Improved Nissen Outcomes in Medical Complexity: Fundoplication Complications, Indications, and Education

Purpose/Objectives: The purpose of our project was to investigate the prevalence and outcomes of Nissen Fundoplication in our children with medical complexity - both with and without mechanical ventilation. After examining the impact of a standard recommendation for Nissen in all children who have clinical reflux or aspiration in the context of also being on home ventilation, we noticed several patterns in prevalence and outcomes. We then decided to use these outcomes to inform a second phase of the quality improvement project in which we form protocols for standardizing timing of initial studies and surgical referral for Nissen consideration. We are also planning an educational intervention for hospitalists and surgical colleagues on the outcomes and benefits of fundoplication with changes in practice patterns.

Design/Methods: The first step was to systematize our Complex Care services recommendations surrounding our medically complex patients, including those with invasive and non-invasive ventilators, as it relates to Nissen fundoplication. Our approach was that clinical reflux and admissions for emesis, aspiration, or pneumonia would be referred to our surgical colleagues for assessment. We then collected data on our patients relating to admissions one year before and one year after fundoplication to establish a consistent case and control for the intervention. Quality was measured in number of admissions, length of stay, reasons for admission, and overall care needs. We also recorded need for repeat surgery or repair and any complications reported. The next phase of the study was a protocol for our group in timing and patient identification for early referral for Nissen. A further stage will be designing an educational module that we will pilot with the surgery residents in evaluating the positive impacts of Nissen on this population.

Results: We found a significant inverse correlation between Nissen and gastrointestinal related admission numbers including: emesis, reflux, feeding intolerance, and choking. We also found that patients with Nissen had overall lower numbers of certain types of respiratory admissions including those relating to bacterial pneumonia and aspiration. Average length of stay was also decreased post fundoplication for overall admission numbers. Interestingly, we found that pre-surgery and post-surgery total admissions from all cause remained the same. A possible confounder is that we incidentally found that in patients without Nissen but with mechanical ventilation that admissions tended to increase overtime.

Conclusion/Discussion: Recommendation for Nissen fundoplication seems to benefit patients in decreasing certain types of admissions. A standardized protocol and educational interventions for surgical colleagues may inform more patient-centered practice in the population of pediatric medical complexity. Our quality improvement project indicates that the surgery, though it is not without its complications or requirements for return-to-surgery, reflects an overall benefit for these children. These benefits are reflected in decreased hospitalization and length of stay.