Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care.
External ventricular drains (EVDs) are commonly used to facilitate removal of cerebrospinal fluid in patients with neurologic dysfunction. Despite a high risk for infection (upward of 45%), many hospitals lack strict protocols for EVD placement and maintenance. In addition, EVD infections are typically not tracked with the same diligence as central-line catheter infections, because there are no widely accepted standards for routine management of EVDs. The purpose of this review is to provide a guide for the development of a standardized, best practice EVD protocol for catheter insertion, care, and maintenance to reduce ventriculostomy-related infections. A secondary goal of this review is to provide support for the future development of guidelines for the consistent tracking of EVD insertion and maintenance practices.
At an academic medical center, an interdisciplinary team of nurses, advanced practice nurses, and neurointensivists reviewed recent medical and nursing literature as well as research-based institutional protocols on EVD insertion and maintenance from the United States and abroad to determine global best practices. The goal of this literature review was to identify key areas of focus in EVD insertion and maintenance as well as to identify recent studies that have shown success in managing EVDs with low rates of infection. The following terms were used in this search: EVD, externalized ventricular drains, EVD infections, EVD insertion, EVD Care and Maintenance, Nursing and EVDS. The following databases were utilized by each member of the interdisciplinary team to establish a state of the science on EVD management: American Association of Neurosurgical Surgeons, CINAHL, Cochrane, National Guidelines Clearinghouse, and PubMed. The following common EVD themes were identified: preinsertion hair removal and skin preparation, aseptic technique, catheter selection, monitoring of EVD insertion technique using a "bundle" approach, postinsertion dressing type and frequency of dressing changes, techniques for maintenance and cerebrospinal fluid sampling, duration of catheter placement, staff education/competence, and surveillance.
Keywords: EVD, EVD infection, EVD protocol, externalized ventricular drain, ventriculostomy
In neuroscience intensive care units, external ventricular drains (EVDs) are commonly used to facilitate removal of cerebrospinal fluid (CSF) in patients with neurologic dysfunction related to hydrocephalus and increased intracranial pressure. Although the literature reports that the incidence of infections related to EVD insertion and maintenance is most commonly between 10% and 17%, rates as high as 45% have been reported (Babu, Patel, Marsh, & Wijdicks, 2012; Lozier, Sciacca, Romagnoli, & Connolly, 2002; Lyke et al., 2001; Zingale, Ippolito, Pappalardo, Chibbaro, & Amoroso, 1999). Despite high infection rates, many hospitals do not have strict protocols for EVD placement and maintenance nor do they track these infections with the same diligence as central-line catheter infections.
Complications of EVD placement include skin and soft tissue infections, ventriculitis, meningitis, subdural empyemas, osteomyelitis, sepsis, endocarditis, and both intracranial and intra-abdominal abscesses (Beer, Lackner, Pfausler, & Schmutzhard, 2008). Risk for infection may be associated with insertion technique, catheter type, number of days the EVD remains in place, EVD care and maintenance, and frequency of CSF sampling (Keong et al., 2012; Lozier et al., 2002; Sonabend et al., 2011). EVD-related infection is associated with more expensive and prolonged hospitalizations and increased neurocritical care morbidity and risk of death (Chatzi et al., 2014; Zingale et al., 1999). Despite the potential for infection in this vulnerable patient population, no accepted standards for routine management of EVDs are available.
In 2014, the International Multidisciplinary Consensus Conference on Multimodality Monitoring declared that incidence of ventriculostomy-related infections may be a useful indicator for intensive-care-unit quality of care (Le Roux et al., 2014). As such, at one academic medical center's neuroscience intensive care unit, an interdisciplinary team of nurses, advanced practice nurses, and neurointensivists formed to explore the best practices in EVD maintenance and management that contribute to improved quality of care and reduction in infection rates. This was accomplished by directly contacting academic medical centers and community hospitals in both the United States and abroad that have published EVD protocols that were found using the aforementioned databases and reviewing their organizational practices in EVD care as well as searching EVD research studies found in medical and nursing literature. This synthesis of literature represents a summary of the various findings in regard to current practices for EVD insertion and maintenance to establish best practices in EVD care. This review served as a guide for the development of a new standardized, best practice evidence-based EVD protocol at one institution and may also serve as the foundation for creation of a comprehensive, universal standard for EVD insertion, care, and tracking.
Protocols for EVD maintenance and insertion were acquired from other institutions via three means: (a) protocols provided by EVD device manufacturers, (b) an Internet search of Google.com using the search terms "EVD protocol" and "external ventricular drain protocol," and (c) direct personal requests to physicians and nurses at other hospitals. To be included in this synthesis, protocols needed to describe EVD maintenance and management procedures (e.g., not only EVD insertion technique). Upon review of each protocol, descriptive data were recorded about the protocol itself as well as the presence or absence of information pertaining to insertion and maintenance practices. The protocols were de-identified and assigned an identification number.
A literature search of American Association of Neurosurgical Surgeons, CINAHL, Cochrane, National Guidelines Clearinghouse, and PubMed databases was conducted using the search strings "EVD protocol," "EVD nursing," "external ventricular drain nursing," "EVD management," "external ventricular drain management," "EVD bundle," and "external ventricular drain bundle." Through review of abstracts (by all members of the interdisciplinary team including bedside registered nurses [RNs], advanced practice nurses, and neurointensivists), manuscripts that described EVD management and maintenance procedures that focused on infection reduction techniques were identified and reviewed further by the team. Articles published greater than 15 years ago (e.g., before 1999) were excluded, as were abstracts published without complete manuscripts, to ensure data were both current and thorough. Each article was then reviewed, and recommendations for insertion and maintenance techniques were recorded. Themes that addressed infection reduction were identified, and various strategies employed were categorized by theme. A model was created to organize these themes and strategies, and this ultimately served to guide the development of a state-of-the-science EVD protocol.
