Comprehensive pediatric neurosurgical implant checklist to maintain low implant infection rates: lessons on compliance and institutional culture.

Abstract

ObjectiveImplant infection is a significant contributor to morbidity and mortality for children with hydrocephalus and other neurosurgical conditions requiring shunts and other neurosurgical implants. To standardize pediatric neurosurgical care and minimize the risk of infections related to implanted shunts and neurosurgical devices, the authors introduced a 23-point checklist for all pediatric neurosurgical implant procedures at Stanford University in March 2019. This protocol minimizes operating room traffic and standardizes sterile technique, preparation, and antibiotic use.MethodsProspective quality initiative data obtained for surgeries completed in the checklist era (March 2019-May 2023, follow-up through November 2023) were compared with retrospective chart review data of the prechecklist era cases (March 2016-February 2019). Checklist compliance was monitored by individual checklist elements. Infections of shunts or implanted devices within 6 months of the surgical date were identified prospectively and by routine audits. Infection rates in the prechecklist era were compared to infection rates in the checklist era using Fisher's exact test.ResultsThere were 4 infections in the 356 prechecklist era surgeries (1.1% infection rate, 95% CI 0.03%-2.21%) and 9 infections in the 630 postchecklist era surgeries (1.4% infection rate, 95% CI 0.50%-2.34%), resulting in an overall implant infection rate of 1.3% (95% CI 0.60%-2.02%). Infection rates did not significantly change during a period of significant case volume growth, with an absolute risk difference of 0.3% (95% CI -1.13% to 1.73%) and relative risk of 1.3 (95% CI 0.39-4.12, p > 0.999). Shunt infections were the most common infections observed. One baclofen pump infection was observed and no vagus nerve stimulators, deep brain stimulators, generators, Ommaya reservoirs, neonatal reservoirs, or cranioplasties were infected in the study period. The majority of shunt infections occurred in infants younger than 6 months of age.ConclusionsAdherence to a strict implant protocol can ensure very low rates of infections for pediatric shunts and neurosurgical implants. This study found a lower shunt infection rate than the national pediatric benchmark-the 5.1% infection rate observed within the Hydrocephalus Clinical Research Network (HCRN) and the 3.9% infection rate observed within the HCRN quality network, to which the authors' institution contributes data. Despite surgeon and staff turnover, high overall institutional checklist compliance and consistently low infection rates were observed over time.