Neurocritical care nursing research priorities

Continuous Electroencephalographic Training for Neuroscience Intensive Care Unit Nurses: A Feasibility Study

BACKGROUND

Use of continuous electroencephalographic (cEEG) monitoring has more than doubled at our institution for the last 4 years. Although intensive care unit cEEG is reviewed remotely by board-certified epileptologists every 4 to 6 hours, there are inherent delays between occurrence, recognition, and treatment of epileptiform activity. Neuroscience intensive care unit (NSICU) nurses are uniquely positioned to monitor cEEG in real time yet do not receive formal training. The purpose of this study was to evaluate the effectiveness of an education program to teach nurses to monitor cEEG, identify a burst suppression pattern, and measure the duration of suppression.

METHODS

We performed a retrospective analysis of pretest and posttest data. All NSICU nurses (40) were invited to complete the pretest (PT-0), with 25 participating. Learning style/preference, demographics, comfort with cEEG, and knowledge of EEG fundamentals were assessed. A convenience cohort of NSICU nurses (13) were selected to undergo EEG training. Posttests evaluating EEG fundamental knowledge were completed immediately after training (PT-1), at 3 months (PT-3), and at 6 months (PT-6). The cohort also completed a burst suppression module after the training, which assessed ability to quantify the duration of suppression.

RESULTS

Mean cohort test scores significantly improved after the training (P < .001). All nurses showed improvement in test scores, and 76.9% passed PT-1 (a score of 80% or higher). Reported mean comfort level with EEG also significantly improved after the training (P = .001). There was no significant difference between mean cohort scores between PT-1, PT-3, and PT-6 (all 88.6%; P = 1.000). Mean cohort score from the bust suppression module was 73%, with test scores ranging from 31% to 93%.

CONCLUSIONS

NSICU nurses can be taught fundamentals of cEEG, to identify a burst suppression pattern, and to quantify the duration of suppression. Further research is needed to determine whether this knowledge can be translated into clinical competency and affect patient care.

Nursing research priorities based on CINAHL database: A scoping review

Aim

To analyse nursing research based on the CINAHL database to identify research priorities for nursing.

Design

A scoping literature review was conducted. The CINAHL Plus (EBSCO) Full Text was searched between 2012-2018.

Methods

Out of 1522 original publications, 91 fulfilled the inclusion criteria. The Joanna Briggs Institute critical appraisal tools were applied. Data were analysed by a thematic analysis method.

Results

A strong emphasis should be put on development and evaluation of nursing theories and, in addition, randomized controlled trial studies, meta-synthesis, experimental and intervention studies are needed in nursing research. Development of competencies and skills in the nursing profession ought to be studied more extensively and research should be focused on variety fields of nursing practice.

A National Trial on Differences in Cerebral Perfusion Pressure Values by Measurement Location

BACKGROUND

Cerebral perfusion pressure (CPP) is a key parameter in management of brain injury with suspected impaired cerebral autoregulation. CPP is calculated by subtracting intracranial pressure (ICP) from mean arterial pressure (MAP). Despite consensus on importance of CPP monitoring, substantial variations exist on anatomical reference points used to measure arterial MAP when calculating CPP. This study aimed to identify differences in CPP values based on measurement location when using phlebostatic axis (PA) or tragus (Tg) as anatomical reference points. The secondary study aim was to determine impact of differences on patient outcomes at discharge.

METHODS

This was a prospective, repeated measures, multi-site national trial. Adult ICU patients with neurological injury necessitating ICP and CPP monitoring were consecutively enrolled from seven sites. Daily MAP/ICP/CPP values were gathered with the arterial transducer at the PA, followed by the Tg as anatomical reference points.

RESULTS

A total of 136 subjects were enrolled, resulting in 324 paired observations. There were significant differences for CPP when comparing values obtained at PA and Tg reference points (p < 0.000). Differences remained significant in repeated measures model when controlling for clinical factors (mean CPP-PA = 80.77, mean CPP-Tg = 70.61, p < 0.000). When categorizing CPP as binary endpoint, 18.8% of values were identified as adequate with PA values, yet inadequate with CPP values measured at the Tg.

