Introduction

Welcome to the APSA Quality and Safety committee Abdominal Wall Defects Toolkit. This page is intended to help anyone who is interested in quality improvement of the management of patients with abdominal wall defects such as omphalocele or gastroschisis. Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Clinical Pathways

OHSU Doernbecher Children’s Hospital

Has a quality improvement (QI) project titled: Minimizing Variance in Gastroschisis Management Leads to Earlier Full Feeds in Delayed Closure in which a standardized management pathway was created, inclusive of feeding advancement, for simple gastroschisis. For example, the protocol details when an orogastric tube should be removed, when feeds should be started, and how quickly to advance to goal. It also includes timing for initiation of total parenteral nutrition (TPN) and discontinuation of antibiotics after birth.

This particular protocol is part of an IRB-approved OHSU program titled Minimizing Variance in Pediatric Surgery. The initiative calls for the pediatric surgery fellows to present new ideas for minimizing variance study protocols at the faculty division meetings, with the goal of incorporating two new protocols, per year, per fellow. Upon topic/idea agreement by the faculty, the proposing fellow develops the evidence-based protocol, while ensuring multidisciplinary discussions and buy in from stakeholders. Subsequently, it is presented to the surgery faculty for final approval. The fellow-driven initiative suffices the quality improvement program requirement, and contributes to their core competencies, while enhancing patient care. Management and outcomes data are collected retrospectively and analyzed.

Protocol:

• OHSU Gastroschisis Protocol

Resources:

• Tools: Surgery Resident Handbook Gastroschisis Protocol (OHSU Gastroschisis Protocol)
• Pediatric surgery fellow contact information for questions
• Order Sets: No specific order set was used. Rather, the neonatology feeding order set is used, where feeds are usually advanced by approximately 20mL/kg/day. Daily discussion amongst the surgical and neonatology teams occurs daily, prior to advancements

Stakeholders: neonatologists, pediatric surgeons, pediatric surgery advanced practice providers (for both institutions involved)

Challenges and solutions:

Agreement amongst stakeholders – the pediatric surgery fellows are key in implementing the protocols, as they facilitate multi-disciplinary communication, teaching and patient care across our two institutions. Concerns from individual providers were addressed in protocol development, with adjustments to the protocol over time as needed.

Specific to the gastroschisis protocol – care of complicated gastroschisis patients is often not amenable to protocolized management, and therefore, analysis of the protocol was limited to simple/uncomplicated gastroschisis patients.

Links to published data: Minimizing Variance in Gastroschisis Management Leads to Earlier Full Feeds in Delayed Closure [1].

Submitted by: Elizabeth Fialkowski

University of California Fetal Consortium (UCFC)

The Gastroschisis Clinical Pathway was created after completing a retrospective analysis of inborn gastroschisis patients at all five University of California medical campuses. The pathway provides suggested guidelines, which are endorsed by the University of California Fetal Care Consortium, with the goal of standardizing and improving care by reducing the percentage of cesarean deliveries, ventilator days, antibiotic days, opioid doses, parenteral nutrition days, silo days, exposure to general anesthesia, length of stay, and cost.The clinical pathway is updated based on ongoing monitoring and evaluation.

Protocol:

• UCFC Gastroschisis Clinical Pathway

Resources:

• UCFC 2019 APSA Abstract

Stakeholders: maternal fetal medicine specialists, pediatric surgeons, neonatologists

Challenges and solutions:

Challenges – Adoption was initially delayed by resistance from surgeons and neonatologists that were unfamiliar and/or uncomfortable with skin-closure techniques. The providers initially had concerns that the complication rate might increase with the ‘new’ guidelines.

Solutions:

1. In 2015, our multi-center consortium retrospectively reviewed experiences with gastroschisis management and provided consensus recommendations that advocated for less-invasive approaches that emphasized antibiotic and opioid stewardship.
2. Site champions (including nurses) provided local education and encouragement at multidisciplinary meetings and via nurse in-service.
3. Guidelines were printed and made available at the bedside.
4. Prospective monitoring facilitated real-time feedback to providers to encourage adoption.
5. Surgeons familiar with bedside-skin closure joined faculty and introduced the technique, which facilitated adoption of the recommended guidelines.

Links to published data:

Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: a report from the University of California Fetal Consortium (UCFC) [2].

Factors associated with gastroschisis outcomes [3].

Adherence to and outcomes of a University-Consortium gastroschisis pathway [4].

Submitted by: Daniel DeUgarte

Additional Implementers: Kara L. Calkins, Yigit Guner, Jae Kim, Karen Kling, Katelin Kramer, Hanmin Lee, Leslie Lusk, Payam Saadai, Cherry Uy, Catherine Rottkamp, on behalf of the University of California Fetal Consortium.

British Columbia Children’s Hospital

Developed a gastroschisis QI project through multidisciplinary care standardization in order to improve outcomes for gastroschisis patients.

