Neuro Nursing – Quality Markers

Quality can be defined as “the extent to which health care services provided to individuals and populations improve desired health outcomes”. –WHO

Deeparani1, Satheesh Grahadurai2, Ponniah Vanamoorthy3

1Deputy Nursing Superintendent, Kauvery Hospital, Radial Road, Tamil Nadu

2Senior consultant & clinical lead, Interventional Radiology (Neuro), Kauvery Hospital, Radial Road, Tamil Nadu

3Head &Senior consultant, neuroanesthesiology & neurocritical care, Kauvery Hospital, Radial Road, Tamil Nadu

Neuro Nursing

It is a wide set of distinctive area within the discipline of nursing. It focuses on the care of individuals with brain, spine and nervous system disorders. In neuro, nursing quality indicators are measurable elements used to assess and enhance the quality and safety of care provided to the patients with neurological conditions.

Why these indicators are essential

  • Early detection and escalation to prompt intervention
  • To improve quality and patient safety in general
  • Promote evidence based practice and continuity of care
  • Guides clinical decision making
  • Reduced hospital re-admission
  • Positive self-reported Quality of life
  • Increases independency in performing Activities of Daily Living

Application of Donabedian model Quality indicators in Neuro nursing

The Donabedian model is a widely used framework for assessing healthcare quality by categorizing information into three interconnected components: structure, process and outcomes. Each component serves as a basis for developing specific quality indicators.

Source extracted from Donabedian model

Structure Measures

  • Nurse-to-patient ratio in neuro-critical care units.
  • Nursing work force in neuro critical care areas is to be determined by the criticality/acuity level of the patients.
  • 1:1 ratio for high acuity level and 1:2/3 for non-ventilated patients and for patients who need minimal support by the nursing staff.
  • This means the number of patients per nurse can be adjusted based on:
  • The severity and complexity of each patient’s illness.
  • The number of admissions, discharges, and transfers during a shift.
  • The experience and skill mix of the nursing staff.
  • The physical layout and available resources of the unit.

Availability of specialized equipment (e.g., ICP monitors, stroke carts)

A Neuro ICU’s equipment availability includes essential life support like ventilators and monitors, alongside specialized neurological tools such as electroencephalogram (EEG), Transcranial Doppler and intracranial pressure monitors. Advanced facilities also have on-site or easily accessible neuroimaging like CT and MRI scans, and devices for targeted temperature management.

Access to neurosurgical and interdisciplinary teams.

Access to neurosurgical and interdisciplinary teams refers to the availability of both specialized neurosurgeons and a group of healthcare professionals from different fields working together to provide patient care. This integrated approach is crucial for complex cases, leading to improved outcomes, fewer errors, and more efficient treatment plans.

Certification and training levels of neuro nurses (e.g., RN certification).

Neuro ICU nursing training involves obtaining a certification in BSc/DGNM Nursing is mandatory and followed by specialized training in critical care skills like advanced assessments (GCS/NIHSS (National institutes of health stroke scale) interpreting complex data and managing critical interventions. Privileging in neuro ICU nursing means nurse-demonstrated skills in independently handling patients with complex neurological conditions like stroke, brain tumors, poly trauma.

Staff training on ACLS and staff matrix with neuro experience

Staff training on ACLS in the neuro ICU should focus on the core ACLS principles, including a systematic approach, high-quality BLS, advanced airway management, rhythm recognition, defibrillation, and medication administration. Training should also emphasize the unique considerations of neuro-critical care, such as supporting oxygenation and circulation to preserve neurological function, and understanding potential reversible causes of cardiac arrest like the “H’s and T’s” in the context of the neurological patient. Hands-on simulations and focusing on team leader roles are also crucial for effective implementation.

Process Measures

Neurological Assessment Frequency & Accuracy

  • Regular and accurate documentation of Glasgow Coma Scale (GCS) scores.
  • Monitoring of pupil size and reactivity, limb power, sensation, and mental status, behavioral pain scale.
  • Early identification and reporting of neurological deterioration.
  • Intracranial Pressure (ICP) Management
  • Timely recognition and response to elevated ICP.
  • Proper use and monitoring of external ventricular drains (EVDs) and ICP monitors.

