Protocolized approach to the management of congenital diaphragmatic hernia: benefits of reducing variability in care.
OBJECTIVE
Variable approaches to the care of infants with congenital diaphragmatic hernia (CDH) by multiple providers may contribute to inconsistent care. Our institution developed a comprehensive evidence-based protocol to standardize the management of CDH infants. This report reviews patient outcomes before and after the implementation of the protocol.


METHODS
Retrospective chart review of CDH infants managed with individualized care (preprotocol group, January 1997-December 2001, n = 22) or on the protocol (Protocol group, January 2002-July 2009, n = 47). Survival and other categorical variables were compared by chi(2) analysis, and continuous variables were compared using 1-sided analysis of variance analysis, with significance defined as P < .05.


RESULTS
Survival to discharge was significantly greater in the Protocol group (40/47; 85%) than the preprotocol group (12/22; 52%; P = .006), although mean gestational age, mean birth weight, and expected survival were not statistically different between the 2 groups. The use of supportive therapies, including high-frequency jet ventilation, inhaled nitric oxide, and extracorporeal life support, was similar between groups as well.


CONCLUSIONS
Since the implementation of a management protocol for infants with CDH, survival has improved significantly compared with expected survival and preprotocol controls. Reduction in the variability of care through use of an evidence-based protocol may improve the survival of CDH infants.
Tracy
Elisabeth T
ET
Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Mears
Sarah E
SE
Smith
P Brian
PB
Danko
Melissa E
ME
Diesen
Diana L
DL
Fisher
Kimberley A
KA
Hoehner
Jeff C
JC
Goldberg
Ronald N
RN
Cotten
C Michael
CM
Rice
Henry E
HE
D000280:Administration, Inhalation; D002985:Clinical Protocols; D005112:Extracorporeal Circulation / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D005865:Gestational Age; D006548:Hernia, Diaphragmatic / Q000503:physiopathology / Q000628:therapy*; D065630:Hernias, Diaphragmatic, Congenital; D006612:High-Frequency Ventilation / Q000379:methods / Q000592:standards; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D009569:Nitric Oxide / Q000008:administration & dosage; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D012189:Retrospective Studies
D009569:Nitric Oxide