Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance.

BACKGROUND/OBJECTIVE: Systemic prophylactic antibiotics have been used to reduce the rate of neurosurgical drain-related infections (DRIs) but the optimal duration is unknown. The Neurocritical Care Society Consensus Statement for External Ventricular Drain (EVD) management recommends a single antibiotic dose preoperatively. Data regarding antibiotic management for other neurosurgical drains (e.g. subgaleal and subdural drains) are lacking. Previously at our institution antibiotics were continued for the duration of drain placement. In 2016 an EVD bundle was implemented to standardize nursing care, and antibiotic duration was changed to one preoperative dose for all neurosurgical drains. The objective of this study was to compare the incidence of DRI, non-DRI, and antibiotic resistance before and after the implementation of an EVD bundle and limited duration antibiotics. PATIENTS AND METHODS: This was a single center, quasi-experimental study that included patients status post EVD or craniotomy/craniectomy with subgaleal or subdural drain placement. The pre-intervention period was June 2014 through May 2015 and the post-intervention period was January 2017 through December 2017. RESULTS: Ninety-one patients were included in the pre-intervention group and 54 in the post-intervention group. The use of limited duration antibiotics (< 48 h) was 14.3 % in the pre-intervention group and 96.3 % in the post-intervention group (p < 0.001). Five DRIs were identified in the pre-intervention group and 3 in the post-intervention group (5.5 % vs 5.6 %, p = 1.00). Of patients who developed a non-DRI, 77.5 % had a resistant non-DRI in the pre-intervention group compared to 48 % in the post-intervention group (p = 0.01). The rates of resistant DRI (80 % vs 66.7 %, p = 1.00) and Clostridium difficile infection (1.1 % vs 3.7 %, p = 0.56) were similar between groups. CONCLUSIONS: Implementation of an EVD bundle and limited duration antibiotics reduced antibiotic exposure with no associated increase in risk of DRI. Rates of resistant non-DRI were significantly lower in the post-intervention group.

Evaluación del impacto de una intervención educativa sobre el conocimiento y los cuidados de enfermería del drenaje ventricular externo / Evaluation of the impact of an educational intervention on the knowledge and nursing care of the external ventricular drain

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"Mock herniations" to assess nurses' response times and accuracy in setting up ventriculostomies in the pediatric intensive care unit.

When an emergent ventriculostomy is required for relief of increased intracranial pressure, it is critical that participating physicians and nurses work as an efficient team for optimal outcomes. From our experience, problems in ventriculostomy insertion have occurred because of delays in obtaining correct supplies and lack of skill in assembling the drainage system. The goals of this study were to (a) decrease the response time and (b) increase competency for successful insertion and setup of a ventriculostomy by using a "mock herniation" scenario. Three different nursing shifts in the pediatric intensive care unit at the University of Missouri Health Care were presented with a mock scenario of a child with increased intracranial pressure and impending herniation. Each group was timed on its ability to gather the correct supplies and scored on accuracy in setting up the drainage system. Subsequently, all pediatric intensive care unit nurses underwent skills laboratory training on correct assembly of the drainage system. After training, three different groups of nurses were tested again using the mock herniation scenario. This time, there was improvement in all areas tested, particularly in the mean time taken for accurate assembly and setup of the emergency ventriculostomy drainage system. We conclude that skills laboratory training reinforced by periodic mock herniations significantly decreases response time and increases accuracy of assembling supplies and setting up the drainage system for ventriculostomy insertion.

A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit.

External ventricular drain (EVD) placement is a common practice in neurocritical care units. The EVDs are the "gold" standard and the most cost-effective treatment for intracranial hypertension and hydrocephalus caused by a variety of neurological conditions. The EVD drains excess cerebrospinal fluid in an attempt to maintain balance within the cranial vault and provides intermittent monitoring of intracranial pressure. This invasive procedure, as with any other procedures, carries an increased risk of a device-related infection that can lead to devastating consequences such as meningitis, ventriculitis, and death. This article will discuss how Riverside Methodist Hospital, which is located in Central Ohio, identified an increase in the rate of EVD infections in 2007 and responded with changes in procedure and processes. The implementation of the improvement plan has resulted in 25 months without an EVD infection, a triumph for the patients, staff, and the hospital system.

[External ventricular drainage. Nursing care]. / Drenaje Ventricular Externo (DVE). Cuidados de Enfermería.

The authors review the anatomy of the ventricular system, Intracranial Pressure and the alteration of ventricular function which leads to the temporary installation of an external drainage system, the complications derived from the installation and maintenance of that system, as well as the care which will be provided to the patient.

Benchmarking best practice for external ventricular drainage.

