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Quality systems to avoid secondary brain injury in neurointensive care
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Outcome after traumatic brain injury (TBI) depends on the extent of primary cell death and on the development of secondary brain injury. The general aim of this thesis was to find strategies and quality systems to minimize the extent of secondary insults in neurointensive care (NIC).

An established standardized management protocol system, multimodality monitoring and computerized data collection, and analysis systems were used.

The Uppsala TBI register was established for regular monitoring of NIC quality indexes. For 2008-2010 the proportion of patients improving during NIC was 60-80%, whereas 10% deteriorated. The percentage of ‘talk and die’ cases was < 1%. The occurrences of secondary insults were less than 5% of good monitoring time (GMT) for intracranial pressure (ICP) > 25 mmHg, cerebral perfusion pressure (CPP) < 50 mmHg and systolic blood pressure < 100 mmHg. Favorable outcome was achieved by 64% of adults.

Nurse checklists of secondary insult occurrence were introduced. Evaluation of the use of nursing checklists showed that the nurses documented their assessments in 84-85% of the shifts and duration of monitoring time at insult level was significantly longer when secondary insults were reported regarding ICP, CPP and temperature. The use of nurse checklist was found to be feasible and accurate.

 A clinical tool to avoid secondary insults related to nursing interventions was developed. Secondary brain insults occurred in about 10% of nursing interventions. There were substantial variations between patients. The risk ratios of developing an ICP insult were 4.7 when baseline ICP ≥ 15 mmHg, 2.9 when ICP amplitude ≥ 6 mmHg and 1.7 when pressure autoregulation ≥ 0.3.

Hyperthermia, which is a known frequent secondary insult, was studied. Hyperthermia was most common on Day 7 after admission and 90% of the TBI patients had hyperthermia during the first 10 days at the NIC unit. The effects of hyperthermia on intracranial dynamics (ICP, brain energy metabolism and BtipO2) were small but individual differences were observed. Hyperthermia increased ICP slightly more when temperature increased in the groups with low compliance and impaired pressure autoregulation. Ischemic pattern was never observed in the microdialysis samples. The treatment of hyperthermia may be individualized and guided by multimodality monitoring. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 89 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1113
Keyword [en]
Traumatic brain injury, Subarachnoid hemorrhage, Intracranial pressure, Quality register, Checklist, Nursing interventions, Pressure autoregulation, Intracranial compliance, Hyperthermia, Cerebral energy metabolism, Microdialysis and Brain tissue oxygenation.
National Category
Anesthesiology and Intensive Care
Research subject
Neurosurgery
Identifiers
URN: urn:nbn:se:uu:diva-253005ISBN: 978-91-554-9270-0 (print)OAI: oai:DiVA.org:uu-253005DiVA: diva2:812442
Public defence
2015-09-10, Grönwallsalen, Akademiska sjukhuset. Ing 70, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2015-06-10 Created: 2015-05-18 Last updated: 2015-07-07Bibliographically approved
List of papers
1. Introduction of the Uppsala Traumatic Brain Injury register for regular surveillance of patient characteristics and neurointensive care management including secondary insult quantification and clinical outcome
Open this publication in new window or tab >>Introduction of the Uppsala Traumatic Brain Injury register for regular surveillance of patient characteristics and neurointensive care management including secondary insult quantification and clinical outcome
2013 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 118, no 3, 169-180 p.Article in journal (Refereed) Published
Abstract [en]

Background. To improve neurointensive care (NIC) and outcome for traumatic brain injury (TBI) patients it is crucial to define and monitor indexes of the quality of patient care. With this purpose we established the web-based Uppsala TBI register in 2008. In this study we will describe and analyze the data collected during the first three years of this project. Methods. Data from the medical charts were organized in three columns containing: 1) Admission data; 2) Data from the NIC period including neurosurgery, type of monitoring, treatment, complications, neurological condition at discharge, and the amount of secondary insults; 3) Outcome six months after injury. Indexes of the quality of care implemented include: 1) Index of improvement; 2) Index of change; 3) The percentages of 'Talk and die' and `Talk and deteriorate' patients. Results. Altogether 314 patients were included 2008-2010: 66 women and 248 men aged 0-86 years. Automatic reports showed that the proportion of patients improving during NIC varied between 80% and 60%. The percentage of deteriorated patients was less than 10%. The percentage of Talk and die/Talk and deteriorate cases was <1%. The mean Glasgow Coma Score (Motor) improved from 5.04 to 5.68 during the NIC unit stay. The occurrences of secondary insults were less than 5% of good monitoring time for intracranial pressure (ICP) >25 mmHg, cerebral perfusion pressure (CPP) <50 mmHg, and systolic blood pressure <100 mmHg. Favorable outcome was achieved by 64% of adults. Conclusion. The Uppsala TBI register enables the routine monitoring of NIC quality indexes.

