91% Decrease in Mortality with Gastroschisis Bundle!

The article I'll be discussing today is entitled a Gastroschisis bundle, effects of a quality improvement protocol on morbidity and mortality. This was a study that was carried out by Hospital Infantiel de Mexico Federico Gomez with Christian Zayas Vidal as the first author and Jamie Nieto Zermenio as the senior author. The rationale behind the study was that in Latin American countries, mortality from gastroschisis can exceed 15%. The authors felt that by developing an evidence-based protocol, they could achieve mortality rates close to that of the developed world. They therefore developed such a protocol, resulting in changed pretty much their entire management of the patient. They then looked at the first 42 patients treated after implementation of the protocol and compared the outcomes to the last 42 patients treated prior to adoption of the protocol. In terms of pre-transfer communication, prior to the protocol, this was incredibly limited. After implementation of the protocol, the accepting hospital was in much closer communication. In terms of Venus access, prior to the protocol, every patient got a central line. After the protocol, every patient had a PICC attended. In terms of the actual surgical treatment, prior to the protocol, all patients were taken to the operating room, which was limited by OR availability and which required general anesthesia. And then a primary reduction was attempted after extension of the defect. After the protocol, bedside reduction was attempted in most patients. In terms of post-operative management, prior to the protocol, all patients were mechanically ventilated and paralyzed and enteral advancement of feeds was totally at the discretion of the surgeon. After the protocol, only patients with respiratory distress were intubated, no patients were paralyzed, and the authors followed a regimented feeding advancement schedule. When comparing the two groups, the results were remarkable. The author's found a shorter time to arrival, less general anesthesia, fewer central lines placed, fewer patients who needed to be intubated and less time on the ventilator for those who were. Most remarkable, however, was the reduction in mortality rate, which went from 22% to just 2%. Alex, thanks for that review. That was actually a really good review and a great article. I think what's great about this article is this is a group of surgeons that looked at their results, they were not happy with the results, and so they did something about it. They saw that they had a 22% mortality with gastroschisis. So, they saw that that was higher than most. They did five things, they changed their protocol and they saw a massive reduction down to 2% mortality. So number one is they improved communication with their referring providers. Number two is instead of using surgical central lines, they moved to PICC lines, which reduced their mortality. Number three is instead of taking all these patients to the operating room for a mandated laparotomy or repair in the operating room, they did a bedside reduction with a silo. Number four is instead of having random feeding regimens, they all agreed upon one protocol and had a standardized feeding regimen for gastroschisis. And number five is that instead of mandating that all patients get intubated, they did not intubate these patients. They did a bedside reduction without intubating when possible. And with that they went from a 22% mortality to a 2% mortality. Yeah, it was pretty amazing. Pretty incredible. Great review, great study. Congratulations to the authors. We'll see you next time. Thanks.