British Journal of Neurosurgery, February 2015; 29(1): 9–10 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.957162
COMMENTARY
External ventricular drainage: Is it time to look at national practice? Aimun A. B. Jamjoom1, Angelos G. Kolias2, Malik Zaben3, Aswin Chari2, John Kitchen4, Alexis Joannides2, Paul M. Brennan1, Jothy Kandasamy1, Silvia Gatscher5, William P. Gray3, Michael D. Jenkinson4, Diederik O. Bulters6, Conor L. Mallucci7, Helmut Schuster8, Peter J. Hutchinson2 & Aminul I. Ahmed6; UK Neurosurgical Research Network & British Neurosurgical Trainee Research Collaborative
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1Division of Neurosurgery, Department of Clinical Neurosciences, Western General Hospital & University of Edinburgh,
Edinburgh, UK, 2Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital & University of Cambridge, Cambridge, UK, 3Institute of Psychological Medicine and Clinical Neurosciences, National Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK, 4Department of Neurosurgery, The Walton Centre, Liverpool, UK, 5Department of Neurological Surgery, The John Radcliffe Hospital, Oxford, UK, 6Wessex Neurological Centre, University Hospital Southampton & University of Southampton, Southampton, UK, 7Department of Paediatric Neurosurgery, Alder Hey Children’s Hospital, Liverpool, UK and 8Department of Microbiology, University Hospital Southampton, Southampton, UK
We propose to build upon this experience and infrastructure to undertake a prospective, multi-centre audit of EVD management in the UK and Ireland. The proposed audit has the following objectives:
External ventricular drainage (EVD) is one of the commonest neurosurgical procedures with more than 2500 EVDs inserted in England from April 2012 to March 2013.1 Though invariably life-saving, each EVD placement has a risk of an EVD-related infection (ERI). ERIs can result in mortality, commit patients to extended courses of antibiotics, increase the likelihood of permanent CSF diversion and increase the length of hospital stay with its associated costs. Various strategies have been employed in attempts to minimize ERIs. They include technical modifications such as extended tunnelling lengths, strict sampling protocols, and both systemic and local prophylactic antibiotics. Local antimicrobial delivery has been facilitated by impregnated EVD catheters; both antibiotic- and silver-impregnated EVDs have shown efficacy compared to the standard catheters in randomized controlled trials.2 However, despite these innovations, there has not been a comprehensive assessment of EVD management and infection rates across the UK; the majority of studies investigating ERIs have concentrated on either a single unit’s experience or the pooled results of a handful of neurosurgical units. This limits the generalizability of the results and does not provide information on national variation. The British Neurosurgical Trainee Research Collaborative (BNTRC) is a trainee-led surgical research network set-up to overcome such limitations through nationwide audit and research. The BNTRC’s first national audit, of chronic subdural haematoma management, collected data on more than 1200 patients, making it the largest prospective multi-centre cohort of such patients in the literature, and demonstrated the network’s grass-roots effectiveness.
1.
2. 3.
To establish the demography, contemporary practice patterns and complications (including rate of infections) of EVDs across the UK and Ireland. To identify practices that may be associated with improved outcomes. To guide future research questions and studies.
