54 Journal of Neuroscience Nursing

Establishment of an External Ventricular Drain

Best Practice Guideline: The Quest for a
Comprehensive, Universal Standard for
External Ventricular Drain Care
Millie Hepburn-Smith, Irina Dynkevich, Marina Spektor, Aaron Lord, Barry Czeisler,
Ariane Lewis

ABSTRACT
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.

Keywords: EVD, EVD infection, EVD protocol, externalized ventricular drain, ventriculostomy

I
n neuroscience intensive care units, external ven-
tricular drains (EVDs) are commonly used to
facilitate removal of cerebrospinal fluid (CSF) in
patients with neurologic dysfunction related to hy-
drocephalus and increased intracranial pressure.
Although the literature reports that the incidence of
infections related to EVD insertion and maintenance
is most commonly between 10% and 17%, rates as
high as 45% have been reported (Babu, Patel, Marsh,
& Wijdicks, 2012; Lozier, Sciacca, Romagnoli, &
Connolly, 2002; Lyke et al., 2001; Zingale, Ippolito,
Pappalardo, Chibbaro, & Amoroso, 1999). Despite
high infection rates, many hospitals do not have strict
protocols for EVD placement and maintenance nor do
they track these infections with the same diligence as
central-line catheter infections.

Questions or comments about this article may be directed to
Millie Hepburn-Smith, RN MSN MPhil SCRN ACNS-BC, at millie.
hepburn@gmail.com. She is a Neuroscience, Rehabilitation and
Inpatient Psychiatry Nurse Educator, NYU Langone Medical Center,
New York, NY.
Irina Dynkevich, RN MSN CNRN, is a Staff RN, Department of
Neurosciences, NYU Langone Medical Center, New York, NY.
Marina Spektor, RN CNRN CSRN, is a Staff RN, Department of
Neurosciences, NYU Langone Medical Center, New York, NY.
Aaron Lord, MD, is Assistant Professor, Division of Neurocritical Care,
Department of Neurology, NYU Langone Medical Center, New York, NY.
Barry Czeisler, MD MS, is Assistant Professor, Division of Neuro-
critical Care, Department of Neurology, NYU Langone Medical
Center, New York, NY.
Ariane Lewis, MD, is Assistant Professor, Division of Neurocritical Care,
Department of Neurology, NYU Langone Medical Center, New York, NY.
The authors declare no conflicts of interest.
Copyright B 2016 American Association of Neuroscience Nurses
DOI: 10.1097/JNN.0000000000000174

Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Complications of EVD placement include skin and
soft tissue infections, ventriculitis, meningitis, subdural
empyemas, osteomyelitis, sepsis, endocarditis, and both
intracranial and intra-abdominal abscesses (Beer, Lackner,
Pfausler, & Schmutzhard, 2008). Risk for infection may
be associated with insertion technique, catheter type,
number of days the EVD remains in place, EVD care
and maintenance, and frequency of CSF sampling
(Keong et al., 2012; Lozier et al., 2002; Sonabend et al.,
2011). EVD-related infection is associated with more
expensive and prolonged hospitalizations and increased
neurocritical care morbidity and risk of death (Chatzi
et al., 2014; Zingale et al., 1999). Despite the poten-
tial for infection in this vulnerable patient population,
no accepted standards for routine management of EVDs
are available.
In 2014, the International Multidisciplinary Consen-
sus Conference on Multimodality Monitoring declared
that incidence of ventriculostomy-related infections may
be a useful indicator for intensive-care-unit quality of
care (Le Roux et al., 2014). As such, at one academic
medical center’ s neuroscience intensive care unit, an
interdisciplinary team of nurses, advanced practice nurses,
and neurointensivists formed to explore the best prac-
tices in EVD maintenance and management that con-
tribute to improved quality of care and reduction in
infection rates. This was accomplished by directly con-
tacting academic medical centers and community hos-
pitals in both the United States and abroad that have
published EVD protocols that were found using the
aforementioned databases and reviewing their orga-
nizational practices in EVD care as well as searching
EVD research studies found in medical and nursing
literature. This synthesis of literature represents a sum-
mary of the various findings in regard to current prac-
tices for EVD insertion and maintenance to establish
best practices in EVD care. This review served as a
guide for the development of a new standardized, best
practice evidence-based EVD protocol at one institu-
tion and may also serve as the foundation for creation
of a comprehensive, universal standard for EVD inser-
tion, care, and tracking.
Methods
Protocols for EVD maintenance and insertion were
acquired from other institutions via three means: (a)
protocols provided by EVD device manufacturers, (b)
an Internet search of Google.com using the search
terms ‘‘EVD protocol’’ and ‘‘external ventricular drain
protocol,’’ and (c) direct personal requests to physi-
cians and nurses at other hospitals. To be included in
this synthesis, protocols needed to describe EVD main-
tenance and management procedures (e.g., not only
EVD insertion technique). Upon review of each
protocol, descriptive data were recorded about the
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 48 & Number 1 & February 2016 55
The authors summarize
their recommendations for
7 insertion practices
and 7 maintenance practices.
protocol itself as well as the presence or absence of
information pertaining to insertion and maintenance
practices. The protocols were de-identified and assigned
an identification number.
A literature search of American Association of Neu-
rosurgical Surgeons, CINAHL, Cochrane, National
Guidelines Clearinghouse, and PubMed databases was
conducted using the search strings ‘‘EVD protocol,’’
‘‘EVD nursing,’’ ‘‘external ventricular drain nursing,’’
‘‘EVD management,’’ ‘‘external ventricular drain man-
agement,’’ ‘‘EVD bundle,’’ and ‘‘external ventricular
drain bundle.’’ Through review of abstracts (by all
members of the interdisciplinary team including bed-
side registered nurses [RNs], advanced practice nurses,
and neurointensivists), manuscripts that described EVD
management and maintenance procedures that focused
on infection reduction techniques were identified and
reviewed further by the team. Articles published greater
than 15 years ago (e.g., before 1999) were excluded,
as were abstracts published without complete manu-
scripts, to ensure data were both current and thorough.
Each article was then reviewed, and recommendations
for insertion and maintenance techniques were recorded.
Themes that addressed infection reduction were identi-
fied, and various strategies employed were categorized
by theme. A model was created to organize these themes
and strategies, and this ultimately served to guide the
development of a state-of-the-science EVD protocol.
Results
Protocols
The EVD protocol selection process culminated in
the acquisition of 10 protocols from hospitals in the
United States, Canada, Australia, and the United
Kingdom. The protocols were created between the
years 1990 and 2013 and updated between the years
2006 and 2014. They ranged from 3 to 19 pages in
length. Six of ten protocols were illustrated with fig-
ures. Two protocols clearly stated the authors’ titles
(one is a nurse practitioner, and another is an RN), but
the rest did not explicitly indicate the positions of the
authors. Although not every protocol specified the type
of EVD the institution uses, those that did referenced
drains manufactured by Codman (6), Medtronic (3),
Ventrix (1), or Becker (2). Some organizations used
56 Journal of Neuroscience Nursing
more than one type of EVD catheter as dictated by
physician preference. Some organizations used
antibiotic-coated catheters, and some did not. Not
all EVD protocols indicated the area of the hospital
that EVD placement occurs. Four protocols noted that
placement of EVDs may occur only in the operating
room, and three stated that EVD placement can be per-
formed in intensive care units, operating rooms, and/or
emergency rooms.
The interdisciplinary team independently reviewed
and compared each protocol to determine if instruc-
tions were present regarding EVD insertion with refer-
ence to aseptic technique, antibiotic prophylaxis, hair
removal, and skin preparation and compared their find-