The EVD protocol selection process culminated in the acquisition of 10 protocols from hospitals in the United States, Canada, Australia, and the United Kingdom. The protocols were created between the years 1990 and 2013 and updated between the years 2006 and 2014. They ranged from 3 to 19 pages in length. Six of ten protocols were illustrated with figures. Two protocols clearly stated the authors' titles (one is a nurse practitioner, and another is an RN), but the rest did not explicitly indicate the positions of the authors. Although not eveiy protocol specified the type of EVD the institution uses, those that did referenced drains manufactured by Codman (6), Medtronic (3), Ventrix (1), or Becker (2). Some organizations used more than one type of EVD catheter as dictated by physician preference. Some organizations used antibiotic-coated catheters, and some did not. Not all EVD protocols indicated the area of the hospital that EVD placement occurs. Four protocols noted that placement of EVDs may occur only in the operating room, and three stated that EVD placement can be performed in intensive care units, operating rooms, and/or emergency rooms.
The interdisciplinary team independently reviewed and compared each protocol to determine if instructions were present regarding EVD insertion with reference to aseptic technique, antibiotic prophylaxis, hair removal, and skin preparation and compared their findings. Three protocols did not include the details of EVD insertion, but the remainder described use of sterile technique including hand hygiene and use of gown/gloves/mask, face mask, and caps for all clinicians in the room during the procedure as well as use of the nontouch technique (single use of a sterile gauze to handle nonsterile items). An insertion checklist was mentioned in one of the seven protocols that described the insertion process. One of the seven protocols that included details of EVD insertion indicated that antibiotic prophylaxis is used at the time of EVD placement. Four of the ten protocols described the use of antibiotic prophylaxis after insertion as a component of EVD maintenance. In regard to hair removal, three protocols mentioned clipping hair on the scalp (one of which referred to "generous clipping" and one of which merely indicated the need for clipping at the site of entry), and one described shaving, but there was no mention of hair management during EVD maintenance in the remaining six protocols. Of the protocols that included clear recommendations for skin preparation, four mentioned use of chlorhexidine, whereas four described use of povidone iodine, and one referred to use of alcohol to prep the insertion site.
The team further reviewed the EVD maintenance instructions in each protocol including mention of EVD manipulation and equipment changes, CSF sampling, types of dressings, and frequency of dressing changes. Table 1 summarizes these findings.
Articles reviewed included descriptions of 10 single-institution protocols from Brazil, France, Greece, Netherlands, Singapore, the United Kingdom, and the United States published from 2004 to 2014. Every institution reported that implementation of their protocol significantly decreased the rate of EVD-related infections (Table 2). The protocols addressed multiple risk factors for EVD-related infections during both insertion and maintenance. Each protocol identified gaps in prior practice and targeted interventions to address these gaps. A summary of recommendations based on a review of articles is presented in Tables 3 and 4.
It was discovered that there are a number of common trends in EVD insertion and maintenance procedures, most notable of which was use of aseptic technique (hand washing; broad draping; use sterile gloves and gown, cap, and mask for all personnel in the room during EVD placement and manipulation) during both insertion and maintenance to prevent infection. However, there are also many points of divergence and controversy among different protocols including catheter selection, insertion venue, hair management, skin preparation, dressing type and maintenance, drain replacement, and frequency of CSF sampling. Although trends do exist in EVD insertion and maintenance, these trends are generally the result of hospital-based quality initiatives. Randomized controlled studies in EVD insertion and maintenance are rarely conducted because of relatively low rates of EVD insertions in hospitals, thereby limiting the reporting of scientific evidence.
A variety of different types of catheters are used, but the use of an antibiotic-impregnated catheter, if available, is recommended because this has been shown to be associated with decreased rates of infection (Flint et al., 2013; Honda et al., 2010; Kubilay et al., 2013; Mikhaylov et al., 2014; Sonabend et al., 2011). In fact, a cost-consequence cumulative analysis of trials comparing antibiotic-impregnated and regular catheters showed that, in 100 patients with EVDs, use of antibiotic-impregnated catheters may be associated with 2.7 fewer deaths, 82 fewer hospital days because of infection, and an estimated savings of $264,069 (Edwards, Engelhart, Casamento, & McGirt, 2015). In the absence of an antibiotic-coated catheter, continuation of intravenous prophylactic antibiotics is recommended, and this practice might also be beneficial with an antibiotic-coated catheter (Camacho et al., 2013; Chatzi et al., 2014; Sonabend et al., 2011).
Whereas some of the protocols indicated that placement only occurred in the operating room, others included reference to placement in the intensive care unit or the emergency room. As long as aseptic technique and a stepwise protocol are employed and personnel in the procedural suite are limited to only necessary individuals, there is no evidence that infection rate is related to venue of placement (Lozier et al., 2002).
Hair clipping is preferred over shaving in most of the protocols and articles reviewed, but the amount of hair clipped varies among protocols, and it is not clear what quantity of hair removal is ideal (Camacho et al., 2013; Flint et al., 2013; Korinek et al., 2005; Kubilay et al., 2013). Skin is prepped with a variety of agents including chlorhexidine, povidone iodine, isopropyl alcohol, and alcoholic chlorhexidine (American Association of Neuroscience Nurses [AANN], 2011; Camacho et al., 2013; Flint et al., 2013; Kubilay et al., 2013). Historically, protocols avoided use of chlorhexidine, based on a concern that chlorhexidine could cause neurotoxicity. However, it was recently reported that there are no additional risks of neurotoxicity associated with use of chlorhexidine and that it is both effective and safe and therefore is considered to be the preferred agent for skin disinfection (Checketts, 2012).
