Survey of Bedside Clinical Neurologic Assessments in U.S. PICUs*

Abstract

Objective To understand how routine bedside clinical neurologic assessments are performed in U.S. PICUs. Design Electronic survey. Setting Academic PICUs throughout the United States. Subjects Faculty representatives from PICUs throughout the United States. Interventions None. Measurements and Main Results We surveyed how routine bedside neurologic assessments are reported to be performed in U.S. PICUs and the attitudes of respondents on the utility of these assessments. The survey contained questions regarding 1) components of neurologic assessments; 2) frequency of neurologic assessments; 3) documentation and communication of changes in neurologic assessment; and 4) optimization of neurologic assessments. Surveys were received from 64 of 67 institutions (96%). Glasgow Coma Scale and pupillary refl were the most commonly reported assessments (80% and 92% of institutions, respectively). For patients with acute brain injury, 95% of institutions performed neurologic assessments hourly although assessment frequency was more variable for patients at low risk of developing brain injury and those at high risk for brain injury, but without overt injury. In 73% of institutions, any change detected on routine neuroassessment was communicated to providers, whereas in 27%, communication depended on the severity or degree of neurologic decline. Seventy percent of respondents thought that their current practice for assessing and monitoring neurologic status was suboptimal. Only 57% felt that the Glasgow Coma Scale was a valuable tool for the serial assessment of neurologic function in the ICU. Ninety-two percent felt that a standardized approach to assessing and documenting preillness neurologic function would be valuable. Conclusions Routine neurologic assessments are reported to be conducted in nearly all academic PICUs in the United States with fellowship training programs although the content, frequency, and triggers for communication vary between institutions. Most physicians felt that the current paradigms for neurologic assessments are suboptimal. These data suggest that optimizing and standardizing routine bedside nursing neurologic assessments may be warranted. (Pediatr Crit Care Med 2018; 19:339–344)

Training needs analysis of Korean nurses' neurological assessment competency

“…Among 297 neurological ward nurses, perceived proficiency in performing an orientation exam, documenting mental status, and testing extremity muscle strength was high, while that of assessing accessory nerves, hypoglossal nerves, and cerebellar function was low (Kim et al, ). Kirschen et al () also supports this point, as their study indicates that the bedside nursing neurological assessment is suboptimal in pediatric intensive care units.…”

“…With the score of 3.32 on a 4 point scale (75th percentile) defined as the cut-off value for overall competency, 74.6% of nurses reported scores below that level. Some previous studies have also highlighted the suboptimal neurological assessment competency in assessing the consciousness level (Brunker & Harris, 2015), cerebellar function (Kim et al, 2016), application of the Glasgow Coma Scale (Waterhouse, 2008), pupil size interpretation (Brunker & Harris, 2015;Kerr et al, 2016), and bedside nursing neurological assessment practice (Kirschen et al, 2018). Standardized practice in the use of assessment scales is needed, because the greatest variation existed in training methods for the use of the instruments (Kirschen et al, 2019;Vink et al, 2018).…”

Bedside clinical neurologic assessment utilisation in paediatric cardiac intensive care units

“…Current literature focusses mainly on predictability and reliability of the Glasgow Coma Scale, with data derived largely from adults with altered consciousness from acute neurologic injury 10 . A recent paediatric ICU survey showed that routine bedside neurologic assessments were conducted at nearly all institutions 15 . Although examination elements were variable, Glasgow Coma Scale and pupillary reflex were the most commonly performed elements.…”

“…Numerous paediatric coma scales have been developed to address some these issues, although they have not been validated in the cardiac ICU population 10 14 We demonstrated substantial variability in neurologic assessment practices in academic paediatric medical–surgical ICUs throughout the United States, 15 although it remains unclear how neurologic assessment is performed in cardiac ICUs.…”

Pediatric Neurocritical Care and Neuromonitoring in 2018—Maybe We Need to Go Back to the Basics?*

“…It seems plausible that a “back to basics” approach might be appropriate so that assumptions can be questioned regarding these resource-intense studies. In this issue of the Journal, Kirschen and colleagues provide substantial evidence to advance this approach (8). Fundamental to all clinical studies – and good clinical practice – is a common understanding of the child’s neurologic condition.…”