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Effectiveness of a clinical pathway for patients with cerebrospinal fluid shunt malfunction
Joshua J Chern1, Charles G Macias, Andrew Jea
1Department of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA.
Insights
A new emergency department (ED) protocol significantly reduced assessment times for patients with cerebrospinal fluid (CSF) shunts. This expedited care improved surgical intervention rates and shortened hospital stays for those with shunt malfunction.
Area of Science:
- Pediatric Emergency Medicine
- Neurosurgery
- Healthcare Protocol Implementation
Background:
- Patients with cerebrospinal fluid (CSF) shunts frequently present to emergency departments (EDs) with suspected malfunctions.
- Timely evaluation and treatment are critical for improving outcomes in patients with CSF shunt issues.
- Existing ED workflows may not adequately expedite care for these potentially critical presentations.
Purpose of the Study:
- To evaluate the effectiveness of a newly implemented ED protocol designed to expedite the care of patients with suspected CSF shunt malfunction.
- To assess the impact of the protocol on ED assessment times and clinical outcomes.
- To compare the efficiency and outcomes across different pathways within the protocol.
Main Methods:
- A 3-pathway protocol (emergency, expedited, default) was implemented in a tertiary children's hospital ED for patients with CSF shunts.
- Patients were triaged into pathways based on clinical presentation and risk factors for shunt malfunction.
- Data on ED assessment times, imaging, surgical intervention, and hospital length of stay were collected and compared between pre-protocol and protocol periods, and among pathways.
Main Results:
- The protocol significantly reduced the total time for ED physician evaluation and initiation of imaging (104 vs. 147 minutes).
- The expedited pathway, which prioritized imaging before physician evaluation, showed a 29% time saving compared to the default pathway (95 vs. 134 minutes).
- Patients in the expedited pathway had higher rates of surgery (36% vs. 17%) and shorter hospital stays (3.4 days vs. 5.7 days) compared to the default pathway.
Conclusions:
- An ED-based protocol effectively identifies at-risk patients early, streamlining the assessment process for potential neurosurgical intervention.
- Implementing such protocols can significantly shorten the time to care for patients with CSF shunt failure.
- Reducing assessment and treatment delays is crucial, as morbidity and mortality associated with shunt failure are time-dependent.
Object:
Patients with CSF shunts often present to the emergency department (ED) with suspected shunt malfunction. Timely assessment and treatment are important factors affecting patient outcomes. A protocol was implemented at a tertiary children's hospital ED to expedite the care of these patients. This study evaluated the effectiveness of this protocol.
Methods:
The protocol assigned all patients with CSF shunts into 1 of 3 pathways. If a patient presented with altered mental status, the Cushing triad, acute focal neurological deficit, ongoing seizure activity, or severe dehydration due to emesis, an ED physician was immediately notified (emergency pathway). If a patient presented with emesis, headache, increasing frequency of seizure, or parental concern for shunt malfunction, the patient entered the expedited pathway, and imaging studies were ordered prior to physician evaluation. All other patients entered the default pathway, in which a physician would evaluate the patient before deciding on further workup. Outcomes of interest included measures of timeliness in the ED and clinical outcomes. Comparisons were made between preprotocol and protocol periods and among the 3 pathways.
Results:
The total time to complete both ED physician evaluation and to initiate imaging studies was significantly shorter in the protocol period than in the preprotocol period (104 vs 147 minutes). Similar time saving over the 2 processes was demonstrated comparing expedited and default pathways during the protocol period (95 vs 134 minutes, a 29% difference). Clinically, more patients underwent surgery in the expedited pathway than the default pathway (36% vs 17%), and patients in the expedited pathway had a shorter hospital stay (3.4 ± 0.9 days vs 5.7 ± 4.0 days; p = 0.02).
Conclusions:
An ED-based protocol helped identify patients at risk for shunt failure early in the triage process and shortened the assessment process prior to neurosurgical intervention. Improving the timeliness of care for patients with shunt failure is important because morbidity and mortality associated with shunt failure are time dependent.
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