CONCLUSION

Findings identify numerical differences for CPP based on anatomical reference location and highlight importance of a standard reference point for both clinical practice and future trials to limit practice variations and heterogeneity of findings.

Patient and Family Engagement in the ICU. Untapped Opportunities and Underrecognized Challenges

The call for meaningful patient and family engagement in health care and research is gaining impetus. Healthcare institutions and research funding agencies increasingly encourage clinicians and researchers to work actively with patients and their families to advance clinical care and research. Engagement is increasingly mandated by healthcare organizations and is becoming a prerequisite for research funding. In this article, we review the rationale and the current state of patient and family engagement in patient care and research in the ICU. We identify opportunities to strengthen engagement in patient care by promoting greater patient and family involvement in care delivery and supporting their participation in shared decision-making. We also identify challenges related to patient willingness to engage, barriers to participation, participant risks, and participant expectations. To advance engagement, clinicians and researchers can develop the science behind engagement in the ICU context and demonstrate its impact on patient- and process-related outcomes. In addition, we provide practical guidance on how to engage, highlight features of successful engagement strategies, and identify areas for future research. At present, enormous opportunities remain to enhance engagement across the continuum of ICU care and research.

Medical Device Connectivity Challenges Outline the Technical Requirements and Standards For Promoting Big Data Research and Personalized Medicine in Neurocritical Care

Brain injuries are complicated medical problems and their management requires data from disparate sources to extract actionable information. In neurocritical care, interoperability is lacking despite the perceived benefits. Several efforts have been underway, but none have been widely adopted, underscoring the difficulty of achieving this goal. We have identified the current pain points of data collection and integration based on the experience with two large multi-site clinical studies: Transforming Research And Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) in the United States and Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) in Europe. The variability of measurements across sites remains a barrier to uniform data collection. We found a need for annotation standards and for a standardized archive format for high-resolution data. Overall, the hidden cost for successful data collection was initially underestimated.Although the use of bedside data integration solutions, such as the Moberg's Component Neuromonitoring System (Moberg Research, Inc., Ambler, PA, USA) or ICM+ software (Cambridge Enterprise, Cambridge, UK), facilitated the homogenous collection of synchronized data, there remain issues that need to be addressed by the neurocritical care community. To this end, we have organized a Working Group on Neurocritical Care Informatics, whose next step is to create an overarching informatics framework that takes advantage of the collected information to answer scientific questions and to accelerate the translation of trial results to actions benefitting military medicine.

Stakeholder Engagement in Trial Design: Survey of Visitors to Critically Ill Patients Regarding Preferences for Outcomes and Treatment Options during Weaning from Mechanical Ventilation

RATIONALE

Stakeholder engagement in research is expected to provide unique insights, make research investments more accountable and transparent, and ensure that future research is applicable to patients and family members.

OBJECTIVES

To inform the design of a trial of strategies for weaning from mechanical ventilation, we sought to identify preferences of patient visitors regarding outcome and treatment measures.

METHODS

We conducted an interviewer-administered questionnaire of visitors of critically ill patients in two family waiting rooms serving three intensive care units (ICUs) in Toronto, Canada. Respondents rated the importance of general and ventilation-related outcomes in two hypothetical scenarios (before a first spontaneous breathing trial, and after a failed spontaneous breathing trial) and selected a preferred technique for the breathing trials. With regard to the patient they were visiting, respondents identified the most important outcome to them at ICU admission, during the ICU stay, and at ICU discharge.

MEASUREMENTS AND MAIN RESULTS

We analyzed 322 questionnaires (95.5% response rate). All outcomes were highly rated (average range: 7.82-9.74). Across scenarios, outcomes rated as most important were ICU and hospital survival (9.72, 9.70), avoiding complications (9.45), quality of life (9.394), patient comfort (9.393), and returning to previous living arrangements (9.31). Overall, the most important ventilation-related outcomes were being ventilator-free (8.95), avoiding reintubation (8.905), and passing a spontaneous breathing trial (8.903). Passing a spontaneous breathing trial assumed greater importance after an initial failed attempt. "Time to event" outcomes were less important to visitors. We did not identify a preferred spontaneous breathing trial technique. Although ICU survival was the most important outcome at ICU admission and during the ICU stay, visitors rated quality of life higher than hospital survival at ICU discharge.

