Quiet Time: A Noise Reduction Initiative in a Neurosurgical Intensive Care Unit.

BACKGROUND: High noise levels in intensive care units are common. Increased noise levels can lead to sleep deprivation, increased pain perception, and delirium. The most common cause of reducible noise in intensive care units often is attributed to staff conversations. OBJECTIVES: In January 2015, the neurosurgical intensive care unit staff identified noise as a problem, referencing complaints from other disciplines and family members. Quiet times from 3 am to 5 am and from 3 pm to 5 pm were agreed upon. An improvement plan was developed with a goal to decrease noise levels by 10 decibels in 6 months. METHODS: Using a decibel meter, noise data were collected in 4 locations every 30 minutes during the chosen times for 8 days. Quiet time was implemented 1 week after staff, patient, and family education was completed. Decibel data were collected and evaluated after 60 days. RESULTS: There were statistically significant reductions in noise levels at nurses' station left (P = .04) and the bed 9 entrance (P = .02). Noise levels were lower, but not significantly so, for nurses' station right (P = .12) and the bed 4 entrance (P = .06). Noise levels during quiet time decreased to an average of 10 to 15 decibels lower than baseline data. CONCLUSIONS: Sharing baseline data was effective to heighten noise awareness. During quiet time, limiting conversations, eliminating environmental noise, and dimming the lights as a reminder to be quiet are 3 simple strategies that can be implemented to lessen noise.

Making GCS as easy as 1, 2, 3, 4, 5, 6.

The Glasgow Coma Scale (GCS) is an easy to use tool for assessing neurological function and brain injury in comatose patients particularly in acute stages of traumatic injury or illness. Due to the simplicity of the scale, however, proper training is often overlooked limiting its usefulness. This manuscript describes the basic components of the GCS and the proper scoring method to elicit accurate evaluations.

AACN CSI Academy, part 2: Nurses emerge as change leaders.

In the first part of this three-part series, we explored how the American Association of Critical-Care Nurses (AACN) Clinical Scene Investigator (CSI) Academy aids clinical nurses in cultivating skills that measurably demonstrate how nonproductive time is a misnomer that interferes with achieving optimal patient outcomes. Join us for part 2, as we examine how the CSI Academy helped one hospital's neurosurgical ICU (NSCU) nurses achieve zero CAUTIs.

Staff Nurses Eliminated Catheter-Associated Urinary Tract Infections in a Neurosurgical Intensive Care Unit.

Catheter-associated urinary tract infections (CAUTIs) are among the leading causes of health care-associated infections in neurosurgical populations. Successful reduction of CAUTIs involve the development of staff nurses as front-line change agents equipped with preventative strategies, educational interventions, and sustainable maintenance for positive patient outcomes.

Measuring workload of nurses on a neurosurgical care unit.

AIM OF THE STUDY: The aim of this study was to create a model of workload that could be used to manage workload and increase satisfaction of workload for nurses on a neuroscience care unit. BACKGROUND: No study was found that delineated a model of workload that could be used to manage or improve satisfaction with workload for a neuroscience care unit at either the individual nurse or unit level. METHODS: Staff, management, and a researcher collaboratively developed a model to examine workload on a neuroscience care unit. Forty-three independent variables of workload and the dependent variable of satisfaction with workload were studied over 28 days using stepwise regression. Stepwise regression is appropriate for model building. Criteria to enter any independent variable into a regression equation included correlating with the dependent variable of satisfaction with workload, validation of central tendency assumptions, and good data fit using residual diagnostics. RESULTS: Independent variables of workload that explained the variance of satisfaction with workload included time (15.9%), undelegated work (4.0%), number of isolation patients (2.9%), individual employees (2.1%), number of patients (1.3%), and number of postoperative neurosurgical patients (1.1%). On the unit level, satisfaction with workload was predicted by time (42.5%) and the number of nurses on duty (7.7%). CONCLUSIONS: Satisfaction with workload as reported by staff nurses is predicted by both individual- and unit-level factors of workload. Staff input is crucial to the development of a model of workload on clinical specialty units like neuroscience care. Staff nurses identify key variables, otherwise overlooked, affecting workload and satisfaction and satisfaction with workload. IMPLICATIONS FOR NURSING MANAGEMENT: It is vital to develop unit-specific models of workload and consider both individual- and unit-level factors. Such models have potential for deeper research into both management and increasing satisfaction of workload at the level of clinical specialty/unit.

