Brain Code: A Standardized Response to a Neurological Emergency

Intracranial hypertension (IH) is a neurological emergency that can lead to profound disability and death and is consequently referred to as a brain code. Intracranial hypertension is the sequelae of typical acute care diseases or injuries such as stroke, traumatic brain injuries (TBIs), and hepatic encephalopathy. The progression of IH to disability and death can be rapid, and the need to respond quickly in a methodical manner is imperative. The purpose of this Doctorate of Nursing Practice (DNP) project was to create an evidence-based guideline to streamline the care for this devastating event. By facilitating faster recognition and treatment, the quality of care for this patient population could dramatically improve. At a tertiary hospital in Salt Lake City, Utah, a standardized guideline for IH does not exist. This is a problem because it is a level-one trauma center and an advance comprehensive stroke center. Many patients with conditions that can trigger IH are frequently treated at this facility. The facility is a teaching hospital with interns, residents, and fellows who rotate through various specialties, floors, and units. It is unrealistic to expect these individuals to become and remain competent in the care of patients with this neurological emergency. Due to there being disagreements on managing IH, each provider approaches management differently. This further emphasized the need for a thorough literature review to ensure evidence-based recommendations were utilized. Four objectives were identified for this project. The primary objective was to create a brain code guideline to standardize how intracranial hypertension is recognized and managed at the tertiary hospital mentioned above. Secondly, the completed guideline was presented to neurocritical care providers for approval and/or revision. Thirdly, nursing staff outside specialty neurology floors were provided education on how to appropriately recognize and respond to intracranial hypertension. Lastly, the findings for this project were disseminated to a larger audience. Project implementation included developing the guideline and presenting it to key stakeholders. Feedback was received and necessary revisions were made. An IH presentation was given to nursing staff, and their understanding was evaluated with a multiple choice pre-and post-test. Those nurses were also asked to comment on the usability and feasibility of the guideline. Lastly, a clinical poster was accepted for presentation at the Ogden Surgical-Medical Society Conference in May. Standardization via clinical practice guidelines or protocols have resulted in increased efficiency, better patient outcomes, lower costs, and decreased morbidity and mortality. The best example of a neurology-specific guideline is a stroke alert protocol, which has been found to reduce both treatment time and time to computed tomography (CT). The treatment for IH includes but is not limited to hyperventilation, surgery, and ICP monitor placement and pharmacological interventions include hyperosmolar therapy, blood pressure management, and sedation. Brain codes are as serious as cardiac and respiratory arrests, which is precisely why this project was undertaken. The need to quickly recognize and effectively treat IH is imperative, because as eluded to above, it can lead to profound complications and potentially death. By having a guideline in place, the care for this neurologic emergency will become standardized. Future implications of this DNP project are piloting the guideline and validating its usefulness within a neurocritical care unit.

Running head: BRAIN CODE 1 Brain Code: A Standardized Response to a Neurological Emergency Erin Szemak BSN, RN, DNP Candidate University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice BRAIN CODE 2 Executive Summary Intracranial hypertension (IH) is a neurological emergency that can lead to profound disability and death and is consequently referred to as a brain code. Intracranial hypertension is the sequelae of typical acute care diseases or injuries such as stroke, traumatic brain injuries (TBIs), and hepatic encephalopathy. The progression of IH to disability and death can be rapid, and the need to respond quickly in a methodical manner is imperative. The purpose of this Doctorate of Nursing Practice (DNP) project was to create an evidence-based guideline to streamline the care for this devastating event. By facilitating faster recognition and treatment, the quality of care for this patient population could dramatically improve. At a tertiary hospital in Salt Lake City, Utah, a standardized guideline for IH does not exist. This is a problem because it is a level-one trauma center and an advance comprehensive stroke center. Many patients with conditions that can trigger IH are frequently treated at this facility. The facility is a teaching hospital with interns, residents, and fellows who rotate through various specialties, floors, and units. It is unrealistic to expect these individuals to become and remain competent in the care of patients with this neurological emergency. Due to there being disagreements on managing IH, each provider approaches management differently. This further emphasized the need for a thorough literature review to ensure evidence-based recommendations were utilized. Four objectives were identified for this project. The primary objective was to create a brain code guideline to standardize how intracranial hypertension is recognized and managed at the tertiary hospital mentioned above. Secondly, the completed guideline was presented to neurocritical care providers for approval and/or revision. Thirdly, nursing staff outside specialty neurology floors were provided education on how to appropriately recognize and respond to intracranial hypertension. Lastly, the findings for this project were disseminated to a larger audience. Project implementation included developing the guideline and presenting it to key stakeholders. Feedback was received and necessary revisions were made. An IH presentation was given to nursing staff, and their understanding was evaluated with a multiple choice pre-and post-test. Those nurses were also asked to comment on the usability and feasibility of the