ings. Three protocols did not include the details of EVD
insertion, but the remainder described use of sterile
technique including hand hygiene and use of gown/
gloves/mask, face mask, and caps for all clinicians in
the room during the procedure as well as use of the
nontouch technique (single use of a sterile gauze to
handle nonsterile items). An insertion checklist was
mentioned in one of the seven protocols that described
the insertion process. One of the seven protocols that
included details of EVD insertion indicated that anti-
biotic prophylaxis is used at the time of EVD place-
ment. Four of the ten protocols described the use of
antibiotic prophylaxis after insertion as a component
of EVD maintenance. In regard to hair removal, three
protocols mentioned clipping hair on the scalp (one of
which referred to ‘‘generous clipping’’ and one of which
merely indicated the need for clipping at the site of
entry), and one described shaving, but there was no
mention of hair management during EVD maintenance
in the remaining six protocols. Of the protocols that
included clear recommendations for skin preparation,
four mentioned use of chlorhexidine, whereas four
described use of povidone iodine, and one referred to
use of alcohol to prep the insertion site.
The team further reviewed the EVD maintenance
instructions in each protocol including mention of EVD
manipulation and equipment changes, CSF sam-
pling, types of dressings, and frequency of dressing
changes. Table 1 summarizes these findings.
Articles
Articles reviewed included descriptions of 10 single-
institution protocols from Brazil, France, Greece,
Netherlands, Singapore, the United Kingdom, and
the United States published from 2004 to 2014. Every
institution reported that implementation of their pro-
tocol significantly decreased the rate of EVD-related
infections (Table 2). The protocols addressed multiple
risk factors for EVD-related infections during both
insertion and maintenance. Each protocol identified gaps
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
in prior practice and targeted interventions to address
these gaps. A summary of recommendations based on
a review of articles is presented in Tables 3 and 4.
Discussion
It was discovered that there are a number of common
trends in EVD insertion and maintenance procedures,
most notable of which was use of aseptic technique
(hand washing; broad draping; use sterile gloves and
gown, cap, and mask for all personnel in the room
during EVD placement and manipulation) during both
insertion and maintenance to prevent infection. How-
ever, there are also many points of divergence and con-
troversy among different protocols including catheter
selection, insertion venue, hair management, skin pre-
paration, dressing type and maintenance, drain replace-
ment, and frequency of CSF sampling. Although trends
do exist in EVD insertion and maintenance, these
trends are generally the result of hospital-based quality
initiatives. Randomized controlled studies in EVD
insertion and maintenance are rarely conducted because
of relatively low rates of EVD insertions in hospitals,
thereby limiting the reporting of scientific evidence.
A variety of different types of catheters are used,
but the use of an antibiotic-impregnated catheter, if
available, is recommended because this has been shown
to be associated with decreased rates of infection (Flint
et al., 2013; Honda et al., 2010; Kubilay et al., 2013;
Mikhaylov et al., 2014; Sonabend et al., 2011). In fact,
a cost-consequence cumulative analysis of trials com-
paring antibiotic-impregnated and regular catheters
showed that, in 100 patients with EVDs, use of antibiotic-
impregnated catheters may be associated with 2.7 fewer
deaths, 82 fewer hospital days because of infection, and
an estimated savings of $264,069 (Edwards, Engelhart,
Casamento, & McGirt, 2015). In the absence of an
antibiotic-coated catheter, continuation of intravenous
prophylactic antibiotics is recommended, and this prac-
tice might also be beneficial with an antibiotic-coated
catheter (Camacho et al., 2013; Chatzi et al., 2014;
Sonabend et al., 2011).
Whereas some of the protocols indicated that
placement only occurred in the operating room, others
included reference to placement in the intensive care
unit or the emergency room. As long as aseptic technique
and a stepwise protocol are employed and personnel in
the procedural suite are limited to only necessary indi-
viduals, there is no evidence that infection rate is related
to venue of placement (Lozier et al., 2002).
Hair clipping is preferred over shaving in most of
the protocols and articles reviewed, but the amount
of hair clipped varies among protocols, and it is not
clear what quantity of hair removal is ideal (Camacho
et al., 2013; Flint et al., 2013; Korinek et al., 2005;
 TABLE 1. Review of Hospital Protocols on External Ventricular Drain Maintenance
Dressing Cerebrospinal Fluid Equipment Changes
Frequency of Frequency of Personnel Allowed Drain
Protocol Type Dressing Changes Bag Changes Sampling Port Sampling Frequency to Sample Tubing Changes Replacement
1 Biopatch Once a week or 1/2 full j j j j j
as needed
2 Bio occlusive Only as needed Full Below burette Mon/Wed/Fri RN j No routine exchanges
3 j j j Proximal q24hrs for fever/ NP/PA/MD j Exchange the drain
follow-up for known only if it stops working
infection/pre-VPS
4 Tegaderm and 24 hours 3/4 full j q24hrs for known Healthcare q24hrs until Exchange the drain
steristrips postprocedure, infection/antibiotic professional with cultures are only if the catheter
then weekly or levels/fever, before competency negative, then is disconnected
as needed shunt placement every 2 weeks or damaged
5 Dermabond or j 3/4 full or j j RN Only if break j
bacitracin every 7 days in system
6 j j 3/4 full Distal Daily RN j Exchange the drain
only if the catheter
is disconnected
or damaged
7 Sterile head j j Proximal/distal j RN (distal), j j
dressing (per MD) neurosurgeon
Volume 48