The type of dressing used and the frequency of dressing changes are variable. The use of an occlusive dressing with a Biopatch disc at the insertion site and of sterile adhesive strips to secure the dressing in place is recommended (Flint et al., 2013; Hill et al., 2012). Dressing changes should only be performed by trained competent personnel and should only occur weekly or if the dressing is dislodged to minimize direct contact with the EVD insertion site (Flint et al., 2013; Hill et al., 2012). Of note, a comparison of infection rates in patients with semiocclusive adhesive dressings that were changed every 48 hours and those with onetime applications of 2-octyl cyanoacrylate dressings (Dermabond, Ethicon, Inc.) showed a decrease in the rate of ventriculitis in those with 2-octyl cyanoacrylate dressings (Bookland, Sukul, & Connolly, 2014). Further evaluation comparing use of occlusive dressings with Biopatch discs and sterile adhesive strips with weekly dressing changes with a single application of 2-octyl cyanoacrylate dressings is warranted.
Frequency of equipment changes is variable. It is recommended to minimize contact with the catheter, tubing, and CSF collection bag because manipulation of the system may increase risk of infection (AANN, 2011; Beer et al., 2008; Lozier et al., 2002). Tubing should be clearly labeled to prevent confusion with intravenous tubing and inadvertent administration of medications intrathecally (McConnell & Macneil, 2011). It remains controversial whether prophylactic catheter exchanges could lead to a decrease in rates of infection (Honda et al., 2010), but none of the protocols reviewed recommended routine exchanges. However, it is ideal to remove catheters as quickly as possible given that prolonged catheterization has been associated with increased risk of infection (Holloway et al., 1996; Lozier et al., 2002). A large multicenter trial would be required to assess the benefit of routine catheter exchange, and when such a trial was conducted to evaluate the benefit of prophylactic central-line catheter exchange, there was no reduction in infection rate noted, and there was an increase in iatrogenic complications (Cobb et al., 1992; Lozier et al., 2002; Lyke et al., 2001).
The frequency of CSF sampling varies from scheduled collection daily (Bota, Leffanc, Vilallobos, Brimioulle, & Vincent, 2005; Kitchen et al., 2011; Schade et al., 2006); three times per week (Hoefnagel, Dammers, Ter Laak-Poort, & Avezaat, 2008; Williams, Leslie, Dobb, Roberts, & van Heerden, 2011); or collection only when needed for evaluation of fever, leukocytosis, headache, nuchal rigidity, or decline in neurologic status (Camacho et al., 2013; Chatzi et al., 2014; Dasic et al., 2006; Flint et al., 2013; Korinek et al., 2005; Leverstein-van Hall et al., 2010). To decrease risk of infection, sampling should only be performed on an as-needed basis. It is recommended that CSF be sampled from the distal port, because this has been shown to accurately diagnose infections and to minimize risk of infection (Wong, 2011). Recommendations for EVD insertion and maintenance are summarized in Figure 1.
Although specific practices vary at different institutions, a few factors consistently correlate with decreased rates of infection: (a) identification of shortcomings: To improve practice, it is necessary to be transparent regarding practice shortcomings and determine aspects of care that require modification (Hoefnagel et al., 2008; Kubilay et al., 2013; Leverstein-van Hall et al., 2010; Lwin et al., 2012). (b) Protocols: Prior techniques for EVD insertion and maintenance were at the discretion of individual physicians and nurses. The development of a meticulous standardized protocol for EVD insertion, maintenance, and management is associated with reduction in frequency of infection (AANN, 2011; Dasic et al., 2006; Flint et al., 2013; Hill et al., 2012; Kubilay et al., 2013). (c) Compliance monitoring: Given the relatively small number of EVDs that are placed nationally and the fact that EVD infection rates are not required reporting by infection control departments to each state's Department of Health with the same rigor as central-line infections or urinary-catheter-associated infections, many hospitals do not consistently track EVD infections. It is important to have a consistent methodology for identifying infections related to EVD insertion, care, or maintenance. Vigilant and consistent monitoring is integral to success. The creation of written policies will not improve rates of infection if clinical practices are not amended to reflect those policies. The use of a checklist during EVD insertion and development of a team to monitor EVD maintenance and management techniques on a regular basis reinforce the need for compliance with policies (Hill et al., 2012; Korinek et al., 2005; Kubilay et al., 2013). (d) Multidisciplinary effort: Because physician and nursing teamwork is essential to successful reduction of rates of infection, it is important that efforts to improve infection rates be organized by multidisciplinary teams (Chatzi et al., 2014; Korinek et al., 2005; Leverstein-van Hall et al., 2010; Lwin et al., 2012). (e) Education: Frequent education and reeducation sessions for nurses, physicians, trainees, and physiotherapists about EVD maintenance and infection prevention promote understanding of risk factors for infection and compliance with protocols (Camacho et al., 2013; Chatzi et al., 2014).
Although there are numerous published studies related to reduction of ventriculostomy-related infection, most of these studies reflect practices at individual institutions and may not be generalizable. As such, a multidisciplinary team synthesized the existing literature and current practices regarding EVD insertion and maintenance. Additional prospective trials to further define best practice for EVD management and maintenance are warranted. To that end, the British Neurosurgical Trainee Research Collaborative plans a comprehensive assessment of EVD management and infection rates across the United Kingdom and Ireland from November 2014 through February 2015 to define contemporary practice patterns, identify practices associated with improved patient outcomes, and guide further research questions and studies (Jamjoom et al., 2014). Ventriculostomy-related infections are associated with significant morbidity, mortality, and cost. Therefore, organizational goals should be to strive for a 0% infection rate.
