(20) Improving Intervention Times in Neonatal Post-hemorrhagic Ventricular Dilatation

Grace Y. Lai, Northwestern Feinberg School of Medicine, United States; Melissa L. Neveu, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Taylor Heald-Sargent, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Ellen Benya, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Janine Y. Khan, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Tiffani L. McDonough, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Andrea C. Pardo, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; David Ritacco, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Allan Wu, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Sandi Lam, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Maria Dizon, Ann & Robert H. Lurie Children's Hospital of Chicago, United States

Background: Frontal-occipital horn ratio (FOHR) in preterm infants with post-hemorrhagic ventricular dilatation (PHVD) is an independent correlate of functional outcome at school-age. Earlier intervention may lead to improved outcomes. The Hydrocephalus Research Network proposes an FOHR >=0.55 with signs and symptoms of increasing intracranial pressure for neurosurgical consultation and possible CSF diversion. At our academic, level IV NICU the average FOHR was 0.62 and 0.75 at time of Neurosurgery consult and first intervention, respectively.

Objectives: The aim of this quality initiative is to decrease the time to Neurosurgery consult and intervention in preterm infants with PHVD, by decreasing the average FOHR for consult to 0.50 and consideration of intervention to 0.55.

Design/Methods: Stakeholders from Neonatology, Neurology, Neurosurgery, and Radiology were involved in this initiative. Based on literature review, retrospective analysis of our processes and outcomes, and the perceived most impactful intervention, we developed a new head ultrasound (HUS) protocol which includes measurements to calculate FOHR. Process measures include rate of use of the new HUS order. Outcome measures include FOHR at the time of Neurosurgery consult and intervention. Data collection was performed via monthly audit.

Results: We implemented the new HUS order and distribution of protocols for neurosurgical consultation in July 2021. The rate of appropriate use of the HUS order was 89%. Between July 2021 and April 2022, there were 17 preterm infants with intraventricular hemorrhage; 3/17 infants had grade I/II hemorrhage and 14/17 infants had grade III/IV hemorrhage. Of these patients, 14 had a neurosurgery consult and 3 were considered for intervention. Average FOHR at consultation was 0.54, at the time of consideration for intervention was 0.66, and at intervention was 0.77.

Conclusion: We have successfully lowered the average FOHR at the time of neurosurgical consult from 0.62 to 0.54. The FOHR at first intervention is still higher than our goal. Per chart review, the delay between consideration for and actual intervention was due to clinical factors that raised concern for operating. We will continue data collection on a balancing metric of neurosurgical consultations not resulting in intervention. The next phase of this project will assess rates of VP shunt placement and neurodevelopmental outcomes. We believe this project will improve outcomes of our preterm NICU graduates through identification of barriers to timely, evidence-based care.