Changing Team Practice: Applying Evidence-Based Brain Injury Guidelines to Clinical Practice

Abstract

Background: Trauma teams strive to provide care based on best practice. Examining the outcomes of patients sustaining severe traumatic brain injury (TBI) at our trauma center from 1994–1997, we discovered that at 6 months, 43% of the patients had expired and 30% sustained severe disability. The outcomes were consistent with some studies published on TBI in the 1980s and early 1990s. Research in the past decade on resuscitation efforts and new technology for monitoring the effects of secondary brain injury has produced improved outcomes in managing these patients. In 1995, evidence-based clinical guidelines for treating severe TBI were published recommending changes in the care of these patients. The guidelines challenged hospitals to evaluate their care practices and examine the clinical outcomes of this high-risk group. Approach: Motivated by the new practice recommendations and the potential for impacting patient outcomes, the neuro clinical nurse specialist (CNS) formed a multidisciplinary team to begin the process of performance improvement. Patient management practices were examined and relevant research evaluated. The team melded the national guidelines and supporting literature into hospital-based clinical guidelines with a series of care algorithms directing the care of these patients from admission, through the operative period, to the intensive care (ICU) phase. Prospective data were collected, and care patterns were analyzed on an annual basis. The team reconvened as needed every 12 to 18 months to discuss issues, review new literature, and alter the clinical guidelines. A vital issue emerged in 2000, which was brought to the neuro CNS by several families. Although liberal family presence was supported in the ICU, this practice was not present on the floor or rehab areas. A team of practitioners and former patients and families collaborated in August of 2000 exploring the patient-family experiences during the hospitalization. Supporting evidence-based nursing literature was reviewed, which led to the adoption of family-centered care throughout patients' hospitalization. Findings: Seven years after integrating these changes, the 6-month outcomes have improved dramatically: 72.1% showed good outcome/moderate disability, 13.6% showed severe disability to persistent vegetative state, and 14.3% died. In addition, families have become a vital force in our team's care. With key hospital team members, the families have developed a TBI family manual and formed a “call-back program” to provide support to new TBI families. The TBI families have donated more than $3 million in gifts/money to support the program. Discussion: This presentation will utilize a performance improvement approach revealing the actions used by the team to apply evidence-based guidelines and literature to the clinical setting. Statistical analysis using an ordinal regression model will provide outcome data emphasizing the positive aspects of applying evidence-based guidelines/literature to practice.