guideline. Lastly, a clinical poster was accepted for presentation at the Ogden Surgical-Medical Society Conference in May. Standardization via clinical practice guidelines or protocols have resulted in increased efficiency, better patient outcomes, lower costs, and decreased morbidity and mortality. The best example of a neurology-specific guideline is a stroke alert protocol, which has been found to reduce both treatment time and time to computed tomography (CT). The treatment for IH includes but is not limited to hyperventilation, surgery, and ICP monitor placement and pharmacological interventions include hyperosmolar therapy, blood pressure management, and sedation. Brain codes are as serious as cardiac and respiratory arrests, which is precisely why this project was undertaken. The need to quickly recognize and effectively treat IH is imperative, because as eluded to above, it can lead to profound complications and potentially death. By having a guideline in place, the care for this neurologic emergency will become standardized. Future implications of this DNP project are piloting the guideline and validating its usefulness within a neurocritical care unit. This project has been guided by faculty chair, Heidi Favero, DNP, AGACNP-BC; content expert Shawn Smith, M.D.; program director Denise Ward DNP, ACNP-BC, FNP-BC; and director of MSN and DNP programs Pamela Hardin, Ph.D., RN, CNE. BRAIN CODE 3 Table of Contents Executive Summary ........................................................................................................................ 2 Problem Statement .........................................................................Error! Bookmark not defined. Clinical Significance ....................................................................................................................... 5 Purpose & Objectives ..................................................................................................................... 6 Literature Search Strategy............................................................................................................... 6 Literature Review............................................................................................................................ 7 Pathophysiology.................................................................................................................. 7 Interventions ....................................................................................................................... 7 The Impacts of Evidence-Based Guidelines ..................................................................... 11 Theoretical Framework ................................................................................................................. 12 Implementation ............................................................................................................................. 13 Evaluation ..................................................................................................................................... 15 Results ........................................................................................................................................... 15 Recommendations ......................................................................................................................... 17 DNP Essentials.............................................................................................................................. 18 Conclusion .................................................................................................................................... 19 References ..................................................................................................................................... 20 Appendix A ................................................................................................................................... 24 Appendix B ................................................................................................................................... 26 Appendix C ................................................................................................................................... 30 Appendix D ................................................................................................................................... 32 Appendix E ................................................................................................................................... 35 Appendix F.................................................................................................................................... 38 Appendix G ................................................................................................................................... 40 Appendix H ................................................................................................................................... 42 Appendix I .................................................................................................................................... 44 Appendix J .................................................................................................................................... 46 Appendix K ................................................................................................................................... 51 Appendix L ................................................................................................................................... 