The association of type of surgical closure on length of stay among infants with gastroschisis born ≥ 34 weeks’ gestation

doi:10.1016/j.jpedsurg.2013.12.020

Journal of Pediatric Surgery

Volume 49, Issue 8, August 2014, Pages 1220-1225

https://doi.org/10.1016/j.jpedsurg.2013.12.020 Get rights and content

Abstract

Background/Purpose

The optimal surgical approach in infants with gastroschisis (GS) is unknown. The purpose of this study was to estimate the association between staged closure and length of stay (LOS) in infants with GS.

Design/Methods

We used the Children's Hospital Neonatal Database to identify surviving infants with GS born ≥ 34 weeks' gestation referred to participating NICUs. Infants with complex GS, bowel atresia, or referred after 2 days of age were excluded. The primary outcome was LOS; multivariable linear regression was used to quantify the relationship between staged closure and LOS.

Results

Among 442 eligible infants, staged closure occurred in 68.1% and was associated with an increased median LOS relative to odds ration (OR):primary closure (37 vs. 28 days, p < 0.001). This association persisted in the multivariable equation (β = 1.35, 95% CI: 1.21, 1.52, p < 0.001) after adjusting for the presence of necrotizing enterocolitis, short bowel syndrome, and central-line associated bloodstream infections.

Conclusions

In this large, multicenter cohort of infants with GS, staged closure was independently associated with increased LOS. These data can be used to enhance antenatal and pre-operative counseling and also suggest that some infants who receive staged closure may benefit from primary repair.

Section snippets

Materials & methods

The CHND captures clinical data on all infants admitted to 27 participating regional NICUs. Variables were defined prospectively, and chart abstractors at each site undergo prospective training including review of clinical definitions, participation in web-based seminar tutorials, and case-based practice. Since 2010, both initial and semi-annual measurements of inter-rater agreement scores are calculated at each site; over 90% intra-site concordance in abstraction is required for initial and

Results

Of the 28,299 infants in the CHND, 602 had GS during the study period. After sequentially excluding those born < 34 weeks’ gestation (n = 66), those admitted after their second day of life (n = 10) and those who died (n = 3), we then omitted those with major congenital heart disease (n = 3), congenital neurological disorders (n = 4), bowel atresia (n = 39), other markers of complex GS (n = 10), and those without data available on the type of received closure (n = 25). Of the infants who died, one had bilateral

Discussion

Gastroschisis is one of the most common congenital anomalies requiring surgery [1], [28]. With a rising incidence, understanding the implications of the current management strategies is critical to optimize these infants’ outcomes while minimizing unnecessary resource utilization. In this large, multi-center cohort of infants with uncomplicated GS born ≥ 34 weeks’ gestation, our study demonstrates that staged closure was associated with a greater LOS independent of patient characteristics [29].

Acknowledgments

Jeanette Asselin, David Durand, Francine Dykes, Jacquelyn Evans (Chair), Karna Murthy, Michael Padula, Eugenia Pallotto, Kristina Reber and Billie Short are members of the Children’s Hospitals Neonatal Consortium, Inc. (CHNC: http://www.TheCHNC.org). The CHNC has partnered with Children’s Hospital Association, Inc (Overland Park, KS, Alexandria, VA) in order to design, launch, and maintain the CHND.

We are indebted to the following institutions that serve the infants and their families, and

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Cited by (22)

