Early Intervention Management Pathway for Intraventricular Hemorrhage of Prematurity: A Quality Improvement Analysis

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.