Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution

Clinical article

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Ventricular infection after ventriculostomy placement carries a high mortality rate. Responding to ventriculostomy infection rates, a multidisciplinary performance improvement team was formed, a comprehensive protocol for ventriculostomy placement was developed, and the efficacy was evaluated.


A best-practice protocol was developed, including hand hygiene before the procedure; prophylactic antibiotics; sterile gloves changed between preparation, draping, and procedure; hair removal by clipping for dressing adherence; skin preparation using iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74%); full body and head drape; full surgical attire for the surgeon and other bedside providers; and an antimicrobial-impregnated catheter. A checklist of critical components was used to confirm proper insertion and to monitor practice. Procedure-specific infection rates were calculated using the number of infections divided by the number of patients in whom an external ventricular drainage (EVD) device was inserted × 100 (%). Data were reported back to providers and to the committee. Bundle compliance was monitored over a 4-year period.


At the authors' institution, 2928 ventriculostomies were performed between the beginning of the fourth quarter of 2006 and the end of the first quarter of 2012. Although the best-evidence bundle was applied to all patients, only 588 (20.1%) were checklist monitored (increasing from 7% to 23% over the study period). The infection rate for the 2 quarters before bundle implementation was 9.2%. During the study period, the rate decreased quarterly to 2.6% and then to 0%. Over a 4-year period, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), and 0.34% (2010); it was 0% in 2011 and the first quarter of 2012. The overall EVD infection rate was 0.46% after bundle implementation.


Bundle implementation including an antimicrobial-impregnated catheter dramatically decreased EVD-related infections. Training and situational awareness of appropriate practice, assisted by the checklist, plus use of the antibiotic-impregnated catheter resulted in sustained reduction in ventriculitis.

Abbreviation used in this paper:EVD = external ventricular drainage.

Article Information

Current address for Dr. Kubilay: Department of Medicine, Marmara University, Istanbul, Turkey.

Current address for Dr. Amini: Department of Anesthesiology, Zahedan University of Medical Sciences, Zahedan, Iran.

Current address for Dr. Layon: Department of Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania.

Address correspondence to: A. Joseph Layon, M.D., Department of Critical Care Medicine, Geisinger Health System, 100 North Academy Avenue, Danville, Pennsylvania 17822-2037. email:

Please include this information when citing this paper: published online December 21, 2012; DOI: 10.3171/2012.11.JNS121336.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Graph showing epidemiological curve of the ventricular infection problem over time. The data show that this was not a single outlier masquerading as an infection problem, but a real concern. Data points represent the percentage of infections. Q1 = first quarter, Q2 = second quarter, and so on.

  • View in gallery

    The ventriculostomy insertion checklist developed for the project. This incorporated best-practice data where available.

  • View in gallery

    Graph comparing ventriculostomy infection rates over the period of the quality study through the end of the 1st quarter of 2012. FMEA = Failure Mode Evaluation and Analysis; Qtr = quarter.



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