Abdominal Wall Defects
2023, Avery's Diseases of the Newborn
Minimizing Variance in Gastroschisis Management Leads to Earlier Full Feeds in Delayed Closure
2021, Journal of Surgical Research
Citation Excerpt :
Risk factors include younger maternal age and potentially exposure to other teratogens such as smoking and vasoconstrictive medications. Earlier gestational age of infants with gastroschisis has been associated with a longer hospitalization and higher rate of sepsis.4 After birth, these infants typically undergo immediate decompression with an orogastric tube (OG tube), and a decision is made by the surgical team on whether to return the contents immediately into the abdomen and close the abdominal wall defect (primary closure) or to place the intestines within a plastic silo and gradually reduce the bowel into the abdominal cavity (delayed closure).
Limited guidance exists regarding appropriate timing for feed initiation and advancement in gastroschisis. We hypothesized that implementation of a gastroschisis management protocol would allow for standardization of antibiotic and nutritional treatment for these patients.
We conducted a retrospective comparison of patients with simple gastroschisis at two pediatric hospitals before and after initiation of our gastroschisis care protocol. Complicated gastroschisis and early mortality were excluded. The control group extended from January 2012 to January 2014 and the protocol group from July 2014 to July 2016. Variables of interest included time to feed initiation, time to goal feeds, length of stay, and National Surgical Quality Improvement Program–defined complications. We performed a subgroup analysis for primary versus delayed gastroschisis closure. Statistical analyses, including F-tests for variance, were conducted in Prism.
Forty-seven patients with simple gastroschisis were included (control = 22, protocol = 25). Protocol compliance was 76% with no increase in complication rates. There was no difference in length of stay or time from initiation to full feeds overall between the control and protocol groups. However, neonates who underwent delayed closure reached full feeds significantly earlier, averaging 9 d versus 15 d previously (P = 0.04).
For infants undergoing delayed closure, the time to full feeds in this group now appears to match that of patients undergoing primary closure, indicating that delayed closure should not be a reason for slower advancement. Additional studies are needed to assess the impact of earlier full enteral nutrition on rare complications and rates of necrotizing enterocolitis.
Assessment of gastroschisis risk factors in Egypt
2020, Journal of Pediatric Surgery
Citation Excerpt :
Low-risk (simple) GS have an ipso facto shorter LOS compared to high-risk (complex) cases [29]. Staged silo infants in our study had a longer LOS which has been independently associated with an increased LOS [40]. Our staged closure cases were on TPN for longer, in keeping with other reports in the literature [41].
Mortality in infants born with gastroschisis (GS) in low-to-middle-income countries (LMICs) is high. This study aimed to assess factors which might affect outcome in Egypt in order to improve survival.
A prospective study over a 15-month duration was completed. Variables assessed covered patient, maternal, antenatal, treatment, and complications. The Gastroschisis Prognostic Score (GPS) was used to predict outcome. A validated questionnaire was used to assess socioeconomic status. The main outcome was mortality.
Twenty-four cases were studied. Median gestational age was 37 (26–40) weeks, and 9 (38%) were preterm. Mortality occurred in 15 (62%) infants. Median transfer time was 8 (1.5–35) hours, and 64% survived if transferred before 8 h. Median maternal age was 20 (16–27) years. All families were of a low or very-low socioeconomic level. Only 25% had antenatal scans. Most cases were simple GS, and only 3 (12.5%) were complex GS. Median length of stay was 14 (1–52) days, TPN duration was 12 (0–49) days, and days to full feeds was 5 (3–11) days. The GPS score ranged from 0 to 6 in the studied cases and negatively correlated with outcome (r_S = − 0.98; p = 0.03).
The mortality of GS in Egypt is very high, mainly due to sepsis and prematurity. Young maternal age and poor socioeconomic status are linked to GS. The GPS is a good indicator of morbidity and mortality in a LMIC setting. Survival improved with better resuscitation and strict management protocols. More effort is needed to improve antenatal detection, and transfer time should be ideally below 8 h.
Level IV.
Association of Neonatologist Continuity of Care and Short-Term Patient Outcomes
2019, Journal of Pediatrics
Citation Excerpt :
We linked clinical data to blinded neonatologist schedules. Four regional NICUs provided retrospective clinical data from the Children's Hospitals Neonatal Database (CHND),2,15-18 a data registry that captures demographic data, diagnoses, and selected inpatient outcomes for every infant admitted to a participating hospital's NICU. The criteria for CHND participation include >400 annual admissions or >25 NICU beds, and >50% outborn infants.