53 BRAIN CODE 4 Brain Code: A Standardized Response to a Neurological Emergency Problem Statement Prolonged intracranial hypertension (IH) is a neurological emergency. Intracranial hypertension is life-threatening and denotes the instability of intracranial dynamics, which describes the ability of the brain to compensate for increased pressures and volumes (Kalanuria, Geocadin, & Püttgen, 2013; Stevens, Shoykhet, & Cadena, 2015). The skull is noncompliant, so a rise in intracranial pressure without compensation can compromise cerebral blood flow and may lead to decreased cerebral perfusion, cerebral herniation, coma, and death (Kalanuria et al., 2013). Thus, IH is coined a "brain code", an event that should be taken seriously and managed aggressively (Stevens et al., 2015). Intracranial hypertension may arise as a consequence to common medical conditions including, but not limited to, intracranial hemorrhages, ischemic strokes, brain tumors, brain abscesses, traumatic brain injuries (TBIs), meningitis, and hepatic encephalopathy (Kalanuria et al., 2013; Stevens et al., 2015). If not recognized and treated in a timely manner, a "brain code" can become catastrophic. This is a problem at a tertiary hospital in Salt Lake City, Utah, because it is a level-one trauma center and an advanced comprehensive stroke center. Many of the conditions mentioned above are frequently treated at this facility. In 2015, this facility admitted 1,164 patients with the diagnosis of ischemic stroke, intracerebral hemorrhage, and/or subarachnoid hemorrhage alone. Additionally, the facility is a teaching hospital with interns, residents, and fellows who rotate through various specialties, floors, and units. Expecting house staff to become and remain experts in the treatment of IH is not realistic, but by having a guideline in place, the care for this neurologic emergency would become standardized. The creation of a guideline would also permit core staff to become familiar with the presenting signs and treatment of IH. Finally, it is BRAIN CODE 5 important to note patients suffering from a brain code are not always confined to specialized neurology floors and units. Clinical Significance Annually in the U.S., 800,000 people suffer a stroke, and 280,000 are hospitalized for TBIs, which emphasizes the prevalence of these conditions (Centers for Disease Control and Prevention [CDC], 2016a; CDC, 2016b). These are only two of multiple diagnoses that can precipitate IH. In a study of patients with intracerebral hemorrhage with intracranial pressure (ICP) monitors in place, 70 percent had at least one episode of IH (Kamel & Hemphill, 2012). Patients with severe traumatic brain injuries with abnormalities present on CT scan have a 50 percent chance of developing IH (Ghajar, 2000). This is significant because TBIs with IH are associated with increased risk of death. For those who survive these devastating neurological complications, many are left with neurological disabilities, decreased quality of life, and financial burden (Ghajar, 2000). As mentioned above, a brain code can be the effect of pathologies that are commonly encountered in an acute care setting (Kalanuria et al., 2013; Stevens et al., 2015). Therefore, this problem is far-reaching, and a substantial number of hospitalized patients could be profoundly impacted by this neurologic crisis. In addition to patients, acute care healthcare providers are key stakeholders. In order to reduce morbidity and mortality from these neurological emergencies, the healthcare team must be supportive, engaged, and willing to participate with this quality improvement effort. To prevent permanent injury and/or death, brain codes must be identified and treated without delay (Stevens et al., 2015). Standardization via clinical practice guidelines or protocols have resulted in improved efficiency, better outcomes, lower costs, and decreased morbidity and BRAIN CODE 6 mortality. For TBIs, the use of evidence-based practice guidelines have been shown to improve patient care and outcomes (Ghajar, 2000). Hoegerl, Goldstein, and Sartorius (2011) found that by implementing a stroke protocol, coupled with provider education, reduced the time between recognizing stroke-like symptoms and obtaining a computed tomography (CT) scan by 50 percent. Therefore, the development of a brain code guideline will provide a large, non-profit, medical center in Utah, with a framework that could positively impact patient care and prognosis. Purpose & Objectives The primary goal of this Doctor of Nursing Practice (DNP) scholarly project was to develop an evidence-based guideline for intracranial hypertension. The objectives for the project were as follow: 1. Create a brain code guideline to standardize how intracranial hypertension is recognized and managed at a tertiary hospital in Salt Lake City, Utah 2. Present completed brain code guideline to the medical director of neurocritical care and other neurocritical care providers for approval and/or revision 3. Provide education on IH to non-neuro intensive care unit (ICU) nursing staff 4. Disseminate brain code guideline by participating in a clinical poster presentation at the Ogden Surgical-Medical Society Conference Literature Search Strategy Both PubMed and CINHAL were the databases used for the literature review. Search terms included: intracranial hypertension, elevated intracranial pressure, acquired brain injury, traumatic brain injury, brain code, cerebral herniation, neurological protocols, intracranial pressure management, epidemiology of acquired brain injuries, hypertonic saline, mannitol, BRAIN CODE 7 hyperosmolar therapy, hyperventilation, thermoregulation for acquired brain injury, hypothermia for brain injury, brain monitoring, and medications for rapid-sequence intubation. Filters were set to publication dates within five years and humans as species. This search strategy was used to eliminate dated research findings and to ensure treatment approaches had been trialed on human participants. Literature Review Pathophysiology The intracranial space is comprised of brain tissue, blood, and cerebral spinal fluid (CSF). The Monro-Kellie doctrine states the sum of these parts remain constant, which is explained by a pressure-volume relationship. Therefore, if one part increases, compensation occurs, and volume will be reduced in one or both of the remaining two parts (Kalanuria et al., 2013). Like many physiologic adaptive mechanisms, this pressure-volume relationship can become overwhelmed by events such as trauma, intracranial hemorrhage, cerebral infarction, hepatic encephalopathy, brain abscesses, and meningitis (Stevens, Shoykhet, & Cadena, 2015; Kalanuria, et al., 2013). When this occurs, the ability to adjust intracranial volumes vanishes, and pressure rises (Stevens et al., 2015). The cranial vault cannot expand in response to sustained intracranial hypertension; thus, the brain herniates in one or multiple directions (Kalanuria et al., 2013). Common presenting signs and symptoms of IH include altered level of consciousness, headache, nausea, vomiting, ipsilateral