The quality improvement paper “Early Intervention Management Pathway for Intraventricular Hemorrhage of Prematurity: A Quality Improvement Analysis” ^{Reference Abraham, Elder and Watson1} provides a real-world example of how a quality improvement initiative can be used to implement institutional and provincial changes in patient management in order to support an evolving standard of care.

Intraventricular hemorrhage (IVH) of prematurity and its sequelae, posthemorrhagic ventricular dilation (PHVD) and posthemorrhagic hydrocephalus (PHH), are associated with a significantly increased risk of long-term cognitive and physical developmental disability. ^{Reference Radic, Vincer and McNeely2} Newer evidence suggests that earlier intervention (when there is PHVD present on head ultrasound, but not yet any clinical signs or symptoms of raised intracranial pressure (ICP)) may lead to improved long-term neurodevelopmental outcomes. ^{Reference Leijser, Miller and Van Wezel-Meijler3} As a result, there has been increasing interest among North American neurosurgeons and neonatologists to trial earlier intervention for PHVD management.

This can be easier said than done. The management of IVH of prematurity and PHVD/PHH necessarily involves a multidisciplinary care team, spanning neonatology, neurosurgery, diagnostic imaging and allied health team members. A strategy of earlier intervention requires resources (e.g., frequent ultrasound examinations, access to operating room (OR) time, need for personnel to perform ventricular access device (VAD) taps, etc.) to facilitate implementation of this new protocol. Given these barriers and complexities, a quality improvement approach is an ideal way to build “buy-in” by encouraging team members to work together to problem-solve new management protocols and monitor any changes in care so that further improvements can then be made on an ongoing basis.

In this paper, the Vancouver team has outlined their institutional management protocol for IVH and PHVD. The authors also share some of the barriers encountered while implementing their protocol and changes made to improve compliance (e.g., allowing VADs to be inserted outside of regular work hours). Through a historical comparison, the authors demonstrate that this new management protocol can be safely implemented without an increased complication rate. Though the efficacy of the new protocol will be assessed at a later date once long-term outcome data is collected, their published experience can still serve as a reference for other teams that may be interested in changing to an earlier intervention approach for the management of PHVD of prematurity.