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Early Intervention Management Pathway for Intraventricular Hemorrhage of Prematurity: A Quality Improvement Analysis
Ananth P Abraham1,2, Madeline W Elder3, Isabella Watson1
1Division of Pediatric Neurosurgery, British Columbia Children's Hospital, Vancouver, Canada.
Insights
Implementing an early ventricular access device (VAD) protocol for premature infants with post-hemorrhagic ventricular dilatation showed satisfactory compliance and no safety concerns. Delays in intervention and operating room access require improvement for this neuroprotective strategy.
Area of Science:
- Neonatal Neurology
- Pediatric Neurosurgery
- Quality Improvement Science
Background:
- Post-hemorrhagic ventricular dilatation (PHVD) in premature infants poses significant neurodevelopmental risks.
- Traditional management often relies on clinical symptoms, potentially delaying intervention.
- An early, size-criteria-driven ventricular access device (VAD) protocol aims to improve outcomes by controlling ventricular size.
Purpose of the Study:
- To evaluate the safety and resource implications of implementing a quality improvement protocol for early VAD placement in PHVD.
- To assess compliance with a new treatment paradigm involving size-based VAD intervention and aggressive tapping.
- To identify areas for optimization in a novel care pathway for premature infants with PHVD.
Main Methods:
- Retrospective comparison of infants treated under a new size-driven VAD protocol versus a historical clinical symptomatology cohort.
- Tracking of process and compliance measures for protocol implementation.
- Monitoring of complications and resource utilization associated with the new protocol.
Main Results:
- VAD placement occurred earlier and at smaller ventricular sizes, though often outside the protocol timeframe.
- High compliance was observed for protocol-directed ultrasounds and VAD aspirations by trained clinicians.
- No increase in complications was noted despite earlier and more aggressive treatment in fragile infants.
Conclusions:
- The implemented VAD protocol demonstrated satisfactory compliance and a favorable safety profile.
- Intervention timing and ventricular size thresholds were frequently exceeded, highlighting a need to streamline care pathways.
- Reducing transfer delays and improving operating room access are key areas for future improvement.
- Ultrasound surveillance frequency may be reduced without compromising infant safety.
Objective:
Early placement of a ventricular access device (VAD) in premature post-hemorrhagic ventricular dilatation based on ventricular size criteria, coupled with an aggressive tapping regimen to control ventricular size, may improve developmental outcomes. As this treatment paradigm represents a significant departure from traditional care, we present results of an institutional quality improvement protocol implementation study focusing on safety and resource use for those seeking to implement a similar care pathway.
Methods:
Infants treated under the new ventricular size-driven protocol were retrospectively compared to a historical cohort managed according to clinical symptomatology. Process and compliance measures related to protocol implementation were tracked, as were complications and measures of resource use.
Results:
Ventricular access device (VAD) placement occurred earlier and at a smaller ventricle size, but beyond the protocol-mandated timeframe. Although more resource-intensive than customary care, compliance with protocol-directed screening ultrasounds and VAD aspirations by trained clinicians was high. Intensive ultrasound surveillance altered the management of only one infant during their treatment course. An increased rate of complications related to earlier and more aggressive treatment in these fragile infants was not observed.
Conclusions:
Protocol compliance was satisfactory and no safety issues were noted. Although VAD placement occurred sooner, a majority of infants received intervention outside of the mandated timeframe and at a ventricular size above the desired intervention threshold. Minimizing transfer delays from peripheral neonatal intensive care units and improving access to the operating room were identified as areas for improvement. It appears possible to decrease the frequency of ultrasound surveillance without compromising safety.
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