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Huang WC, Chen YJ, Lin MHC, Lee MH. Analysis of neurosurgical procedures with unplanned reoperation for quality improvement: A 5-year single hospital study. Medicine (Baltimore) 2021; 100:e28403. [PMID: 34967375 PMCID: PMC8718219 DOI: 10.1097/md.0000000000028403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/02/2021] [Indexed: 01/05/2023] Open
Abstract
The unplanned return to the operating room rate is a quality metric for assessing hospital performance. This study aimed to evaluate the cause, incidence, and time interval of unplanned returns in index neurosurgical procedures within 30 days of the initial surgery as an internal audit. We retrospectively analyzed neurosurgical procedures between January 2015, and December 2019, in a single regional hospital. The definition of an unplanned return to the operating room was a patient who underwent two operations within 30 days when the second procedure was not planned, staged, or related to the natural course of the disease.A total of 4365 patients were identified in our analysis, of which 93 (2%) had an unplanned return to the operating room within 30 days of their initial surgery during admission. The most common reason for an unplanned return to the operating room for a cranial procedure was hemorrhage, followed by hydrocephalus and subdural effusion, which accounted for 49.5%(46/93), 12%(11/93), and 5.4%(5/93) of cases, respectively. In spinal procedures, the most common cause of return was a residual disc, followed by surgical site infection, which accounted for 5.4%(5/93) and 4.3%(4/93) of cases, respectively. The overall median time interval for unplanned returns to the operating room was 3 days (interquartile range, 1-9).Lowering the rate of postoperative hemorrhage in cranial surgery and postoperative residual disc in spine surgery was crucial as an internal audit in a 5-year single institute follow-up. However, the unplanned reoperation rate is less helpful in benchmarking because of the heterogeneity of patients between hospitals.
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Affiliation(s)
- Wei-Chao Huang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chia-Yi Branch, Pu Tz City, Chia-Yi, Taiwan
| | - Yin-Ju Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chia-Yi Branch, Pu Tz City, Chia-Yi, Taiwan
| | - Martin Hsiu-Chu Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chia-Yi Branch, Pu Tz City, Chia-Yi, Taiwan
| | - Ming-Hsueh Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chia-Yi Branch, Pu Tz City, Chia-Yi, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
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Kaestner S, Poetschke M, Kehler U, Antes S, Krause M, Deinsberger W. Revision surgery following CSF shunt insertion: how often could it be avoided? Acta Neurochir (Wien) 2020; 162:9-14. [PMID: 31667581 DOI: 10.1007/s00701-019-04083-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) shunt revision surgery represents a huge social and economic burden. Few studies, however, have evaluated shunt revision surgeries in the context of their avoidability, and existing data are from paediatric populations. Using ratings from an expert panel, we classified avoidable and unavoidable shunt revisions in a mixed cohort of CSF-shunt patients. METHODS In a retrospective review of a prospectively maintained, single-centre database, we identified all shunt systems implanted for the first time over a 10-year period (2007-2016) and all subsequent revision surgeries with a follow-up of at least 1 year. A panel of five expert shunt surgeons classified each revision surgery as avoidable or unavoidable. Rates of each were calculated and correlated with clinical data. RESULTS Of 210 revision surgeries (314 patients, mean age, 49.9 years; mean follow-up, 4.2 years), the panel judged 114 as unavoidable (54.3%) and 96 (45.7%) as avoidable. Level of surgeon education correlated with these rates, but even in the most experienced hands, 12.5% of revisions were classified as avoidable. Avoidable revisions occurred significantly earlier than unavoidable interventions (mean; 112 and 448 days, respectively) after the index surgery. CONCLUSION Rates of avoidable shunt revision surgery are alarmingly high, even in experienced hands. Avoidable revisions occur significantly earlier, predominantly within the first 3 months after the index surgery.