(proximal)
&

8 j As needed j Distal Daily Two RNs Every 7 days j

9 Sterile head Daily Either every CSF bag is sent Every other day Title not specified, If vent filter is wet j
dressing other day for but two people
CSF sampling required
Number 1

or when full
&

10 j As needed Full j j j j j

Note. RN = registered nurse; NP = nurse practitioner; PA = physician assistant; MD = medical doctor; CSF = cerebrospinal fluid.
February 2016

Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
57
58 Journal of Neuroscience Nursing
TABLE 2. Reduction of Ventriculostomy-Related Infections After Implementation of a Protocol
Study, Year; Country
Camacho et al., 2013; Brazil
Chatzi et al., 2014; Greece
Dasic, Hanna, Bojanic, & Kerr,
2006; United Kingdom
Flint et al., 2013; United States
Hill et al., 2012; United States
Honda et al., 2010; France
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Infection Rate Infection Rate
Interventions Preintervention Postintervention
The protocol defined appropriate EVD care 9.5% 4.8%
(hand hygiene before/after handling the EVD,
use of clippers for whole scalp hair removal
before insertion) and implemented educational
interventions for neurosurgery residents,
neurosurgeons, and nursing staff in the intensive
care unit (training sessions, handouts, posters).
This institution created a bundle of 28% 10.5%
EVD-associated ventriculitis reduction measures,
which included reeducation of personnel on
issues of infection control related to EVDs,
meticulous EVD handling, CSF sampling only
when clinically necessary, and routine replacement
of the drainage catheter on the seventh drainage
day if the catheter was still necessary.
This institution introduced an evidence-based 27% 12%
protocol for EVD insertion and management,
which included insertion taking place in
operating room only, the use of prophylactic
antibiotics, tunneling of the catheter at least
10 cm, avoidance of daily sampling unless
clinically indicated, and avoidance of routine
catheter changes at 5 days, unless
clinically indicated.
These authors generated formal EVD infection 9.8% 0.8%
control policies and procedures that established
strict standards for placement and manipulation
of EVDs (use of an antibiotic-impregnated catheter,
broad clipping of hair, chlorhexidine skin
preparation before draping, tunneled catheter
that is secured in a question-mark pattern using
surgical staples, chlorhexidine-eluting patch
applied over catheter exit site) and education
on the protocol through face-to-face meetings
and web-based multimedia.
As part of a multidisciplinary review, guidelines 16 per 1000 0 in 25 months
were generated regarding the insertion and catheter daysa
maintenance of EVDs (sterile EVD dressing
change as needed by RNs, dressing caddies
with laminated cards outlining the dressing
change process, check-off list, accurate
documentation of procedures, and weekly
infection control rounds by the educator and
infection prevention practitioner to ensure that
EVD dressings are sterile and occlusive).
This hospital introduced three interventions: (a) 3.56 per 1000 0.87 per 1000
a requirement for all personnel in the procedure catheter daysa catheter days
room to wear a mask and a cap, (b) a standardized
dressing protocol (use of sterile gauze dressing
with adhesive tape to cover the catheter site,
changing of the intraventricular catheter site
dressing every 48 hours by nurses who received
standard training, and documentation of the
date and time of gauze-dressing change), and
(c) use of an antibiotic-impregnated EVD.
(continues)
 Volume 48 & Number 1 & February 2016 59

TABLE 2. Reduction of Ventriculostomy-Related Infections After Implementation of a

Protocol, Continued
Study, Year; Country
Korinek et al., 2005; United States
Kubilay et al., 2013; United States
Leverstein-van Hall et al., 2010;
Netherlands
Lwin, Low, Choy, Yeo, & Chou,
2012; Singapore
Infection Rate Infection Rate
Interventions Preintervention Postintervention
These authors created a written protocol 9.9% 4.6%
for EVD insertion (hair clipping, tunneled
catheter), nursing (sterile dressing covering
the entire head, routine CSF cultures not
performed), and surveillance (file
documenting dates of dressing changes,
forbidden manipulations, CSF samplings,
EVD bag emptying, daily maximal
temperature, cause of EVD removal,
result of catheter culture, and presence
of a CSF leak).
This institution developed an insertion 9.2% 0.46%
bundle that included training of staff, strict
hygienic measures, full surgical draping,
use of prophylactic antibiotics, feedback
of infection rates to the care team, and use
of an antimicrobial-impregnated catheter.
These authors introduced an intervention 37% 9%
strategy based on five pillars: increased
awareness (surveillance and educational
programs), focused standard operating
procedures (insertion and handling of the
EVDs), a diagnostic and therapeutic
algorithm for patients with clinical
suspicion of drain-related meningitis,
timely administration of prophylaxis, and
improvement of the drainage system
(compared with the previous system, the
number of sampling sites was reduced
from five to four, and a Luer Lock injection
site was provided with the system).
The following measures to reduce EVD 6.1% 0%
infection rate were introduced: proper
surgical techniques, minimization of the
number of catheterization days, CSF
sampling only in the setting of clinical
suspicion of an infection, development
of standard operating procedures on
nursing management of EVDs,
conduction of EVD care workshops and
competency skill checks for nurses,
and use of silver-coated EVDs.