pupillary dilation, and contralateral hemiparesis (Stevens et al., 2015). Without immediate intervention, neurologic deficits, coma, and death can ensue. Interventions Once signs and symptoms have been recognized, prompt management and treatment is essential. Brain code interventions include both non-pharmacological and pharmacological BRAIN CODE 8 actions. In 2016, Emergency Neurologic Life Support (ENLS) guidelines were released. The guidelines provided a flowchart of suggestions on how brain codes should be approached. In some of the tiers, rather than prioritizing one intervention over the other, the choice is placed in the hands of the treating provider. In addition, rather than providing concrete drug recommendations to reach/maintain cerebral perfusion pressure parameters, the suggestion is simply fluids, vasopressors or inotropes. Non-pharmacological. Upon recognition of IH symptoms, a CT scan should be obtained to identify a cause (Stevens et al., 2015). If warranted, an artificial airway should be established. Considering the pathophysiology and the interventions/mechanisms used to address IH, the majority of patients who do not already have an artificial airway will need one placed. The discerning provider may decide the type of airway and the process by which it is established. The head of bed should be elevated greater than 30 degrees with the patient's head in a midline position to facilitate venous drainage. If a cervical collar is in place, consider slightly loosening it, with consideration of not compromising spinal stabilization. All noxious stimulus should be eliminated and avoided (Rangel-Castillo & Robertson, 2006). The patient should be sedated to minimize agitation. Ideally, the CT scan will pinpoint the cause, and thus, direct further interventions such as surgery. Surgical candidacy is determined by the neurosurgeon. The two surgeries that are performed for brain codes are removal of mass lesions and/or decompressive craniectomy, which involves removing a portion of an individual's skull (ENLS, 2016). Meanwhile, the patient's temperature and serum carbon dioxide (CO 2 ) must be assessed and addressed (ENLS, 2014). Hyperventilation was once the mainstay of intracranial hypertension treatment. In fact, Oertel et al. (2002), found that hyperventilation was the most effective way of reducing intracranial pressure (ICP) when compared to other interventions. BRAIN CODE 9 While it has been shown to be an efficient technique, Bagwell et al. (2016) found that an endtidal CO 2 less than 30 resulted in reduced cerebral blood flow, which resulted in reduced tissue oxygenation. Currently, it is recommended that hyperventilation only be used transiently with end tidal CO 2 monitoring in place. With regard to temperature, targeted temperature management is often used to improve neurological outcome; however, randomized control trials are lacking in this area (Dunkley & McLeod, 2016; Yokobori & Yokota, 2016). When compared to normothermia, hypothermia did not result in improved patient outcomes (Zhu, Yin, Zhang, Ye, & Wei, 2016). Additionally, one study established an association between therapeutic temperature modulation and increased incidents of pulmonary complications (O'Phelan, Merenda, Denny, Zaila, & Gonzalez, 2015). There has not been a temperature parameter goal established for this patient population, further supporting the need for future randomized control trials. Roh and Park (2016) advise using cerebral monitors, but emphasize the importance of tailoring the device choice to the patient's injury. For example, certain patients require CSF drainage, while others do not. Intracranial monitoring is associated with low risk of bleeding and infections, but when choosing between bolted versus tunneled ventricular drainage devices, bolted devices have been found to have the fewest complications (Roh & Park, 2016; Jensen, Carlsen, Sørensen, & Poulsen, 2016). A few studies have demonstrated the use of ICP monitoring is better at determining ICP elevations, when compared to clinical assessment and radiography (Chesnut et al., 2012; Zeng, Zheng, Tong, & Fang, 2014). Prior to placing a monitor, it is crucial to consider the patient's injury, and then choose the appropriate modality. Pharmacological. There are a variety of pharmacological interventions for brain codes, which include hyperosmolar agents, sedatives, antipyretics, inotropes, and vasopressors. Often BRAIN CODE 10 debated is whether mannitol or hypertonic saline should be used as first-line therapy. Multiple studies have found no significant differences based on long-term patient outcomes between the two (Boone, Oren-Grinberg, Robinson, Chen, & Kasper, 2015; Burgess, Abu-Laban, Slavik, Vu, & Zed, 2016; Jagannatha, Sriganesh, Devi, & Rao, 2016). Two studies have demonstrated that hypertonic saline was more effective at quickly reducing ICP when compared to mannitol (Jagannatha, Sriganesh, Devi, & Rao, 2016; Mangat et al., 2016). Lastly, some argue that hypertonic saline is safer than mannitol because it does not cause acute kidney injury. Yet, one study illustrated out of 432 patients receiving mannitol for intracerebral hemorrhage and ischemic stroke, only 6.5% developed acute kidney injury (Lin et al., 2015) While there is a need for more randomized control trials to determine which of these two therapies is superior, in an emergent situation, using these medications simultaneously is appropriate. Another pharmacological intervention includes sedation and rapid sequence intubation (RSI) agents. Patients with IH often require these medications for intubation, agitation, elevated ICP, and/or shivering. Careful consideration must be taken when selecting a sedative or RSI agent for this patient population, because a drop in blood pressure could dramatically impact the patient's cerebral perfusion pressure. Moreover, long-acting agents are not ideal, because these patients require serial neurological examinations. While a perfect agent does not exist, some are more suitable than others for patients with IH. These medications will be discussed below. Per Pillay and Hardcastle (2016), etomidate for induction has little effect on cardiovascular function and can also reduce intracranial pressure, which makes it a favorable choice in IH