Introduction: Hourly nursing neurologic assessments for traumatic brain injury (TBI) in the critical care setting are common practice but prolonged use may actually be harming through sleep deprivation. We reviewed practice patterns at our institution in order to gain insight into the role of frequent neurological assessments.
Methods: A 6-month retrospective review was performed for patients who were admitted to an ICU with the diagnosis of TBI. Electronic medical records and brain imaging were reviewed. Variables collected included but were not limited to: patient demographics, frequency of nursing neurologic evaluations, GCS, length of stay, and disposition.
Results: A total of 124 patients were identified, 71% male with the average age of 52 years (range 19-96). TBI was classified as severe (GCS 3-8) in 44, moderate (GCS 9-12) in 18, and mild (GCS 13-15) in 62 patients. 73 (58%) underwent hourly nursing assessments for an average of 2.8 days. The median length of stay for all patients was 7 days (range 0-109). Time to advancement from hourly checks was significantly longer for the severe TBI group (54 vs 103 hours, p = 0.006). Twenty patients remained hourly for greater than 7 days. Two of these went home, 10 to rehab, 4 to SNF, and 4 died.
There were 20 patients (16%) who underwent a surgical procedure (not including ICP monitor) and had a mortality rate of 30%. The average time to surgery was 27 hours (range 0-325). There were only 2 patients who underwent surgery after 48 hours, both for chronic subdural hematomas.
Conclusions: Hourly neurologic checks are necessary in the hyperacute period for patients with potentially expansile intracranial hemorrhages or malignant cerebral edema but prolonged use may be harmful. Patients with a low probability of requiring neurosurgical intervention may benefit from reducing the total duration of hourly assessments.
Patient Care: Potentially prevent harm secondary to sleep deprivation for TBI in the ICU
Learning Objectives: By the conclusion of this session, participants should gain further insight into the use and potential dangers of prolonged hourly neurological assessements.