External Ventricular Drain Safety Campaign: A Global Patient Safety Initiative

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The Society for Neuroscience in Anesthesiology and Critical Care
Anesthesia Patient Safety Foundation

External Ventricular Drain Safety Campaign: A Global Patient Safety Initiative

What is an external ventricular drain?

An external ventricular drain is a multi-orifice catheter that is placed into the cerebrospinal fluid (CSF) containing space (ventricle) in the brain. This is done to facilitate external diversion of CSF in patients in whom the absorption and or circulation of CSF is hampered due to pathology.

External Ventricular Drain

Why is it important to maintain quality and safety related to EVD management?

In the United States alone, more than 25,000 patients have an EVD placed every year.1 Many of these patients undergo surgical procedures. Management of EVD may fall upon the anesthesiology or the critical care provider. However, many anesthesiology providers are not comfortable in managing EVDs in their practice.2 In addition EVD-associated complications such as overdrainage, under-drainage of CSF, inadvertent injection of unwanted medications inside the brain, and intrahospital transport-associated elevated in intracranial pressure3 has been reported in the perioperative and critical care setting. These complications may result in poor neurological outcomes.

As perioperative clinicians, we should be clinically proficient in EVD management. Thus, it is important to educate perioperative clinicians and work together to reduce the risk of adverse events related to EVD management in the perioperative and critical care area.

What is the EVD safety campaign?

The EVD Safety Campaign is a global patient safety initiative led by The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) and the Anesthesia Patient Safety Foundation (APSF).

We have created an EVD Knowledge Hub to provide you with valuable resources in order to provide highest quality of care to patients with EVD.

Goals
The goal of the EVD Safety Campaign is to improve patient outcomes by ensuring the highest standards of care in the management of external ventricular drains (EVDs).

Objectives

  1. Raise Awareness:
    1. Increase awareness about the importance of EVD management among healthcare professionals.
    2. Highlight the risks associated with improper EVD management.
  2. Provide Education:
    1. Develop and disseminate educational resources and materials for perioperative clinicians.
  3. Promote Standardized Guidelines:
    1. Promote evidence-based guidelines for the perioperative care of patients with EVDs.
    2. Encourage the adoption of these guidelines in healthcare institutions globally.
  4. Enhance Clinical Proficiency:
    1. Improve the clinical skills of anesthesiologists and critical care providers in managing EVDs.
    2. Ensure healthcare professionals are comfortable and competent in EVD management practices.
  5. Reduce Complications:
    1. Identify and mitigate risks associated with EVD management.
    2. Work towards reducing the incidence of EVD-related complications such as overdrainage, under-drainage, and infections.
  6. Foster Collaboration:
    1. Promote collaboration among different healthcare teams to ensure cohesive and comprehensive patient care.
    2. Engage with stakeholders to support and enhance EVD management protocols.

EVD Guidelines:
In the year 2017, SNACC created a task force to publish write evidence-based best-practice recommendations for the perioperative care of patients with external ventricular drains.4

These guidelines can be summarized as follows:

  1. Comprehensive Preoperative Assessment: It is critical to perform a detailed baseline neurological examination, check the setting and output of the EVD and review any trends in intracranial pressure (ICP) and cerebrospinal fluid (CSF) characteristics before surgery. This ensures that any changes during the procedure or post-procedure can be quickly identified and addressed.
  2. Preparation for Transporting Patients: When transporting patients with EVD, specific measures must be confirmed such as the clamping status of the drain, head-of-bed (HOB) elevation, and ensuring proper leveling at the external auditory meatus. These measures are crucial to maintain drain function and prevent complications during movement. Intracranial pressure monitoring should be carried out in every transport.
  3. Intraoperative Management: During surgery, it is important to continuously monitor and manage the indwelling drains. This includes confirming tubing identification, HOB status, and leveling of EVD to ensure accurate function and pressure readings.
  4. Communication and Documentation: Detailed communication and documentation between caregivers, especially during handoffs between intensive care and anesthesia providers, are emphasized. Providing complete details of the EVD settings, along with any significant intraoperative changes, is essential for ongoing patient management.
  5. Monitoring and Response to Changes: Key indicators such as sudden changes in CSF drainage, CSF color, and ICP waveform should be monitored closely. Specific thresholds for drain output and other changes are set to prompt immediate clinical response, ensuring timely intervention to prevent complications.

