Hill, Michelle; Baker, Glenna; Carter, Deneen; Henman, Lita Jo; Marshall, Kristi; Mohn, Kristina; Moody, Elizabeth
Theory of Intracranial Pressure
The Monro–Kellie doctrine hypothesizes that “the skull, a rigid compartment, is filled with essentially noncompressible contents—brain and interstitial fluid (80%), intravascular blood (10%), and CSF (in the ventricles and subarachnoid space; 10%)” (Hickey, 2009, p. 270). The Monro–Kellie doctrine theorizes that there is a fine balance in maintaining cerebrospinal fluid (CSF) volume and intracranial pressure (ICP). When this balance is disturbed by formation, flow, or absorption of CSF, there is an increase in CSF volume or hydrocephalus and intracranial hypertension. When ICP increases, neurological consequences may range from minor to severe, including death.
External ventricular drains (EVDs) are the standard of care for acute hydrocephalus in a neurocritical care (NCC) setting and are the most commonly used method of ICP measurement. The radiopaque catheter is inserted by a neurosurgeon or an advanced practice nurse (APN) through a burr hole, which is most commonly anterior to the coronal suture. The catheter is advanced into the ventricular system. The intraventricular catheter is connected to the external drainage system, which is then zeroed to the patient. The point of reference used to zero the system is the external auditory meatus or the outer canthus of the eye. These points approximate the location of the catheter tip at the foramen of Monro (Hickey, 2009). The drip chamber collecting CSF can be moved up or down against the zero reference level according to physician order. When ICP rises above the physician-determined level (measured in mmHg or cmH2O), CSF will drain off into the collection chamber. The level of the drip chamber will be increased as patients become more able to drain their own CSF in a normal physiological fashion. The desired outcome is the eventual clamping and removal of the EVD. Patients who are unable to tolerate this will require placement of a permanent internal ventricular shunt (see Figure 1).
The EVD predisposes the patient to infection and can further aggravate neurological insults. It is crucial for positive patient outcomes that healthcare personnel avoid the transmission of harmful pathogens through the EVD site, which provides a direct transmission route into the cranial vault and the brain. According to the American Association of Neuroscience Nursing (AANN) Guidelines on External Ventricular Drainage, the average infection rate is 8%–9% (AANN, 2011). The Centers for Disease Control reports an infection rate of 0%–40% with an average of 10% (Hickey, 2009). The AANN Guidelines were consulted when this infection control project first began.
Background of Infections in the NCC
Hospital-acquired infections (HAIs) typically affect patients who are immunocompromised because of age, underlying disease, and medical or surgical treatments. “The aging of the U.S. population along with increasingly aggressive medical and therapeutic interventions, have created a cohort of particularly vulnerable persons. As a result, the highest infection rates are in intensive care units (ICU) patients. [HAI] rates in adult and pediatric ICUs are approximately three times higher than elsewhere in hospitals. The sites of infection and the pathogens involved are directly related to treatment in ICUs. In these areas, patients with invasive vascular catheters and monitoring devices have more bloodstream infections due to coagulase-negative staphylococci” (Weinstein, 1998). It is estimated that, in 2007, HAIs cost $6.7 billion annually (Scott, 2009). In 2002, HAIs contributed to more than 98,987 deaths; 1.7 million patients were infected with HAI (Klevens et al., 2007). The statistical numbers from 2002 to 2007 present a grim picture for patients and hospital systems. These infections increase hospital stay and cost associated with treatment and, in severe cases, can result in death. The presence and prevention of HAIs are still a high priority for healthcare systems worldwide.
The Riverside Methodist Hospital (RMH), located in Central Ohio, is a tertiary care hospital that admits 50,230 patients annually, with 11.3% of patients experiencing a neurological insult. The RMH was ranked as number 2 in Columbus by the U.S. News & World Report’s Best Hospitals and was given high rankings in neurology and neurosurgical care (U.S. News & World Report, 2011). It is an accredited Joint Commission Stroke Center and the only institution in the region that provides specific invasive radiological interventions such as coiling of cerebral aneurysms. Aneurysms, when left untreated, can result in subarachnoid hemorrhage and often require EVDs and ICP monitoring.
