Assessment of the Neonatal Referral and Transport System for Patients With Gastroschisis Reffered to Kenyatta National Hospital

Abstract

Background: Gastroschisis is a surgical condition where the bowel eviscerates through an anterior abdominal wall defect. This is a source of major heat and fluid loss and infection in the neonate. Patients with gastroschisis born within a tertiary level hospital with specialty services available have better outcomes as compared to those who are born outside such a hospital. Birth outside a tertiary level facility confers serious challenges in pretransit and intra-transit care with resultant morbidity and mortality. Objective: The main objective of this study was to assess the neonatal referral and transport system for patients with gastroschisis referred to KNH. Materials and Methods: A prospective cross-sectional study design was used. Using consecutive sampling approach, patients received at Kenyatta Nation Hospital (KNH) pediatrics surgery unit(PSU) after referral from peripheral facilities were recruited. Data were collected on referring hospital factors, pre- and intra- transit factors, time and distance covered. Assessment of the neonatal referral and transport system for patients with gastroschisis referred to KNH was done using pre and intra transit factors as per the standard transport protocols in literature. Stata 16.0 was used for data analysis. Descriptive statistics such as percentages, means, mode and medians were used to describe the characteristics of study participants. Data were presented in pie charts, bar graphs, frequency tables and written reports. Results: Twenty-nine patients presented with gastroschisis during the study period. Mean age was 7.07 hours range 3 – 18 hours. There were 16 (55.2%) males and 13 (44.8%) females. Mean birthweight was 2019.8 grams, and a mean gestational age of 36.5 weeks. Mean duration of transit was 5 hours, median 5 hours and a range of 1 – 9 hours. Mean distance from referring facility to tertiary facility was 153.1 km, range 19 – 348. Out of 10 pre-transit factors assessed, 27.6% of patients scored 7, 48.3% scored 6, 17.2% scored 5 and 6.9% of patients scored 4. Most affected factors in the pre-transit protocol were lack of monitoring chart (0%) and comment on blood investigations (0%), gastric decompression (3.4%), prenatal obstetric scan (44.8%). Only 2/13 cases with gastroschisis were picked by the prenatal ultrasound. For intratransit scores, out of 14 parameters, 9 were only in 6.9%, 8 in 17.2%, 7 in 20.7%, 6 in 24.1% and 5 in 31%. Most affected were incubator use (0), pulse oximetry (31%), thermometer (55.2%), blood pressure monitor (44.8%), neonatal resuscitation training (58.6%), functioning nasogastric tube (13.8%), bowel monitoring (0%), adequate bowel cover (34.5%), parent content (48.3%). Conclusion: This study demonstrates that pretransit and transit care of neonates with gastroschisis is grossly inadequate. Interventions to promote care of neonates with gastroschisis are advised to reduce mortality. Such interventions would target areas of need as identified by this study.