The effectiveness of clinical pathway-directed care on hospitalisation-related outcomes in patients with severe traumatic brain injury: A quasi-experimental study

Project to improve the management of the head injury patients presenting to the emergency department

INTRODUCTION

At Sandwell General Hospital, there was no risk stratification tool or pathway for head injury (HI) patients presenting to the emergency department (ED). This resulted in significant delays in the assessment of HI patients, compromising patient safety and quality of care.

AIMS

To employ quality improvement methodology to design an effective adult HI pathway that: ensured >90% of high-risk HI patients being assessed by ED clinicians within 15 min of arrival, reduce CT turnaround times, and aiming to keep the final decision making <4 hours.

METHODS

SWOT analysis was performed; driver diagrams were used to set out the aims and objectives. Plan-Do-Study-Act cycle was used to facilitate the change and monitor the outcomes. Process map was designed to identify the areas for improvement. A new HI pathway was introduced, imaging and transporting the patients was modified, and early decisions were made to meet the standards.

RESULTS

Data were collected and monitored following the interventions. The new pathway improved the proportion of patients assessed by the ED doctors within 15 min from 31% to 63%. The average time to CT head scan was decreased from 69 min to 53 min. Average CT scan reporting time also improved from 98 min to 71 min. Overall, the average time to decision for admission or discharge decreased from 6 hours 48 min to 4 hours 24 min.

CONCLUSIONS

Following implementation of the new HI pathway, an improvement in the patient safety and quality of care was noted. High-risk HI patients were picked up earlier, assessed quicker and had CT head scans performed sooner. Decision time for admission/discharge was improved. The HI pathway continues to be used and will be reviewed and re-audited between 3 and 6 months to ensure the sustained improvement.

Nursing Interventions to Prevent Secondary Injury in Critically Ill Patients with Traumatic Brain Injury: A Scoping Review

Background: Traumatic brain injury is a prevalent health issue with significant social and economic impacts. Nursing interventions are crucial in preventing secondary injury and improving patient prognosis. This scoping seeks to map and analyze the existing scientific evidence on nursing interventions aimed at preventing secondary injuries in critically ill patients with traumatic brain injury. Methods: The review was conducted according to Arksey and O'Malley's methodological framework. The electronic databases Pubmed, MEDLINE Complete, CINAHL Complete, Nursing & Allied Health Collection: Comprehensive, Cochrane Central Register of Controlled Trials, and Cochrane Clinical Answers were consulted in May 2023. We included articles published in English and Portuguese between 2010 and 2023. Results: From the initial search, 277 articles were identified, with 15 meeting the inclusion criteria for the review. Nursing interventions for TBI patients include neuromonitoring, therapeutics, analytical surveillance, professional training, and family support. Nurses play a crucial role in detecting neurological changes, administering treatments, monitoring metabolic markers, training staff, and involving families. These interventions aim to prevent secondary injury and improve patient outcomes. Conclusions: By prioritizing evidence-based practice and utilizing innovative technologies, nurses enhance TBI patient care and contribute to overall well-being.

Clinical Pathway for Enhanced Recovery in the Management of Non-Variceal Upper Gastrointestinal Bleeding: A Randomized Controlled Trial

Purpose

To explore the effects of the clinical pathway on the outcomes of patients with non-variceal upper gastrointestinal bleeding.

Materials and Methods

Randomized controlled trial. The study was conducted in two medical centers in China from 1 June 2022 to 31 December 2022. Patients with a diagnosis of non-variceal upper gastrointestinal bleeding who provided written informed consent were consecutively assigned to the intervention group. The patients in the intervention group were treated using the clinical pathway, while the control group received routine care and follow-up. Time, cost, complications, and prognostic indicators were analyzed. Intentional-to-treat analysis and per-protocol analysis were used for data analysis.

Results

A total of 114 eligible patients with non-variceal upper gastrointestinal bleeding were randomly divided into two groups and included in the intention-to-treat analysis. In addition, 106 patients were included in the per-protocol analysis. The median age of the 106 patients was 57 years (range, 18-92 years) and 83.0% were male. There were no significant differences between groups regarding the baseline characteristics. The intervention group demonstrated a statistically significantly shorter length of stay, lower hospital cost (ie, cost during hospitalization, cost in the emergency room, and cost in the ward), significantly fewer cases of complications, and a higher level of patient satisfaction when compared with the control group. There was no significant difference between the two groups in the rates of transfusion, repeat endoscopy, rebleeding readmission, and mortality.

