Mary Kay Bader

The Impact on Outcomes in a Community Hospital Setting of Using the Aans Traumatic Brain Injury Guidelines

BACKGROUND Traumatic brain injury poses a serious public health challenge. Treatment paradigms have dramatically shifted with the introduction of the American Association of Neurologic Surgeons (AANS) Guidelines for the Management of Severe Head Injury. Implementation of the AANS guidelines positively affects patient outcomes and can be successfully introduced in a community hospital setting. METHODS Data were collected both retrospectively and prospectively from the records of all trauma patients between 1994 and 1999. A cohort of 93 patients was selected. Thirty-seven patients were treated before the implementation of the AANS guidelines, and these were statistically compared with 56 patients treated after the implementation of the guidelines. RESULTS Implementation of the recommendations in the AANS guidelines in a standardized protocol resulted in a 9.13 times higher odds ratio of a good outcome relative to the odds of a poor outcome or death compared with a group managed before the practice change. A Glasgow Coma Scale (GCS) admission score > 8 was associated with a 6.58 times higher odds ratio of a good outcome compared with a GCS admission score < or = 8. Odds ratio of a good outcome decreased by a factor of 0.92 for each year increase in age of patients starting at age 9. A dedicated neurotrauma team and comprehensive treatment algorithms are critical elements to this success. Hospital charges increased by more than

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: A statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine

97,000 per patient, but are justifiable in the face of significantly improved outcomes. CONCLUSION Implementation of a traumatic brain injury protocol in a community hospital setting is practical and efficacious. Appropriate invasive monitoring of systemic and cerebral parameters guides care decisions. The protocol results in an increase in resource usage, but it also results in statistically improved outcomes justifying the increase in expenditures.

Consensus Summary Statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: A statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants’ collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

Brain tissue oxygenation in brain death

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants’ collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

Prevention of Secondary Brain Injury: Targeting Technology

Introduction: The value of brain tissue oxygenation (PbtO2) measurements in determining brain death is unknown.Methods: Eleven of 72 patients who had brain tissue oxygen monitors placed experienced brain death. Admission diagnoses included six severe traumatic brain injuries, one multiple trauma with cardiac arrest, one brain tumor, one subarachnoid hemorrhage, one intracerebral hemorrhage, and one cerebral stroke. Eleven males and zero females were studied, with an average age of 26 years (range: 20–70 years). Nine patients had Glasgow Coma Scores (GCS) of 3 on admission, one patient had a GCS of 5, and one patient had a GCS of 15.Results: Time from admission to declaration of brain death varied from 5 hours to 7 days; the most common interval was 1 or 2 days. Cerebral perfusion pressure (CPP) fell to 0 in eight patients, which indicated primary failure of cerebral perfusion. CPP stayed above 60 mmHg in three patients, indicating primary tissue failure, possibly of the cerebral microvasculature. PbtO2 fell to 0 in all patients who experienced brain death, and all patients with PbtO2 of 0 experienced brain death. None of the 61 patients who did not experience brain death had confirmed PbtO2 readings of 0.Conclusion: PbtO2 can be successfully and accurately used as a bedside adjunctive test for brain death. The use of PbtO2 as a sole confirmatory test for brain death in the setting of an appropriate clinical examination will require the evaluation of a larger number of patients to assess its sensitivity and specificity.

Refractory Increased Intracranial Pressure in Severe Traumatic Brain Injury Barbiturate Coma and Bispectral Index Monitoring

Use of technology in the management of the severely brain-injured patient has increased over the past decade and can be confusing and overwhelming to the critical care nurse clinicians who are new to the field of neurology. This article will describe normal physiology and cerebral dynamics and potential abnormal physiology encountered after brain injury. The technology reviewed will include intracranial pressure monitoring, cerebral blood flow monitoring and autoregulation, cerebral oxygen consumption and tissue oxygen monitoring, metabolism, sedation, and temperature monitoring. Integration of appropriate technology into patient management will be discussed using a case study to explore the utility of information at the bedside. Recognizing the difficult task of trying to control secondary injury in our patients is the first step to better outcomes. Implementing the use of technology to mitigate the situation must be done with careful consideration and a team approach to achieve the greatest benefit for the patient.

