Evd bundle care plan

Department of Neurosurgery
Tribhuvan University Teaching Hospital
Journal club
Sandesh Dahal
Sept 23rd 2020
INTRODUCTIONINTRODUCTIONINTRODUCTION

INTRODUCTION

Introduction
• EVD is a common procedure.
• Infection is the commonest and most dangerous complication.
• Different retrospective studies in the past to identify risk and incidence
• recent retrospective analysis of 23 studies encompassing 5,733 EVD insertions
quoted infection rates ranging between 0 and 22%
INTRODUCTION

• But significant inconsistency with contamination, colonization and infection.
• Stringent criteria used for definition.
• The criteria is “a single positive CSF culture obtained from a ventricular catheter or
CSF from lumbar puncture”
• This caused the incidence to be 6%.
INTRODUCTION

• Variety of risk factors identified.
• The most important is opening the drainage system for sampling.
INTRODUCTION

• Other risk factors are
• associated craniotomy,
• concurrent systemic infection,
• depressed cranial fracture,
• intraventricular hemorrhage,
• duration of implantation,
• EVD irrigation and
• insertion site CSF leaks
INTRODUCTION

• Purpose of the study- to evaluate the effects of EVD bundle care.
Studypurpose

Materials and methods
• Two phase study.
• Prospective retrospective model.
• First phase-
• retrospective,
• from 4th November 2010 and 15th January 2013.
• Aimed to find out the incidence of infection and possible causes
Methodology

• Second phase
• Prospective
• 1st January 2014 and 31st December 2015
• Collected data from the people undergoing EVD placement after implementing
bundle care.
• Place of study- department of neurosurgery, Queens Elizabeth hospital, Birmingham.
Methodology

Material and methods…
• Inclusion criteria
• The cases with first exposure to EVD.
• Exclusion criteria
• Pre-existing EVDs that underwent catheter change (for example for blockage or
displacement).
• Confirmed neurosurgical infection (CSF or otherwise) at the time of EVD insertion
• Cases where the CSF sample obtained at the time of insertion demonstrated evidence
of infection
Methodology

• Data recorded from both electronic and paper data.
• Duration of EVD was defined as the from the time of insertion to the time of
diagnosis of infection.
• In non infected case, it was till the time of removal.
• The number of sampling counted were all the times in which csf obtained, excluding
the one which documented infection.
Methodology

EVD care bundle
• Before the care bundle,
• EVD insertion and care was according to the discretion of the operating
neurosurgeon, with no specified protocol except infection prevention technique.
• Sampling recorded on chart or microbiology department.
Methodology

• After the care bundle,
• Universal standardized technique for aseptic CSF sampling that included
• hand-washing technique,
• use of surgical theatre standard scrub and preparation, and
• cleaning of the EVD access ports, together with gown, gloves and mask.
• To ensure documentation of all episodes of sampling, a new procedural tab was
added to the electronic clinical noting system.
Methodology

Methodology

• Nursing colleagues were told to challenge any deviation from the standard procedure
stated.
• All the data maintained strictly electronically.
Methodology

Statistical methods
• EVD infection rate were calculated as crude rates.
• Calculated as infected cases over total number of EVD in that time span.
• Crude infection rate did not account for the duration of EVD.
• So, Kaplan-Meier analysis was used for the infection free time.
• In Kaplan-Meier analysis, follow up started at insertion time, and outcome defined as
infection and cases censored at removal.
Statisticalmethods

• The other approach used was incidence time.
• It calculated the number of EVD days from insertion either to Infection time or
Removal time, and divided by number of infected cases by this number.
• Analysis of the factors related to infection were done.
Statisticalmethods

• For comparing two groups, and those infected and non infected used,
• Mann-Whitney U tests for ordinal and continuous variables
• Fischer’s exact test for nominal variables
• A multivariable analysis was then performed using a binary logistic regression
model, to identify those potentially modifiable factors that were significant
independent predictors of EVD infection
Statisticalmethods