CONCLUSIONS

Visitors to critically ill patients prioritized two general outcomes (ICU and hospital survival) and three ventilation-related outcomes (being ventilator free, avoiding reintubation, passing a spontaneous breathing trial), and valued avoiding complications, maintaining quality of life, comfort, and returning to previous living arrangements. The outcomes preferences of the survey respondents evolved temporally during the ICU stay.

Characterizing Citizens' Preferences for Engagement in Patient Care and Research in Adult and Pediatric Intensive Care Units

RATIONALE

Engagement promotes and supports the active participation of patients and families in health care and research to strengthen their influence on decision-making. We sought to characterize how citizens wish to be engaged in care and research in the intensive care unit (ICU).

METHODS

Interviewers administered questionnaires to visitors in 3 adult ICUs and 1 pediatric ICU.

RESULTS

We surveyed 202 (adult [n = 130] and pediatric [n = 72]) visitors. Adults and pediatric visitors prioritized 3 patient care topics (family involvement in rounds, improving communication between family members and health-care providers, and information transmission between health-care practitioners during patient transfers) and 2 research topics (evaluating prevention and recovery from critical illness). Preferred engagement activities included sharing personal experiences, identifying important topics and outcomes, and finding ways to make changes that respected their needs. Both respondent groups preferred to participate by completing electronic surveys or comment cards and answering questions on a website. Few respondents (<5%) wanted to participate in committees that met regularly. Although adult and pediatric respondents identified common facilitators and barriers to participation, they ranked them differently. Although both groups perceived engagement to be highly important, adult respondents were significantly less confident that their participation would impact care (7.6 ± 2.2 vs 8.3 ± 1.8; P = .01) and research (7.3 ± 2.4 vs 8.2 ± 2.0; P = .01) and were significantly less willing to participate in care (5.6 ± 2.9 vs 6.7 ± 3.0; P = .007) and research (4.7 ± 3.0 vs ± 5.8 ± 3.0; P = .02).

CONCLUSIONS

Adult and pediatric visitors expressed comparable engagement preferences, identified similar facilitators and barriers, and rated engagement highly. Adult visitors were significantly less confident that their participation would be impactful and were significantly less willing to engage in care and research.

The Neurointensive Care Nursery and Evolving Roles for Nursing

Neonatal neurocritical care is an emerging subspecialty that combines the expertise of critical care medicine and neurology with that of nursing and other providers in an interprofessional team approach to care. Neurocritical care of the neonate has roots in adult and pediatric practice. It has been demonstrated that adults with acute neurologic conditions who are treated in a specialized neurocritical care unit have reduced morbidity and mortality, as well as decreased length of stay, lower costs, and reduced need for neurosurgical procedures. In pediatrics, neurocritical care has focused on various primary and secondary neurologic conditions complicating critical care that also contribute to mortality, morbidity, and duration of hospitalization. However, the concept of neurocritical care as a subspecialty in pediatric practice is still evolving, and evidence demonstrating improved outcomes is lacking. In the neonatal intensive care nursery, neurocritical care is also evolving as a subspecialty concept to address both supportive and preventive care and optimize neurologic outcomes for an at-risk neonatal patient population. To enhance effectiveness of this care approach, nurses must be prepared to appropriately recognize acute changes in neurologic status, implement protocols that specifically address neurologic conditions, and carefully monitor neurologic status to help prevent secondary injury. The complexity of this team approach to brain-focused care has led to the development of a specialized role: the neurocritical care nurse (neonatal intensive care nursery [NICN] nurse). This article will review key concepts related to neonatal neurocritical care and the essential role of nursing. It will also explore the emerging role of the NICN nurse in supporting early recognition and management of at-risk infants in this neonatal subspecialty practice.

Electronic Medical Record Validation: Exploring the Reliability of Intracranial Pressure Data Abstracted From the Electronic Medical Record–Pilot

Background and Purpose: Intracranial pressure (ICP) monitoring is crucial to decision making for neurologically injured patients, yet measurement of ICP varies greatly among practitioners. Methods: Unblinded, nonrandomized, observational pilot study comparing ICP values collected using pen and paper (P&P), electronic medical record (EMR), and video data with continuous data acquisition (CDA) technology. Results: ICP values did not significantly differ between EMR and P&P records, despite an average of 16 minutes difference in reporting times. ICP values varied significantly when comparing CDA data to EMR or paper. Conclusion: The results of this pilot study put in to question the validity of ICP values that are recorded in the medical record, which has implications for patient care and research.

