Faculty Bibliography

External ventricular drains (EVDs) are commonly used to facilitate removal of cerebrospinal fluid in patients with neurologic dysfunction. Despite a high risk for infection (upward of 45%), many hospitals lack strict protocols for EVD placement and maintenance. In addition, EVD infections are typically not tracked with the same diligence as central-line catheter infections, because there are no widely accepted standards for routine management of EVDs. The purpose of this review is to provide a guide for the development of a standardized, best practice EVD protocol for catheter insertion, care, and maintenance to reduce ventriculostomy-related infections. A secondary goal of this review is to provide support for the future development of guidelines for the consistent tracking of EVD insertion and maintenance practices.At an academic medical center, an interdisciplinary team of nurses, advanced practice nurses, and neurointensivists reviewed recent medical and nursing literature as well as research-based institutional protocols on EVD insertion and maintenance from the United States and abroad to determine global best practices. The goal of this literature review was to identify key areas of focus in EVD insertion and maintenance as well as to identify recent studies that have shown success in managing EVDs with low rates of infection. The following terms were used in this search: EVD, externalized ventricular drains, EVD infections, EVD insertion, EVD Care and Maintenance, Nursing and EVDS. The following databases were utilized by each member of the interdisciplinary team to establish a state of the science on EVD management: American Association of Neurosurgical Surgeons, CINAHL, Cochrane, National Guidelines Clearinghouse, and PubMed. The following common EVD themes were identified: preinsertion hair removal and skin preparation, aseptic technique, catheter selection, monitoring of EVD insertion technique using a "bundle" approach, postinsertion dressing type and frequency of dressing changes, techniques for maintenance and cerebrospinal fluid sampling, duration of catheter placement, staff education/competence, and surveillance.

INTRODUCTION: Comparison of rates of ventriculostomy-related infections (VRIs) across institutions is difficult due to the lack of a standard definition. We sought to review published definitions of VRI and apply them to a test cohort to determine the degree of variability in VRI diagnosis. MATERIALS AND METHODS: We conducted a PubMed search for definitions of VRI using the search strings "ventriculostomy-related infection" and "ventriculostomy-associated infection." We applied these definitions to a test cohort of 18 positive cerebrospinal fluid (CSF) cultures taken from ventriculostomies at two institutions to compare the frequency of infection using each definition. RESULTS: We found 16 unique definitions of VRI. When the definitions were applied to the test cohort, the frequency of infection ranged from 22 to 94% (median 61% with interquartile range (IQR) 56-74%). The concordance between VRI diagnosis and treatment with VRI-directed antibiotics for at least seven days ranged from 56 to 89% (median: 72%, IQR: 71-78%). CONCLUSIONS: The myriad of definitions in the literature produce widely different frequencies of infection. In order to compare rates of VRI between institutions for the purposes of qualitative metrics and research, a consistent definition of VRI is needed.

Introduction Infections are common inpatient complications after intracerebral hemorrhage (ICH), but little is known about risk of infection after hospital discharge. Methods We performed a retrospective cohort study of patients discharged from non-federal acute-care hospitals in California with a primary diagnosis of ICH between 2006 and 2010. ICH was defined as a primary ICD-9CM discharge diagnosis code of 431. Only the first eligible ICH admission was included for each patient. Exclusion criteria were discharge against medical advice, in-hospital death, and non-California residency. After discharge from index admission, we assessed the proportion of readmissions to an acute-care hospital within 30 days that were related to infection. Clinical Classification Software (CCS) categorization of ICD-9CM codes was utilized for etiology of readmission. Inter-hospital transfers and readmission for likely planned procedures (craniotomy, embolization) were not included. Log-binomial regression was used to assess relationship between baseline characteristics and readmission mortality. Results There were 24,540 index ICH visits from 2006 to 2010. Unplanned readmissions occurred in 14.8% (n=3,269) of index patients. Of the 3,269 revisits, 934 (26%) had an infection-related primary diagnosis code. When evaluating all available revisit diagnosis codes, infection was associated with 1,945 (54%) of readmissions. Other common primary causes for readmission included stroke-related codes (n=894, 24.6%) and complications of medical/surgical care (n=92, 2.5%). The most common infection-related primary diagnosis codes were septicemia (n=422, 11.6%), respiratory infections/aspiration (n=292, 8.0%), urinary tract infection (n=141, 3.9%), and gastrointestinal infection (n=90, 2.5%). Patients with primary infection-related readmissions had higher in-hospital mortality compared to other types of readmission (15.7% vs. 7.7%, p< 0.001). After controlling for other predictors of mortality, primary infection-related readmissions remained associated with in-hospital mortality (RR=1.5, 95% CI 1.2-1.8). Conclusions Readmission for infection after ICH is common and associated with in-hospital death. Efforts should be made to identify ways to reduce infection-related complications in ICH patients after hospital discharge

