Avaliação do impacto da implantação de rotina de cuidados com cateter de drenagem ventricular externa em uma unidade de terapia intensiva neurológica / Evaluation of the impact of implantation of a routine of care of the external ventricular drainage catheter in a neurological intensive care unit

Eduardo Fernandes Camacho

Introduction: an external ventricular drain (EVD) involves the placement of a catheter into the cerebral ventricular space in order to drain excessive cerebrospinal fluid (CSF). The most common complications of this practice include hemorrhage at the insertion site, obstruction of the catheter, disconnection of the system, and infection with indicator values that vary from 1% to more than 27%. Objective: to analyze the indicators of EVD-related infection and assess the impact of intervention on the routine of care of the EVD catheter. Cases and Method: the quasi-experimental study was carried out at the Neurological Intensive Care Unit of the Central Institute at the Clinics Hospital of the University of São Paulo School of Medicine. Data regarding infection from patients submitted to EVD were analyzed in two phases: pre-intervention, which occurred from April 2007 to July 2008, and intervention, which occurred from August 2008 to July 2010. During the first stage, observations were made as to the care given to the EVD and a questionnaire was applied to evaluate the level of knowledge of the healthcare professionals. During the second stage, training was given as to a routine of care, hand hygiene, and biosafety, with intervals of five, six, and seven months; one year after the intervention, observation of hand hygiene was performed. Excluded were all patients presenting with cranioencephalic trauma with exposed fractures, presence of CSF leakage, congenital hydrocephalus, and presence of active infection of the central nervous system. Patients were followed for 30 days after EVD removal and EVDrelated infections were considered those caused by agents microbiologically identified in the CSF according to CDC criteria. We conducted five observations of the care taken with the EVD, one observation of hand hygiene, one preparation of a routine of care, three training sessions with expository classes, and one intervention to reduce the time the EVD catheter remained in place, with a total of five interventions. Results: during the study, 178 patients were submitted to 194 procedures, corresponding to 1217 catheters-day. The mean age of the patients was 48 years, and 62.4% of them were females. Global mortality among the patients was 34.8%. Prophylaxis with antibiotics was given in 80.4% of the procedures. Gramnegative agents were identified in 71.4% of the cases during the preintervention period, and 60% during the intervention period. Gram-positive agents were identified in 14.3% of the cases during the pre-intervention period, and 20% during the intervention period, and 14.3% of them were polymicrobial infection in the pre-intervention period, and 20% during the intervention period. The values of EVD-related infection indicators during the study fell from 9.5% to 4.8% per patient (a 50.5% reduction), from 8.8% to 4.4% per procedure (a 50% reduction), and the density of incidence dropped from 14.0 to 6.9 infections per 1,000 catheters-day (a 49.2% reduction) (p=0.027). After the fourth intervention, no microbiologically confirmed infection was identified throughout twelve consecutive months. Conclusion: we observed a sustained reduction in EVD-related infection and in light of these results, continued educational intervention proved to be a useful tool in reducing these indicators.

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