A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures. Because of the pressure on her brain, the patient had symptoms including mood changes, headaches, and appetite changes. Following the procedure, she was admitted to the intensive care unit (ICU) for monitoring under the care of the ICU team and neurosurgery team. She made progress with recovery as expected and participated in physical therapy. On day 5 of her hospitalization, the physical therapist administered vigorous therapy (as prescribed) with the patient out of bed. The therapist returned the patient to bed at the end of the therapy session. While resting in bed after the session, the patient complained of headaches, decreased appetite, and worsening visual problems. Since the complaints were similar to the patient's symptoms on admission, which should have been addressed by the lumbar drain, the nurse attributed the patient's complaints to depression and took no action, allowing the patient to sleep and keeping unchanged the prescribed frequency of neuro checks every 6 hours while awake.
Early in the morning, the patient was found to be barely arousable. The nurse and the team then discovered that lumbar drain had dislodged and was now on the floor. A stat CT scan was ordered, which revealed extensive hydrocephalus. An external ventricular drain was placed emergently at the bedside after securing the patient's airway. Eventually the patient had a new lumbar drain placement, with improvement of her mental status and other complaints. She was ultimately extubated and discharged to home.
The management of patients with acute neurologic disorders frequently includes the placement of an external ventricular drain (EVD) or lumbar drain for intracranial pressure management. Although most clinical practice guidelines focus on the prevention of infection, malposition, and hemorrhage (8,9), the American Association of Neuroscience Nurses (AANN) has developed guidelines for the interdisciplinary care of patients after EVD or lumbar drain placement.(10) The AANN guidelines recommend an hourly assessment of neurologic function in the ICU and inspection of the drain insertion site every 1–2 hours to identify changes that may be related to the integrity of the lumbar drain.(10) Many institutions have developed protocols requiring an hourly assessment of neurologic function in the ICU and routine inspection of the lumbar drain insertion site, especially after physical therapy and mobilization. In this case, a neurologic assessment was performed every 6 hours only while the patient was awake, and it is unknown if the drain insertion site was routinely inspected. Implementing best practices such as those recommended by the AANN may reduce adverse events associated with lumbar drain insertion and mobilization of patients with a lumbar drain.
Early mobility programs have been shown to reduce adverse events associated with critical illness. Criteria for participation in early mobilization in the intensive care unit should be established to ensure safety and reduce adverse events.
Clinical practice guidelines have been developed to improve management of patients with an external ventricular drain or lumbar drain. These guidelines call for frequent monitoring of neurologic function and inspection of the drainage system, particularly in the setting of early patient mobilization.
Ineffective communication is common in health care and places patients at risk. Effective interdisciplinary communication may reduce adverse events resulting from the mobilization of patients with an external ventricular drain or lumbar drain in the intensive care unit.
Cognitive biases such as anchoring can result in medical errors. Health care providers may benefit from cognitive awareness training and increased interdisciplinary communication to reduce medical errors that may result from cognitive biases.