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Standardizing treatment of preterm infants with post-hemorrhagic hydrocephalus at a single institution with a
Tracy M Flanders1, Alexandra C Kimmel2, Shih-Shan Lang2
1Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA. MaTra@pennmedicine.upenn.edu.
Insights
Standardizing care for preterm infants with post-hemorrhagic hydrocephalus (PHH) using a clinical pathway improved treatment compliance and reduced time to ventricular access device (VAD) placement without increasing infection rates.
Area of Science:
- Neonatal Neurology
- Pediatric Neurosurgery
- Quality Improvement Science
Background:
- Post-hemorrhagic hydrocephalus (PHH) in preterm infants often requires temporary cerebrospinal fluid (CSF) drainage via ventricular access devices (VADs) before permanent ventriculoperitoneal shunt (VPS) placement.
- Lack of consensus on VAD and VPS management leads to practice variations and potentially adverse patient outcomes.
Purpose of the Study:
- To evaluate the impact of a standardized clinical pathway on the management of PHH in preterm infants.
- To assess improvements in treatment compliance, shunt timing, and infection rates following pathway implementation.
Main Methods:
- A quality improvement study was conducted in a single level IV NICU from February 2011 to September 2017.
- A multidisciplinary team developed and implemented a clinical pathway for PHH management, modifying existing protocols.
- CSF diversion and shunt timing were weight-based; VAD aspirations were performed by neonatal care providers guided by clinical and imaging criteria.
Main Results:
- The study included 78 eligible preterm infants with PHH.
- Post-pathway implementation, VAD and VPS infection rates were zero, compared to 4% and 3% respectively prior to the pathway.
- Treatment compliance improved from 55% to 86%, and conversion compliance improved from 89% to 100%.
Conclusions:
- Standardized care pathways for PHH significantly improve patient outcomes, including reduced time to VAD placement.
- Neonatal team-performed VAD aspirations are safe and do not increase infection risk.
- Clinical pathway implementation enhances compliance and optimizes management of PHH in preterm infants.
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.
