Quality and Safety Practices in Patients with External Ventricular Drain:
A Global Patient Safety Campaign

Background:
External ventricular drains (EVDs) are commonplace in healthcare settings. It is estimated that more than 25,000 EVDs are placed annually in the US alone¹. A review of the Vizient hospital database finds that the annual number of EVDs ranges from 0-5 EVDs per year to >250 EVDs per year (unpublished data). Patients in whom EVDs are placed are critically ill and may have spontaneous subarachnoid hemorrhage or spontaneous intraventricular/intraparenchymal hemorrhage, acute ischemic stroke, or traumatic brain injury. Some patients may have chronic hydrocephalus, and their permanent cerebrospinal diversion devices may get infected or malfunction and thus require an EVD until those can be replaced.

Anesthesiologists routinely care for these patients either in the operating room (OR) or in a non-operating room (NORA) for various types of neurosurgical and non-neurosurgical procedures. It is expected that the anesthesiologist should be able to take care of the EVDs just as they do with other indwelling catheters, tubes, or drains.

Gap analysis:
A multi-center survey-based study of anesthesiologists in a worldwide sample of hospitals found that approximately 50% of anesthesiologists are uncomfortable managing EVDs.² The knowledge gap in clinical proficiency may be related to exposure to the number of patients/year with EVDs as well as self-reported comfort in managing EVDs. Specific areas in which knowledge gaps exist include a) leveling and zeroing of the EVD, b) accurately measuring intracranial pressure, and c) safely transporting patients with EVDs between the OR/NORA and the intensive care unit, and general discordance with published guidelines³.

Various types of EVD-associated adverse events have been reported in the operating room, ranging from accidental disconnection/explanation of the EVD to accidental introduction of medications in the CSF via the EVD. These can lead to downstream events such as infections. Another significant gap noted is the prevalence of intrahospital transport-associated complications when EVDs are routinely clamped during transport and patients experience elevated ICP during transport.⁴ This poses risks for certain patients who rely on continuous CSF drainage due to reduced intracerebral compliance.

Finally, hospital policies and practices regarding EVD care may not necessarily align with published guidelines and recommendations and may vary between hospitals.⁵ This introduces variation in quality and safety practices.

EVD Safety Campaign Project Charter

1. Project Description:
The EVD Safety Campaign, a global patient safety initiative aims to improve quality and patient safety by promoting the External Ventricular Drain Safety Knowledge Hub within healthcare settings. This campaign is a coordinated effort to raise awareness provide education regarding best practices related to EVD safety.

2. Project Objectives:
The primary objective is to create and disseminate External Ventricular Drain Safety Knowledge Hub. The External Ventricular Drain Safety Knowledge Hub contains:

• Self-assessment quiz which can be used as a yearly refresher.
• Access to an educational video that demonstrates correct leveling, zeroing, and highlights safe transport practices.
• Access to the guidelines published by the Society for Neuroscience in Anesthesiology and Critical Care regarding the perioperative management of patients with EVDs.
• Access to an evidence-based standard operating procedure/policy document that may be used by the hospital.
• Creating awareness of EVD-associated adverse events and encouraging hospitals to create their own infrastructure and tracking system.

3. Project Scope:
The project scope includes the following components:

• Development and distribution of External Ventricular Drain Safety Knowledge Hub
• Design and implementation of a communication plan, including social media, newsletters.

4. Stakeholders:

• Project Sponsor: SNACC
• Project Manager:

Abhijit V. Lele, MBBS, MD, MSCR, FNCS, CPHQ
Certified Professional in Healthcare Quality (National Association for Healthcare Quality)
Certified Lean Six Sigma Black Belt Professional
Director, Neurocritical Care Service
Director, Neurocritical care Quality Improvement
Professor, Anesthesiology and Neurological Surgery (Adj)
Harborview Medical Center, University of Washington, Seattle, WA, USA

Chair, Quality and Safety Committee of the Society for Neuroscience in Anesthesiology and Critical Care

For details on how you can get involved with the campaign, please reach out to Dr.Abhijit Lele.

• Campaign Team Members

If you would like to join the discussion, log in to the forum.

References

1. Sekula RF, Cohen DB, Patek PM, Jannetta PJ, Oh MY. Epidemiology of ventriculostomy in the United States from 1997 to 2001. Br J Neurosurg. 2008;22(2):213-218. doi:10.1080/02688690701832084

2.  Lele AV, Mills B, Qiu Q, et al. International Multicenter Survey of Perioperative Management of External Ventricular Drains: Results of the EVD Aware Study. J Neurosurg Anesthesiol. Published online February 11, 2019. doi:10.1097/ANA.0000000000000580

3.  Lele AV, Hoefnagel AL, Schloemerkemper N, Wyler DA, Chaikittisilpa N, Vavilala MS, Naik BI, Williams JH, Venkat Raghavan L, Koerner IP; Representing SNACC Task Force for Developing Guidelines for Perioperative Management of External Ventricular and Lumbar Drains. 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 Jul;29(3):191-210. doi: 10.1097/ANA.0000000000000407. PMID: 28169966.

4.  Chaikittisilpa N, Lele AV, Lyons VH, et al. Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients. Neurocrit Care. 2017;26(2):196-204. doi:10.1007/s12028-016-0308-0

5.  Thamjamrassri T, Yuwapattanawong K, Chanthima P, Vavilala MS, Lele AV, 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(1):21-28. doi:10.1097/ANA.0000000000000694