The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: Evidentiary Tables: A Statement for Healthcare Professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine

Patients with severe traumatic brain injury resulting in increased intracranial pressure refractory to first-tier interventions challenge the critical care team. After exhausting these initial interventions, critical care practitioners may utilize barbiturate-induced coma in an attempt to reduce the intracranial pressure. Titrating appropriate levels of barbiturate is imperative. Underdosing the drug may fail to control the intracranial pressure, whereas overdosing may lead to untoward effects such as hypotension and cardiac compromise. Monitoring for a therapeutic level of barbiturate coma includes targeting drug levels and using continuous electroencephalogram monitoring, considered the gold standard. New technology, the Bispectral Index monitor, utilizes electroencephalogram principles to monitor the level of sedation and hypnosis in the critical care environment. This technology is now being considered for targeting appropriate levels of barbiturate coma.

Rescue me: saving the vulnerable non-ICU patient population.

A variety of technologies have been developed to assist decision-making during the management of patients with acute brain injury who require intensive care. A large body of research has been generated describing these various technologies. The Neurocritical Care Society (NCS) in collaboration with the European Society of Intensive Care Medicine (ESICM), the Society for Critical Care Medicine (SCCM), and the Latin America Brain Injury Consortium (LABIC) organized an international, multidisciplinary consensus conference to perform a systematic review of the published literature to help develop evidence-based practice recommendations on bedside physiologic monitoring. This supplement contains a Consensus Summary Statement with recommendations and individual topic reviews on physiologic processes important in the care of acute brain injury. In this article we provide the evidentiary tables for select topics including systemic hemodynamics, intracranial pressure, brain and systemic oxygenation, EEG, brain metabolism, biomarkers, processes of care and monitoring in emerging economies to provide the clinician ready access to evidence that supports recommendations about neuromonitoring.

The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a list of recommendations and additional conclusions: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.

BACKGROUND From 2003-2005, a comprehensive review of all cardiac/respiratory arrests at Mission Hospital (Mission Viejo, California) uncovered deficits in knowledge and judgment in the hours preceding 75% of our non-ICU patients. Nearly half of all arrests were occurring outside the ICU, with an overall mortality rate of 60%. In addition, transfers into ICU from the floor averaged 96 patients per month. METHODS A multidisciplinary team met for 12 months to develop a specialized nurse-driven rapid response team (RRT) to reduce the incidence and mortality of non-ICU arrests, reduce transfers to the ICU from the floor, and provide ICU-level nursing care for emergency department (ED) patients in extremis. The team developed an RRT protocol, a methodology for rounds and calls, and a data collection system. After gaining consensus among the nursing managers, 4.2 full-time equivalent (FTE) RRT nurse positions were created by each unit contributing portions of an FTE. RESULTS Prospective data collected demonstrated an inpatient call frequency averaging 118 calls per 1,000 discharges; 138 calls per month were in support of the ED. Floor codes were reduced from 36 to 17 per year, and the mortality rate in the floor-code patients decreased from 61% to 26%. Unanticipated transfers from the floor units to the ICU decreased significantly. DISCUSSION The RRT initiative delivered measurable outcomes demonstrating the hospitals commitment to saving the vulnerable hospitalized patient population. In addition, the identification of critical system and clinical issues resulted in efforts to improve processes and identify patient subpopulations at risk (for example, patients with congestive heart failure, end-stage heart disease, high-dose narcotics).

Significant practice pattern variations associated with intracranial pressure monitoring

Abstract Careful patient monitoring using a variety of techniques including clinical and laboratory evaluation, bedside physiological monitoring with continuous or non-continuous techniques and imaging is fundamental to the care of patients who require neurocritical care. How best to perform and use bedside monitoring is still being elucidated. To create a basic platform for care and a foundation for further research the Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to develop recommendations about physiologic bedside monitoring. This supplement contains a Consensus Summary Statement with recommendations and individual topic reviews as a background to the recommendations. In this article, we highlight the recommendations and provide additional conclusions as an aid to the reader and to facilitate bedside care.