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Implementation and Evaluation of a Protocol for the Management of Type C Tracheoesophageal Fistula
Sage A Vincent1, Lori Silveira2, Samantha Bothwell2
1Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado.
Insights
A new protocol for esophageal atresia/tracheoesophageal fistula (EA/TEF) management improved nutritional support and favored thoracoscopic repair. However, protocol knowledge and utilization require enhancement for better outcomes in EA/TEF patients.
Area of Science:
- Pediatric Surgery
- Neonatology
- Clinical Protocol Development
Background:
- A multidisciplinary protocol for esophageal atresia/tracheoesophageal fistula (EA/TEF) management was developed.
- The protocol was introduced in July 2022 to improve patient care.
- This study evaluates the protocol's utilization and impact on patient outcomes.
Purpose of the Study:
- To assess the utilization of a new multidisciplinary EA/TEF management protocol.
- To determine the association between protocol implementation and patient outcomes.
- To identify challenges and areas for improvement in protocol adoption.
Main Methods:
- Retrospective review of 103 neonatal patients undergoing type C EA/TEF repair (2010-2024).
- Comparison of preprotocol and postprotocol management and outcomes using logistic regression.
- Prospective provider survey to assess protocol knowledge and sustainability.
Main Results:
- Postprotocol implementation, thoracoscopic repair increased significantly (68.8% vs. 31.0%).
- Patients were more likely to receive total parenteral nutrition until full enteral feeds (OR 75.6) and start enteral feeds within 24h with a transanastomotic tube (OR 3.71).
- No significant changes in anastomotic leak or stricture rates; provider knowledge of protocol elements was limited.
Conclusions:
- The EA/TEF protocol enhanced nutritional support and promoted minimally invasive surgical approaches.
- Despite improved feeding practices, clinical outcomes like anastomotic complications did not change significantly.
- Challenges in protocol implementation and provider education were identified, necessitating improved strategies.
Introduction:
A multidisciplinary protocol for the management of esophageal atresia/tracheoesophageal fistula (EA/TEF) was developed with stakeholders from pediatric surgery and neonatology. Introduced in July 2022, this study aims to assess protocol utilization and association with patient outcomes.
Methods:
We performed a single-center, retrospective review of neonatal patients who underwent type C EA/TEF repair between 2010 and 2024. Utilization of protocol elements was assessed, as well as clinical outcomes. Preprotocol and postprotocol management and outcomes were compared using logistic regression. A prospective provider survey was administered to assess protocol sustainability and knowledge.
Results:
There were 103 patients who underwent type C EA/TEF repair, 87 preprotocol and 16 postprotocol implementation. Thoracoscopic repair was more common postprotocol (68.8% versus 31.0%, P = 0.003). Patients were more likely to receive total parenteral nutrition until full enteral feeds were reached (odds ratio 75.6; 95% confidence interval 4.2, 1445; P = 0.003) and receive enteral feeds within 24 h of surgery when transanastomotic tube was in place (odds ratio 3.71; 95% confidence interval 1.04, 13.27; P = 0.043) postprotocol. There was no significant change in outcomes including anastomotic leak and stricture. Providers could correctly identify 2/3 of the EA/TEF protocol elements and 22% reported receiving education on its contents.
Conclusions:
Implementation of an EA/TEF protocol was associated with a 75 times greater likelihood of patients receiving total parenteral nutrition until full feeds were reached and 3.7 times greater likelihood of starting enteral feeds within 24 h of surgery when transanastomotic tube was in place. There was a shift toward thoracoscopic repair of EA/TEF and no change in clinical outcomes including anastomotic leak and stricture. Implementation and knowledge of the protocol faced challenges and provider surveys identified avenues for improving education strategies.
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