Standardizing treatment of preterm infants with post-hemorrhagic hydrocephalus at a single institution with a multidisci
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ORIGINAL ARTICLE
Standardizing treatment of preterm infants with post-hemorrhagic hydrocephalus at a single institution with a multidisciplinary team Tracy M. Flanders 1 & Alexandra C. Kimmel 1 & Shih-Shan Lang 1 & Richard Bellah 2 & John Chuo 3 & John C. Wellons III 4 & John J. Flibotte 3 & Gregory G. Heuer 1 Received: 27 September 2019 / Accepted: 10 January 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Background Preterm infants with post-hemorrhagic hydrocephalus (PHH) are often treated with temporizing measures such as ventricular access devices (VADs) in order to drain cerebrospinal fluid (CSF) prior to permanent diversion with ventriculoperitoneal shunt (VPS) placement. Local problem There is little consensus on the timing and management of VADs and VPSs. This leads to marked practice variations among treating services that can adversely affect patient outcomes. Methods This is a quality improvement study evaluating practices from February 2011 to September 2017 including infants with PHH in a single level IV NICU. Interventions A multidisciplinary team created a local clinical pathway modified from the Hydrocephalus Clinical Research Network’s Shunting Outcomes in Post-Hemorrhagic Hydrocephalus protocol to manage infants with PHH. Methods of CSF diversion and shunt timing were based on weight. Neonatal care providers performed VAD aspiration; timing was guided by imaging and clinical exam criteria. Surgical procedures were performed in the NICU. Results There were 78 patients eligible for the study. Prior to pathway implementation, infections occurred in 4% of VAD and 3% of VPS patients. There have been no infections since inception of the pathway. With pathway implementation, treatment compliance improved from 55 to 86% while conversion compliance rate improved from 89 to 100%. Conclusions Standardization of care for PHH infants leads to improvement in patient outcomes such as a decrease in time to VAD placement. Reservoir aspirations by the neonatology team did not result in an increase in infection rate. Keywords Post-hemorrhagic hydrocephalus (PHH) . Ventricular access device (VAD) . Quality improvement (QI) . Standardization
Introduction Problem description * Tracy M. Flanders [email protected] 1
Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
2
Division of Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
3
Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
4
Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
Approximately 15–35% of preterm infants with intraventricular hemorrhage (IVH) develop post-hemorrhagic hydrocephalus (PHH) [1]. The occurrence of PHH requiring neurosurgical intervention is one of the strongest predictors of future neurodevelopmental delay [2]. Despite its frequency and implications for later outcomes, the management of PHH remains controversial. Further complicating the treatment
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