Note. EVD = external ventricular drain; CSF = cerebrospinal fluid.

a
Percentages of patients with infection were not documented; rates of infection were recorded per 1000 catheter days.

Kubilay et al., 2013). Skin is prepped with a variety
of agents including chlorhexidine, povidone iodine,
isopropyl alcohol, and alcoholic chlorhexidine
(American Association of Neuroscience Nurses [AANN],
2011; Camacho et al., 2013; Flint et al., 2013;
Kubilay et al., 2013). Historically, protocols avoided
use of chlorhexidine, based on a concern that chlor-
hexidine could cause neurotoxicity. However, it was
recently reported that there are no additional risks
of neurotoxicity associated with use of chlorhexidine
and that it is both effective and safe and therefore
is considered to be the preferred agent for skin
disinfection (Checketts, 2012).
The type of dressing used and the frequency of
dressing changes are variable. The use of an occlusive
dressing with a Biopatch disc at the insertion site and

Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
60 Journal of Neuroscience Nursing
TABLE 3. Summary of Reported Recommendations for EVD Insertion Practices
Category Recommendation
Aseptic technique h Physicians should use maximal barrier
precautions including sterile gloves, sterile
gown, cap, and mask.
h The patient’ s head and body should be
covered with a full sterile drape.
h All personnel in the procedure room are
required to wear a mask and a cap.
h The number of personnel in the procedure
room should be limited to necessary
personnel.
Antibiotic prophylaxis h A single dose of antibiotic (e.g., cefazolin)
preinsertion should be given 15Y45 minutes before
incision.
Hair removal h Hair is removed from the whole scalp
before catheter insertion.
h Hair is clipped broadly using coarse and
fine clippers to allow sufficient room to
place a medium-sized adherent
transparent dressing.
Skin preparation h Skin is prepped with chlorhexidine before
draping and then again after draping.
h Skin is prepped with iodine povacrylex and
isopropyl alcohol.
h Skin is prepped with chlorhexidine soap
(2%) followed by alcoholic chlorhexidine (0.5%).
EVD catheter h An antibiotic-impregnated ventricular catheter
is used.
h A silver catheter is used.
h Neither antibiotic nor silver catheters are used.
h The EVD catheter is tunneled.
h The catheter should be secured in a
question-mark pattern using surgical staples.
Dressing h A sterile dressing is applied to the insertion site
once the catheter is in place. The dressing
must remain occlusive and dry at all times. The
dressing should cover only the insertion site.
h Apply benzoin tincture to skin and allow it to
fully dry and then apply a chlorhexidine-eluting
patch over the catheter exit site and a
medium-sized adherent transparent dressing
film. Secure the borders of the dressing film
with sterile adhesive strips.
Insertion checklist h A checklist was generated for central-line
insertion (based on CDC recommendations)
and then modified for EVD insertions. The
checklist was completed by an RN.
Note. EVD = external ventricular drain; RN = registered nurse; CDC = Centers for Disease Control and Prevention.
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Reference
Camacho et al., 2013; Flint et al., 2013;
Richardson, Forsyth, Todd, Grady, & Brown,
2012; Saskatoon Health Region Hospital
Nursing Practice Committee, 2012
Honda et al., 2010; Kubilay et al., 2013
Jefferson Hospital, 2006, 2013a, 2013b
St. Joseph Health, 2010
Chatzi et al., 2014; Flint et al., 2013;
Korinek et al., 2005; Kubilay et al., 2013,
Leverstein-van Hall et al., 2010
Camacho et al., 2013; Korinek et al.,
2005; Leverstein-van Hall et al., 2010;
Lwin et al., 2012
Flint et al., 2013; Jefferson Hospital, 2006,
2013a, 2013b; Kubilay et al., 2013
Flint et al., 2013; O’ Connor, 2012;
Saskatoon Health Region Hospital Nursing
Practice Committee, 2012
Kubilay et al., 2013
Camacho et al., 2013; West Virginia
University Nursing Service, 2013
Flint et al., 2013; Honda et al., 2010;
Kubilay et al., 2013
Lwin et al., 2012
Chatzi et al., 2014
Dasic et al., 2006; Flint et al., 2013;
Korinek et al., 2005
Flint et al., 2013
Hill et al., 2012; Honda et al., 2010;
Jefferson Hospital, 2006, 2013a, 2013b
Flint et al., 2013
Hill et al., 2012; Kubilay et al., 2013
 Volume 48 & Number 1 & February 2016 61

