Recognize and Treat Intracranial Hypertension to Improve the Quality of Patient Outcomes Who are Treated in the Neuro Critical Care Unit

Background Treating intracranial hypertension (IH) and brain herniation quickly and effectively is imperative in reducing morbidity and mortality. Local Problem The Neuro Critical Care Unit (NCCU) at Intermountain Medical Center (IMC) is considered the leader within Intermountain Health Care (IHC) in treating patients with neurological conditions. There are currently no standardized protocols or guidelines in place in NCCU for the treatment of IH and brain herniation. Methods The project took place in a 12-bed NCCU. It is estimated that approximately 50 to 80 patients are treated for IH in the unit annually. The healthcare team is composed of neurologist/intensivists, neurosurgeons, advanced practice clinicians (APCs), consisting of both nurse practitioners (NPs) and physician's assistants (PAs), registered nurses (RNs), and patient care assistants (PCAs). Interventions The project involved training the physicians, APCs and RNs on the implementation of the Intracranial Hypertension and Brain Herniation guideline contained within the Emergency Neurological Life Support (ENLS) Brain Code protocol. This was done via a PowerPoint training presentation. Pre- and post-surveys were administered to the staff and the scores were compared to evaluate the effectiveness of the training. The staff members were also surveyed on whether they thought they would be able to implement the guideline in their practice. A smart phone app, which contained detailed information about the IH guideline, was developed and made available to the staff. Following one month of guideline implementation, feedback was collected from the staff members on the usability, feasibility, and satisfaction with the guideline. They were also asked to give comments on any suggestions related to the project. Pre- and post-implementation patient data was collected via electronic health record (EHR) review to compare standard NCCU treatment of IH patients to the guideline as well as evaluate the ability of the staff members to implement the guideline in their practice. Results The findings showed a statistically significant improvement (p<0.001) in the staff members' average score (M=4.02). Prior to implementation of the guideline, 16 patients were identified as having IH, three of which were treated in accordance with the IH treatment recommendations. Following implementation of the guideline, eight patients were identified as having IH and seven were treated using the IH guideline. A paired t-test between proportions was performed and showed that these results were also statistically significant (p<0.0001). Following implementation of the guideline, staff members (n=20) were surveyed regarding the usability, feasibility, and satisfaction with the guideline implementation. They responded 90% (n=18), 100% (n=20), and 85% (n=17) respectively in favor of the guideline. Conclusion This project demonstrate that providing staff members with training on the IH guideline results in improved post-survey scores when compared to the pre-survey. The NCCU staff members were able to improve their understanding of the recognition and treatment of IH and were able to successfully implement the IH guideline in their practice. The staff members also considered the usability, feasibility, and their satisfaction with the guideline to be mostly favorable.