Accuracy and Safety of External Ventricular Drain Placement by Physician Assistants and Nurse Practitioners in Aneurysmal Acute Subarachnoid Hemorrhage

Alejandro Enriquez-Marulanda, Luis C. Ascanio, Mohamed M. Salem, Georgios A. Maragkos, Ray Jhun, Abdulrahman Y. Alturki, Justin M. Moore, Christopher S. Ogilvy, Ajith J. Thomas

Research output: Contribution to journalArticlepeer-review

18 Scopus citations


Background: In the current dynamic health environment, increasing number of procedures are being completed by advanced practitioners (nurse practitioners and physician assistants). This is the first study to assess the clinical outcomes and safety of external ventricular drain (EVD) placements by specially trained advanced practitioners. Objective: Compare the safety and outcomes of EVD placement by advanced practitioners in patients with subarachnoid hemorrhage (SAH). Methods: A cohort comparison study was performed from an aneurysmal SAH database selecting patients treated with EVD from a single major academic institution in the USA between June 2007 and June 2017. Safety, accuracy, and complications of EVD placement were compared between advanced practitioners and neurosurgical physicians (attending neurosurgeon and subspecialty clinical fellow). Statistical analysis was performed using the Mann–Whitney test for continuous variables and χ2 test for categorical variables, with p values set at < 0.05 for significance. Results: We identified 203 patients for this cohort with 238 EVD placements; eighty-seven (36.6%) placements were performed by advanced practitioners and 151 (63.4%) by neurosurgeons. Most of the ventriculostomies were placed in the emergency room (n = 114; 47.9%). Additional procedures performed concurrently with the EVD placements were significantly higher among the physicians’ group (21.8 vs. 4.6%; p < 0.001). Bedside placement and usage of Ghajar guide were significantly higher among advanced practitioner’s (58.3 vs. 98.9 and 9.9 vs. 64.4%, respectively, with a p < 0.001 for both). There were, however, no significant differences in terms of the number of attempts for insertion, intraprocedural complications, tract hemorrhages, accuracy, infection rates, catheter dislodgments, and need for repositioning/replacement of EVD. Conclusion: After appropriate training, EVD placement can be safely performed by advanced practitioners with an adequate accuracy of placement.

Original languageEnglish
Pages (from-to)435-442
Number of pages8
JournalNeurocritical Care
Issue number3
StatePublished - 1 Dec 2018
Externally publishedYes


  • Advanced practitioners
  • External ventricular drain
  • Mid-levels
  • Nurse practitioners
  • Operative complications
  • Physician assistants
  • Subarachnoid hemorrhage
  • Ventriculostomy


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