The 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. The largest national database of healthcare-acquired infections is operated by the Centers for Disease Prevention and Control (CDC). The National Healthcare Safety Network (NHSN) gathers data from over 2,400 hospitals across the country. Currently, data on EVD infections are not collected or reported. However, NHSN has set the reporting standard of other devices (central line, ventilator, and Foley catheter) to be infections per 1,000 device days. Although, historically, EVD infections were reported as the number of infections per 100 inserted devices, this is beginning to change. Examples of articles published on EVD infections over the last 2 years have begun to report traditional infection rates along with infections per 1,000 EVD days (Camacho et al., 2011; Scheithauer et al., 2009). This system of tracking the days of exposure instead of the total EVDs placed allows for increased accuracy and analysis of infection rates. Our 24-bed NCC unit averages between 75 and 150 EVD days monthly.
During the period of August to October 2007, four EVD infections were identified in NCC patients. Initial review of the infections failed to show any commonalities between causative organism, placement, procedure area, or personnel. The length of time between EVD placement and infection was 5–23 days. All patients with an EVD infection during this time were on ventilator support and had respiratory colonization with the same organism that was identified in their CSF culture. Three of the infections were caused by gram-negative bacillus, and one was caused by enterococci. All offending organisms were resistant to Cefazolin, which is the antibiotic routinely used for prophylaxis in patients with an EVD. Each case had problems with leakage around the EVD site that caused increased handling of the sterile dressing. This apparent increase in EVD infections prompted a quick response and review of the current process for inserting and maintaining EVDs.
Infection is the most common complication of an EVD (AANN Guidelines). The drain provides a direct route for bacteria to invade the ventricular system of the brain. Patients who develop a ventricular infection will have high fever, decreased mental status, seizures, nuchal rigidity, and photophobia, and the infection may progress to sepsis. Early recognition and treatment are necessary for successful treatment (Agrawal, Cincu, & Timothy, 2008).
Multidisciplinary Work Team: Define Infection
A multidisciplinary team was formed to address the problem of EVD infections. The team consisted of APNs who place EVDs, NCC nursing staff, infection prevention practitioner, neuroscience educator, physician assistants, pharmacists, case manager, outcome manager, and the NCC management team. The team conducted literature reviews for evidence-based practice in inserting and maintaining EVDs. The first step for the team was to understand the criteria for an EVD infection from the CDC. The CDC tracks HAIs using the NHSN, a voluntary, web-based quality bench-marking system (CDC-NHSN, 2005/2011).
The CDC defines healthcare-acquired infections as “localized or systemic condition that results from adverse reaction to the presence of an infectious agent(s) or its toxins and that was not present or incubating at the time of admission to the hospital or acute care setting” (Horan, Andrus, & Dudeck, 2008). The CDC definition that would be applicable for determining an EVD infection falls under the central nervous system infection, subcategory of meningitis or ventriculitis, which requires that at least one of the following criteria are present:
1. Patient has organisms cultured from CSF.
2. Patient has at least one of the following signs or symptoms with no other recognized cause: fever (38.8 °C), headache, stiff neck, meningeal signs, cranial nerve signs, or irritability.
3. Patient has at least one of the following:
A. increased white cells, elevated protein, and/or decreased glucose in CSF;
B. organisms seen on gram stain of CSF;
C. organisms cultured from blood;
D. positive antigen test of CSF, blood, or urine;
E. diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen, and if diagnosis is made antemortem, physician institutes appropriate antimicrobial therapy (Horan et al., 2008).
Multidisciplinary Work Team: Identification of Gaps
The next step was to review the entire EVD process from insertion through discontinuation and identify potential gaps in current practice. The gaps were identified as follows:
1. There was inconsistency in the sterile technique used during the insertion process.
2. Sterile occlusive dressings were often moist from leakage at the insertion site that promoted a nonocclusive dressing.
3. Physicians and APNs were the only people permitted to change the dressings; this allowed for a lag in the dressing change if they were not readily available.
4. Surveillance of EVD infections was not routinely performed and reported.
5. Colloidal liquid used to adhere the transparent dressing was from a multiple-use bottle and was not sterile.
6. There was no documentation of sterile dressing changes.
7. There was an interruption of the EVD drainage closed system by the nursing staff, either inadvertently or purposefully.
8. Staff members considered an infection to be an unavoidable consequence of EVDs.
9. Physicians and APNs were not documenting the EVD placement in the progress notes.
10. There was no documentation on the procedure note by the physician or APN when interrupting the closed system for withdrawal of CSF or when flushing drainage system or catheter.