Of course, there are several limitations of this review. The protocols included represent only 10 hospitals. Although this number is quite small and the authors' methods did not include a survey of institutions through a single organization (i.e., the American Association of Neuroscience Nursing), the protocols are from a number of different countries so the workgroup believes that these are representative of a variety of different practices around the world. In addition, the protocols discovered all had different formats, so they did not all include the same details regarding placement location or type of catheter employed. In terms of the articles reviewed, they largely represented reports of single-institution experiences. Articles published before 1999 were excluded in the interest of keeping the data as current as possible, but there may be relevant articles published before our cutoff. It is also possible that there are other articles that were not discovered in this search, but this was avoided by using multiple different sites for the search.
Neuroscience Nursing Implications
Neuroscience nurses are routinely at the center of the development of hospital practice protocols and are accountable to ensure care is safe, excellent, and evidence based. The recommendations identified in this manuscript provide a toolkit for intensive care neuroscience nurses to develop or revise institutional EVD protocols so that they are consistent with the latest evidence. Identification of specific recommendations for EVD insertion and maintenance (as shown in Figure 1) is intended to facilitate consistent reduction of EVD infections by offering a best practice bundle for protocol development, which could be used in conjunction with the recommendations produced by the AANN (2011) and a broad review of the literature.
Recommendations for EVD insertion as a result of this review of the literature include the following as identified in Figure 1: (a) clipping hair around EVD, (b) using chlorhexidine skin prep, (c) using maximal barrier precautions, (d) minimizing the number of personnel present during procedure, (e) using only antibiotic-coated EVD catheters, and (f) using an EVD insertion checklist. Recommendations for EVD maintenance and CSF sampling include (a) employing aseptic technique when handling EVD, (b) labeling EVD tubing, (c) sampling CSF only from distal port, (d) obtaining samples only when clinically indicated, and (e) minimizing EVD manipulation and length of time catheter is in place.
Specific recommendations for EVD dressing include (a) use of a bio-occlusive dressing with Biopatch and (b) changing dressing weekly or if dislodged and (c) that EVD dressing changes should be performed only by RNs or MDs who have had their competency in dressing change validated. Recommended staff education and surveillance include (a) providing ongoing education/competency assessment for staff regarding EVD care, (b) performing infection control rounds for EVD maintenance, and (c) monitoring the rates of infection.
Our interdisciplinary team has implemented the aforementioned recommendations for EVD insertion and maintenance practices into an approved hospital policy and procedure, using the model developed because of this review, and is currently collecting 1 year of data using this policy (to be published) to provide evidenced-based support for the development of an integrated new gold standard for EVD insertion, care, and maintenance that can serve as a foundation for future research in the prevention of EVD-related infections.
Alabama Children's Hospital. (2011). EVD (external ventriculostomy drainage) care in an acute care unit. Unpublished manuscript.
American Association of Neuroscience Nurses. (2011). Care of the patient undergoing intracranial pressure monitoring/extemal ventricular drainage or lumbar drainage. Glenview, IL: Author. Retrieved from http://www.guideline.gov/content.aspx?id= 34438&searech=evd
Babu, M. A., Patel, R., Marsh, W. R., & Wijdicks, E. F. (2012). Strategies to decrease the risk of ventricular catheter infections: A review of the evidence. Neurocritical Care, 16(1), 194-202. doi: 10.1007/sl2028-011-9647-z
Bayside Health. (2006). Intracranial pressure (ICP) monitoring and extraventricular drains (EVDs). Unpublished manuscript.
Beer, R., Lackner, P., Pfausler, B., & Schmutzhard, E. (2008). Nosocomial ventriculitis and meningitis in neurocritical care patients. Journal of Neurology, 235(11), 1617-1624. doi: 10. 1007/s00415-008-0059-8
Bookland, M. J., Sukul, V., & Connolly, P. J. (2014). Use of a cyanoacrylate skin adhesive to reduce external ventricular drain infection vates. Journal of Neurosurgery, 121(1), 189-194. doi:10.3171/2013.12.JNS13700
Bota, D. R, Lefranc, F., Vilallobos, H. R., Brimioulle, S., & Vincent, J. L. (2005). Ventriculostomy-related infections in critically ill patients: A 6-year experience. Journal of Neurosurgery, 703(3), 468-472. doi:10.3171/jns.2005.103.3.0468
Brigham and Women's Hospital. (2013). BWH protocol for EVD placement. Unpublished manuscript.
