Neurosurgery
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The most common surgical options for trigeminal neuralgia (TN) are microvascular decompression (MVD) and gamma knife surgery (GKS). Currently, there is no definitive consensus as to which of the 2 options is more effective at providing immediate and long-lasting pain relief. This study seeks to better evaluate the differences between these 2 options in terms of rates of complete pain relief and pain-free recurrence. ⋯ MVD may be a more effective intervention than GKS because of the higher rates of initial pain-free outcomes and long-term pain-free outcomes, and lower rates pain-free recurrences.
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Delivery of higher-value health care is an ultimate government and public goal. Improving efficiency in the operating room and standardization of surgical steps would improve patient outcome and reduce costs, and lead to higher-value health care. Lean principles have been applied to processes proceeding and following surgery and have improved timeliness; however, value stream mapping of surgery itself has not been performed; therefore, pure waste has not been targeted for improvement. We applied plan, do, study, act (PDSA) cycles to posterior instrumented fusion (PIF) in an attempt create a standard work flow, identify waste, and remove special cause variability among similar cases. ⋯ Lean principles can be applied to neurosurgical procedure time, and can be used to standardize surgical workflow and identify waste; common to all procedures was waiting and defect waste from nonsurgical sources. These preliminary data were the basis of a quality improvement Kaizen event to decrease the causes of variability, improve efficiency, and decrease overall cost.
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Shunt infection and failure are associated with significant medical costs and hospitalization days. Current practice relies on microbiology culture, which significantly delays definitive diagnosis. Complement activation in the cerebrospinal fluid (CSF) has been shown to be a reliable biomarker of meningitis but has not been evaluated in shunt infection or failure. A rapid diagnostic complement assay could aid in identifying patients with hydrocephalus-associated complications. ⋯ Preliminary results show CSF MAC levels may help differentiate between pyogenic infection, symptomatic ventricular enlargement, and asymptomatic/P acnes infected children. We are currently expanding this study with respect to patient number and complement biomarkers to establish predictive values that facilitate clinical decision making in this challenging population.
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Neurosurgical indications for patient transfer include absence of local or available neurosurgical coverage, subspecialty or interdisciplinary requirements, and family preference. Transfer of patients to regional centers will increase with further centralization of medical care. ⋯ Interhospital transfer requires a coordinated effort among hospital administrators, physicians, and staff to make complex decisions that govern this important and costly process. These data suggest common failures and numerous opportunities for improvement in transfer efficiency, diagnostic accuracy, triage, and resource allocation.
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Complications from ventriculoperitoneal shunting are well-known and costly. Revision rates at certain time periods (eg 30, 60, and 180 days) have been proposed as quality metrics. The purpose of this study was to perform a detailed analysis of shunt failure etiology in an effort to produce a more appropriate quality metric. ⋯ An overall shunt revision rate at any time period is not an appropriate quality metric. However, we have identified a new metric the preventable shunt revision rate (PSRR) at 90 days as a metric that is meaningful, measureable, and modifiable. It is the one that all institutions should track and institute processes to minimize.