The audit will be run under the auspices of the BNTRC, the UK Shunt Registry, the Reduction of Shunt- and EVD-related infections collaborative group and the UK Neurosurgical Research Network. The audit will be part of the National Neurosurgical Audit Programme of the Society of British Neurological Surgeons (SBNS). A Steering Committee, which will include representatives from the above groups and other relevant non-corporate stakeholders, will have the overall responsibility for overseeing the strategic direction and running of the audit. All neurosurgical units within the UK and Ireland are eligible to participate. Each unit will have a trainee and consultant co-principal investigator to lead the audit in their own unit. They will be asked to register the audit in accordance with their local clinical governance policies. The audit will aim to include all patients of any age who have had an EVD inserted within the participating neurosurgical units in the UK and Ireland during the study period. ERIs will be defined in one of two possible
Correspondence: Aimun A. B. Jamjoom, Department of Clinical Neurosciences, Division of Neurosurgery, Western General Hospital & University of Edinburgh, Crewe Road South, Edinburgh, EH4 2XU UK. E-mail: [email protected] Received for publication 8 August 2014; accepted 14 August 2014
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Table I. Audit primary and secondary outcome measures. Primary outcome measures
Br J Neurosurg Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
1. Confirmed EVD-related Infection: Gram-positive and/ or culture-positive CSF sample that is not deemed to be a contaminant by the managing team and prompts antibiotic therapy and/or catheter removal 2. Suspected EVD-related infection: clinical suspicion of meningitis (clinical signs, serum inflammatory markers and CSF pleocytosis) that prompts antibiotic therapy and/ or catheter removal but is CSF culture- and Gram negative
categories: ‘confirmed’ ERI will be defined as a Grampositive or culture-positive CSF sample that is not deemed a contaminant by the managing team and prompts antibiotic therapy and/or catheter removal. ‘Suspected’ infection will be allocated when the managing team has a clinical suspicion of meningitis (clinical signs, serum inflammatory markers and CSF pleocytosis) that prompts the use of antibiotics and/or catheter removal but CSF is culture- and Gram negative. The final infection rate will be a combination of both the confirmed and the suspected cases. The audit aims to follow up patients for infection up to 30 days from EVD insertion. The secondary outcome measures of the audit will be Glasgow Coma Scale Score on discharge or at 30 days, duration of stay in neurosurgical unit, patient mortality up to 30 days, modified Rankin Score at 30 days and need for permanent CSF diversion up to 90 days (Table I).
Secondary outcome measures 1. Glasgow Coma Scale Score (at 30 days or on discharge if sooner) 2. Time to discharge (duration of neurosurgical stay) 3. Patient mortality (up to 30 days) 4. Modified Rankin Score (at 30 days or on discharge if sooner) 5. Need for permanent CSF diversion (up to 90 days)
If you are interested to lead the audit in your own unit, please contact Aimun Jamjoom ([email protected]) or Aminul Ahmed ([email protected]). The full audit protocol can be accessed through the BNTRC website (www. bntrc.org.uk). Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Hospital Episode Statistics, Admitted Patient Care, England 2012–13. The Health and Social Care Information Centre. Available from http://www.hscic.gov.uk/home [accessed 29 July 2014]. 2. Wang X, Dong Y, Qi XQ, et al. Efficacy of antimicrobial-impregnated catheters in external ventricular drainage – a systematic review and meta-analysis. Crit Care 2013;17:234.
COMMENTARY
External ventricular drainage: Is it time to look at national practice? Aimun A. B. Jamjoom1, Angelos G. Kolias2, Malik Zaben3, Aswin Chari2, John Kitchen4, Alexis Joannides2, Paul M. Brennan1, Jothy Kandasamy1, Silvia Gatscher5, William P. Gray3, Michael D. Jenkinson4, Diederik O. Bulters6, Conor L. Mallucci7, Helmut Schuster8, Peter J. Hutchinson2 & Aminul I. Ahmed6; UK Neurosurgical Research Network & British Neurosurgical Trainee Research Collaborative
Br J Neurosurg Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
1Division of Neurosurgery, Department of Clinical Neurosciences, Western General Hospital & University of Edinburgh,
Edinburgh, UK, 2Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital & University of Cambridge, Cambridge, UK, 3Institute of Psychological Medicine and Clinical Neurosciences, National Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK, 4Department of Neurosurgery, The Walton Centre, Liverpool, UK, 5Department of Neurological Surgery, The John Radcliffe Hospital, Oxford, UK, 6Wessex Neurological Centre, University Hospital Southampton & University of Southampton, Southampton, UK, 7Department of Paediatric Neurosurgery, Alder Hey Children’s Hospital, Liverpool, UK and 8Department of Microbiology, University Hospital Southampton, Southampton, UK
We propose to build upon this experience and infrastructure to undertake a prospective, multi-centre audit of EVD management in the UK and Ireland. The proposed audit has the following objectives:
External ventricular drainage (EVD) is one of the commonest neurosurgical procedures with more than 2500 EVDs inserted in England from April 2012 to March 2013.1 Though invariably life-saving, each EVD placement has a risk of an EVD-related infection (ERI). ERIs can result in mortality, commit patients to extended courses of antibiotics, increase the likelihood of permanent CSF diversion and increase the length of hospital stay with its associated costs. Various strategies have been employed in attempts to minimize ERIs. They include technical modifications such as extended tunnelling lengths, strict sampling protocols, and both systemic and local prophylactic antibiotics. Local antimicrobial delivery has been facilitated by impregnated EVD catheters; both antibiotic- and silver-impregnated EVDs have shown efficacy compared to the standard catheters in randomized controlled trials.2 However, despite these innovations, there has not been a comprehensive assessment of EVD management and infection rates across the UK; the majority of studies investigating ERIs have concentrated on either a single unit’s experience or the pooled results of a handful of neurosurgical units. This limits the generalizability of the results and does not provide information on national variation. The British Neurosurgical Trainee Research Collaborative (BNTRC) is a trainee-led surgical research network set-up to overcome such limitations through nationwide audit and research. The BNTRC’s first national audit, of chronic subdural haematoma management, collected data on more than 1200 patients, making it the largest prospective multi-centre cohort of such patients in the literature, and demonstrated the network’s grass-roots effectiveness.