Interdisciplinary approach to neurocritical care in the intensive care nursery

Neurocritical care is a multidisciplinary subspecialty that combines expertise in critical care medicine, neurology, and neurosurgery, and has led to improved outcomes in adults who have critical illnesses. Advances in resuscitation and critical care have led to high rates of survival among neonates with life-threatening conditions such as perinatal asphyxia, extreme prematurity, and congenital malformations. The sequelae of neurologic conditions arising in the neonatal period include lifelong disabilities such as cerebral palsy and epilepsy, as well as intellectual and behavioral disabilities. Centers of excellence have adapted the principles of neurocritical care to reflect the needs of the developing newborn brain, including early involvement of a neurologist for recognition and treatment of neurologic conditions, attention to physiology to help prevent secondary brain injury, a protocol-driven approach for common conditions like seizures and hypoxic-ischemic encephalopathy, and education of specialized teams that use brain monitoring and imaging to evaluate the effect of critical illness on brain function and development.

Priorities for Future Intensive Care Research in the UK: Results of a James Lind Alliance Priority Setting Partnership

This James Lind Alliance (JLA) Priority Setting Partnership aimed to identify and prioritise unanswered questions about adult intensive care that are important to people who have been critically ill, their families, and the health professionals who care for them. Consensus techniques (modified Delphi and Nominal Group) were used to generate suggestions using online and postal surveys. Following verification and iterative editorial review, research topics were constructed from these suggestions. These topics were presented in a second online and postal survey for rating. A Nominal Group of 21 clinicians, patients and family representatives subsequently met to rank the most important research topics and produce a prioritised list. The project was coordinated by a representative Steering Group and independently overseen by the JLA. The initial survey and review of the literature generated over 1,300 suggestions. Preliminary editing and verification permitted us to encapsulate these suggestions within 151 research topics. Iterative review by members of the Steering Group produced 37 topic statements, subsequently rated by participants. Using the mode to determine importance, 19 topics were presented to the group from which a ‘top three’ intensive care research priorities were identified and a further nine topics were prioritised. By applying and adapting the JLA methodology to focus on an area of care rather than to a single disease, we have provided a means to ensure that patients, their families and professionals materially contribute to the prioritisation of intensive care research in the UK.

Continuous cerebral spinal fluid drainage associated with complications in patients admitted with subarachnoid hemorrhage

Object

Cerebral artery vasospasm is a major cause of death and disability in patients recovering from subarachnoid hemorrhage (SAH). Although the exact cause of vasospasm is unknown, one body of research suggests that clearing blood products by CSF drainage is associated with a lower frequency and severity of vasospasm. There are multiple approaches to facilitating CSF drainage, but there is inadequate evidence to determine the best practice. The purpose of this study was to explore whether continuous or intermittent CSF drainage was superior for reducing vasospasm.

Methods

The authors performed a randomized clinical trial. Within 72 hours of admission for SAH, patients with an external ventricular drain (EVD) were randomized to undergo continuous CSF drainage with intermittent intracranial pressure (ICP) monitoring (open-EVD group) or continuous ICP monitoring with intermittent CSF drainage (monitor-ICP group).

Results

After 60 patients completed the study, an interim analysis was performed. The complication rate of 52.9% for the open-EVD group was significantly higher than the 23.1% complication rate for the monitor-ICP group (OR 3.75, 95% CI 1.21–11.66, p = 0.022). These results were reported to the Data Safety and Monitoring Board and enrollment was terminated. The odds ratio of vasospasm for the open-EVD versus monitor-ICP group was not significant (OR 0.44, 95% CI 0.13–1.45, p = 0.177).

Conclusions

Continuous CSF drainage with intermittent ICP monitoring is associated with a higher rate of complications than continuous ICP monitoring with intermittent CSF drainage, but there is no difference between the two types of monitoring in vasospasm. Clinical trial registration no.: NCT01169454 (clinicaltrials.gov).