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Dave P, Venable GT, Jones TL, Khan NR, Albert GW, Chern JJ, Wheelus JL, Governale LS, Huntoon KM, Maher CO, Bruzek AK, Mangano FT, Mehta V, Beaudoin W, Naftel RP, Basem J, Whitney A, Shimony N, Rodriguez LF, Vaughn BN, Klimo P. The Preventable Shunt Revision Rate: A Multicenter Evaluation. Neurosurgery 2020; 84:788-798. [PMID: 29982642 DOI: 10.1093/neuros/nyy263] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/17/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Preventable Shunt Revision Rate (PSRR) was recently introduced as a novel quality metric. OBJECTIVE To evaluate the PSRR across multiple centers and determine associated variables. METHODS Nine participating centers in North America provided at least 2 years of consecutive shunt operations. Index surgery was defined as new shunt implantation, or revision of an existing shunt. For any index surgery that resulted in a reoperation within 90-days, index surgery information (demographic, clinical, and procedural) was collected and a decision made whether the failure was potentially preventable. The 90-day shunt failure rate and PSRR were calculated per institution and combined. Bivariate analyses were performed to evaluate individual effects of each independent variable on preventable shunt failure followed by a final multivariable model using a backward model selection approach. RESULTS A total of 5092 shunt operations were performed; 861 failed within 90 days of index operation, resulting in a 16.9% combined 90-day shunt failure rate and 17.6% median failure rate (range, 8.7%-26.9%). Of the failures, 307 were potentially preventable (overall and median 90-day PSRR, 35.7% and 33.9%, respectively; range, 16.1%-55.4%). The most common etiologies of avoidable failure were infection (n = 134, 44%) and proximal catheter malposition (n = 83, 27%). Independent predictors of preventable failure (P < .05) were lack of endoscopy (odds ratio [OR] = 2.26), recent shunt infection (OR = 3.65), shunt type (OR = 2.06) and center. CONCLUSION PSRR is variable across institutions, but can be 50% or higher. While the PSRR may never reach zero, this study demonstrates that overall about a third of early failures are potentially preventable.
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Affiliation(s)
| | - Garrett T Venable
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Tamekia L Jones
- Departments of Pediatrics and Preventive Medicine, University of Tennessee Health Science Center, Children's Foundation Research Institute, Memphis, Tennessee
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Gregory W Albert
- Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas.,Department of Neurosurgery, University of Arkansas, Little Rock, Arkansas
| | - Joshua J Chern
- Pediatric Neurosurgical Associates, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Jennifer L Wheelus
- Pediatric Neurosurgical Associates, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Lance S Governale
- Division of Pediatric Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Amy K Bruzek
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Vivek Mehta
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Robert P Naftel
- Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jade Basem
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna Whitney
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nir Shimony
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Luis F Rodriguez
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey, Memphis, Tennessee
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Venable GT, Dave P, Gordon WE, Fraser BD, Wallace DA, Mangham W, Taylor DR, Khan NR, Michael LM, Vaughn BN, Klimo P. Application of the Preventable Shunt Revision Rate to an Adult Population. World Neurosurg 2019; 134:e815-e821. [PMID: 31715417 DOI: 10.1016/j.wneu.2019.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The preventable shunt revision rate (PSRR) was recently introduced in pediatric hydrocephalus as a quality metric for shunt surgery. We evaluated the PSRR in an adult hydrocephalus population. METHODS All ventricular shunt operations (January 1, 2013 to March 31, 2018) performed at a university-based teaching hospital were included. For any index surgery (de novo or revision) resulting in reoperation within 90 days, the index surgery details were collected, and a consensus decision was reached regarding whether the failure had been potentially avoidable. Preventable failure was defined as failure due to infection, malposition, disconnection, migration, or kinking. The 90-day shunt failure rate and PSRR were calculated. Bivariate analyses were performed to evaluate the individual effects of each independent variable on preventable shunt failure. RESULTS A total of 318 shunt operations had been performed in 245 patients. Most patients were women (62%), with a median age of 48.2 years (interquartile range, 31.2-63.2 years). Most had had ventriculoperitoneal shunts placed (86.5%), and just more than one half were new shunts (51.6%). A total of 53 cases (16.7%) in 42 patients experienced shunt failure within 90 days of the index operation. Of these, 27 failures (8.5% of the total cases; 51% of the failures) were considered potentially preventable. The most common reasons were infection (37%; n = 10) and malposition of the proximal and distal catheters (both 25.9%; n = 7). Age was the only statistically significant difference between the 2 groups, with the patients experiencing preventable shunt failure older than those without preventable shunt failure (51.4 vs. 37.1 years; P = 0.017). CONCLUSIONS The 90-day PSRR can be applied to an adult population and serve as a quality metric.
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Affiliation(s)
- Garrett T Venable
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - William E Gordon
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - David A Wallace
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - William Mangham
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Douglas R Taylor
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Semmes Murphey Clinic, Memphis, Tennessee, USA
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Semmes Murphey Clinic, Memphis, Tennessee, USA; Le Bonheur Children's Hospital, Memphis, Tennessee, USA.
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