Hourly neurologic assessments for traumatic brain injury in the ICU

Hourly neurologic assessments for traumatic brain injury (TBI) in the critical care setting are common practice but prolonged use may actually be harming patients through sleep deprivation. We reviewed practice patterns at our institution in order to gain insight into the role of frequent neurological assessments.

A 6-month retrospective review was performed for patients who were admitted to an intensive care unit (ICU) with the diagnosis of TBI. Electronic medical records were reviewed based on billing codes. Variables collected included but were not limited to patient demographics, frequency of nursing neurologic evaluations, Glasgow coma scale (GCS), length of stay (LOS), and disposition.

A total of 124 patients were identified, 71% male with the average age of 52 years (range 19-96). Traumatic brain injury was classified as severe in 44, moderate in 18, and mild in 62 patients. A total of 89 (71.8%) patients underwent hourly nursing assessments for an average of 2.82 days. The median LOS for all patients was 7 days (range 0-109). There were 18 patients who remained on hourly neurological assessments for greater than 4 days and had a greater LOS (23 days vs 9 days, P  =  0.001). Only two patients required surgery after 48 hours, both for chronic subdural hematomas.

Hourly neurologic checks are necessary in the acute period for patients with potentially expansible intracranial hemorrhages or malignant cerebral edema, but prolonged use may be harmful. Patients with a low probability of requiring neurosurgical intervention may benefit from reducing the total duration of hourly assessments.