TABLE 4. Summary of Reported Recommendations for EVD Maintenance Practices

EVD manipulation h Aseptic technique must be used when handling the Camacho et al., 2013
EVD system.
h The minimal touch principle should be employed Leverstein-van Hall et al., 2010
because each manipulation risks contamination.
Antibiotic prophylaxis h Administer antibiotics every 8 hours. Camacho et al., 2013
postinsertion
h Antibiotics should be administered 6Y8 hours after Chatzi et al., 2014
insertion but not continuously during the drainage period.
CSF sampling h CSF samples should only be obtained when there is Camacho et al., 2013; Chatzi
suspicion of CSF infection (fever of unknown origin, et al., 2014; Dasic et al., 2006;
nuchal rigidity, headache, mental status changes, Ellis, 2013; Korinek et al., 2005;
cranial nerve signs, and/or peripheral leukocytosis Leverstein-van Hall et al., 2010
not related to other infections).
h CSF draws and flushes should be performed with strict Flint et al., 2013
sterile technique.
h Only the neurosurgeon or APN may obtain CSF specimens. Hill et al., 2012
Dressing change h Routine dressing changes should not be performed. Flint et al., 2013; Hill et al.,
Dressings should only be changed if they are 2012
compromised. Sterile dressing change should be
performed by RNs. Dressing caddies with laminated
cards outlining the dressing change process are helpful.
h Catheter dressing changes should be performed Honda et al., 2010
every 48 hours.
h Daily dressing changes that include cleansing of the Bayside Health, 2006;
surgical incisions with saline solution, applying alcoholic Camacho et al., 2013
chlorhexidine (0.5%), covering with dry sterile gauze,
and wrapping of the head should be performed by
neurosurgery residents.
EVD exchange h It is still controversial whether EVD exchanges could Honda et al., 2010
lead to a decrease in CSF infection rates.
Educational programs h Education on the protocol should be provided for Camacho et al., 2013;
neurosurgery residents and neuro-ICU nurses through Flint et al., 2013
face-to-face meetings (classes with an open session for
questions and answers), handouts,
Web-based multimedia, posters, and rounds.
h EVD care workshops and competency skill checks Lwin et al., 2012
for nurses improve EVD awareness.
Surveillance h Weekly infection control rounds by the educator and Hill et al., 2012
infection prevention practitioner improve rates of infection.
h Currently, data on EVD infections are not collected or Alabama Children’s Hospital,
reported. However, the National Healthcare Safety 2011; Brigham and Women’s
Network has set the reporting standard of other devices Hospital, 2013; Camacho et al.,
(central line, ventilator, and Foley catheter) to be infections 2013; Flint et al., 2013;
per 1000 device days. Although, historically, EVD Honda et al., 2010
infections were reported as the number of infections per
100 inserted devices, this is beginning to change. This
system of tracking the days of exposure instead of the
total EVDs placed allows for increased accuracy and
analysis of infection rates. EVD catheter days are
calculated by tracking the number of patients with an EVD
on a daily basis. The daily totals are added together at
the end of the month to determine the monthly EVD days.

Note. EVD = external ventricular drain; CSF = cerebrospinal fluid; RN = registered nurse; APN = advanced practice nurse; CDC = Centers for
Disease Control and Prevention; ICU = intensive care unit.

Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
62 Journal of Neuroscience Nursing
of sterile adhesive strips to secure the dressing in place
is recommended (Flint et al., 2013; Hill et al., 2012).
Dressing changes should only be performed by trained
competent personnel and should only occur weekly or
if the dressing is dislodged to minimize direct contact
with the EVD insertion site (Flint et al., 2013; Hill
et al., 2012). Of note, a comparison of infection rates
in patients with semiocclusive adhesive dressings that
were changed every 48 hours and those with one-
time applications of 2-octyl cyanoacrylate dressings
(Dermabond, Ethicon, Inc.) showed a decrease in the
rate of ventriculitis in those with 2-octyl cyanoacry-
late dressings (Bookland, Sukul, & Connolly, 2014).
Further evaluation comparing use of occlusive dress-
ings with Biopatch discs and sterile adhesive strips with
weekly dressing changes with a single application of
2-octyl cyanoacrylate dressings is warranted.
Frequency of equipment changes is variable. It is
recommended to minimize contact with the catheter,
tubing, and CSF collection bag because manipulation
of the system may increase risk of infection (AANN,
2011; Beer et al., 2008; Lozier et al., 2002). Tubing
should be clearly labeled to prevent confusion with
intravenous tubing and inadvertent administration of
medications intrathecally (McConnell & Macneil, 2011).
It remains controversial whether prophylactic catheter
exchanges could lead to a decrease in rates of infection
(Honda et al., 2010), but none of the protocols re-
viewed recommended routine exchanges. However, it
is ideal to remove catheters as quickly as possible given
that prolonged catheterization has been associated
with increased risk of infection (Holloway et al., 1996;
Lozier et al., 2002). A large multicenter trial would be
required to assess the benefit of routine catheter ex-
change, and when such a trial was conducted to evalu-
ate the benefit of prophylactic central-line catheter
exchange, there was no reduction in infection rate
noted, and there was an increase in iatrogenic com-
plications (Cobb et al., 1992; Lozier et al., 2002; Lyke
et al., 2001).
The frequency of CSF sampling varies from
scheduled collection daily (Bota, Lefranc, Vilallobos,
Brimioulle, & Vincent, 2005; Kitchen et al., 2011;
Schade et al., 2006); three times per week (Hoefnagel,
Dammers, Ter Laak-Poort, & Avezaat, 2008; Williams,
Leslie, Dobb, Roberts, & van Heerden, 2011); or
collection only when needed for evaluation of fever,
leukocytosis, headache, nuchal rigidity, or decline in
neurologic status (Camacho et al., 2013; Chatzi et al.,
2014; Dasic et al., 2006; Flint et al., 2013; Korinek
et al., 2005; Leverstein-van Hall et al., 2010). To
decrease risk of infection, sampling should only be
performed on an as-needed basis. It is recommended
that CSF be sampled from the distal port, because this
has been shown to accurately diagnose infections and
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
to minimize risk of infection (Wong, 2011). Recom-
mendations for EVD insertion and maintenance are
summarized in Figure 1.
Although specific practices vary at different institu-
tions, a few factors consistently correlate with decreased
rates of infection: (a) identification of shortcomings:
To improve practice, it is necessary to be transparent
regarding practice shortcomings and determine aspects
of care that require modification (Hoefnagel et al.,
2008; Kubilay et al., 2013; Leverstein-van Hall et al.,
2010; Lwin et al., 2012). (b) Protocols: Prior tech-
niques for EVD insertion and maintenance were at the
discretion of individual physicians and nurses. The
development of a meticulous standardized protocol
for EVD insertion, maintenance, and management is
associated with reduction in frequency of infection
(AANN, 2011; Dasic et al., 2006; Flint et al., 2013;
Hill et al., 2012; Kubilay et al., 2013). (c) Compli-
ance monitoring: Given the relatively small number
of EVDs that are placed nationally and the fact that
EVD infection rates are not required reporting by in-
fection control departments to each state’ s Department
of Health with the same rigor as central-line infections
or urinary-catheter-associated infections, many hos-
pitals do not consistently track EVD infections. It is
important to have a consistent methodology for iden-
tifying infections related to EVD insertion, care, or
maintenance. Vigilant and consistent monitoring is in-
tegral to success. The creation of written policies will
not improve rates of infection if clinical practices are
not amended to reflect those policies. The use of a
checklist during EVD insertion and development of a
team to monitor EVD maintenance and management
techniques on a regular basis reinforce the need for
compliance with policies (Hill et al., 2012; Korinek
et al., 2005; Kubilay et al., 2013). (d) Multidisciplinary
effort: Because physician and nursing teamwork is es-
sential to successful reduction of rates of infection,
it is important that efforts to improve infection rates
be organized by multidisciplinary teams (Chatzi et al.,
2014; Korinek et al., 2005; Leverstein-van Hall et al.,
2010; Lwin et al., 2012). (e) Education: Frequent edu-
cation and reeducation sessions for nurses, physicians,
trainees, and physiotherapists about EVD maintenance
and infection prevention promote understanding of risk
factors for infection and compliance with protocols
(Camacho et al., 2013; Chatzi et al., 2014).
Although there are numerous published studies re-
lated to reduction of ventriculostomy-related infection,
most of these studies reflect practices at individual in-
stitutions and may not be generalizable. As such, a
multidisciplinary team synthesized the existing literature
and current practices regarding EVD insertion and main-
tenance. Additional prospective trials to further define
best practice for EVD management and maintenance are

