For the second year in a row, Le Bonheur Neurosurgeon Paul Klimo MD, MPH, was awarded the Pediatrics Paper of the Year by the Congress of Neurological Surgeons (CNS) during the CNS annual meeting in San Francisco, Calif. The paper, “The Preventable Shunt Revision Rate: A Multicenter Evaluation,” was published in Neurosurgery in March 2019.
The Preventable Shunt Revision Rate (PSRR) was introduced in 2016 as a quality metric to determine which shunt failures were avoidable. Shunt surgery is the most common procedure performed in neurosurgery, and shunt malfunction is the second most common cause of rehospitalization in children.
“PSRR goes directly to the heart of the current quality movement in health care,” said Klimo. “Quality metrics lead to the implementation of processes to avert negative consequences and maximize positive results.”
The paper evaluated two years of shunt operations data from nine participating centers in North America to determine the PSRR across institutions as well as the most common reasons for shunt failure. Of the 5,092 shunt operations performed, 861 failed within 90 days, an overall failure rate of 16.9%.
Of the failed shunts, 307 were determined to be potentially preventable — an overall 90-day PSRR of 35.7%. Preventability was defined as cerebrospinal fluid (CSF) infection, wound breakdown or infection, suboptimal position of the proximal or distal catheter or an improperly assembled or inadequately secured shunt that resulted in postoperative disconnection, migration, kinking or obstruction. The most common etiologies of preventable failure were shunt infection, malposition of the proximal catheter and an error in judgment.
This study shows that approximately one third of early shunt failures are preventable. The paper suggests that the overall shunt infection rate for any major children’s institution should be 5% or less. Predictors of preventable failure included lack of endoscopy, recent shunt infection, shunt type and participating center.
“Direct involvement and oversight by staff is critical and can help reduce the risk of all causes for preventable shunt failures,” said Klimo. “PSRR allows practitioners and institutions to identify areas that may be improved such as investing in image guidance technology, implementing a shunt surgery checklist and reaching out to general surgeons
to assist in accurate distal catheter placement.”
Future efforts with PSRR include creating a real-world registry as well as re-evaluating centers that have implemented changes in an effort to lower PSRR.
Klimo also won Pediatrics Paper of the Year in 2018 for his research on survival rates for pineoblastoma tumors.
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