Protocol:

• BC Women’s Hospital + Health Centre - Gastroschisis Initial Management & Abdominal Closure Policy

Resources:

• BC Women’s Hospital + Health Centre NICU Gastroschisis Admission Initial Management Order Set
• BC Women’s Hospital + Health Center NICU Gastroschisis Post Closure Management Order Set

Stakeholders: anesthesiologists, antibiotic stewardship/infectious disease members, maternal fetal medicine specialists, neonatologists, neonatal nursing, NICU nursing manager, NICU/Surgical quality departments.

Challenges and solutions: Priority setting (finding common ground), getting the right stakeholders in a room together, managing protocol failures (usually sedation failures), documenting compliance.

Links to published data: Impact of Multidisciplinary Standardization of Care for Gastroschisis: Treatment, Outcomes, and Cost [5].

Submitted by: Erik Skargard

Centre Hospitalier Universitaire Sainte Justine, Université de Montréal

In 2013 created a standardized gastroschisis practice bundle developed via the collaboration of a multidisciplinary team of pediatric surgeons, neonatologists, advanced practice and bedside nurses, and pharmacists, in an effort to streamline the care of gastroschisis patients. The goal of the standardized protocol is to increase bedside “sutureless” umbilical flap closure of gastroschisis. Given the lack of evidence-based guidelines for many aspects of the care of neonates with gastroschisis, decisions regarding controversial aspects of the practice bundle—such as the necessity for intubation and the duration of antibiotic therapy—were arrived at through discussion and ultimate consensus among all stakeholders.

Protocol:

Resources:

• CHU Sainte-Justine Gastroschisis Admission Standardized Order Set (English Version)
• CHU Sainte-Justine Gastroschisis Admission Standardized Order Set (French Version)

• CHU Sainte-Justine Gastroschisis Reduction Standardized Order Set (English Version)
• CHU Sainte-Justine Gastroschisis Reduction Standardized Order Set (French Version)

• CHU Sainte-Justine Gastroschisis Dressing Change, Nursing Guide (English Version)
• CHU Sainte-Justine Gastroschisis Dressing Change, Nursing Guide (French Version)

4.

Stakeholders: pediatric surgeons, pediatric surgery trainees, neonatologists, neonatology trainees, NICU advanced practice nurses, NICU bedside nurses, and NICU pharmacists.

Challenges and solutions:

Antibiotic use: decreased duration and spectrum in second 2020 iteration of the bundle.

Intubation: plan to make an attempt at reduction without intubation in next iteration of the bundle, based on the results of a CAPSNet propensity

matched study.

Submitted by: Shahrzad Joharifard

Additional implementers: Andréanne Villeneuve (neonatologist), Mona Beaunoyer (pediatric surgeon), Rebecca Brooks (pediatric surgeon)

Sutureless Closure of Gastroschisis

Nemours/Alfred I. Dupont Hospital for Children (AIDHC)

The pediatric surgery team worked with neonatal intensive care unit (NICU) staff to explain the rationale of the tecnhique and develop detailed description with pictures of what sutureless closure for gastroschisis is expected to look like. Two different formats were used to deliver this information, a slide presentation, as well as a typed document as a reliable method to reference for wound care instructions.

Protocol:

• Nemours AIDHC Sutureless Closure Protocol

Resources:

• Nemours AIDHC Sutureless Closure Presentation

Stakeholders: surgeons, neonatologists, NICU nurses

Challenges and solutions: Everyone freaks out when they can see bowel so this normalizes it.

Submitted by: Loren Berman

University of Virginia Children’s Hospital

Developed a quality improvement (QI) initiative for sutureless gastroschisis closure. The project involves decreasing the need for intubation, traditional surgical closure of gastroschisis and anesthesia. Patients with gastroschisis have a silo placed without need for intubation in the NICU. After the bowel is reduced over the subsequent days, the remaining umbilical cord is used as a biologic covering over the defect. A presentation was used to introduce the concept of sutureless closure of gastroschisis as well as steps to the procedure to NICU providers. Moreover, the initial results on sutureless closure are included in poster format under the resources section.

Protocol:

• UVA Gastroschisis Sutureless Closure Flow Diagram

NICU Gastroschisis Presentation – Slides from a presentation given to NICU providers introducing the background of sutureless closure of gastroschisis and steps to the procedure. Flow Diagram – Decision algorithm on the steps of sutureless closure of gastroschisis.Gastroschisis Poster – Results of initial study on sutureless closure at UVA.

Resources:

• UVA Poster: Sutureless Closure of Gastroschisis is Cost Effective and Reduces Need for General Anesthesia

Stakeholders: patients, neonatologists, NICU nurses, pediatric anesthesiologists and pediatric surgeons

Challenges and solutions: The first challenge, the initial surprise of leaving the umbilical cord long. This is new to the NICU who may be used to the patient needing surgery. An additional challenge is keeping the umbilical cord moist while the bowel is in a silo. This is overcome by wrapping it in gauze and a plastic covering. The cord is moistened every few hours with saline by the nurses or the rounding team. A final challenge is some of the NICU nurses do not like the smell for the initial few days of the umbilical cord after it is placed on the defect. This is overcome by placing scented oils in the area and after the first dressing change.

Links to published data: Sutureless closure: a versatile treatment for the diverse presentations of gastroschisis.[6]

Submitted by: Jeffrey Gander

References