patients. Ketamine also has positive effects on the cardiovascular system including increased blood pressure, heart rate, and cardiac output (Pillay & Hardcastle, 2016). Propofol is fast acting and quickly cleared metabolically, and it has been found to decrease ICP (Stollings, BRAIN CODE 11 Diedrich, Oyen, & Brown, 2014). Stollings et al. (2014) state, propofol can cause hypotension and should be avoided in IH patients with labile blood pressures. For neuromuscular blockades, Pillay and Hardcastle (2016) prefer rocuronium over succinylcholine in severe traumatic brain injuries, because it does not cause transient increases in ICP. Some argue the elevation of ICP following succinylcholine administration is minimal; however, in patient's with IH a 5 to 10mmHg increase could be detrimental (Stollings et al., 2014). For sedation, fentanyl seems to be a good opioid of choice for patients with cerebral disregulation. Fentanyl also becomes an attractive choice because of its fast onset and short duration (Stollings et al., 2014). Per Stollings et al. (2014), when compared to the use of benzodiazepines and opioids, mean arterial pressure was maintained and vasopressor requirements declined with the use of ketamine for sedation and analgesia. In mechanically ventilated and sedated patients, the use of ketamine has not resulted in elevated ICP (Stollings et al., 2014). The Impacts of Evidence-Based Guidelines The severity of this neurologic emergency is evident. Consequently, elevated intracranial pressure and brain herniation have been coined "brain codes" (Stevens et al., 2015). Recognition of a brain code is key to time-sensitive treatment. There have been guidelines developed for another time-sensitive, neurological emergency: an ischemic stroke. Multiple studies have demonstrated that the implementation of evidence-based stroke guidelines have improved the timeliness of stroke care, and ultimately, patient outcomes (Cumbler, Zaemisch, Graves, Brega, & Jones, 2012; Hoegerl, Goldstein, & Sartorius, 2011; Ruff et al., 2014). This literature review highlights how the management and treatment of brain codes can vary between providers. Currently, no evidence-based guidelines exist for brain codes at a large, nonprofit hospital in BRAIN CODE 12 Utah. The aim of this DNP project was to create a brain code guideline that would streamline care and improve patient outcomes. Theoretical Framework The theoretical framework that best supported and guided this DNP project was the Normalization Process Theory (NPT). The premise of this sociological framework is to identify how a new practice is first rendered doable, and then how it is integrated in a specific social context (May & Finch, 2009). The creators of the NPT believe that in order for a new practice to become normalized, the people of the organization must collectively endorse the practice, which is why this theory is fundamental to this project (Murray et al., 2010). This endorsement is promoted by addressing the four constructs of this theory: coherence, cognitive participation, collective action, and reflexive monitoring (see Appendix A). Using these domains to guide this project's objectives, inquiry must occur on how this new guideline would impact key stakeholders. Among the constructs, Murray et al. (2010) have formulated questions to consider. Coherence asks if the purpose behind creating this guideline make sense and whether it is meaningful to stakeholders. Do they think it will benefit them and patients? Is the new guideline in line with the organization's goals? Can it be differentiated from what is already done in current practice? Cognitive participation is based on gaining buy-in from future implementers. Do they think it is a good idea? Are they prepared for the change, work, and energy they will have to put into embedding this new guideline into normal practice? Collective action considers what type of impact this intervention will have on the key stakeholders. How much training will it take? How will it affect current workflows, and is it compatible? Reflexive monitoring requires stakeholders to forecast the future of this intervention. Do they predict it to be useful BRAIN CODE 13 and effective? This includes assuring them that if this guideline is implemented, the effect of this intervention will be measured, and they will be able to contribute feedback. By allowing this framework to guide this project, there is a better chance this guideline will be implemented into standard practice. Implementation The first objective of this DNP project was to create a brain code guideline that standardizes how intracranial hypertension is recognized and acknowledged at a tertiary hospital in Salt Lake City, Utah. Prior to implementation, the DNP project proposal was presented to, and accepted by, the faculty panel (see Appendix B). Before guideline development was initiated, an Institutional Review Board (IRB) application was completed and approval obtained (see Appendix C). It was determined that this DNP project did not involve human subjects; therefore, it did not require IRB oversight. Thus, the brain code guideline development began. The first objective was to develop a brain code guideline. This was initiated by conducting a literature review of current recommendations for managing IH. After critically evaluating the resources, the ENLS recommendations were used as a skeleton to the guideline. Other findings were incorporated into the guideline as applicable. Development of the guideline also involved continuous input from the content expert and other key stakeholders including pharmacists and neurocritical care staff. Open-ended discussions occurred via email, by phone, and/or in-person. Each discussion revealed how the department approaches neurologic emergencies including items such as medication preferences, workflows, and healthcare team members' roles. Consequently, the guideline blended evidence-based recommendations with current practices at the chosen facility. The physical guideline was developed using Lucidchart software. Lucidchart is a web-based flowchart diagram program that allows for multiple users to BRAIN CODE 14 share comments, brainstorm, and make edits to the flowchart. The final guideline was approved by both the content expert and project chair prior for