Conclusion

The implementation of the clinical pathway for patients with non-variceal upper gastrointestinal bleeding may help improve patient outcomes and satisfaction.

Trial Registration Number

ChiCTR2200060316.

Registration Link

https://www.chictr.org.cn/.

Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature

Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.

Outcomes of family-centred auditory and tactile stimulation implementation on traumatic brain injured patients

AIM

To determine the outcomes of Family-centred Auditory and Tactile Stimulation Implementation on Traumatic Brain Injured Patients in Egypt.

BACKGROUND

Family engagement in the care of their relatives in the Intensive care units is limited due to patients' life-threatening conditions, in addition to the use of high technology in these settings. Auditory and tactile sensory stimulations are among the diverse sensory stimulations that have received more attention in brain injured patients than other senses as being considered safe, and effective measures.

DESIGN

A Quasi-experimental design was used to test the hypotheses of this study.

METHODS

A convenience sample of 60 adult patients suffering from Traumatic Brain Injury and admitted to the intensive care units of two University Hospitals in Egypt was included in the study. Patients were assigned into two equal groups: control and study groups (30 patients each). The auditory and tactile stimulations were provided by trained family members, once daily for 2 weeks for the study group. Whereas routine communication was provided by the family of traumatic brain injured patients in the ICU for the control group. Two tools were used for data collection; tool one, the "Glasgow Coma Scale" to assess patient's level of consciousness, and tool two the "Physiological Adverse Events Assessment" to monitor patients for the occurrence of physiological adverse events.

DATA COLLECTION

January to October 2019.

RESULTS

The implementation of an organized auditory and tactile stimulation by trained family members is associated with highly statistically significant positive effects . Patients in the study group showed a higher mean of consciousness, lower incidence rate of physiological adverse events, and a lower mean duration of ICU stay.

CONCLUSIONS

Implementation of an organized auditory and tactile stimulation by trained family members enhanced the consciousness level of comatose Traumatic Brain Injured patients, decreased the occurrence of physiological adverse events, and ICU length of stay. Thus, it is recommended for use in the daily routine nursing care of comatose Traumatic Brain Injured patients.

RELEVANCE TO CLINICAL PRACTICE

This study gives a deeper understanding of how family engagement in the care of their critically ill relative enhances their recovery and improve their level of consciousness.

Effect Analysis of Clinical Pathway Nursing Combined with Humanized Nursing in Cerebral Infarction

Objective

To make the application effect of clinical pathway nursing combined with humanized nursing clear in cerebral infarction.

Methods

Hundred patients who suffered from cerebral infarction had been hospitalized in our hospital and they become our study objects. By means of the random number table, they were separated into 50 cases both in the control group and in the observation group. The control group accepted the routine nursing, and the observation group accepted the clinical pathway nursing mixed with humanized nursing. The followings were compared including the hospitalization expenses and length of stay, National Institutes of Health Stroke Scale (NIHSS), Barthel index rating scale (BI), Fugl-Meyer Assessment (FMA), and the incidence of complications and recurrence rate. A comparison was made between the two groups about satisfaction with nursing.

Results

In contrast with the control group, the treatment expenses and length of stay in the observation group were considerably reduced (P < 0.05). In contrast, before nursing, the NIHSS marks of the two groups decreased considerably after nursing, and the scores of BI and FMA increased considerably, the NIHSS scores of the observation group were considerably lower than those of the control group, and the scores of BI and FMA were considerably higher than those of the control group (P < 0.05). In contrast with the control group (44.00%, 12.00%), the incidence of complications (22.00%) and recurrence rate (2.00%) in the observation group were considerably lower (P < 0.05). In contrast with the control group (72.00%), the satisfaction of nursing in the observation group (96.00%) was considerably higher (P < 0.05).

Conclusion

The application effect of clinical pathway nursing combined with humanized nursing in cerebral infarction is significant. It can not only effectively reduce hospitalization expenses and hospitalization time, improve neurological function, ability of daily living, and limb motor function but also reduce complications and recurrence and improve patients' satisfaction with nursing, which has a high clinical reference value.