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John R. W. Kestle, Jay Riva-Cambrin, John C. Wellons III, Abhaya V. Kulkarni, William E. Whitehead, Marion L. Walker, W. Jerry Oakes, James M. Drake, Thomas G. Luerssen, Tamara D. Simon and Richard Holubkov

. Typical hospitalizations last 7–21 days. 9 Despite these measures, recurrent infection is common. 9 , 10 Clearly, prevention of infection is essential, and many techniques have been promoted to minimize the risk. Recent work in other areas of medicine and surgery has demonstrated beneficial results using quality improvement methodology. This methodology involves the development and application of standardized, stepwise protocols for common health care processes, measurement of compliance, and observation of the effect on outcome. Single-center studies using these

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John R. W. Kestle

uncommon. When smaller centers are implementing published protocols, they may not have the volume of patients to demonstrate statistical significance, especially if they are starting from a lower baseline infection rate than was observed in Calgary. This presents a problem for demonstrating the generalizability of published protocols. To generate adequate sample size, it may be necessary to pool data from multiple sites using the same protocol. For this reason, a plan is currently being developed to expand the quality improvement activity in the HCRN protocol to multiple

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Michael M. H. Yang, Walter Hader, Kelly Bullivant, Mary Brindle and Jay Riva-Cambrin

multicenter international study, generalizability to independent, small- to medium-volume children’s hospitals has not been established. After learning about the effectiveness of the HCRN shunt protocol in 2012, the authors at the University of Calgary, Alberta Children’s Hospital (ACH), set out to implement a similar protocol as part of a quality improvement initiative. The 9-step Calgary Shunt Protocol (CSP) was created around the 2011 HCRN protocol 14 and was implemented beginning on May 23, 2013. The goals for the current study were as follows: 1) to determine whether

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Prospective multicenter studies in pediatric hydrocephalus

JNSPG 75th Anniversary Invited Review Article

John R. W. Kestle and Jay Riva-Cambrin

registries discussed above have been supported by government funding (UK Shunt Registry) or philanthropy (HCRN). Prospective Multicenter Quality-Improvement Studies Two prospective multicenter quality-improvement studies have focused on pediatric hydrocephalus. Both are HCRN reports examining a shunt infection prevention protocol. In 2011, Kestle et al. 16 reported a drop in shunt infection from 8.8% to 5.7% after protocol implementation at 4 institutions. A multivariable analysis found that BioGlide catheters and the use of antiseptic cream both increased the risk of

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Heather S. Spader, Dean A. Hertzler, John R. W. Kestle and Jay Riva-Cambrin

introduction of the shunt infection protocol. Because culture change is an important component of quality improvement, it is possible that members of the operating room team may have changed their behavior as a result of their experiences with the shunt insertion protocol, and perhaps this contributed to the decreased infection rate. The only change in behavior during VAD operations that we could reliably identify in the medical record was IT antibiotic use, which increased from 0% to 87.5% to 100%. Although antibiotic use alone did not impact infection rates in shunt

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Heather S. Spader, Robert J. Bollo, Christian A. Bowers and Jay Riva-Cambrin

treated with intrathecal baclofen therapy: 14-year experience . J Neurosurg Pediatr 13 : 301 – 306 , 2014 9 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 10 Simon TD , Whitlock KB , Riva-Cambrin J , Kestle JR , Rosenfeld M , Dean JM , : Revision surgeries are associated with significant increased risk of subsequent cerebrospinal fluid shunt infection . Pediatr Infect Dis J 31 : 551 – 556

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John R. W. Kestle, Richard Holubkov, D. Douglas Cochrane, Abhaya V. Kulkarni, David D. Limbrick Jr., Thomas G. Luerssen, W. Jerry Oakes, Jay Riva-Cambrin, Curtis Rozzelle, Tamara D. Simon, Marion L. Walker, John C. Wellons III, Samuel R. Browd, James M. Drake, Chevis N. Shannon, Mandeep S. Tamber, William E. Whitehead and The Hydrocephalus Clinical Research Network

I nfection continues to be a common complication of CSF shunts for children with hydrocephalus, and there are ongoing efforts to identify methods or devices that may reduce this risk. Quality-improvement research has suggested that standardized protocols may reduce device-related infection in a number of areas. 1 , 3 , 11 The Hydrocephalus Clinical Research Network (HCRN) has used this approach to minimize shunt infection rates since 2007. A protocol was developed using the available literature that included 11 steps aimed at reducing infection, such as

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James M. Drake, Jay Riva-Cambrin, Andrew Jea, Kurtis Auguste, Mandeep Tamber and Maria Lamberti-Pasculli

more common and more serious than we anticipated, is a risk from almost any neurosurgical intervention, and is one that can be targeted for improvement, possibly with significant benefit. One of the limitations in comparing adverse event rates from different institutions at present is a paucity of consensus on definitions of the events. Hopefully, this limitation can be addressed in the future. Conclusions Most neurosurgery centers review morbidity and mortality events as part of a quality improvement process, and such review is usually required for hospital

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Tamara D. Simon, Kathryn B. Whitlock, Jay Riva-Cambrin, John R. W. Kestle, Margaret Rosenfeld, J. Michael Dean, Richard Holubkov, Marcie Langley and Nicole Mayer-Hamblett

quality improvement efforts. Prior studies of the association of indication for CSF shunt placement with subsequent shunt surgery 14 have yielded conflicting conclusions. 4 , 11 , 14 , 20 , 32 , 33 , 35 , 37 , 38 , 40 , 43–45 , 48 Some studies were conducted in cohorts that were selected based on procedures, rather than on patient characteristics, limiting the conclusions that can be drawn about patientlevel characteristics, 37 , 38 , 40 , 44 whereas other studies do not report the association of indication with subsequent failure. 10 In studies that have examined

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John C. Wellons III, Chevis N. Shannon, Richard Holubkov, Jay Riva-Cambrin, Abhaya V. Kulkarni, David D. Limbrick Jr., William Whitehead, Samuel Browd, Curtis Rozzelle, Tamara D. Simon, Mandeep S. Tamber, W. Jerry Oakes, James Drake, Thomas G. Luerssen, John Kestle and For the Hydrocephalus Clinical Research Network

versus Shunt” rubric or the conversion rubrics. The role of compliance in protocols is complex and the requirements necessary for consideration of surgeon compliance vary from study to study. In the initial HCRN shunt infection quality improvement study, it was noted that the infection trend declined as the compliance gradually rose, 12 but there were many variables that could have been responsible for the outcome. The well-noted WHO surgical checklist paper published in 2009 in the New England Journal of Medicine reported that 56.7% of the patients received