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Hospital Readmission Among Infants with Gastroschisis

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Hospital Readmission Among Infants with Gastroschisis Journal of Perinatology (2011) 31, 546–550 r 2011 Nature America, Inc. All rights reserved. 0743-8346/11 www.nature.com/jp ORIGINAL ARTICLE Hospital readmission among infants with gastroschisis AP South1,2, JJ Wessel1,2, A Sberna1, M Patel1 and AL Morrow1 1Division of Neonatology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA and 2Intestinal Rehabilitation Program, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA Introduction Objective: Infants with gastroschisis have significant perinatal morbidity Gastroschisis is a congenital abdominal wall defect that results in including long hospitalizations and feeding intolerance. Two thirds are evisceration of the bowel into the amniotic space. The birth premature and 20% are growth restricted. Despite these known risk factors prevalence is increasing, affecting B4.5 per 10 000 births.1 While for post-natal complications, little is known about readmission for infants in-hospital morbidity and mortality are well described, there is with gastroschisis. Our objective was to determine the frequency and limited information regarding post-discharge outcomes. Infants indication for hospital readmission after initial discharge among infants with gastroschisis have multiple risk factors for poor long-term with gastroschisis. outcome, including prematurity in two thirds,2 and poor in utero Study Design: Retrospective cohort study. All surviving infants treated growth in 20%.3 Despite absence of extreme prematurity in most for gastroschisis at Cincinnati Children’s Hospital Medical Center, born cases, all infants with gastroschisis are at risk for the development between January 2006 and December 2008 were included. Main outcome of necrotizing enterocolitis with subsequent bowel injury or loss. In measures included the frequency and indication for readmission. addition, 11% of infants have complex gastrointestinal involvement Associated neonatal risk factors also were assessed. (atresia, stenosis, perforation, necrosis or volvulus) which requires 4 Result: Fifty-eight patients were analyzed. Twenty-three (40%) subjects surgical resection of bowel. After repair of the abdominal wall were readmitted (five with multiple readmissions); 65% of readmissions defect, infants with or without a complex lesion experience a period occurred in the first year and 70% involved complications directly related of bowel dysmotility, resulting in prolonged time on parenteral to gastroschisis. The most common reasons for readmission were bowel nutrition and subsequent prolonged hospitalizations lasting 5,6 obstruction and abdominal distention/pain. Median time to readmission 4 to 8 weeks. directly related to gastroschisis was 23 weeks (range 5 to 92). All three Changes in bowel function over time have not been formally infants with home parenteral nutrition were readmitted. Readmission was evaluated among infants with gastroschisis, but persistent not associated with gestational age, birth weight or length of initial dysfunction could contribute to post-discharge morbidity and hospitalization. rehospitalization. Our objective was to identify the frequency of readmissions after initial hospital discharge among infants with Conclusion: Readmission after initial hospitalization is common in gastroschisis and identify modifiable perinatal risk factors for gastroschisis patients. Parental counseling should include education readmission. regarding the possibility of complications requiring readmission. Determinants of readmission require further study. Journal of Perinatology (2011) 31, 546–550; doi:10.1038/jp.2010.206; Methods published online 10 February 2011 After obtaining Institutional Review Board approval from Keywords: abdominal wall defect; gastroschisis; readmission; long-term Cincinnati Children’s Hospital Medical Center (CCHMC), a outcomes; bowel obstruction; surgical complications retrospective cohort study was performed. Subjects included all neonates treated for gastroschisis at CCHMC, born between 1 January 2006 and 31 December 2008, and who survived until initial hospital discharge. Infants were not excluded for comorbid conditions including bowel resection or other congenital anomalies. Infants whose initial surgical procedure was not Correspondence: Dr AP South, Cincinnati Children’s Hospital Medical Center, 3333 Burnet performed at CCHMC were excluded. Subjects were identified Avenue, ML 7009, Cincinnati, OH 45229, USA. through review of the diagnosis codes assigned by the attending E-mail: [email protected] Received 26 August 2010; revised 31 October 2010; accepted 2 November 2010; published online neonatologist over the specified time period. For each identified 10 February 2011 