Sharing of best practice and use of all available evidence is important in developing effective clinical guidelines for nursing practice. This can be achieved through benchmarking. Sharing of good practice and achieving consensus guidelines can avoid repetition of effort by nurses engaged in similar fields of practice. The Pan London Neuroscience Practice Development Forum was established in 1998 to share best practice within the field of neuroscience nursing across London. The Pan London Forum has now achieved consensus and developed evidence-based clinical guidelines for the management of external ventricular drainage. Within the scope of this article, the principles of external ventricular drainage will be highlighted, before identifying the evidence base for nursing management of patients. Approaches for troubleshooting common problems will also be discussed and the benchmarked clinical guidelines will be presented.

Nursing management of patients with an implanted Ommaya reservoir.

The Ommaya reservoir (NeuroCare Group, Pleasant Prairie, WI) is an implanted ventricular device that permits delivery of drugs directly into the central nervous system (CNS). It is used in the management of patients whose cancer has invaded or may potentially invade the CNS; for pain management; for treatment of CNS infection; for monitoring of CNS pressure; and for cerebrospinal fluid sampling. Nursing care related to the Ommaya reservoir includes assessing patients, providing patient and family education, and, in some situations, accessing the device.

External ventriculostomy: a practical application for the acute care nurse.

External ventricular drainage systems (EVDs), or external ventriculostomies, are challenging additions for the neurosurgical patient. An EVD involves a catheter placed in the ventricular space. It is used to drain off excess cerebrospinal fluid that is causing hydrocephalus and increased intracranial pressure. The cerebrospinal fluid is produced in the brain and flows through the four ventricles, to the arachnoid space around the spinal cord, then is absorbed by the arachnoid villi in the brain. The causes of hydrocephalus include tumors and hemorrhage. The nursing responsibilities include monitoring for infection, bleeding, herniation, documenting aspects of the drainage system and providing emotional support for the patient and family.

Accuracy of levelling intraventricular collection drainage systems.

In neuroscience critical care units, patients may have ventricular drains placed to aid management of acutely elevated intracranial pressure from a variety of causes. Correct placement of the ventricular drainage collection system, a nursing responsibility, is key to the process, and has the potential to influence patient outcome. A two-part study investigated the accuracy with which registered nurses levelled a ventricular drainage collection system. Part 1 found that nurses (N = 33) were unable to accurately level using visual means only. Part 2 found that nurses' (N = 31) use of a tool (a carpenter's level or a newly developed laser levelling device) dramatically improved accuracy. However, demographic differences between nurses in Part 1 and Part 2 may have contributed to this outcome. While both tools were accurate, the laser levelling device was superior to the carpenter's level for speed of use, nurses' rating of ease of use and patient safety.

Neuroendoscopic third ventriculostomy: a nursing perspective.

Endoscopic third ventriculostomy is an old technique that has gained greater acceptance in recent years with the advent of new endoscopic technology. This procedure, which involves fenestrating the floor of the third ventricle to communicate the basilar cisterns with the third ventricle offers new hope to patients with non-communicating hydrocephalus. Until recently, the only accepted treatment for these patients was the placement of a ventriculoperitoneal shunt to drain the accumulating cerebrospinal fluid. It is well known that shunting carries the risks of infection, blockage and overdrainage. This technique provides an alternative to a less than perfect treatment for reestablishing CSF pathways. Patients best suited for the procedure have delayed onset aqueductal stenosis caused by a tumor, cyst or hemorrhagic event. Patients with aqueductal stenosis as a consequence of myelomeningeocele fare less well, but show better success with the technique if it is performed as a follow-up to shunting rather than as an initial procedure. Several techniques may be used to perform third ventriculostomy. An understanding of the special needs of the patient undergoing the procedure is essential to optimum care.

Neuroendoscopic laser-assisted ventriculostomy of the third ventricle.

Hydrocephalus is caused by an imbalance between the production and absorption of cerebrospinal fluid. Ventriculostomy of the third ventricle now is an acceptable treatment alternative for this problem. This procedure reduces costs over the course of the illness because the patient does not require subsequent shunt revisions throughout his or her life. The specialized care and the fear associated with the dependency on mechanical hardware also are eliminated if shunt placement is avoided. Postoperative complications may include increased intracranial pressure, bleeding, infection, and pain.

The relationship of selected nursing activities to ICP.

Study of a number of routine nursing care activities has suggested a relationship between activities and intracranial pressure (ICP). The purpose of this study was to focus on the relationship between nursing care activities and variations in ICP. A case study method was used to study ICP in five brain-injured patients with a Glasgow Coma Scale (GCS) score of 4 or more. Each patient's condition warranted continuous ICP monitoring with a fiberoptic catheter in a neurological intensive care unit (ICU) of two hospitals in the Upper Midwest. Selected nursing measures--turning, suctioning and bathing--were recorded on the data collection tool as they occurred. Suctioning and turning were noted to be associated with an increase in ICP; however, a sustained increase in ICP was not observed. During the bathing procedures only two baths elicited an ICP greater than 20 mm Hg. All other bathing procedures elicited minimal increases in ICP. These findings further support the need for nurses to be aware of the patient's ICP prior to turning and suctioning.