Implementing Quantitative Electroencephalogram Monitoring by Nurses in a Pediatric Intensive Care Unit.

BACKGROUND: Nonconvulsive seizures occur frequently in pediatric intensive care unit patients and can be impossible to detect clinically without electroencephalogram monitoring. Quantitative electroencephalography uses mathematical signal analysis to compress data, monitoring trends over time. Nonneurologists can identify seizures with quantitative electroencephalography, but data on its use in the clinical setting are limited. LOCAL PROBLEM: Bedside quantitative electroencephalography was implemented and nurses received education on its use for seizure detection. This quality improvement project aimed to describe the time between nurses' recognition of electrographic seizures and seizure treatment. METHODS: Education was provided in phases over several months. Retrospective medical record review evaluated quantitative electroencephalograms and medication interventions from September 2019 through March 2020. A bedside form was used to measure nurses' use of quantitative electroencephalograms, change recognition, clinician notification, and seizure treatment. A nurse survey evaluated the education after implementation. RESULTS: Data included 44 electroencephalograms from 30 pediatric intensive care unit patients aged 18 years or less with electroencephalogram monitoring durations of 4 hours or longer. Nurses monitored quantitative electroencephalograms in 73% of cases, documented at least 1 change in the quantitative electroencephalogram display in 28% of these cases, and contacted the neurocritical care team in 78% of cases in which they documented a change. Seizure treatment was initiated in response to the nursing call in 1 patient. Time to treatment was approximately 20 minutes. CONCLUSIONS: An education program for quantitative electroencephalogram interpretation by nurse providers is feasible yet complex, requiring multiple reeducation cycles.

Targeted Temperature Management Protocol in a Pediatric Intensive Care Unit: A Quality Improvement Project.

BACKGROUND: In patients with acute neurological injury, abrupt temperature change exacerbates increased intracranial pressures and negatively affects perfusion pressure and cerebral blood flow. Critical care nurses must provide coordinated and effective interventions to maintain normothermia without precipitating shivering immediately after acute neurological injury in pediatric patients. OBJECTIVE: To improve hyperthermia management in a 40-bed pediatric intensive care unit, an interdisciplinary pediatric critical care team developed, implemented, and evaluated a targeted temperature management protocol. METHODS: The project was guided by the organization's plan-do-study-act quality improvement process. Quality improvement was assessed retrospectively using electronic medical records of patients meeting eligibility criteria. Samples of pediatric patients who received temperature interventions were compared before and after protocol implementation. The protocol included environmental, pharmacological, and body surface cooling device interventions, as well as use of a bedside shivering assessment scale and stepwise interventions to prevent and control shivering. RESULTS: Before implementation of the targeted temperature management protocol, 64% of patients had documented temperatures higher than 37.5 °C, and body surface cooling devices were used in 10% of patients. After protocol implementation, more than 80% of patients had documented temperatures higher than 37.5 °C, and body surface cooling devices were used in 62% of patients. Four patients (6%) before and 5 patients (31%) after protocol implementation were treated with body surface cooling without requiring use of neuromuscular blockade. CONCLUSIONS: Creation and implementation of a targeted temperature management protocol increased nurses' documented use of body surface cooling to manage hyperthermia in pediatric intensive care unit patients with acute neurological injury.