1.
2. 3.
To establish the demography, contemporary practice patterns and complications (including rate of infections) of EVDs across the UK and Ireland. To identify practices that may be associated with improved outcomes. To guide future research questions and studies.
The audit will be run under the auspices of the BNTRC, the UK Shunt Registry, the Reduction of Shunt- and EVD-related infections collaborative group and the UK Neurosurgical Research Network. The audit will be part of the National Neurosurgical Audit Programme of the Society of British Neurological Surgeons (SBNS). A Steering Committee, which will include representatives from the above groups and other relevant non-corporate stakeholders, will have the overall responsibility for overseeing the strategic direction and running of the audit. All neurosurgical units within the UK and Ireland are eligible to participate. Each unit will have a trainee and consultant co-principal investigator to lead the audit in their own unit. They will be asked to register the audit in accordance with their local clinical governance policies. The audit will aim to include all patients of any age who have had an EVD inserted within the participating neurosurgical units in the UK and Ireland during the study period. ERIs will be defined in one of two possible
Correspondence: Aimun A. B. Jamjoom, Department of Clinical Neurosciences, Division of Neurosurgery, Western General Hospital & University of Edinburgh, Crewe Road South, Edinburgh, EH4 2XU UK. E-mail: [email protected] Received for publication 8 August 2014; accepted 14 August 2014
9
10
A. A. B. Jamjoom et al.
Table I. Audit primary and secondary outcome measures. Primary outcome measures
Br J Neurosurg Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
1. Confirmed EVD-related Infection: Gram-positive and/ or culture-positive CSF sample that is not deemed to be a contaminant by the managing team and prompts antibiotic therapy and/or catheter removal 2. Suspected EVD-related infection: clinical suspicion of meningitis (clinical signs, serum inflammatory markers and CSF pleocytosis) that prompts antibiotic therapy and/ or catheter removal but is CSF culture- and Gram negative
categories: ‘confirmed’ ERI will be defined as a Grampositive or culture-positive CSF sample that is not deemed a contaminant by the managing team and prompts antibiotic therapy and/or catheter removal. ‘Suspected’ infection will be allocated when the managing team has a clinical suspicion of meningitis (clinical signs, serum inflammatory markers and CSF pleocytosis) that prompts the use of antibiotics and/or catheter removal but CSF is culture- and Gram negative. The final infection rate will be a combination of both the confirmed and the suspected cases. The audit aims to follow up patients for infection up to 30 days from EVD insertion. The secondary outcome measures of the audit will be Glasgow Coma Scale Score on discharge or at 30 days, duration of stay in neurosurgical unit, patient mortality up to 30 days, modified Rankin Score at 30 days and need for permanent CSF diversion up to 90 days (Table I).
Secondary outcome measures 1. Glasgow Coma Scale Score (at 30 days or on discharge if sooner) 2. Time to discharge (duration of neurosurgical stay) 3. Patient mortality (up to 30 days) 4. Modified Rankin Score (at 30 days or on discharge if sooner) 5. Need for permanent CSF diversion (up to 90 days)
If you are interested to lead the audit in your own unit, please contact Aimun Jamjoom ([email protected]) or Aminul Ahmed ([email protected]). The full audit protocol can be accessed through the BNTRC website (www. bntrc.org.uk). Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Hospital Episode Statistics, Admitted Patient Care, England 2012–13. The Health and Social Care Information Centre. Available from http://www.hscic.gov.uk/home [accessed 29 July 2014]. 2. Wang X, Dong Y, Qi XQ, et al. Efficacy of antimicrobial-impregnated catheters in external ventricular drainage – a systematic review and meta-analysis. Crit Care 2013;17:234.