patient, surgical procedure notes and attending neonatologist gastroschisis and hospital readmission AP South et al 547 progress notes were evaluated to confirm the diagnosis of 33 weeks (range 28 to 36) and birth weight of 1870 g (range 950 to gastroschisis. Complete ascertainment of subjects was confirmed 2480). Three infants died of bowel-related morbidity, including by comparing identified patients with hospital billing records. total necrosis, necrotizing enterocolitis totalis and intestinal failure. All data were abstracted retrospectively from the medical record. Two infants died secondary to pulmonary morbidity (pulmonary Perinatal management including delivery hospital, mode of hypertension with alveolar–capillary dysplasia). delivery, method of repair and nutritional management were Demographic characteristics and initial medical course are determined. Neonatal characteristics including gestational age, presented in Table 1. Seventy-five percent of infants were preterm. birthweight and gender were determined. Medical and surgical The mean gestational age of all infants was 35.6 weeks. Infant complications, including the presence of complex bowel birth weight was below expected for gestational age (mean, 32nd involvement (atresia, stenosis, necrosis, volvulus or perforation) and bowel resection, and length of initial hospitalization were recorded. Readmission after initial hospital discharge was Table 1 Demographics and initial medical course of surviving infants with determined by reviewing the complete medical record for each gastroschisis identified infant. Details recorded include the primary indication Maternal/infant demographics and date of readmission. Gestational age (n ¼ 56) During the time period of study, the surgical management plan Mean (s.d.), weeks 35.6 (2.0) was determined by the attending pediatric surgeon. There was no Preterma, n/N (%) 42/56 (75%) standard practice or protocol among the group of >15 surgeons. A Birth weight (n ¼ 58) primary closure was attempted only when viscero-abdominal Mean (s.d.), g 2463 (508) disproportion was not significant. Birth weight for gestational age (n ¼ 56) All statistical analysis was performed with Stata 10.1 (College Percentile, mean (s.d.) 32.0 (22.9) Station, TX, USA). Both primary outcomes and co-variates are z-score, mean (s.d.) À0.6 (0.8) described using mean values and standard deviations for normally Small for gestational ageb, n/N (%) 10/56 (18%) distributed data and median values with inter-quartile range for Male gender, n/N (%) 34/58 (59%) non-normal distributions. Birth at level 3 Neonatal Intensive Care Unit, n/N (%) 48/57 (84%) Kaplan–Meier survival estimates were determined using Maternal age (n ¼ 58) Mean (s.d.), years 22.2 (4.6) readmission as the censored variable. Infants were censored at the Teenage motherc, n/N (%) 17/58 (29%) time of readmission, or on 31 December 2009, whichever came Prenatal diagnosis, n/N (%) 53/58 (91%) first. Variables analyzed included preterm birth, small for Vaginal delivery, n/N (%) 33/58 (57%) gestational age (birth weight less than the 10th percentile), gender, birth at a hospital with a level three neonatal intensive care unit, Medical/surgical care and complications mode of delivery, prenatal diagnosis, method of surgical Primary closure, n/N (%) 12/58 (21%) management, age of enteral feeding initiation, days on parenteral Complex defectd, n/N (%) 4/58 (7%) nutrition, length of hospitalization, development of necrotizing Age enteral feeds initiated (n ¼ 58) enterocolitis, complex gastrointestinal involvement. Cox Median (IQR), days 16 (13–19) proportional hazards models were performed to determine Range, days 6–104 statistically significant differences in readmission rates between Enteral feeds initiated at p30 days after birth, n/N (%) 55/58 (95%) dichotomous variables. For co-variates found to be statistically Days on parenteral nutrition (n ¼ 55) Median (IQR), days 31 (23–41) associated with readmission rate, baseline neonatal demographics Range, days 14–176 were compared using Student’s t-test for continuous data, Length of initial perinatal hospitalization 2 and w or Fisher’s exact test for dichotomous data. Tests were Median (IQR), days 44 (36–72) considered statistically significant for P-values <0.05 using Range, days 27–178 a two-sided distribution. Necrotizing enterocolitis, n/N (%) 4/58 (7%) Discharged with home parenteral nutrition, n/N (%) 3/58 (5%) Discharged with home nasogastric or gastrostomy 13/58 (22%) Results tube feedings, n/N (%) Sixty-three neonates with gastroschisis had their initial Abbreviations: IQR, interquartile range; s.d., standard deviation. gastroschisis repair at CCHMC from January 2006 through aPreterm defined as gestational age <37 weeks. b December 2008. Five (8%) infants died during hospitalization, Small for gestational
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