To describe neonatologist continuity of care and estimate the association between these transitions and selected patient outcomes.
We linked Children's Hospitals Neonatal Database records with masked neonatologist daily schedules at 4 centers, which use 2- and 3-week and 1-month “on service” blocks to provide care. After describing the neonatologist transitions, we estimated associations between these transitions and selected short-term patient outcomes using multivariable Poisson, logistic, and linear regression analyses, independent of length of stay (LOS) and case-mix. We also completed analyses after stratifying the cohort by LOS, birthweight, age at admission categories, and selected diagnoses.
Stratified by LOS, patient transitions varied between centers in both unadjusted (P < .001) and multivariable analyses (adjusted incidence rate ratio; 95% CI for center B = 3.98 (3.81-4.15), center C = 4.92 (4.71-5.13), center D = 4.2 (4.0-4.4), P < .001), independent of LOS, gestational age, birthweight, surgical intervention, ventilator duration, and mortality. Only central venous line duration (adjusted incidence rate ratio 1.015, 95% CI 1.01-1.02) was minimally and independently associated with the number of transitions. No differences were observed in ventilator duration, oxygen use at neonatal intensive care unit discharge, bloodstream infections, or urinary tract infections. Surviving infants with meconium aspiration, hypoxic ischemic encephalopathy, cerebral infarction, bronchopulmonary dysplasia, and diaphragmatic hernia demonstrated similar findings.
Transitions in neonatologists are frequent in regional neonatal intensive care units but appear unrelated to short-term patient outcomes. Future work to define continuity of care and develop effective strategies that promote longitudinal inpatient management is needed.
Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis
2018, Journal of Pediatric Surgery
Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS).
A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis. The specific aim was to decrease median LOS from a baseline of 34 days. We used statistical process control charts including rational subgroup analysis to monitor LOS.
From December 2008 to December 2016, 119 patients with uncomplicated gastroschisis were evaluated. Retrospective data were obtained on 25 patients prior to protocol implementation. Ninety-four patients with uncomplicated gastroschisis comprised the prospective process stage. The median LOS for this retrospective cohort was 34 days (IQR: 30.5–50.5), while the median LOS for the prospective cohort following implementation of the protocol decreased to 29 days (IQR: 23–43).
With the use of quality improvement methodology, including standardization of care and a change in surgical approach, the median LOS for newborns with uncomplicated gastroschisis at our institution decreased from 34 days to 29 days.
3.
Impact of Multidisciplinary Standardization of Care for Gastroschisis: Treatment, Outcomes, and Cost
2018, Journal of Pediatric Surgery
Elimination of unnecessary practice variation through standardization creates opportunities for improved outcomes and cost-effectiveness. A quality improvement (QI) initiative at our institution used evidence and consensus to standardize management of gastroschisis (GS) from birth to discharge.
An interdisciplinary team utilized best practice evidence and expert opinion to standardize GS care. Following stakeholder engagement and education, care standardization was implemented in September 2014. A comparative cohort study was conducted on consecutive patients treated before (n = 33) and after (n = 24) standardization. Demographic, treatment, and outcome measures were collected from a prospective GS registry. Direct costs were estimated, and protocol compliance was audited.
BW, GA, and bowel injury severity were comparable between groups. Key practice changes were: closure technique (pre-88% primary fascial, post-83% umbilical cord flap; p < 0.001), closure location (pre-97% OR, post-67% NICU; p < 0.001), and GA avoidance (pre-0%, post-48%; p < 0.001). Median post-closure ventilation days were shorter (pre-4, post-1; p < 0.001), and SSI rates trended lower (pre-21%, post-8%; p = 0.3) in the post-implementation group with no differences in TPN days or LOS. No significant difference was seen in average per-patient costs: pre-$85,725 ($29,974–221,061), post-$76,329 ($14,205–176,856).
Care standardization for GS enables practice transformation, cost-effective outcome improvement, and supports an organizational culture dedicated to continuous improvement.
III.

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Original ArticleThe association of type of surgical closure on length of stay among infants with gastroschisis born ≥ 34 weeks’ gestation

Abstract

Background/Purpose

Design/Methods

Results

Conclusions

Section snippets

Materials & methods

Results

Discussion

Acknowledgments

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Am J Infect Control

Lancet

J Pediatr Surg

J Pediatr

J Pediatr

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Pediatr Neonatol

Original Article
The association of type of surgical closure on length of stay among infants with gastroschisis born ≥ 34 weeks’ gestation