presentation to neurocritical care providers (see Appendix D). The second objective was to present the finalized brain code guideline to the medical director of neurocritical care and other neurocritical care providers to obtain approval and/or receive recommended revisions. This selected group included neurointensivists, neurosurgical advance practice clinicians, pharmacists, and nursing staff. A visual handout containing the guideline was created for the above individuals. Each individual was asked to remark on the feasibility of the brain code guideline and to include any feedback regarding items to include or omit. Feedback was received via email and will be discussed below. The third objective was to provide education to nursing staff outside of the neurocritical care setting. Utilizing scholarly resources and evidence-based practice recommendations, a PowerPoint presentation was created (see Appendix E). Content included the pathophysiology of IH, the clinical significance of the problem, etiology, signs and symptoms of which to be aware, and common treatment modalities. The presentation took place during a quarterly charge nurse meeting at the chosen facility. These charge nurses and their staff frequently care for patients with conditions that can predispose them to IH, which is precisely why they were selected for this educational opportunity. The effectiveness of the education was measured via a five-question multiple choice pre-/post-test (see Appendix F). Additionally, the brain code guideline was presented to the staff, and their feedback was obtained via a Likert scale questionnaire (see Appendix G). The questionnaire addressed the feasibility, usability, and the impact the guideline would have on their ability to respond to this neurological emergency. There was also an optional section for nurses to include additional comments and feedback. BRAIN CODE 15 Lastly, the fourth objective was to disseminate the brain code guideline to a broader audience. This was first achieved by creating and presenting the project during the graduate poster presentation session at University of Utah's College of Nursing (see Appendix H). Then, a clinical poster was prepared and will be presented in May at the Ogden Surgical-Medical Society Conference (See Appendix I). This poster was made using the instructions set forth by the organization (see Appendix J). Evaluation The objectives of this project were evaluated in several ways. First, the DNP proposal presentation was accepted, and IRB approval was obtained. Then the developed guideline was critically reviewed and approved by both content expert and project chair. The developed guideline was then presented to and thorough critique was received from neurocritical care providers. After the educational PowerPoint presentation, the effectiveness of the teaching was evaluated via a pre-/post-test, which was distributed to the nursing staff before and after the presentation. The nursing staff also completed a Likert-scale questionnaire to provide feedback regarding the brain code guideline. The results of the tests and questionnaire, along with the completed PowerPoint, were presented to the project chair. Finally, proof of dissemination was submitted to the project chair and included a completed clinical poster. Results The first objective of this project was to create a brain code guideline. This was completed by collecting and reviewing evidence-based studies that pertained to the interventions within the guideline such as sedation and hyperosmolar therapy. As mentioned above, the ENLS recommendations were used as the foundation. This was built upon by using other evidencebased practice findings and the current practices at the chosen facility. The first draft of the BRAIN CODE 16 guideline has been completed. Key facilitators for completion of this objective were the content expert and project chair. Originally, the brain code guideline was intended to include recommendations for patients with ICP monitors in place. However, after reviewing the primary goal of this project, it was determined that this inclusion did not meet the original aims of the guideline. The second objective was to submit the final brain code guideline to neurocritical care providers. A total of seven providers were selected to participate in this feedback process. Unfortunately, only one of the providers contributed feedback. Feedback was sent via email and included a list of suggestions. The list included both omissions and additions. These comments were discussed with both the content expert and project chair, and appropriate revisions were made. Due to time constraints and conflicting schedules, a formal face-to-face meeting and presentation of the brain code guideline did not occur. This likely contributed to the poor response rate and was an unanticipated outcome of this project. Additional feedback is anticipated and those comments will be considered during the revision process. The third objective was to provide education on IH to nursing staff outside of the neurocritical care area. This objective was accomplished by obtaining a meeting time with nonneuro nursing staff at the chosen facility. After emailing several nurse managers, a medicaloncology floor agreed to receive IH education. A total of 10 (N=10) participants received education on IH and completed the pre-/post-test. The mean and standard deviation for the pre-/post-test were calculated using an Excel spreadsheet (see Appendix K). Out of five possible points the average pre-test score was 2.9, with a standard deviation ± 0.99. The average post-test score was 4.2, with a standard deviation ± 1.03. Due to a small sample size, a Wilcoxon signedrank test was calculated (see Appendix L). The w-value was 0.00 at a p-value less than or equal BRAIN CODE 17 to 0.05, indicating the change in nurse's knowledge pre- to post-education was statistically significant (Stangroom, 2017). Furthermore, the nurses were given the brain code guideline to review and were asked for feedback via a Likert scale questionnaire. Of the 10 participants, they all either agreed or strongly agreed that the brain code guideline was feasible, useable, and would positively impact how their staff could respond to this neurologic emergency. Some examples of open-ended feedback