Camacho, E. F., Boszczowski, I., Freire, M. R, Pinto, F. C., Guimaraes, T., Teixeira, M. J., & Costa, S. F. (2013). Impact of an educational intervention implanted in a neurological intensive care unit on rates of infection related to external ventricular drains. PLoS One, 8(2), e50708. doi:10.1371/journal .pone.0050708
Chatzi, M., Karvouniaris, M., Makris, D., Tsimitrea, E., Gatos, C., Tasiou, A., ... Zakynthinos, E. (2014). Bundle of measures for external cerebral ventricular drainage-associated ventriculitis. Critical Care Medicine, 42(1), 66-73. doi:10.1097/CCM,0b013e31829a70a5
Checketts, M. R. (2012). Wash & go--But with what? Skin antiseptic solutions for central neuraxial block. Anaesthesia, 67(8), 819-822. doi: 10.1111 /j. 1365-2044.2012.07263.x
Cobb, D. K, High, K. R, Sawyer, R G., Sable, C. A., Adams, R. B., Lindley, D. A., ... Farr, B. M. (1992). A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. New England Journal of Medicine, 327(15), 1062-1068. doi: 10.1056/NEJM199210083271505
Dasic, D., Hanna, S. J., Bojanic, S., & Kerr, R. S. (2006). External ventricular drain infection: The effect of a strict protocol on infection rates and a review of the literature. British Journal of Neurosurgery, 20(5), 296-300. doi: 10.1080/02688690600999901
Edwards, N. C., Engelhart, L., Casamento, E. M., & McGirt, M. J. (2015). Cost-consequence analysis of antibiotic-impregnated shunts and external ventricular drains in hydrocephalus. Journal of Neutosurgery, 722(1), 139-147. doi: 10.3171/2014.9JNS131277
Ellis, J. (2013). The Royal Childrens Hospital Melbourne. External ventricular drains and intracranial pressure monitoring guideline. Unpublished manuscript Retrieved from http://www.rch.org.au/rchcpg/hospital_clinicaljguideline_index/Extemal_Ventricular_ Drains and lntracranial Pressure Monitoring/
Flint, A. C., Rao, V A., Renda, N. C., Faigeles, B. S., Lasman, T. E., & Sheridan, W. (2013). A simple protocol to prevent external ventricular drain infections. Neurosurgery, 72(6), 993-999. doi: 10.1227/NEU.ObO 13e31828e8dfd
Hill, M., Baker, G., Carter, D., Henman, L. J., Marshall, K., Mohn, K., & Moody, E. (2012). A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. Journal of Neuroscience Nursing, 44(4), 188-193. doi: 10.1097/JNN.0b013e3182527672
Hoefnagel, D., Dammers, R., Ter Laak-Poort, M. R, & Avezaat, C. J. (2008). Risk factors for infections related to external ventricular drainage. Acta Neurochirurgica, 150(2), 209-214. doi:10.1007/s00701-007-1458-9
Holloway, K. L., Barnes, T., Choi, S., Bullock, R., Marshall, L. F., Eisenberg, H. M., ... Marmarou, A. (1996). Ventriculostomy infections: The effect of monitoring duration and catheter exchange in 584 patients. Journal of Neurosurgery, 55(3), 419-424. doi:10.3171/jns.1996.85.3.0419
Honda, H., Jones, J. C., Craighead, M. C., Diringer, M. N., Dacey, R. G., & Warren, D. K. (2010). Reducing the incidence of intraventricular catheter-related ventriculitis in the neurology-neurosurgical intensive care unit at a tertiary care center in St Louis, Missouri: An 8-year follow-up study. Infection Control and Hospital Epidemiology, 31(10), 1078-1081.
Jamjoom, A. A., Kolias, A. G., Zaben, M., Chari, A., Kitchen, J., Joannides, A., ... UK Neurosurgical Research Network & British Neurosurgical Trainee Research Collaborative. (2014). External ventricular drainage: Is it time to look at national practice? British Journal of Neurosurgeiy, 1-2. doi: 10.3109/02688697.2014.957162
Jefferson Hospital. (2006). Intracranial pressure (ICP) monitoring: Using the Codman express system. Unpublished manuscript.
Jefferson Hospital. (2013a). Collecting a CSF sample from an external ventricular drainage system. Unpublished manuscript.
Jefferson Hospital. (2013b). Intracranial pressure (ICP) monitoring: Ventricular catheter. Unpublished manuscript.
Keong, N. C., Bulters, D. O., Richards, H. K., Farrington, M., Sparrow, O. C., Pickard, J. D., ... Kirkpatrick, P. J. (2012). The SILVER (Silver Impregnated Line Versus EVD Randomized Trial): A double-blind, prospective, randomized, controlled trial of an intervention to reduce the rate of external ventricular drain infection. Neurosurgery, 71(2), 394-403. doi: 10.1227/NEU.ObO 13e318257bebb
Kitchen, W. J., Singh, N., Hulme, S., Galea, J., Patel, H. C., & King, A. T. (2011). External ventricular drain infection: Improved technique can reduce infection rates. British Journal of Neurosurgery, 25(5), 632-635. doi: 10.3109/02688697.2011.578770
Korinek, A. M., Reina, M., Boch, A. L., Rivera, A. O., De Bels, D., & Puybasset, L. (2005). Prevention of external ventricular drain-related ventriculitis. Acta Neurochirurgica, 147(1), 39-45. doi: 10.1007/s00701-004-0416-z
Kubilay, Z., Amini, S., Fauerbach, L. L., Archibald, L., Friedman, W. A., & Layon, A. J. (2013). Decreasing ventricular infections through the use of a ventriculostomy placement bundle: Experience at a single institution. Journal of Neurosurgery, 118(3), 514-520. doi: 10.3171/2012.11 .JNS1 1336
Le Roux, P, Menon, D. K., Citerio, G., Vespa, P, Bader, M. K., Brophy, G. M., ... Taccone, F. (2014). Consensus summary statement of the international multidisciplinary consensus conference on multimodality monitoring in neurocritical care: A statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocritical Care, 21(Suppl. 2), S1-S26. doi: 10 .1007/s 12028-014-0041-5
Leverstein-van Hall, M. A., Hopmans, T. E., van der Sprenkel, J. W., Blok, H. E., van der Mark, W. A., Hanlo, P. W., & Bonten, M. J. (2010). A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections. Journal of Neurosurgery, 112(2), 345-353. doi:10.3171/2009.6.JNS09223
Lozier, A. R, Sciacca, R. R., Romagnoli, M. F., & Connolly, E. S. Jr. (2002). Ventriculostomy-related infections: A critical review of the literature. Neurosurgery, 51(1), 170-181. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12182415
Lwin, S" Low, S. W, Choy, D. K., Yeo, T. T, & Chou, N. (2012). External ventricular drain infections: Successful implementation of strategies to reduce infection rate. Singapore Medical Journal, 53(4), 255-259. Retrieved from http://www.ncbi .nlm.nih.gov/pubmed/22511048
Lyke, K. E., Obasanjo, O. O., Williams, M. A., O' Brien, M., Chotani, R., & Perl, T. M. (2001). Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients. Clinical Infectious Diseases, 33(12), 2028-2033. doi: 10.1086/324492
McConnell, P, & Macneil, C. (2011). Accidental intraventricular administration of phenytoin through an external ventricular drain: Case report. American Journal of Critical Care, 20, 347. doi:10.4037/ajcc2011733
Mikhaylov, Y., Wilson, T. J., Rajajee, V., Thompson, B. G., Maher, C. O., Sullivan, S. E., ... Pandey, A. S. (2014). Efficacy of antibiotic-impregnated external ventricular drains in reducing ventriculostomy-associated infections. Journal of Clinical Neuroscience, 21(5), 765-768. doi:10.1016/j.jocn.2013.09.002
O' Connor, J. (2012). Great Ormond Street Hospital external ventricular drainage. Unpublished manuscript.
