1
|
Pongkaew C, Noiphithak R, Rukskul P, Yodwisithsak P, Tantongtip D, Nimmannitya P, Punyarat P, Duangprasert G, Kaewwichai W, Songphul S, Chancharoenrat W, Jantarathaneewat K, Chokaouychai C, Sukhor S, Apisarnthanarak P, Camins BC, Weber DJ, Apisarnthanarak A. Effectiveness of a multimodal strategy to reduce external ventricular drain-associated infection: A quasi-experimental study. Am J Infect Control 2024:S0196-6553(24)00586-8. [PMID: 38969072 DOI: 10.1016/j.ajic.2024.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/28/2024] [Accepted: 06/29/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Infection is a serious complication in neurosurgical patients who undergo external ventricular drain (EVD) insertion. METHODS We conducted a quasi-experimental study in patients who underwent EVD insertion to evaluate the impact of a multi-modal strategy to reduce the incidence of external ventricular drain associated infections (EVDAIs). The study was divided into 2 periods; (1) the pre-intervention period when techniques for EVD insertion and maintenance were up to the discretion of the neurosurgeons and (2) the post-intervention after implementation of a multi-modal strategy (cefazolin antibiotic prophylaxis, preoperative chlorhexidine showers, application of postoperative chlorhexidine-impregnated dressing, limited manipulation of the EVD, and meticulous EVD management). The primary outcome was the incidence rate of EVDAIs; secondary outcomes included in-hospital mortality rate, the hospital length of stay. RESULTS In total, 135 patients were included. The incidence rate of EVDAIs was significantly reduced in the post-intervention period (5.6 cases/1,000 EVD-days) compared with the pre-intervention period (18.2 cases/1,000 EVD-days; P=0.026). There were no differences in all secondary outcomes analyzed. This multi-modal strategy was associated with high satisfaction among health care personnel. CONCLUSIONS Implementation of a multi-modal strategy was associated with a reduction in the incidence of EVDAIs. This was in line with our goal of promoting a new culture of safety despite being in a resource-limited setting.
Collapse
Affiliation(s)
- Chaiwat Pongkaew
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Pataravit Rukskul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Pornchai Yodwisithsak
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Pree Nimmannitya
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Prachya Punyarat
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Wadrawee Kaewwichai
- Neurosurgical Intensive Care Unit, Nursing Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand
| | - Sirada Songphul
- General Neurosurgical Unit, Nursing Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand
| | - Watcharee Chancharoenrat
- Infection Control Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand
| | - Kittiya Jantarathaneewat
- Research Group in Infectious Diseases Epidemiology and Prevention, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand; Department of Pharmaceutical Care, Faculty of Pharmacy, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Chattrabongkot Chokaouychai
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Piyaporn Apisarnthanarak
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bernard C Camins
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David J Weber
- University of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand; Infection Control Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand.
| |
Collapse
|
2
|
Kaplan A, Kaleem S, Huynh M. Quality Improvement in the Management of Subarachnoid Hemorrhage: Current State and Future Directions. Curr Pain Headache Rep 2023; 27:27-38. [PMID: 36881288 DOI: 10.1007/s11916-022-01097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW Aneurysmal subarachnoid hemorrhage carries high mortality and morbidity. Quality improvement (QI) efforts in the management of this disease process are growing as the field of neurocritical care matures. This review provides updates in QI in subarachnoid hemorrhage (SAH) and discusses gaps and future directions. RECENT FINDINGS Literature published on the topic over the past 3 years were evaluated. An assessment of current QI practices pertaining to the acute care of SAH was conducted. These include processes surrounding acute pain management, inter-hospital coordination of care, complications during the initial hospital stay, role of palliative care, and quality metrics collection, reporting, and monitoring. SAH QI initiatives have shown promise by decreasing ICU and hospital lengths of stay, health care costs, and hospital complications. The review reveals substantial heterogeneity, variability, and limitations in SAH QI protocols, measures, and reporting. Uniformity in QI research, implementation, and monitoring will be crucial as disease-specific QI develops in neurological care.
Collapse
Affiliation(s)
- Aaron Kaplan
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, NY, New York, USA
| | - Safa Kaleem
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, NY, New York, USA
| | - Margaret Huynh
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, NY, New York, USA.
| |
Collapse
|
3
|
External Ventricular Drains: Development and Evaluation of a Nursing Clinical Practice Guideline. NURSING REPORTS 2022; 12:933-944. [PMID: 36548163 PMCID: PMC9782641 DOI: 10.3390/nursrep12040090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/11/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022] Open
Abstract
External ventricular drains (EVDs) are common in intensive care for neurocritical patients affected by different illnesses. Nurses play an essential role to ensure safe care, and guidelines are tools to implement evidence-based care. Thus, the aim of this study was to develop and evaluate the quality of a clinical guideline for critically ill patients with EVDs. Methodological research was conducted. The guideline development was based on a scoping review about nursing care to patients with EVDs. The guideline evaluation occurred in two phases: evaluation of its methodological rigor, with application of the Appraisal of Guidelines Research and Evaluation II to four experts on guidelines evaluation; and the Delphi technique, with a panel of nine specialists in neurocritical care, performed in two rounds. Data were analyzed by descriptive statistics and content validity ratio. In the first phase of the evaluation, three domains did not reach consensus, being reformulated. The second phase was conducted in two rounds, with nine and eight participants respectively, with 13 recommendations being reformulated and reassessed between rounds, inclusion of an EVD weaning category, and two flowcharts on patient's transport and mobility. Therefore, the guideline can be incorporated into nursing care practices. Further studies are necessary to assess its impact on clinical practice.
