J Korean Med Sci.  2023 Dec;38(50):e386. 10.3346/jkms.2023.38.e386.

Significant Reduction in External Ventricular Drain-Related Infections After Introducing a Novel Bundle Protocol: A Before and After Trial

• Choo YH
• Shim Y
• Kim H
• Goh HY
• Kim SJ
• Kim EJ
• Kang CK
• Ha EJ

• KMID: 2549956
• DOI: http://doi.org/10.3346/jkms.2023.38.e386

Abstract

Background
External ventricular drain (EVD)-related infection (ERI) is a serious complication in neurosurgical patients. The estimated ERI rates range from 5 to 20 cases per 1,000 EVD catheter days. The pathophysiology of ERI is similar to central line-associated bloodstream infections (CLABSIs) stemming from skin-derived bacterial colonization. The use of bundle management can reduce CLABSI rates. Due to the pathogenic similarities between infections related to the two devices, we developed and evaluated the effectiveness of an ERI-bundle protocol based on CLABSI bundles.
Methods
From November 2016 to November 2021, we conducted a study to evaluate the effectiveness of an ERI-bundle protocol. This study adopted a before-and-after trial, comparing the ERI rates for the 2 years before and 3 years after the introduction of the newly developed ERI-bundle protocol. We also analyzed the contributing factors to ERI using logistic regression analysis.
Results
A total of 183 patients with 2,381 days of catheter use were analyzed. The ERI rate decreased significantly after the ERI-bundle protocol from 16.7% (14 of 84; 14.35 per 1,000 catheter days) to 4.0% (4 of 99; 3.21 per 1,000 catheter days) (P = 0.004).
Conclusion
Introduction of the ERI-bundle protocol was very effective in reducing ERI.

Keyword

External Ventricular Drain; Infection; Intensive Care Unit; Protocols; Bundle

Figure

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  Fig. 1 Application of chlorhexidine-impregnated gel pad dressing. The transparent chlorhexidine-impregnated gel pad dressing is applied to the exit zone of the EVD catheter. Place the exit zone in the center of the chlorhexidine-impregnated gel pad (A). If the exit site of the catheter is not located in the center of the gel pad (B), or the pad dressing did not adhere well due to hair, or there was oozing/hematoma (C, D), a new dressing should be applied.EVD = external ventricular drain.

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  Fig. 2 Checklist for insertion of external ventricular drainage catheter.

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  Fig. 3 Checklist for maintaining and manipulating external ventricular drainage.EVD = external ventricular drain.

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  Fig. 4 Checklist for dressing external ventricular drainage.EVD = external ventricular drain.

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  Fig. 5 The Kaplan-Meier curves for ERI. Before the introduction of the ERI-bundle protocol, the 7-day ERI-free rate was 79.2%, and the 14-day ERI-free rate was 78.6%. In comparison, after the introduction of the ERI-bundle protocol, the rates significantly increased to 98.9% at 7-day and 92.6% at 14-day (P = 0.004).ERI = external ventricular drain-related infection, EVD = external ventricular drain.

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