Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for EVD care

Purpose:
The purpose of this this presentation is to translate practice improvements in externalized ventricular drains (EVDs) insertion, care and maintenance into a state of the science universal practice model for hospital organizations and to disseminate this information.

Relevance/Significance:
External ventricular drains (EVDs) are devices commonly used in neurocritical care. Despite the extraordinary high mortality rates associated with EVD infections, many hospitals lack strict protocols for EVD placement and maintenance. Additionally, if tracked, EVD infections are typically not tracked with the same diligence as central lines, catheter infections, as there are no widely accepted standards for routine management of EVDs.

Strategy and Implementation:
An interdisciplinary team of RNs, adult/pediatric MDSs and APNs was assembled. Protocols for EVD maintenance and insertion were acquired by: 1) EVD device manufacturers, 2) Online:Google.com using “EVD protocol” and “external ventricular drain protocol” 3)Requests to other hospitals. For inclusion, protocols described EVD maintenance/management procedures. Descriptive data was recorded regarding presence/absence of insertion/maintenance practices. Protocols were de-identified and assigned a number. A literature search:PubMed,Cochrane Library,American Academy of Neurosurgery (AANS) databases searched “EVD protocol,” “EVD protocol,” “EVD nursing,” “EVD nursing,” “EVD management,” “external ventricular drain management,” “EVD bundle,” and “EVD bundle.” Articles were identified that described EVD management/maintenance procedures and focused on infection reduction. We excluded articles prior to 1999 and abstracts without complete manuscripts, to ensure current and thorough data.

Evaluation:
Ten protocols were selected for review between 2006-13. Analysis included asepsis, antibiotic prophylaxis, hair removal, and skin preparation. A model was developed to engage all aspects of EVD care strategically so as to develop a hospital EVD interdisciplinary standard. Infection control now tracks EVD infections using an automated approach, similar to the process of CLABSI tracking.

Implications for Practice:
Nurses are routinely at the center of hospital protocols and are held accountable to safety. The recommendations identified here provide a toolkit for intensive care nurses to develop/revise institutional EVD protocols to ensure a reduction of EVD infections by using best practice 'bundles'.