:
In this study, adherence to a clinical pathway for gastroschisis across different facilities was feasible and led to reduction in exposure to mechanical ventilation and antibiotics. The adoption of a bedside skin closure technique appears to facilitate compliance with the pathway.
Level Of Evidence:
Level II/III TYPE OF STUDY: Prospective comparative study with historical cohort.
