Routine Neurological Assessments by Nurses in the Pediatric Intensive Care Unit

Kirschen, Matthew P.; Lourie, Kristen; Snyder, Megan; Agarwal, Kenya; DiDonato, Pamela; Kraus, Blair; Madu, Chinonyerem; Geddes, Kylie; Nadkarni, Vinay; Davis, Daniela; Wolfe, Heather; Topjian, Alexis

doi:10.4037/ccn2019198

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Cover| June 01 2019

Routine Neurological Assessments by Nurses in the Pediatric Intensive Care Unit

Matthew P. Kirschen, MD, PhD;

Matthew P. Kirschen, MD, PhD

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

Corresponding author: Matthew Kirschen, md, phd, Children’s Hospital of Philadelphia, Department of Critical Care Medicine, 3401 Civic Center Blvd, 8 NE, Ste 8566, Philadelphia, PA 19104 (email: kirschenm@chop.edu).

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Kristen Lourie, BSN, RN, CCRN;

Kristen Lourie, BSN, RN, CCRN

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Megan Snyder, MSN, RN, ACCNS-P, CCRN;

Megan Snyder, MSN, RN, ACCNS-P, CCRN

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Kenya Agarwal, BSN, RN, CPN, CCRN;

Kenya Agarwal, BSN, RN, CPN, CCRN

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Pamela DiDonato, BSN, CCRN;

Pamela DiDonato, BSN, CCRN

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Blair Kraus, MSN, RN;

Blair Kraus, MSN, RN

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Chinonyerem Madu, MPH;

Chinonyerem Madu, MPH

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Kylie Geddes, LSSGB;

Kylie Geddes, LSSGB

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Vinay Nadkarni, MD;

Vinay Nadkarni, MD

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Daniela Davis, MD, MSCE;

Daniela Davis, MD, MSCE

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Heather Wolfe, MD, MSHP;

Heather Wolfe, MD, MSHP

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Alexis Topjian, MD, MSCE

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children’s Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children’s Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia.

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Crit Care Nurse (2019) 39 (3): 20–32.

https://doi.org/10.4037/ccn2019198

Background

Brain injury with changes in clinical neurological signs and symptoms can develop while children are undergoing treatment in the intensive care unit. Critical care nurses routinely screen for neurological decline by using serial bedside neurological assessments. However, assessment components, frequency, and communication thresholds are not standardized.

Objectives

To standardize neurological assessment procedures used by nurses, improve compliance with physicians’ ordering and nurses’ documentation of neurological assessments, and explore the frequency with which changes from preillness neurological status and previous assessments can be detected by using the assessment tool developed.

Methods

A quality improvement intervention was implemented during a 1-year period in a 55-bed pediatric intensive care unit with 274 nurses. Procedures for neurological assessment by nurses were standardized, a system for physicians to order neurological assessments by nurses at a frequency based on the patient’s risk for brain injury was developed and implemented, and a system to compare patients’ current neurological status with their preillness neurological status was developed and implemented.

Results

Process metrics that focused on compliance of ordering and documenting the standardized neurological assessments indicated improvement and sustained compliance greater than 80%. Exploratory analyses indicated that 29% of patients had an episode of neurological decline and that these episodes were more common in patients with developmental disabilities than in patients without such disabilities.

Conclusions

Compliance with physicians’ ordering and nurses’ documentation of standardized neurological assessments significantly increased and had excellent sustainability. Further work is needed to determine the sensitivity of standardized nurses’ neurological assessment tools for clinically meaningful neurological decline.

2019

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