Collapse
|
4
|
Thamjamrassri T, Yuwapattanawong K, Chanthima P, Vavilala MS, Lele AV. 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. [PMID: 32467476 PMCID: PMC9014964 DOI: 10.1097/ana.0000000000000694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/20/2020] [Indexed: 01/03/2023]
Abstract
External ventricular drain (EVD) placement and management pose risks to neurocritically ill patients. Yet, little is known about EVD management or hospital EVD management practices and policies in US hospitals. A narrative review was conducted to describe EVD-related publications reported in PubMed and Embase between 1953 and 2019, and a survey was used to examine US hospital EVD practices and policies, including adherence to EVD guideline recommendations. Overall, 912 relevant articles were published between 1953 and 2019 (average 21; range, 0 to 102 articles, per year), primarily related to indications for EVD placement (n=275, 30.2%), EVD-associated complications (n=206, 22.6%), and EVD care (n=200, 21.9%). The number of EVD publications increased over time (R2=0.7), and most publications addressed EVD-associated infection (n=296, 73.4%) and EVD insertion (n=195, 45.2%). Survey responses were received from 30 hospitals (37.5% response rate), and reported use of antimicrobial-impregnated catheters in 80% of hospitals, preinsertion antibiotic administration in 70%, collection of cerebrospinal fluid samples for suspicion of ventriculitis in 73.3%, tracking of EVD-associated infection in 86.7%, routine EVD clamping during transport in 66.7%, and monitoring of intracranial pressure during transport in 33.3%. Adherence to hospital policies was high for recommendations related to flushing an EVD and changing cerebrospinal fluid drainage systems (100% [range, 0% to 100%] each), but low for intrahospital transportation (16.7% [0% to 83.3%]), EVD removal (0% [0% to 66.7%]), patient and family education (0% [0% to 100%]), and administration of intraventricular medication (0% [0% to 100%]). In summary, the published literature related to EVD insertion and maintenance, and reported EVD hospital practices and policies, primarily focus on reducing EVD-associated infections. Still, overall adherence of hospital EVD policies to guideline recommendations is modest. To promote a culture of EVD safety, clinicians should focus on reducing all EVD-associated adverse events.
Collapse
Affiliation(s)
| | | | | | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, Harborview Medical Center
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
| | - Abhijit V Lele
- Harborview Injury Prevention and Research Center, Harborview Medical Center
- Neurocritical Care Service
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
| |
Collapse
|
5
|
Basha AK, Mahmoud MA, Al Ashwal MI, Aglan O, ElShawady SB, Abdel-Latif AM, Elsayed AM, AbdelGhany W. Management of Severe Traumatic Brain Injury: A Single Institution Experience in a Middle-Income Country. Front Surg 2021; 8:690723. [PMID: 34746219 PMCID: PMC8570277 DOI: 10.3389/fsurg.2021.690723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Severe traumatic brain injury (TBI) is a major public health problem usually resulting in mortality or severe disabling morbidities of the victims. Intracranial pressure (ICP) monitoring is recently recognized as an imperative modality in the management of severe TBI, whereas growing evidence, based on randomized controlled trials (RCTs), suggests that ICP monitoring does not affect the outcome when compared with clinical and radiological data-based management. Also, ICP monitoring carries a considerable risk of intracranial infection that cannot be overlooked. The aim of this study is to assess the different aspects of our current local institutional management of severe TBI using non-invasive ICP monitoring for a potential need to change our management strategy. Methods: We retrospectively reviewed our data of TBI from June 2019 through January 2020. Patients with severe TBI were identified. Their demographics, Glasgow coma score (GCS) at presentation, treatments received, and imaging data were extracted from the charts. Glasgow outcome scale extended (GOS-E) at 6 months was also assessed for the patients. Results: Twenty patients with severe TBI were identified on chart review. Ten patients received only medical treatment measures to lower the ICP, whereas the other 10 patients had additional surgical interventions. In one patient, a ventriculostomy tube was inserted to monitor ICP and to drain cerebrospinal fluid (CSF). This was complicated by ventriculostomy-associated infection (VAI) and the tube was removed. In our cohort, the total mortality rate was 40%. The average GOS-E for the survivor patients managed without ICP monitoring based on the clinical and radiological data was 6.2 at 6 months follow-up. The 6-month overall good outcome, based on GOS-E, was 33.3%. Conclusion: Although recent guidelines advocate for the use of ICP monitoring in the management of severe TBI, they remain underutilized in our practice due to many factors. External ventricular drains were mainly used to drain CSF; however, the higher rates of VAIs in our institution compared with the literature-reported rates are not in favor of the use of ICP monitoring. We recommend doing a comparative study between our current practice using clinical-and radiological-based management and subdural or intraparenchymal bolts. More structured RCTs are needed to validate these findings in our setting.
Collapse
Affiliation(s)
| | | | | | - Osama Aglan
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | | | | | | | | |
Collapse
|