Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: A report from the University of California Fetal Consortium (UCfC)

Abstract

Background/Purpose Gastroschisis is a resource-intensive birth defect without consensus regarding optimal surgical and medical management. We sought to determine best–practice guidelines by examining differences in multi-institutional practices and outcomes. Methods Site-specific practice patterns were queried, and infant-maternal chart review was retrospectively performed for gastroschisis infants treated at 5 UCfC institutions (2007–2012). The primary outcome was length of stay. Univariate analysis was done to assess variation practices and outcomes by site. Multivariate models were constructed with site as an instrumental variable and with sites grouped by silo practice pattern adjusting for confounding factors. Results Of 191 gastroschisis infants, 164 infants were uncomplicated. Among uncomplicated patients, there were no deaths and only one case of necrotizing enterocolitis. Bivariate analysis revealed significant differences in practices and outcomes by site. Despite wide variations in practice patterns, there were no major differences in outcome among sites or by silo practice, after adjusting for confounding factors. Conclusions Wide variability exists in institutional practice patterns for infants with gastroschisis, but poor outcomes were not associated with expeditious silo or primary closure, avoidance of routine paralysis, or limited central line and antibiotic durations. Development of clinical pathways incorporating these practices may help standardize care and reduce health care costs.

Adherence to and outcomes of a University-Consortium gastroschisis pathway

“…Outcomes for the contemporary cohort postimplementation of the pathway (2015-2018) were compared with outcomes from a preimplementation historical cohort (2007-2012) [12]. In order to have a valid comparison with the historical cohort, only inborn infants with uncomplicated gastroschisis were included in the analysis.…”

“…For infants with gastroschisis, single-center protocols that emphasize early primary closure have been associated with earlier initiation of nutritional support and attainment of full feeds and a reduction in ventilator days and hospital length of stay [10,11]. Despite the evidence favoring standardization of care, there remains a lack of consensus in the management of infants with gastroschisis both within and across institutions [12,13]. In an effort to improve the quality of care of infants born with gastroschisis, our multi-institutional consortium developed a clinical pathway to reduce variability in management across centers.…”

“…(Table 1) Our multi-institutional consortium developed a clinical pathway (i.e. clinical practice guidelines) for management of gastroschisis based on retrospective review of practices and outcomes [12]. Consortium meetings provided an opportunity for key stakeholders and site leads to develop consensus guidelines, identify potential barriers to adoption, and share implementation strategies.…”

“…The goal of the pathway was to standardize care, reduce ventilator days, promote antibiotic and opioid stewardship, reduce time to full enteral feeds, and reduce length of stay. No specific closure technique was recommended as beside skin closure techniques had not yet been adopted at many consortium sites and no differences observed in outcomes between primary-closure and routine-silo strategies [12]. Site champions provided education and outreach to health care professionals involved in the primary care of these infants (neonatologists, pediatric surgeons, nurse practitioners, bedside nurses and trainees).…”

Necrotizing Enterocolitis following Gastroschisis Repair: An Update

“…3 The reported rate of necrotizing enterocolitis in gastroschisis patients has been quite variable in previous studies. [4][5][6][7][8][9][10][11][12][13][14][15][16] While many physicians today are aware of the association of NEC in gastroschisis patients, the last publication to explore this association in detail and identify possible risk factors of NEC in gastroschisis patients was published over twenty years ago. 4 We examined our experience with gastroschisis to identify risk factors for necrotizing enterocolitis in this patient population.…”