included "Guideline seems easy to use" and "Simple but to the point-easy to use." One barrier for this objective was finding a group of nurses to receive the education. Multiple nursing unit managers within the institution were contacted, but only one agreed to allow for this nursing education to be presented. While the responses received from the nursing staff were positive, the sample size was small, and the results cannot be generalized. The fourth objective was achieved by corresponding with the Ogden Surgical-Medical Society's executive director. The clinical poster topic was confirmed, and the findings disseminated at the society's annual conference. Recommendations Future efforts towards revising and implementing the brain code guideline at the selected facility should be continued. Formal meetings should be scheduled with providers and nursing staff to obtain additional feedback. Once buy-in has been achieved by hospital staff and administration, the guideline should be piloted within the neurocritical care unit at the chosen facility. It is the intention of the author to remain involved in this process. Key facilitators to ensure expansion of this project include the content expert, hospital staff, and hospital administration. This project has the potential to be far-reaching, as the guideline could also be implemented at rural facilities that do not have the resources to adequately care for patients BRAIN CODE 18 suffering from IH. This would ensure these patients are receiving proper care within the facility's mean prior to being transported to a tertiary care center. This project also emphasized the need for education on IH. Based on the pre-/post-test results, brief education may have an impact on how nurses respond to this neurological emergency. By providing more education to hospital staff, the significance of IH can be communicated and quality of care improved. DNP Essentials One DNP essential addressed by this project is "Clinical Scholarship and Analytical Methods for Evidence-Based Practice." More specifically, this DNP project utilized evidencebased knowledge to solve a practical problem. Neurology providers at a large, non-profit medical center, wished to standardize care for patients suffering from acute, IH. In order to create the clinical guideline, the developer had to scour through current evidence. Once the literature was critically evaluated and deemed to be high-level, it was integrated into the guideline. The clinical guideline developer discovered ways to translate the corresponding evidence to the above-mentioned practice setting. By creating an evidence-based guideline, the timeliness and effectiveness of care could be dramatically improved; thus, patient outcomes positively impacted. Another DNP essential that supported this project was "Interprofessional Collaboration for Improving Patient and Population Health Outcomes." The completion of this guideline required the cooperation and input from nurses, providers, and pharmacists. By employing effective communication and solid leadership skills, the accomplishment of this scholarly project was made possible. This collaboration facilitated the creation of a new guideline, which can impact patient safety, timeliness, effectiveness, and efficiency of patient care. BRAIN CODE 19 Conclusion To summarize, large vessel strokes, intracranial hemorrhages, TBIs, encephalopathies, and brain neoplasms are common acute care conditions that can cause IH (Freeman, 2015). Any delay in identifying and responding to IH can be catastrophic. Coma, profound disability, and death are complications that can often be minimized if this neurological emergency were approached in a rapid, but consistent fashion. Standardized treatment coupled with education has shown to reduce time to CT scan and appropriate interventions for ischemic strokes (Hoegerl et al., 2011). The same standardization and training for IH could benefit patient outcomes, staff efficiency, and reduce healthcare spending. BRAIN CODE 20 References Bagwell, T. A., Abramo, T. J., Albert, G. W., Orsborn, J. W., Storm, E. A., Hobart-Porter, N. W., … Nick, T. (2016). Cerebral oximetry with blood volume index and capnography in intubated and hyperventilated patients. The American Journal of Emergency Medicine, 34(6), 1102-1107. https://doi.org/10.1016/j.ajem.2016.03.005 Boone, M. D., Oren-Grinberg, A., Robinson, T. M., Chen, C. C., & Kasper, E. M. (2015). Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Surgical Neurology International, 6. https://doi.org/10.4103/2152-7806.170248 Burgess, S., Abu-Laban, R. B., Slavik, R. S., Vu, E. N., & Zed, P. J. (2016). A systematic review of randomized controlled trials comparing hypertonic sodium solutions and mannitol for traumatic brain injury: Implications for emergency department management. Annals of Pharmacotherapy, 50(4), 291-300. http://doi.org/10.1177/1060028016628893 Chesnut, R. M., Temkin, N., Carney, N., Dikmen, S., Rondina, C., Videtta, W., … Hendrix, T. (2012). A trial of intracranial-pressure monitoring in traumatic brain injury. New England Journal of Medicine, 367(26), 2471-2481. http://doi.org/10.1056/NEJMoa1207363 Cumbler, E., Zaemisch, R., Graves, A., Brega, K., & Jones, W. (2012). Improving stroke alert response time: Applying quality improvement methodology to the inpatient neurologic emergency. Journal of Hospital Medicine, 7(2), 137-141. https://doi.org/10.1002/jhm.984 Dunkley, S., & McLeod, A. (2016). Therapeutic hypothermia in patients following traumatic brain injury: a systematic review. Nursing in Critical Care. http://doi.org/10.1111/nicc.12242 BRAIN CODE 21 Emergency Neurological Life Support (2016, March 19). Elevated ICP or herniation [PDF file]. Retrieved from http://enlsprotocols.org/files/ICP.pdf Ghajar, J. (2000). Traumatic brain injury. The Lancet, 356(9233), 923-929. Hoegerl, C., Goldstein, F. J., & Sartorius, J. (2011). Implementation of a stroke alert protocol in the emergency department: A pilot study. The Journal of the American Osteopathic Association, 111(1), 21-27. Jagannatha, A. T., Sriganesh, K., Devi, B. I., & Rao, G. S. U. (2016). An equiosmolar study on early intracranial physiology and long term outcome in severe traumatic brain injury comparing mannitol and hypertonic saline. Journal of Clinical Neuroscience, 27, 68-73. https://doi.org/10.1016/j.jocn.2015.08.035 Jensen, T. S., Carlsen, J. G., Sørensen, J. C., & Poulsen, F. R. (2016). Fewer complications with bolt-connected than tunneled external ventricular drainage. Acta Neurochirurgica, 158(8), 1491-1494. https://doi.org/10.1007/s00701-016-2863-8 Kalanuria, A., Geocadin, R., & Püttgen, H. (2013). Brain code and coma recovery: Aggressive management of cerebral herniation. Seminars in Neurology, 33(02), 133-141. http://doi.org/10.1055/s-0033-1348961 Lin, S.