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Samir Sarda, Mike K. Moore and Joshua J. Chern

TO THE EDITOR: We read with great interest 2 recent articles 2 , 3 on 30-day readmission and reoperation rates after CSF shunt surgery by Dr. Piatt, whose insightful and important work is much appreciated (Piatt JH Jr: Thirty-day outcomes of cerebrospinal fluid shunt surgery: data from the National Surgical Quality Improvement Program-Pediatrics. J Neurosurg Pediatr 14: 179–183, August 2014) (Piatt JH Jr, Freibott CE: Quality measurement in the shunt treatment of hydrocephalus: analysis and risk adjustment of the Revision Quotient. J Neurosurg Pediatr 14

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Shunt failure

James M. Drake

, they have been able to demonstrate a reduction in time to obtaining imaging and having a physician examine patients at higher risk of experiencing shunt failure (from 134 to 95 minutes). However, as is often the case in quality improvement projects, the results are more complex than one would anticipate, and while the process was more efficient, there was no clear improvement in outcome. The authors practice in a very busy tertiary pediatric hospital in a large urban setting. They followed a logical implementation process by involving emergency personnel in

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Samir Sarda, Wei Dong and Joshua J. Chern

TO THE EDITOR: We read with great interest recent articles on readmissions by Buchanan et al. 1 [Buchanan CC, Hernandez EA, Anderson JM, et al: Analysis of 30-day readmissions among neurosurgical patients: surgical complication avoidance as key to quality improvement. J Neurosurg 121: 170–175, July 2014] and Marcus et al. 4 [Marcus LP, McCutcheon BA, Noorbakhsh A, et al: Incidence and predictors of 30-day readmission for patients discharged home after craniotomy for malignant supratentorial tumors in California (1995–2010). J Neurosurg 120: 1201

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Anil K. Roy, Jason Chu, Caroline Bozeman, Samir Sarda, Michael Sawvel and Joshua J. Chern

neurosurgical cases. This could be a potential area for investigation. In their study, Mukerji et al. 9 also found a higher reoperation rate for the index procedures performed outside the hours of 8 am . to 5 pm One potential difference to account for their higher overall reoperation rate could be that all pediatric cases at our institution have an attending neurosurgeon scrubbed in, regardless of the hour. We are in the process of implementing some quality improvement reforms to specifically target these off-hour surgeries. These changes include a heightened awareness to

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Joshua J. Chern, Markus Bookland, Javier Tejedor-Sojo, Jonathan Riley, Mohammadali M. Shoja, R. Shane Tubbs and Andrew Reisner

strategies to improve patient care, physicians should be at the forefront of these efforts to ensure the feasibility of such quality improvement initiatives. Comparing Results of This Study to Others In this study, the all-cause readmission rate within 30 days of index shunt surgery was 16.5%. Rates of shunt reoperations (n = 157) and all-neurosurgery reoperations (n = 165) were 8.9% and 9.4%, respectively. Readmissions that were deemed to be related to the index surgery (neurosurgical shunt procedures and nonoperative neurosurgical admissions) accounted for 74.5% of

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Samir Sarda, Harold K. Simon, Daniel A. Hirsh, Andrew Wang, R. Shane Tubbs and Joshua J. Chern

groups of children who visit emergency departments for mental health crises . CMAJ 184 : E665 – E674 , 2012 12 Piatt JH Jr : Thirty-day outcomes of cerebrospinal fluid shunt surgery: data from the National Surgical Quality Improvement Program-Pediatrics . J Neurosurg Pediatr 14 : 179 – 183 , 2014 13 Piatt JH Jr , Freibott CE : Quality measurement in the shunt treatment of hydrocephalus: analysis and risk adjustment of the Revision Quotient . J Neurosurg Pediatr 14 : 48 – 54 , 2014 14 Roberts YH , Huang CY , Crusto CA , Kaufman

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Joshua J. Chern, Charles G. Macias, Andrew Jea, Daniel J. Curry, Thomas G. Luerssen and William E. Whitehead

-county region in southeast Texas. The ED at Texas Children's Hospital evaluates more than 80,000 children per year. All patients coming through the ED are first registered and evaluated by a triage nurse and then enter the waiting area until an examination room becomes available and a physician evaluation can be performed. The study was conducted in conjunction with a quality improvement initiative and was approved by the Baylor College of Medicine Institutional Review Board. Protocol Development The protocol was developed by a multidisciplinary team, including

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David M. Wrubel, Kelsie J. Riemenschneider, Corinne Braender, Brandon A. Miller, Daniel A. Hirsh, Andrew Reisner, William Boydston, Barunashish Brahma and Joshua J. Chern

patients undergoing pediatric neurosurgical procedures. Specifically, we evaluate the measurement of returning to system within 30 days of surgery. This is a measure that was developed and used by the pediatric version of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP Pediatric). We identified and defined necessary elements within our administrative database to establish this measurement. Statistical analysis was used to identify clinical and demographic risk factors associated with an unexpected return. Important lessons were

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Samir Sarda, Markus Bookland, Jason Chu, Mohammadali M. Shoja, Matthew P. Miller, Stephen B. Reisner, Philip H. Yun and Joshua J. Chern

. Efforts to identify actionable areas of quality improvement regarding patients after shunt surgery are, therefore, a critical area of investigation, which the authors have previously addressed in a retrospective review of 1755 cases. 3 However, even in the most shunt-intensive pediatric neurosurgery practices, focusing entirely on postoperative shunt patients ignores a significant portion of pediatric neurosurgery cases. Potentially modifiable risk factors for 30-day readmission among the non-shunt operations would be expected to be divergent from those of patients

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Neurological, general and vascular surgeons all perform carotid endarterectomy. However, the relationship between primary specialty training and outcome of this surgery is unknown. Methods We identified 54, 050 patients who underwent carotid endarterectomy, from 2006–2012 in the National Surgical Quality Improvement Program (NSQIP), a prospectively-collected, national clinical database with established reproducibility and validity. Four hundred and forty eight patients were operated on by neurosurgery, n=2, 653 by general and n=50, 949 by vascular surgery. We compared