Introduction The death of Marlise Munoz, a pregnant woman who suffered an anoxic brain injury in the setting of a presumed pulmonary embolus, instigated a national discussion on management of brain death in pregnancy. We sought to evaluate whether institutions in the United States are prepared to handle the unfortunate situation in which a pregnant woman suffers a catastrophic brain injury. Methods Institutional brain death protocols were procured in cooperation with local and regional organ procurement agencies. Each protocol was reviewed to determine if and how it addressed brain death in pregnancy. Results 225 unique protocols from 21 different states were reviewed. In 3.56% (8) of protocols, it was noted that a pregnant patient could not be diagnosed as brain dead if the fetus could be preserved. Of the protocols that permitted brain death evaluation, 91.71% (199) did not provide guidance as to whether or not protracted somatic support should be provided to a brain dead mother. There was no indication of who was responsible for making decisions for the fetus in 98.67% (222) of protocols. Conclusions Very few institutional brain death policies address the issue of pregnancy.The creation of national guidelines on management of the social and ethical challenges associated with brain death in pregnancy may be helpful

Introduction The prominent case of Jahi McMath highlights the social and ethical controversies that emerge in the setting of brain death diagnosis. While it is well-established that there is significant variability between brain death protocols throughout the United States, the manner in which protocols address a family's objection to discontinuation of the ventilator after diagnosis of brain death has not been explored. Methods Institutional brain death protocols were procured in cooperation with local and regional organ procurement agencies. Each protocol was reviewed to determine if and how it addressed situations in which families object to discontinuation of the ventilator after diagnosis of brain death. Results 225 unique protocols from 21 different states were reviewed. Indications for prolonged ventilator support after diagnosis of brain death described in institutional protocols included family's religious beliefs (8.44%, 19), family's moral beliefs (1.78%, 4), desire to await arrival of family members (4.44%, 10), and nonspecific social reasons/desire to give family members time to accept the patient's death (1.33%, 3). However, 80.44% (181) of protocols made no mention of how to handle situations in which families request ventilator support be continued after diagnosis of brain death. The remainder of the protocols included recommendations to: 1) seek counsel from administrative/ethical/legal/religious/risk management resources; 2) transfer care of the patient to another practitioner or another facility; 3) obtain a second opinion regarding diagnosis of brain death; 4) extubate against the family's wishes; or 5) defer to the family's request and maintain organ support until cardiac death. Conclusions The majority of protocols reviewed did not include mention of how to handle circumstances in which families object to discontinuation of ventilator support after diagnosis of brain death. The creation of national guidelines on management of these socially and ethically complex situations may be helpful to prevent distress to families and hospital staff

Introduction Comparison of rates of ventriculostomy-related infections (VRI) across institutions is difficult due to the lack of a standard definition. We sought to review published definitions of VRI and apply them to a test cohort to determine the degree of variability in VRI diagnosis. Methods We conducted a PubMed search for definitions of VRI using the search strings "ventriculostomy-related infection" and "ventriculostomy-associated infection." We applied these definitions to a test cohort of 18 positive cerebrospinal fluid (CSF) cultures taken from ventriculostomies at two institutions to compare the frequency of infection using each definition. Results We found 16 unique definitions of VRI. When the definitions were applied to the test cohort, the frequency of infection ranged from 22-94% (median 61% with interquartile range (IQR) 56-74%). The concordance between VRI diagnosis and treatment with VRI-directed antibiotics for at least seven days ranged from 56-89% (median 72%, IQR 71-78%). Conclusions The myriad of definitions in the literature produce widely different frequencies of infection. In order to compare rates of VRI between institutions for the purposes of qualitative metrics and research, a consistent definition of VRI is needed

Objective. Hydrocephalus after subarachnoid hemorrhage (SAH) requires temporary cerebrospinal fluid (CSF) drainage using an external ventricular drain (EVD). This drain is removed if patients pass a clamp trial, or a ventriculoperitoneal shunt (VPS) is placed. Little is known about the risk factors for delayed VPS placement in patients who pass a clamp trial and have their EVD removed. In order to explore the risk factors associated with delayed VPS placement, we studied a retrospective cohort of SAH patients at our institution. Methods. We performed a retrospective analysis of SAH patients who had an EVD placed between January 2008 and June 2012 at our institution. We extracted demographic, imaging, and CSF data from the medical record and analyzed risk factors associated with delayed VPS placement. Results. Of 91 patients who passed a clamp trial and had their EVD removed, 12 (13%) required delayed VPS placement at a median of 54 (interquartile range: 15-75) days after EVD removal. After multivariate analysis, risk factors for delayed VPS placement included increased CSF protein concentration within the first 7 days of EVD placement (OR: 1.02, CI: 1-1.04, p = 0.023) and increased third ventricular diameter prior to EVD removal (OR: 1.59, CI: 1.11-2.6, p = 0.026). Conclusion. Patients with increased CSF protein concentration at time of EVD placement and those with increased third ventricular diameter at time of EVD removal should be carefully monitored for development of delayed hydrocephalus.

The diagnosis of brain death has generated numerous medical, legal, social and ethical controversies. The recent highly publicized case of Jahi McMath, a 13-year-old who was declared brain dead and transferred to a long-term care facility, illustrates these issues and raises new challenges and questions about the management of brain dead patients