Reassessing Hourly Neurological Assessments: A Quality Improvement Initiative

BACKGROUND: Frequent neurological assessments (neuro-checks) are critical for early detection of neurological deterioration in patients with acquired brain injuries. However, extended use of hourly neuro-checks may negatively impact patient outcomes by contributing to sleep deprivation, intensive care unit (ICU) delirium, and staff burden. PURPOSE: This quality improvement initiative aimed to evaluate the implementation of a nurse-driven protocol to reduce unnecessary hourly neuro-checks in stable Neurocritical Care Unit (NCCU) patients after 48 hours of admission. METHODS: This project involved adult NCCU patients and staff at an academic medical center. A stepwise nurse-driven protocol, based on patient stability criteria, guided neuro-check frequency. Preimplementation and postimplementation data from electronic health records included hourly neuro-check order volumes, Confusion Assessment Method for the ICU (CAM-ICU) scores, and length of stay. Staff perceptions of the nurse-driven protocol were gathered using a survey. RESULTS: During the 3-month implementation period, the number of hourly neuro-check orders on the NCCU decreased by 19% (from 372 to 301). The proportion of patients with at least 1 positive CAM-ICU score decreased from 90 to 58 (39.8% to 31.7%), and the length of stay distribution showed fewer very short (<2 d) and/or prolonged admissions (>9 d). Staff survey responses indicated increased confidence in patient safety and improved workflow following education and protocol use. CONCLUSIONS: A nurse-led protocol to individualize neuro-check frequency was implemented successfully in the NCCU, with observed trends in patient outcomes, staff workflow efficiency, and nursing confidence. Continued evaluation is warranted to assess sustainability and generalizability across other critical care units.