title: Effectiveness of a clinical pathway for patients with cerebrospinal fluid shunt malfunction.
abstract: OBJECTIVE
  Patients with CSF shunts often present to the emergency department (ED) with suspected shunt malfunction. Timely assessment and treatment are important factors affecting patient outcomes. A protocol was implemented at a tertiary children's hospital ED to expedite the care of these patients. This study evaluated the effectiveness of this protocol.
  
  
  METHODS
  The protocol assigned all patients with CSF shunts into 1 of 3 pathways. If a patient presented with altered mental status, the Cushing triad, acute focal neurological deficit, ongoing seizure activity, or severe dehydration due to emesis, an ED physician was immediately notified (emergency pathway). If a patient presented with emesis, headache, increasing frequency of seizure, or parental concern for shunt malfunction, the patient entered the expedited pathway, and imaging studies were ordered prior to physician evaluation. All other patients entered the default pathway, in which a physician would evaluate the patient before deciding on further workup. Outcomes of interest included measures of timeliness in the ED and clinical outcomes. Comparisons were made between preprotocol and protocol periods and among the 3 pathways.
  
  
  RESULTS
  The total time to complete both ED physician evaluation and to initiate imaging studies was significantly shorter in the protocol period than in the preprotocol period (104 vs 147 minutes). Similar time saving over the 2 processes was demonstrated comparing expedited and default pathways during the protocol period (95 vs 134 minutes, a 29% difference). Clinically, more patients underwent surgery in the expedited pathway than the default pathway (36% vs 17%), and patients in the expedited pathway had a shorter hospital stay (3.4 ± 0.9 days vs 5.7 ± 4.0 days; p = 0.02).
  
  
  CONCLUSIONS
  An ED-based protocol helped identify patients at risk for shunt failure early in the triage process and shortened the assessment process prior to neurosurgical intervention. Improving the timeliness of care for patients with shunt failure is important because morbidity and mortality associated with shunt failure are time dependent.
authors.affiliation: Department of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA.
authors.forename: Joshua J
authors.initials: JJ
authors.lastname: Chern
authors.forename: Charles G
authors.initials: CG
authors.lastname: Macias
authors.forename: Andrew
authors.initials: A
authors.lastname: Jea
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Curry
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Luerssen
authors.forename: William E
authors.initials: WE
authors.lastname: Whitehead
mesh_terms: D000208:Acute Disease; D000465:Algorithms; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects*; D002648:Child; D019091:Critical Pathways / Q000592:standards; D020000:Decision Support Systems, Clinical; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards; D006776:Hospitals, Pediatric / Q000592:standards; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D007902:Length of Stay; D016134:Organizational Policy; D017063:Outcome Assessment, Health Care; D011475:Prosthesis Failure; D011785:Quality Assurance, Health Care; D013997:Time Factors