Keyword
Database, neurointensive care, outcome, quality register, secondary insults, traumatic brain injury
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-204853 (URN)10.3109/03009734.2013.806616 (DOI)000321587100004 ()
Available from: 2013-08-12 Created: 2013-08-12 Last updated: 2017-12-06Bibliographically approved
2. The use of nurse checklists in a bedside computer-based information system to focus on avoiding secondary insults in neurointensive care
Open this publication in new window or tab >>The use of nurse checklists in a bedside computer-based information system to focus on avoiding secondary insults in neurointensive care
Show others...
2012 (English)In: ISRN Neurology, ISSN 2090-5505, E-ISSN 2090-5513, Vol. 2012, 903954- p.Article in journal (Refereed) Published
Abstract [en]

The feasibility and accuracy of using checklists after every working shift in a bedside computer-based information system for documentation of secondary insults in the neurointensive care unit were evaluated. The ultimate goal was to get maximal attention to avoid secondary insults. Feasibility was investigated by assessing if the checklists were filled in as prescribed. Accuracy was evaluated by comparing the checklists with recorded minute-by-minute monitoring data for intracranial pressure-ICP, cerebral perfusion pressure CPP, systolic blood pressure SBP, and temperature. The total number of checklist assessments was 2,184. In 85% of the shifts, the checklists were filled in. There was significantly longer duration of monitoring time at insult level when Yes was filled in regarding ICP (mean 134 versus 30 min), CPP (mean 125 versus 26 min) and temperature (mean 315 versus 120 min). When a secondary insult was defined as >5% of monitoring time spent at insult level, the sensitivity/specificity for the checklist assessments was 31%/100% for ICP, 38%/99% for CPP, and 66%/88% for temperature. Checklists were feasible and appeared relatively accurate. Checklists may elevate the alertness for avoiding secondary insults and help in the evaluation of the patients. This concept may be the next step towards tomorrow critical care.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-190818 (URN)10.5402/2012/903954 (DOI)22844615 (PubMedID)
Available from: 2013-01-08 Created: 2013-01-08 Last updated: 2017-12-06Bibliographically approved
3. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study
Open this publication in new window or tab >>Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study
2014 (English)In: Journal of Neuroscience Nursing, ISSN 0888-0395, E-ISSN 1945-2810, Vol. 46, no 5, 285-291 p.Article in journal (Refereed) Published
Abstract [en]

The patients at a neurointensive care unit are frequently cared for in many ways, day and night. The aim of this study was to investigate the amount of secondary insults related to oral care, repositioning, endotracheal suctioning, hygienic measures, and simultaneous interventions at a neurointensive care unit with standardized care and maximum attention on avoiding secondary insults. The definition of a secondary insult was intracranial pressure > 20 mm Hg, cerebral perfusion pressure < 60 mm Hg and systolic blood pressure < 100 mm Hg for 5 minutes or more in a 10-minute period starting from when the nursing intervention began. The insult minutes did not have to be consecutive. The study included 18 patients, seven women and 11 men, aged 36-76 years with different neurosurgical diagnoses. The total number of nursing interventions analyzed was 1,717. The most common kind of secondary insults after a nursing measure was high intracranial pressure (n = 93) followed by low cerebral perfusion pressure (n = 43) and low systolic blood pressure (n = 14). Repositioning (n = 39) and simultaneous interventions (n = 32) were the nursing interventions causing most secondary insults. There were substantial variations between the patients; only one patient had no secondary insult. There were, overall, a limited number of secondary insults related to nursing interventions when a standardized management protocol system was applied to reduce the occurrence of secondary insults. Patients with an increased risk of secondary insults should be recognized, and their care and treatment should be carefully planned and performed to avoid secondary insults.

National Category
Anesthesiology and Intensive Care
Research subject
Neurosurgery
Identifiers
urn:nbn:se:uu:diva-233431 (URN)10.1097/JNN.0000000000000077 (DOI)000341965200009 ()25188684 (PubMedID)
Available from: 2014-10-03 Created: 2014-10-03 Last updated: 2017-12-05Bibliographically approved
4. A decision-making tool to prevent secondary ICP-insults related to nursing interventions: – Evaluation of the predictive value for baseline ICP, compliance and autoregulation
Open this publication in new window or tab >>A decision-making tool to prevent secondary ICP-insults related to nursing interventions: – Evaluation of the predictive value for baseline ICP, compliance and autoregulation
(English)Manuscript (preprint) (Other academic)
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-252875 (URN)
Available from: 2015-05-13 Created: 2015-05-13 Last updated: 2015-07-07
5. The effects of hyperthermia on intracranial pressure, cerebral oxymetry, and cerebral metabolism in traumatic brain injury patients during neurointensive care
Open this publication in new window or tab >>The effects of hyperthermia on intracranial pressure, cerebral oxymetry, and cerebral metabolism in traumatic brain injury patients during neurointensive care
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-252877 (URN)
Available from: 2015-05-13 Created: 2015-05-13 Last updated: 2015-07-07

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