Standardizing neurological assessments.

Evaluation of neurological status is imperative to patient assessment. Multiple assessment tools are readily available for clinicians to diagnose and report changes in neurological condition. Some of these tools include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale, the Canadian Neurological Scale, and the Four Score. Although assessment tools are beneficial to help standardize the assessment and communication of findings, they are at times cumbersome, leaving bedside clinicians with questions concerning which tool is appropriate for a given patient population. This initiative began as a means to standardize assessments and communication for neuroscience patients. As success was met, the project was moved forward locally at our hospital campus and later extended to the entire health system. With the support of the chief of neurology, the neuroscience patient care services director, the stroke coordinator, and the neuroscience clinical educator, three different neurological examinations were developed. They were defined as the Basic Neurological Check, the Coma Neurological Check, and the National Institutes of Health Stroke Scale/Stroke Neurological Check. The neurological examinations would address the assessment needs of patients with acute stroke, general neurosurgery/neurology patients, and patients in coma.

Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury.

BACKGROUND: Prehospital management of traumatic brain injury (TBI) and trauma system development and organization are aspects of TBI care that have the potential to significantly impact patient outcome. This multi-center study was conducted to explore the effect of prehospital management decisions on early mortality after severe TBI. METHODS: This report is based on 1449 patients with severe TBI (GCS<9) treated at 22 trauma centers enrolled in a New York State quality improvement (QI) program between 2000 and 2004. The prehospital data collected on these patients include time of injury, time of arrival to the trauma center, mode of transport, type of EMS provider, direct or indirect transport, blood pressure and pulse oximetry values, GCS score, pupillary assessment, and airway management procedures. RESULTS: After exclusion criteria were applied, a total of 1,123 patients were eligible for analysis. The majority of patients were male (75%) with a mean age of 36 years. After controlling for arterial hypotension, age, pupillary status, and initial GCS score, direct transport was found to result in significantly lower mortality than indirect transport. Transport mode, time to admission, and prehospital intubation were not found to be related to 2-week mortality. CONCLUSIONS: The present study provides class II evidence that demonstrates a 50% increase in mortality associated with indirect transfer of TBI patients. Patients with severe TBI should be transported directly to a Level I or Level II trauma center with capabilities as delineated in the Guidelines for the Prehospital Management of Traumatic Brain Injury, even if this center may not be the closest hospital.

Predictors of compliance with the evidence-based guidelines for traumatic brain injury care: a survey of United States trauma centers.

BACKGROUND: In 1995, evidence-based guidelines for the management of severe traumatic brain injury (TBI) were published and disseminated. Information regarding their implementation is limited. METHODS: During 1999 to 2000, we contacted all designated U.S. trauma centers caring for adults with severe TBI to determine the degree of guideline compliance and to identify predictors. RESULTS: Of 924 centers identified, 828 participated (90%). Four hundred thirty-three with intensive care units caring for severe TBI were surveyed. Three hundred ninety-five centers transferring patients were excluded. Full guideline compliance was rare (n = 68 [16%]). In multivariate analyses, treatment protocols (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.9-6.6), neurosurgery residency program (OR, 5.0; 95% CI, 2.6-9.8), and state (OR, 2.7; 95% CI, 0.62-12) or American College of Surgeons (OR, 5.1; 95% CI, 1.1-23) designation increased the likelihood of full compliance versus noncompliance. CONCLUSION: Although evidence-based guidelines were published and disseminated in 1995, implementation is infrequent. Focus must turn to changing physician practice and transport decisions to provide guideline-compliant care and improve patient outcome.