SNACC EVD Guidelines [PDF Download]

EVD Quiz: Test your knowledge on EVD management.
The EVD quiz offers a comprehensive exploration of essential concepts, ranging from the fundamentals of EVD placement and monitoring to the intricacies of troubleshooting complications. By engaging with this quiz, you will have the opportunity to enhance your knowledge base, sharpen your decision-making skills, and cultivate a deeper understanding of best practices in EVD management.

EVD Educational Video:
Having trouble remembering how to level and zero the EVD collecting system?
SNACC has created an educational video to assist you with this.

EVD Educational Document:
In the year 2017, SNACC’s task force on the perioperative care of patients with external ventricular drains created an educational document. This document can be found below.

EVD Educational Document [PDF Download]

EVD Policy and Procedure Template:
Are you planning to revise your hospital’s policy and procedures regarding EVDs1? An evidence-based policy and procedure template can be found below. Implement best practices with our customizable template.5 The template is based on evidence-based guidelines regarding insertion and maintenance of EVDs.

EVD Policy and Procedure Template [PDF Download]

EVD Quality Metrics: Measure and improve EVD management with our metrics.

Are you interested in collecting data on quality and safety regarding EVDs? SNACC has created a list of electronic clinical quality metrics that you can start implementing at your hospital. These metrics are based on the evidence-based recommendations.

EVD Quality Metrics [PDF Download]

Questions, Suggestions or Concerns

Questions, suggestions or concerns may be directed to Abhijit V. Lele, MBBS, MD, MSCR, FNCS, CPHQ at [email protected].

References

  1. Sekula, R.F.; Cohen, D.B.; Patek, P.M.; Jannetta, P.J.; Oh, M.Y. Epidemiology of Ventriculostomy in the United States from 1997 to 2001. Br. J. Neurosurg. 2008, 22, 213–218, doi:10.1080/02688690701832084.
  2. Lele, A.V.; Mills, B.; Qiu, Q.; Schloemerkemper, N.; Naik, B.I.; Williams, J.; Venkat-Raghavan, L.; Vavilala, M.S.; EVD Aware Study Collaborators International Multicenter Survey of Perioperative Management of External Ventricular Drains: Results of the EVD Aware Study. J. Neurosurg. Anesthesiol. 2019, doi:10.1097/ANA.0000000000000580.
  3. Chaikittisilpa, N.; Lele, A.V.; Lyons, V.H.; Nair, B.G.; Newman, S.-F.; Blissitt, P.A.; Vavilala, M.S. Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients. Neurocrit. Care 2017, 26, 196–204, doi:10.1007/s12028-016-0308-0.
  4. Lele, A.V.; Hoefnagel, A.L.; Schloemerkemper, N.; Wyler, D.A.; Chaikittisilpa, N.; Vavilala, M.S.; Naik, B.I.; Williams, J.H.; Venkat Raghavan, L.; Koerner, I.P.; et al. Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J. Neurosurg. Anesthesiol. 2017, 29, 191–210, doi:10.1097/ANA.0000000000000407.
  5. Thamjamrassri, T.; Yuwapattanawong, K.; Chanthima, P.; Vavilala, M.S.; Lele, A.V.; EVDPoP Study Collaborators A Narrative Review of the Published Literature, Hospital Practices, and Policies Related to External Ventricular Drains in the United States: The External Ventricular Drain Publications, Practices, and Policies (EVDPoP) Study. J. Neurosurg. Anesthesiol. 2022, 34, 21–28, doi:10.1097/ANA.0000000000000694.
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