Inconsistency in practice and maintenance of the EVD and the sterile dressing seemed to be the resounding theme. Consequently, the team quickly realized that some of the issues with EVD infections mimicked a recent project to decrease central line infections.
Multidisciplinary Work Team: Resolving the Problem
The identified improvement opportunity was to decrease EVD infections. The initial goal was to have a rate of less than 10 infections per 1,000 EVD days. Because of the limited literature identifying the best practices to reduce risk of EVD infections, the team pulled from existing resources and evidence-based practice for preventing central line infections. One such tool was using a checklist generated for central line insertion that was based on recommendations from the CDC (Pronovost et al., 2006; see the Appendix, which is the checklist we created to use at Riverside Methodist Hospital). The central line checklist was slightly modified for EVD insertions, as noted below.
The recommendations are as follows, and a “yes” must be answered to all questions before performing the procedure:
* Hand hygiene was performed.
* Appropriate skin preparation was done. (Povidone iodine was used instead of chlorhexidine gluconate due to meningeal toxicity.)
* Skin preparation agent has completely dried before insertion.
* All five maximal sterile barriers were used:
1. sterile gloves,
2. sterile gown,
4. mask worn, and
5. large sterile drape (CDC, 2010).
The team also reviewed and revised the policy and procedure for EVD insertion and maintenance, sterile dressings, and CSF removal and flushing (Ohio Health Riverside Methodist Hospital Critical Care Policy Committee, 2010). The revised policy allowed for staff nurses who had completed mandatory education and returned demonstrations of skills to change the sterile EVD dressing as needed. Dressing caddies, with laminated cards outlining the dressing change process, were prepared for the unit and were readily available with all the appropriate equipment and single-use cleaning solution. Physicians and mid-level providers were also educated on the new policy changes, check-off list, and the necessity of accurate documentation of procedures. A new initiative was to perform weekly infection control rounds to ensure that EVD dressings were sterile and occlusive. These rounds were done jointly by the educator and infection prevention practitioner and provided opportunity for immediate feedback and education of staff. Monthly round results were posted for staff to easily track unit progress on goals.
Care of an EVD
As part of the multidisciplinary review, specific guidelines were initiated regarding the care and maintenance of EVDs. Decreasing rate of infection was at the forefront of these guidelines, beginning at the time of insertion. The insertion is preceded by hand washing, a pause and confirm, and the preparation of necessary equipment. Sterile technique is observed during the setup of the system, including replacement of the transducer’s provided cap with a solid cap. The neurosurgeon or APN scrubs the site with the appropriate skin preparation and allows it to dry completely before insertion. The practitioner and anyone assisting in the sterile field must wear sterile gloves, a sterile gown, a cap, and a mask and must use a large sterile drape. Also, the door must remain closed during the procedure, and everyone in the room must wear a mask and a cap. This process technique is monitored through the use of an RN completing a checklist, which is started at the beginning of the procedure and prompts the following of all steps.
A sterile dressing is applied to the insertion site once the catheter is in place. The dressing must remain occlusive and dry at all times. It is the responsibility of the RN providing care to these patients to assess the integrity of the dressing and change it when needed. A mask and clean gloves are worn when removing the soiled dressing. This must be done carefully so as not to disrupt the catheter. The RN assesses the site for any drainage and shaves the surrounding area with clippers, if necessary, to allow the new dressing to adhere optimally. Sterile gloves are then applied, and a strict aseptic technique is followed for the remainder of the dressing change. Betadine is used to decontaminate the site, and a product such as benzoin tincture may be used to help the dressing to adhere. Ample time is allowed for the site to dry before applying a new sterile dressing. The dressing should cover only the insertion site, and the catheter as the tubing leading to the drainage chamber should not be sterile. After ensuring that the new dressing is occlusive, it is labeled with date, time, and initials.
The catheter may become occluded with blood or tissue sediment at times, requiring that the EVD be flushed. This procedure was also reviewed by the team. It was decided that only a neurosurgeon, an APN, or a trained neurosurgery “moonlighting physician” would be permitted to irrigate toward the patient. The practitioner must wear sterile gloves and scrub the port with Betadine for 3 minutes before irrigation. The NCC charge RNs were trained to flush the EVD away from the patient and must follow the same guidelines as that for flushing toward the patient. Only the neurosurgeon or APN may obtain CSF specimens from the EVD and must use the same aseptic technique.