Richardson, J., Forsyth, S., Todd, L., Grady, J., & Brown, J. (2012). Royal Hospital for Sick Children external ventricular device (EVD) guideline. Unpublished manuscript.
Saskatoon Health Region Hospital Nursing Practice Committee. (2012). External ventricular drain--Assisting with insertion, care of assisting with removal. Unpublished manuscript.
Schade, R. P, Schinkel, J., Roelandse, F. W., Geskus, R. B., Visser, L. G., van Dijk, J. M., ... Kuijper, E. J. (2006). Lack of value of routine analysis of cerebrospinal fluid for prediction and diagnosis of external drainage-related bacterial meningitis. Journal of Neurosurgery, I04(1), 101-108. doi:10.3171/jns.2006.104.1.101
Sonabend, A. M., Korenfeld, Y, Crisman, C., Badjatia, N., Mayer, S. A., & Connolly, E. S. Jr. (2011). Prevention of ventriculostomy-related infections with prophylactic antibiotics and antibiotic-coated external ventricular drains: A systematic review. Neurosurgery, 68(4), 996-1005. doi:10.1227/NEU.0b013e3182096d84
St. Joseph Health. (2010). Intracranial pressure (ICP) monitoring. Unpublished manuscript.
West Virginia University Nursing Service. (2013). External ventricular drain and intracranial pressure (ICP) monitoring. Unpublished manuscript.
Williams, T. A., Leslie, G. D., Dobb, G. J., Roberts, B., & van Heerden, P. V. (2011). Decrease in proven ventriculitis by reducing the frequency of cerebrospinal fluid sampling from extraventricular drains. Journal of Neurosurgery, 115(5), 1040-1046. doi: 10.3171/2011.6.JNS 11167
Wong, F. W. (2011). Cerebrospinal fluid collection: A comparison of different collection sites on the external ventricular drain. Dynamics, 22(3), 19-24. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21941814
Zingale, A., Ippolito, S., Pappalardo, R, Chibbaro, S., & Amoroso, R. (1999). Infections and re-infections in long-term external ventricular drainage. A variation upon a theme. Journal of Neurosurgical Sciences, 43(2), 125-132. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10735766
Questions or comments about this article may be directed to Millie Hepburn-Smith, RN MSN MPhil SCRN ACNS-BC, at millie. firstname.lastname@example.org. She is a Neuroscience, Rehabilitation and Inpatient Psychiatry Nurse Educator, NYU Langone Medical Center, New York, NY.
Irina Dynkevich, RN MSN CNRN, is a Staff RN, Department of Neurosciences, NYU Langone Medical Center, New York, NY.
Marina Spektor, RN CNRN CSRN, is a Staff RN, Department of Neurosciences, NYU Langone Medical Center, New York, NY.
Aaron Lord, MD, is Assistant Professor, Division of Neurocritical Care, Department of Neurology, NYU Langone Medical Center, New York, NY.
Barry Czeisler, MD MS, is Assistant Professor, Division of Neurocritical Care, Department of Neurology, NYU Langone Medical Center, New York, NY.
Ariane Lewis, MD, is Assistant Professor, Division of Neurocritical Care, Department of Neurology, NYU Langone Medical Center, New York, NY. The authors declare no conflicts of interest.
TABLE 1. Review of Hospital Protocols on External Ventricular Drain Maintenance Dressing Frequency of Frequency of Protocol Type Dressing Changes Bag Changes 1 Biopatch Once a week or as needed 1/2 full 2 Bio occlusive Only as needed Full 3 -- -- -- 4 Tegaderm and 24 hours 3/4 full steristrips postprocedure, then weekly or as needed 5 Dermabond or -- 3/4 full or bacitracin every 7 days 6 -- -- 3/4 full 7 Sterile head -- -- dressing 8 -- As needed -- 9 Sterile head Daily Either every dressing other day for CSF sampling or when full 10 -- As needed Full Cerebrospinal Fluid Personnel Allowed Protocol Sampling Port Sampling Frequency to Sample 1 -- -- -- 2 Below burette Mon/Wed/Fri RN 3 Proximal q24hrs for fever/ NP/PA/MD follow-up for known infection/pre-VPS 4 -- q24hrs for known Healthcare infection/antibiotic professional with levels/fever, before competency shunt placement 5 -- -- RN 6 Distal Daily RN 7 Proximal/distal -- RN (distal), (per MD) neurosurgeon (proximal) 8 Distal Daily Two RNs 9 CSF bag is sent Every other day Title not specified, but two people required 10 -- -- -- Equipment Changes Drain Protocol Tubing Changes Replacement 1 -- -- 2 -- No routine exchanges 3 -- Exchange the drain only if it stops working 4 q24hrs until Exchange the drain cultures are only if the catheter negative, then is disconnected every 2 weeks or damaged 5 Only if break -- in system 6 -- Exchange the drain only if the catheter is disconnected or damaged 7 -- -- 8 Every 7 days -- 9 If vent filter is wet -- 10 -- -- Note. RN = registered nurse; NP = nurse practitioner; PA = physician assistant; MD = medical doctor; CSF = cerebrospinal fluid. TABLE 2. Reduction of Ventriculostomy-Related Infections After Implementation of a Protocol Study, Year; Country Interventions Camacho et al., The protocol defined appropriate EVD care 2013; Brazil (hand hygiene before/after handling the EVD, use of clippers for whole scalp hair removal before insertion) and implemented educational interventions for neurosurgery residents, neurosurgeons, and nursing staff in the intensive care unit (training sessions, handouts, posters). Chatzi et al., This institution created a bundle of 2014; Greece EVD-associated ventriculitis reduction measures, which included reeducation of personnel on issues of infection control related to EVDs, meticulous EVD handling, CSF sampling only when clinically necessary, and routine replacement of the drainage catheter on the seventh drainage day if the catheter was still necessary. Dasic, Hanna, This institution introduced an evidence-based Bojanic, & protocol for EVD insertion and management, Kerr, 2006; which included insertion taking place in United Kingdom operating