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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 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.


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Questions or comments about this article may be directed to Millie Hepburn-Smith, RN MSN MPhil SCRN ACNS-BC, at millie. 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.

DOI: 10.1097/JNN.0000000000000174

TABLE 1. Review of Hospital Protocols on External Ventricular
Drain Maintenance


                                 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    --                          --

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

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

8          Distal            Daily                   Two RNs

9          CSF bag is sent   Every other day         Title not
                                                     specified, but
                                                     two people

10         --                --                      --

                       Equipment Changes

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

Hill et al.,         16 per 1000       0 in 25 months
2012; United      catheter days (a)

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

Kubilay et al.,         9.2%               0.46%
2013; United

Leverstein-van           37%                 9%
Hall et al.,

Lwin, Low,              6.1%                 0%
Choy, Yeo, &
Chou, 2012;

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

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

               * 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.,

               * 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

               * A silver catheter is        Lwin et al., 2012

               * Neither antibiotic nor      Chatzi et al., 2014
                 silver catheters are

               * 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

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
                * 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.,

                * CSF draws and flushes should be       Flint et al.,
                  performed with strict sterile         2013

                * 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

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

                * EVD care workshops and competency     Lwin et al.,
                  skill checks for nurses improve EVD   2012

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

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.
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Author:Hepburn-Smith, Millie; Dynkevich, Irina; Spektor, Marina; Lord, Aaron; Czeisler, Barry; Lewis, Arian
Publication:Journal of Neuroscience Nursing
Article Type:Report
Date:Feb 1, 2016
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