-Y., Tang, S.-C., Tsai, L.-K., Yeh, S.-J., Shen, L.-J., Wu, F.-L. L., & Jeng, J.-S. (2015). Incidence and risk factors for acute kidney injury following mannitol infusion in patients with acute stroke: A retrospective cohort study. Medicine, 94(47), e2032. http://doi.org/10.1097/MD.0000000000002032 Mangat, H. S., Chiu, Y., Gerber, L.M., Alimi, M., Ghajar, J., & Härtl, R. (2016). Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic BRAIN CODE 22 brain injury. Journal of Neurosurgery, 124(1), 277-277. http://doi.org/10.3171/2015.10.JNS132545a Oertel, M., Kelly, D. F., Lee, J. H., McArthur, D. L., Glenn, T. C., Vespa, P., … Martin, N. A. (2002). Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury. Journal of Neurosurgery, 97(5), 1045-1053. O'Phelan, K. H., Merenda, A., Denny, K.G., Zaila, K.E., & Gonzalez, C. (2015). Therapeutic temperature modulation is associated with pulmonary complications in patients with severe traumatic brain injury. World Journal of Critical Care Medicine, 4(4), 296-301. http://doi.org/10.5492/wjccm.v4.i4.296 Pillay, L., & Hardcastle, T. (2016). Collective Review of the Status of Rapid Sequence Intubation Drugs of Choice in Trauma in Low- and Middle-Income Settings (Prehospital, Emergency Department and Operating Room Setting). World Journal of Surgery. https://doi.org/10.1007/s00268-016-3712-x Rangel-Castillo, L., & Robertson, C. S. (2006). Management of intracranial hypertension. Critical Care Clinics, 22(4), 713-732. Roh, D., & Park, S. (2016). Brain multimodality monitoring: Updated perspectives. Current Neurology and Neuroscience Reports, 16(6), 56. http://doi.org/10.1007/s11910-0160659-0 Stevens, R. D., Shoykhet, M., & Cadena, R. (2015). Emergency Neurological Life Support: Intracranial hypertension and herniation. Neurocritical Care, 23, S76-S82. http://doi.org/10.1007/s12028-015-0168-z BRAIN CODE 23 Stangroom, J. (2017). Wilcoxon signed-rank test calculator. Retrieved from http://www.socscistatistics.com/tests/signedranks/Default2.aspx Stollings, J. L., Diedrich, D. A., Oyen, L. J., & Brown, D. R. (2014). Rapid-sequence intubation a review of the process and considerations when choosing medications. Annals of Pharmacotherapy, 48(1), 62-76. Yokobori, S., & Yokota, H. (2016). Targeted temperature management in traumatic brain injury. Journal of Intensive Care, 4(1). https://doi.org/10.1186/s40560-016-0137-4 Zeng, J., Zheng, P., Tong, W., & Fang, W. (2014). Decreased risk of secondary brain herniation with intracranial pressure monitoring in patients with haemorrhagic stroke. BMC Anesthesiology, 14(1), 1. Zhu, Y., Yin, H., Zhang, R., Ye, X., & Wei, J. (2016). Therapeutic hypothermia versus normothermia in adult patients with traumatic brain injury: a meta-analysis. SpringerPlus, 5(1). https://doi.org/10.1186/s40064-016-2391-2 BRAIN CODE 24 Appendix A Model of the components of the Normalization Process Theory BRAIN CODE 25 Model of the components of the Normalization Process Theory BRAIN CODE 26 Appendix B DNP Proposal Presentation BRAIN CODE 27 DNP Proposal Presentation BRAIN CODE 28 BRAIN CODE 29 BRAIN CODE 30 Appendix C IRB Approval BRAIN CODE 31 IRB Approval BRAIN CODE 32 Appendix D Brain Code Guideline BRAIN CODE 33 Brain Code Guideline BRAIN CODE 34 BRAIN CODE 35 Appendix E Elevated ICP PowerPoint BRAIN CODE 36 Elevated ICP PowerPoint BRAIN CODE 37 BRAIN CODE 38 Appendix F Elevated ICP Pre-/Post-Test BRAIN CODE 39 Elevated ICP Pre-/Post-Test 1. What conditions can lead to elevated intracranial pressure (ICP)? a. Ischemic stroke b. Traumatic brain injury c. Subarachnoid hemorrhage d. Seizure e. Hepatic encephalopathy f. B g. A, B, & C h. A, B, C, E i. All of the above 2. What are the possible consequences of elevated ICP? a. Decreased cerebral blood flow b. Cerebral herniation c. Death d. B & C e. All of the above 3. What are common signs/symptoms of elevated ICP? a. Pinpoint pupils, aggressive behavior, tachycardia b. Altered mental status, headache, nausea, vomiting, pupil dilation c. Numbness/tingling of the lower extremities, hypertension, tachypnea d. None of the above 4. If you recognize symptoms of elevated ICP, what should you do? a. Notify a provider immediately b. Order a STAT CT scan c. Place an NG tube d. Perform standard measures e. A and D 5. What are the standard measures for elevated ICP that nurses can perform without an order? Select all that apply. a. HOB elevated >30 degrees b. Tracheal suction and reposition the patient c. Maintain the patient's airway d. Bolus 1L of D5NS e. Lay the patient flat f. Keep the patient's neck in a neutral position BRAIN CODE 40 Appendix G Brain Code Guideline Questionnaire BRAIN CODE 41 Brain Code Guideline Questionnaire Strongly Disagree Disagree Neutral Agree Strongly Agree The guideline appears easy to use. Implementing the guideline would be feasible. The guideline would improve mine and my unit's efficiency towards the care of this emergency. Please feel free to write any additional comments/recommendations below. Your responses are appreciated. BRAIN CODE 42 Appendix H Poster Presentation BRAIN CODE 43 Poster Presentation BRAIN CODE 44 Appendix I Clinical Poster BRAIN CODE 45 Clinical Poster BRAIN CODE 46 BRAIN CODE 47 Appendix J Ogden Surgical-Medical Conference Poster Guidelines BRAIN CODE 48 Ogden Surgical-Medical Conference Poster Guidelines BRAIN CODE 49 BRAIN CODE 50 BRAIN CODE 51 BRAIN CODE 52 Appendix K Pre-/Post-Test Scores BRAIN CODE 53 Pre-/Post-Test Scores NURSE PRE-TEST 1 2 3 4 5 6 7 8 9 10 AVERAGES SD 4 2 3 4 2 2 4 2 4 2 2.9 0.99 POST-TEST DIFFERENCE % CHANGE 5 1 25% 2 0 0% 4 1 33% 4 0 0% 3 1 50% 5 3 150% 4 0 0% 5 3 150% 5 1 25% 5 3 150% 4.2 1.3 45% 1.03 1.25 0.65 Pre-/Post-Test Results PRE-TEST POST-TEST 6 5 Score 4 3 2 1 0 1 2 3 4 5 6 Nurse 7 8 9 10 BRAIN CODE 54 Appendix L Wilcoxon Calculation BRAIN CODE 55 Wilcoxon Calculation