124 - Quality improvement effort to optimize management of post-hemorrhagic ventricular dilation

Earlier identification and quantification of post-hemorrhagic ventricular dilation (PHVD) can offer opportunities for timely interventions with improved outcomes. In the absence of PHVD management guidelines, subjective assessments of dilation lead to delayed intervention.

Objective:

We aimed to reduce the severity of PHVD before intervention and improve outcomes for patients with PHVD by implementing guidelines based on objective neonatal head ultrasound criteria.

Design/Methods:

Our Level 4 NICU cares for 10-20 infants with PHVD annually, of which approximately 20% are inborn. The quality improvement team consisted of neonatology, neurology, neurosurgery, and neuroradiology.

In 2020, we developed guidelines based on assessing frontotemporal horn ratio (FTHR) as an objective measurement of PHVD. During 2020 and 2021, we shared guidelines at local and regional meetings and within a centralized guideline repository. Finally in 2022, we developed an Epic Best Practice Advisory and collaborated with referring hospitals to implement FTHR locally.

The outcome measures were maximum FTHR in patients with PHVD and the rate of conversion of reservoirs to a permanent shunt. Process measures included time to neurology or neurosurgery consult, compliant imaging and head circumference measurements, and documentation of FTHR before transfer. Balancing measures included shunt or reservoir infection in the NICU and transfer for PHVD management without neurosurgical intervention.

Results:

During the study period, our NICU cared for 34 infants with PVHD. There was no change in maximum FTHR which remained at 0.58 (95% Cl 0.55-0.61, Figure 1). The percentage of infants needing a reservoir without a shunt improved (33%, 17%, and 63% in 2020, 2021, and 2022, respectively). We reduced the time to neurology and neurosurgery consults (Figure 2). Compliance with recommended head imaging and circumference measurements remained high. In 2022, among infants transferred for the management of PHVD, 57% had an FHTR measured before transfer. There were no cases of infants transferred for PHVD without neurosurgical intervention. We observed only 2 cases of shunt or reservoir infection.

Conclusion(s):

With the implementation of standard PHVD guidelines, we saw a reduction in infants requiring conversion to permanent shunts. However, we have not seen a change in maximum FTHR. This may be related to infants with an elevated FTHR on first head ultrasound or prior transfer. We speculate that increased compliance with our guidelines internally and at our referral hospitals will improve the timeliness of care.