room only, the use of prophylactic antibiotics, tunneling of the catheter at least 10 cm, avoidance of daily sampling unless clinically indicated, and avoidance of routine catheter changes at 5 days, unless clinically indicated. Flint et al., These authors generated formal EVD infection 2013; United control policies and procedures that established States strict standards for placement and manipulation of EVDs (use of an antibiotic-impregnated catheter, broad clipping of hair, chlorhexidine skin preparation before draping, tunneled catheter that is secured in a question-mark pattern using surgical staples, chlorhexidine-eluting patch applied over catheter exit site) and education on the protocol through face-to-face meetings and web-based multimedia. Hill et al., As part of a multidisciplinary review, guidelines 2012; United were generated regarding the insertion and States maintenance of EVDs (sterile EVD dressing change as needed by RNs, dressing caddies with laminated cards outlining the dressing change process, check-off list, accurate documentation of procedures, and weekly infection control rounds by the educator and infection prevention practitioner to ensure that EVD dressings are sterile and occlusive). Honda et al., This hospital introduced three interventions: (a) 2010; France a requirement for all personnel in the procedure room to wear a mask and a cap, (b) a standardized dressing protocol (use of sterile gauze dressing with adhesive tape to cover the catheter site, changing of the intraventricular catheter site dressing every 48 hours by nurses who received standard training, and documentation of the date and time of gauze-dressing change), and (c) use of an antibiotic-impregnated EVD. Korinek et al., These authors created a written protocol 2005; United for EVD insertion (hair clipping, tunneled States catheter), nursing (sterile dressing covering the entire head, routine CSF cultures not performed), and surveillance (file documenting dates of dressing changes, forbidden manipulations, CSF samplings, EVD bag emptying, daily maximal temperature, cause of EVD removal, result of catheter culture, and presence of a CSF leak). Kubilay et al., This institution developed an insertion 2013; United bundle that included training of staff, strict States hygienic measures, full surgical draping, use of prophylactic antibiotics, feedback of infection rates to the care team, and use of an antimicrobial-impregnated catheter. Leverstein-van These authors introduced an intervention Hall et al., strategy based on five pillars: increased 2010; awareness (surveillance and educational Netherlands programs), focused standard operating procedures (insertion and handling of the EVDs), a diagnostic and therapeutic algorithm for patients with clinical suspicion of drain-related meningitis, timely administration of prophylaxis, and improvement of the drainage system (compared with the previous system, the number of sampling sites was reduced from five to four, and a Luer Lock injection site was provided with the system). Lwin, Low, The following measures to reduce EVD Choy, Yeo, & infection rate were introduced: proper Chou, 2012; surgical techniques, minimization of the Singapore number of catheterization days, CSF sampling only in the setting of clinical suspicion of an infection, development of standard operating procedures on nursing management of EVDs, conduction of EVD care workshops and competency skill checks for nurses, and use of silver-coated EVDs. Study, Year; Infection Rate Infection Rate Country Preintervention Postintervention Camacho et al., 9.5% 4.8% 2013; Brazil Chatzi et al., 28% 10.5% 2014; Greece Dasic, Hanna, 27% 12% Bojanic, & Kerr, 2006; United Kingdom Flint et al., 9.8% 0.8% 2013; United States Hill et al., 16 per 1000 0 in 25 months 2012; United catheter days (a) States Honda et al., 3.56 per 1000 0.87 per 1000 2010; France catheter days (a) catheter days Korinek et al., 9.9% 4.6% 2005; United States Kubilay et al., 9.2% 0.46% 2013; United States Leverstein-van 37% 9% Hall et al., 2010; Netherlands Lwin, Low, 6.1% 0% Choy, Yeo, & Chou, 2012; Singapore Note. EVD = external ventricular drain; CSF = cerebrospinal fluid. (a) Percentages of patients with infection were not documented; rates of infection were recorded per 1000 catheter days. TABLE 3. Summary of Reported Recommendations for EVD Insertion Practices Category Recommendation Reference Aseptic * Physicians should use Camacho et al., 2013; technique maximal barrier Flint et al., 2013; precautions including Richardson, Forsyth, sterile gloves, sterile Todd, Grady, & Brown, gown, cap, and mask. 2012; Saskatoon Health Region Hospital Nursing Practice Committee, 2012 * The patient's head and Honda et al., 2010; body should be covered Kubilay et al., 2013 with a full sterile drape. * All personnel in the Jefferson Hospital, 2006, procedure room are 2013a, 2013b required to wear a mask and a cap. * The number of personnel St. Joseph Health, 2010 in the procedure room should be limited to necessary personnel. Antibiotic * A single dose of Chatzi et al., 2014; prophylaxis antibiotic (e.g., Flint et al., 2013; preinsertion cefazolin) should be Korinek et al., 2005; given 15-45 minutes Kubilay et al., 2013, before incision. Leverstein-van Hall et al., 2010 Hair removal * Hair is removed from Camacho et al., 2013; the whole scalp before Korinek et al., 2005; catheter insertion. Leverstein-van Hall et al., 2010; Lwin et al., 2012 * Hair is clipped broadly Flint et al., 2013; using coarse and fine Jefferson Hospital, 2006, clippers to allow 2013a, 2013b; Kubilay et sufficient room to place al., 2013 a medium-sized adherent transparent dressing. Skin * Skin is prepped with Flint et al., 2013; O' preparation chlorhexidine before Connor, 2012; Saskatoon draping and then again Health Region Hospital after draping. Nursing Practice Committee, 2012 * Skin is prepped with Kubilay et al., 2013 iodine povacrylex and isopropyl alcohol. * Skin is prepped with Camacho et al., 2013; chlorhexidine soap (2%) West Virginia University followed by alcoholic Nursing Service, 2013 chlorhexidine (0.5%). EVD catheter * An Flint et al., 2013; Honda antibiotic-impregnated et al., 2010; Kubilay et ventricular catheter is al., 2013 used. * A silver catheter is Lwin et al., 2012 used. * Neither antibiotic nor Chatzi et al., 2014 silver catheters are used. * The EVD catheter is Dasic et al., 2006; Flint tunneled. et al., 2013; Korinek et al., 2005 * The catheter should be Flint et al., 2013 secured in a question-mark pattern using surgical staples. Dressing * A sterile dressing is Hill et al., 2012; Honda applied to the insertion et al., 2010; Jefferson site once the catheter is Hospital, 2006, 2013a, in place. The dressing 2013b must remain occlusive and dry at all times. The dressing should cover only the insertion site. * Apply benzoin tincture Flint et al., 2013 to skin and allow it to fully dry and then apply a chlorhexidine-eluting patch over the catheter exit site and a medium-sized adherent transparent dressing film. Secure the borders of the dressing film with sterile adhesive strips. Insertion * A checklist was Hill et al., 2012; checklist generated for Kubilay et al., 2013 central-line insertion (based on CDC recommendations) and then modified for EVD insertions. The checklist was completed by an RN. Note. EVD = external ventricular drain; RN = registered nurse; CDC = Centers for Disease Control and Prevention. TABLE 4. Summary of Reported Recommendations for EVD Maintenance Practices EVD * Aseptic technique must be used Camacho et al., manipulation when handling the EVD system. 2013 * The minimal touch principle Leverstein-van should be employed because each Hall et al., manipulation risks contamination. 2010 Antibiotic * Administer antibiotics every 8 Camacho et al., prophylaxis hours. 2013 postinsertion * Antibiotics should be Chatzi et al., administered 6-8 hours after 2014 insertion but not continuously during the drainage period. CSF sampling * CSF samples should only be Camacho et al., obtained when there is suspicion of 2013; Chatzi et CSF infection (fever of unknown al., 2014; origin, nuchal rigidity, headache, Dasic et al., mental status changes, cranial 2006; Ellis, nerve signs, and/or peripheral 2013; Korinek leukocytosis not related to other et al., 2005; infections). Leverstein-van Hall etal., 2010 * CSF draws and flushes should be Flint et al., performed with strict sterile 2013 technique. * Only the neurosurgeon or APN may Hill etal., obtain CSF specimens. 2012 Dressing * Routine dressing changes should Flint et al., change not be performed. Dressings should 2013; Hill et only be changed if they are al., 2012 compromised. Sterile dressing change should be performed by RNs. Dressing caddies with laminated cards outlining the dressing change process are helpful. * Catheter dressing changes should Honda et al., be performed every 48 hours. 2010 * Daily dressing changes that Bayside Health, include cleansing of the surgical 2006; Camacho incisions with saline solution, et al., 2013 applying alcoholic chlorhexidine (0.5%), covering with dry sterile gauze, and wrapping of the head should be performed by neurosurgery residents. EVD exchange * It is still controversial whether Honda et al., EVD exchanges could lead to a 2010 decrease in CSF infection rates. Educational * Education on the protocol should Camacho et al., programs be provided for neurosurgery 2013; Flint et residents and neuro-ICU nurses al., 2013 through face-to-face meetings (classes with an open session for questions and answers), handouts, Web-based multimedia, posters, and rounds. * EVD care workshops and competency Lwin et al., skill checks for nurses improve EVD 2012 awareness. Surveillance * Weekly infection control rounds Hill etal., by the educator and infection 2012 prevention practitioner improve rates of infection. * Currently, data on EVD infections Alabama are not collected or reported. Children's However, the National Healthcare Hospital, 2011; Safety Network has set the Brigham and reporting standard of other devices Women's (central line, ventilator, and Hospital, 2013; Foley catheter) to be infections Camacho et al., per 1000 device days. Although, 2013; Flint et historically, EVD infections were al., 2013; reported as the number of Honda et al., infections per 100 inserted 2010 devices, this is beginning to change. This system of tracking the days of exposure instead of the total EVDs placed allows for increased accuracy and analysis of infection rates. EVD catheter days are calculated by tracking the number of patients with an EVD on a daily basis. The daily totals are added together at the end of the month to determine the monthly EVD days. Note. EVD = external ventricular drain; CSF = cerebrospinal fluid; RN = registered nurse; APN = advanced practice nurse; CDC = Centers for Disease Control and Prevention; ICU = intensive care unit.
|Printer friendly Cite/link Email Feedback|
|Author:||Hepburn-Smith, Millie; Dynkevich, Irina; Spektor, Marina; Lord, Aaron; Czeisler, Barry; Lewis, Arian|
|Publication:||Journal of Neuroscience Nursing|
|Date:||Feb 1, 2016|
|Previous Article:||Hard to swallow: a phenomenological exploration of the experience of caring for individuals with myotonic dystrophy and dysphagia.|
|Next Article:||Let them take the pebble from your hand.|