The final gap identified was the lack of documentation from physicians and APNs when inserting or interrupting the closed system. Similar to placement of a central line, EVD placement requires a note explaining the process used and purpose or need for the device. Without a note, there was no record of who placed the EVD or what precautions were utilized. Meetings were held with the APNs and physicians explaining the importance of writing a progress note with EVD placement.
The Multidisciplinary Team: Outcome
The baseline surveillance from April 2008 to June 2008 indicated an infection rate of 16 per 1,000 EVD catheter days. The rates declined to 4.5 per 1,000 EVD catheter days during the fiscal year from July 2008 to June 2009. A further decrease of 1.3 per 1,000 EVD catheter days was noted the following year. As of September 2011, the NCC has gone 25 months with zero EVD infections. The outcome of performance measures and policy changes, the implementation of the checklist, and the hard work of the entire multidisciplinary team along with NCC staff have surpassed their goal of less than 10 infections per 1,000 EVD catheter days. The team’s diligence and commitment to provide care using evidence-based practice were instrumental in their success.
This team of professionals, ranging from the physicians, APNs, nursing staff, ancillary staff, infection control staff, and management, embraced the challenge to eliminate EVD infections. They instituted practice changes based on the innovative application of central line evidence-based research to EVDs. With the early recognition of the EVD infections and a team approach to process improvement, patients with EVDs can be assured that all measures are being taken to prevent infection and concurrent complications such as meningitis, ventriculitis, and death. This is just one measure of quality assurance conducted by this NCC unit, which significantly led to RMH NCC’s recognition for excellence in neurological and neurosurgical care. Early recognition, identification, and elimination of preventable infections using evidence-based practice are a necessity to improve patient outcomes and provide safe patient care. It is essential to succeed within the industry and be recognized as a leader providing the most effective NCC, keeping cost to a minimum while providing the best outcome for all.
Agrawal A., Cincu R., Timothy J. (2008). Current concepts and approaches to ventriculitis. Infectious Diseases in Clinical Practice, 16 (2), 100–104.
American Association of Neuroscience Nurses. (2011). Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage: AANN Clinical Practice Guideline Series.
Retrieved from http://www.aann.org/uploads/AANN11_ICPEVDnew.pdf
Camacho E. F., Boszczowski I., Basso M., Jeng B. C., Freire M. P., Guimarães T., Costa S. F. (2011). Infection rate and risk factors associated with infections related to external ventricular drain. Infection, 39 (1), 47–51.
Hickey, J. (2009). The clinical practice of neurological and neurosurgical nursing
(6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Horan T., Andrus M., Dudeck M. (2008). CDC/NSHN surveillance definition of healthcare associated infection and criteria for specific types of infections in the acute care setting. American Journal of Infection Control, 36 (5), 309–332. doi:10.1016/j.ajjc.2008.03.002
Khurana, V. (2012). Chapter 13: Drains, shunts, reservoirs and needle biopsy with or without a head frame. In Brain surgery.
Retrieved from http://http://www.brain-surgery.us
Klevens R. M., Edwards J. R., Richards C. L. Jr., Horan T. C., Gaynes R. P., Pollock D. A., Cardo D. M. (2007). Estimating health-care associated infections and deaths in U.S. hospitals, 2002. Public Health Reports, 122, 160–166.
Ohio Health Riverside Methodist Hospital Critical Care Policy Committee. (2010). Procedure for the insertion and care of a patient with an intracranial monitoring device. NUMBERP-120.011 (policy and procedure). Columbus, OH: Author.
Pronovost P., Needham D., Berenholtz S., Sinopoli D., Chu H., Cosgrove S., Goeschel C. (2009). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355, 2725–2732.
Scheithauer S., Bürgel U., Ryang Y. M., Haase G., Schiefer J., Koch S., Lemmen S. (2009). Prospective surveillance of drain associated meningitis/ventriculitis in a neurosurgery and neurological intensive care unit. Journal of Neurology, Neurosurgery, and Psychiatry, 80 (12), 1381–1385.
Weinstein R. A. (1998). Nosocomial infection update. Emerging Infectious Disease, 4 (3), 416–420. ftp://ftp.cdc.gov/pub/EID/vol4no3/adobe/weinstein.pdf
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