FIGURE 1 EVD Model
warranted. To that end, the British Neurosurgical Trainee
Research Collaborative plans a comprehensive assess-
ment of EVD management and infection rates across the
United Kingdom and Ireland from November 2014
through February 2015 to define contemporary practice
patterns, identify practices associated with improved
patient outcomes, and guide further research questions
and studies (Jamjoom et al., 2014). Ventriculostomy-
related infections are associated with significant mor-
bidity, mortality, and cost. Therefore, organizational
goals should be to strive for a 0% infection rate.
Limitations
Of course, there are several limitations of this review.
The protocols included represent only 10 hospitals.
Although this number is quite small and the authors’
methods did not include a survey of institutions through
a single organization (i.e., the American Association
of Neuroscience Nursing), the protocols are from a num-
ber of different countries so the workgroup believes
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 48 & Number 1 & February 2016 63
that these are representative of a variety of different
practices around the world. In addition, the pro-
tocols discovered all had different formats, so they did
not all include the same details regarding placement
location or type of catheter employed. In terms of the
articles reviewed, they largely represented reports of
single-institution experiences. Articles published before
1999 were excluded in the interest of keeping the data
as current as possible, but there may be relevant
articles published before our cutoff. It is also possible
that there are other articles that were not discovered
in this search, but this was avoided by using multiple
different sites for the search.
Neuroscience Nursing Implications
Neuroscience nurses are routinely at the center of the
development of hospital practice protocols and are ac-
countable to ensure care is safe, excellent, and evidence
based. The recommendations identified in this manu-
script provide a toolkit for intensive care neuroscience
64 Journal of Neuroscience Nursing
nurses to develop or revise institutional EVD protocols
so that they are consistent with the latest evidence.
Identification of specific recommendations for EVD
insertion and maintenance (as shown in Figure 1) is
intended to facilitate consistent reduction of EVD
infections by offering a best practice bundle for
protocol development, which could be used in con-
junction with the recommendations produced by the
AANN (2011) and a broad review of the literature.
Recommendations for EVD insertion as a result
of this review of the literature include the following
as identified in Figure 1: (a) clipping hair around EVD,
(b) using chlorhexidine skin prep, (c) using maximal
barrier precautions, (d) minimizing the number of per-
sonnel present during procedure, (e) using only antibiotic-
coated EVD catheters, and (f) using an EVD insertion
checklist. Recommendations for EVD maintenance
and CSF sampling include (a) employing aseptic tech-
nique when handling EVD, (b) labeling EVD tubing, (c)
sampling CSF only from distal port, (d) obtaining
samples only when clinically indicated, and (e) mini-
mizing EVD manipulation and length of time catheter is
in place.
Specific recommendations for EVD dressing include
(a) use of a bio-occlusive dressing with Biopatch and
(b) changing dressing weekly or if dislodged and (c)
that EVD dressing changes should be performed only
by RNs or MDs who have had their competency in
dressing change validated. Recommended staff edu-
cation and surveillance include (a) providing ongoing
education/competency assessment for staff regarding
EVD care, (b) performing infection control rounds
for EVD maintenance, and (c) monitoring the rates
of infection.
Our interdisciplinary team has implemented the
aforementioned recommendations for EVD insertion
and maintenance practices into an approved hospital
policy and procedure, using the model developed be-
cause of this review, and is currently collecting 1 year
of data using this policy (to be published) to provide
evidenced-based support for the development of an
integrated new gold standard for EVD insertion, care,
and maintenance that can serve as a foundation for fu-
ture research in the prevention of EVD-related infections.
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