Simulation workshops as an adjunct to perioperative care bundles in the management of external ventricular drains: improving surgical technique and reducing infection

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OBJECTIVE

Temporary CSF diversion through an external ventricular drain (EVD) comes with the risk of EVD-related infections (ERIs). The incidence of ERIs varies from 0.8% to 22%. ERIs increase mortality, morbidity, length of stay, and costs; require prolonged courses of antibiotics; and increase the need for subsequent permanent CSF diversion. The authors report the results of a quality improvement project designed to improve infection rates and EVD placement using simulation training in addition to a standardized perioperative care bundle. This project resulted not only in a decrease in ERIs, but also a significant improvement in surgical outcomes.

METHODS

A best-practice standardized perioperative approach and care bundle was approved by consensus among the senior neurosurgeons at the authors’ institution, and a standardized operative note was designed to encourage adherence to policy and improve documentation. This approach was adapted from the bundle previously described by Kubilay et al. Simulation workshops were introduced to teach safe sampling technique, administration of intrathecal drugs, and a standardized operative technique using the Rowena head surgical model. Effects of the interventions on placement, infection rates, and displacement were measured at two distinct time points over a 2-year period.

RESULTS

Baseline audits demonstrated satisfactory EVD placement in 74%, an infection rate of 8.5%, and displacement occurring in 20%. In the 2 years following the interventions, satisfactory placement improved to 96%, infection rate fell to 4.8%, and inadvertent displacement occurred in only 1.7%.

CONCLUSIONS

Simulation training and standardizing the perioperative care of patients requiring EVDs dramatically improved placement accuracy, reduced infection rates, and reduced EVD displacement rate.

ABBREVIATIONS EVD = external ventricular drain; ERI = EVD-related infection; ICP = intracranial pressure.
Article Information

Contributor Notes

Correspondence Debayan Dasgupta: National Hospital for Neurology and Neurosurgery, London, United Kingdom. debayan.dasgupta1@nhs.net.INCLUDE WHEN CITING Published online October 19, 2018; DOI: 10.3171/2018.5.JNS172881.

D.D. and L.D. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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