• After the EVD care bundle, a range of factors and outcomes were compared between
the pre- and post-EVD care bundle eras using Mann-Whitney and Fisher’s exact tests
• The incidence of infection were then compared using
• Fisher’s exact test for crude incidence rate
• Log-rank test for Kaplan-Meier analysis
• Mid-P- exact test for incidence approach
Statisticalmethods

• All analyses were performed using IBM SPSS 22 (IBM Corp. Armonk, NY).
• Continuous variables were reported as medians with interquartile ranges (IQRs).
• Patients with missing data were excluded on a per-analysis basis and
• p<0.05 was deemed to be indicative of statistical significance throughout.
Statisticalmethods

Results
• Total data
• 275 total
• Pre-bundle= 120 cases
• Post-bundle= 155
• Median age- 52 years. (IQR 44-65 years)
• Total EVD days 1532 days and 1830 for pre and post bundle care time.
Results

Pre EVD bundle care
• total of 32/120 patients (27%) developed an EVD infection
• The rate was also calculated using the alternative approaches described in the
methods, giving a Kaplan-Meier curve
• estimated EVD infection rate of 33% at 14 days after insertion,
• an incidence of 21 infections per 1,000 EVD-days.
Results

Results

Discussion
• The introduction of the EVD care bundle significantly reduced the rates of EVD
infection in our study, from 27% to 10% (p<0.001).
• The main target of the care bundle was to standardize and improve the process of
accessing the EVD for the purpose of CSF sampling
• Specific aims
• Minimize EVD manipulation
• Improve EVD access and manipulation
Discussion

• In pre bundle era, the number of sampling associated with increased infection rate.
• In post-bundle care era, its similar. So improved technique helps allows sampling
without increased infection rate.
• The observed difference on the two era also explains why there is lot of inconsistency
in the infection data in other literatures.
Discussion

• Some studies reported that EVD infection rates increased with the number of
accesses.
Discussion

• And some studies did show no relation between the number of sampling and the
infection rates.
• Kitchen and colleagues demonstrated that sampling or irrigation of ventricular
drainage systems does not increase infection rate, provided that the operator has
adequate experience and utilizes theatre standard scrub techniques and preparation
Discussion

• Duration of the EVD in this study showed no difference in the infection rate.
• In Kaplan Meier analysis, the infection rate was almost linear for 14 days.
• The infection rate appears 2.7 and 0.7 per EVD day.
• All the literature do not support this view.
Discussion

• Lozier et al. critical review identifies that there is a gradual increase of the daily
infection rate with the peak occurring between the 9th and 11th days
Discussion

• whilst Paramore et al. demonstrated an increase progressively in daily infection rate
and hazard function on each successive day following catheterization (maximal risk
6.9% at Day 6)
Discussion

• In a question whether to change the EVD prophylactically for suspicion of getting
infection needs to be answered.
• Its to be thought that changing EVD in such manner will risk the patient for another
invasive procedure.
• There is no literature support to change EVD in those patients.
Discussion

Other factors
Discussion

• Tunneling distance has been related inversely to the infection rate in studies.
Tunneling for at least 5 cm is advocated.
Discussion

Discussion

Critical appraisal: strength
• Both types of data case and control, present. Prospective would cause ethical
dilemma.
• Adequate sample size for analysis between two groups.
• Both group in case and control, and those infected and non infected are well matched.
• Strict documentation of the protocol.
• Good statistical tools used.
Criticalappraisal

Crit. App…..: weakness
• Single center
• Retrospective component, may have recall bias.
• Catheter type is changed due to dept. protocol, which might have significantly
confounded.
• Inadequate data for subgroup analysis.
• Strict protocol in post-bundle period might have caused Hawthorne effect or observer-
expectancy.
• Protocol has not been evaluated during insertion, the level of expertise and level of
infection prevention is more than significant for infection.
Criticalappraisal

Take home
• Infection is commonest and most fearful complication of EVD.
• Most common source of entry is during handling and sampling.
• Bundle care can significantly reduce the rate of infection.
• Bundle care should be implemented in neurosurgical ICU as strict protocol.
Takehomemessage

Evd bundle care plan

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