Stroke Care Indicators

  • Timeliness of nursing care in stroke protocol activation.
  • Monitoring for signs of bleeding post-thrombolysis or mechanical thrombectomy.
  • Dysphagia screening within 24 hours to prevent aspiration.

Seizure Management

  • Timely administration of anticonvulsants.
  • Accurate documentation of seizure activity, duration, and interventions.
  • Implementation of safety precautions during seizures.

Outcome indicators

  • Mortality Rate (ICU and Hospital): Overall, risk-adjusted by diagnosis (e.g., TBI, SAH, stroke). Percentage of deaths among total Neuro ICU admissions.
  • Neurological Functional Outcome: Scales used are Glasgow Outcome Scale (GOS), Modified Rankin Scale (mRS), or Cerebral Performance Category (CPC). Percentage of patients discharged with GOS ≥4 or mRS ≤3.
  • Length of Stay (LOS): Average ICU LOS and hospital LOS (days).
  • Readmission to ICU within 48/72 hours: Percentage of Neuro ICU discharges readmitted for neurological deterioration.
  • Seizure Control Rate: Percentage of patients with seizures successfully managed within 24 hours.
  • Secondary Neurological Injury Incidence: Elevated ICP, hypoxia, hypotension, or rebleeding (for SAH).
  • Tracheostomy and Ventilation Outcomes: Tracheostomy in the ICU generally improves outcomes for patients on prolonged mechanical ventilation by providing a more secure airway, improving comfort, and facilitating weaning from the ventilator. Early tracheostomy, performed within the first 10 days, is associated with reduced sedation, shorter ICU stays, and a lower incidence of ventilator-associated pneumonia (VAP).
  • Discharge Disposition: Percentage discharged home vs. step-down vs. rehab vs. mortality.

For patients undergoing Neuro rehabilitation

  • Functional gain following rehabilitation (Improvement in physical quality and activity)

Neurology

  • Percentage of stroke patients in whom the Door-to-needle time of 60minutes is achieved. (time taken for stroke patients to receive IV thrombolytic)

Stroke quality indicators

These indicators assess the timeliness, safety and patient outcomes across the stroke care continuum- from emergency response to discharge of patients and rehabilitation services.

Timeliness to treatment

Door to needle time

Door-to-needle time is a quality indicator that measures the time from a patient’s arrival at the emergency department to the administration of intravenous thrombolysis for acute ischemic stroke. A shorter door-to-needle time is a key goal in stroke care.

Door to Imaging time (CT/MRI)

The “door-to-CT scan time” is a quality indicator for emergency care, especially for suspected strokes, measuring the time from a patient’s arrival to the completion of their CT scan. The target is typically under 20 – 25 minutes for acute stroke patients, and faster times are linked to better outcomes.

Door to Groin puncture time

Door to groin puncture time (DTP) is a quality indicator that measures the time from a patient’s arrival at the hospital to the initiation of a catheter-based treatment, such as a mechanical thrombectomy for stroke.

Patient outcomes

30-day re-admission rate

The 30-day unplanned hospital readmission rate is a quality indicator used to assess the quality of inpatient care, with higher rates often indicating potential issues with the initial hospital stay or discharge planning. It measures the percentage of patients who are re-admitted to a hospital within 30 days of being discharged for any reason, such as complications, inadequate discharge preparation, or other avoidable factors

Patient-reported outcome measures (PROMs)

  • Patient-reported outcomes are important to understanding whether health care services and procedures make a difference to patients’ health status and quality of life.

For example:

Quality of life for patient undergone neuro critical care in hospital can be measured by using following standardised tools

QoL toolUses
Short form health survey (SF-36)General health related QoL across 8 domains
EuroQol (EQ-5D)Standardized tool for health status and utility values
World Health Organization Quality of Life scale long form (WHOQOL-100)WHO instrument assessing physical, psychological, social and environment QoL
PDQ-39Parkinsons specific QoL
MSQol-54(Multiple Sclerosis)Combines generic and MS specific QoL items
QoLIE-31Tailored to epilepsy patients
Neuro QOLSpecifically designed for patients with neurological conditions
Stroke impact scaleMeasures the impact of stroke on daily life

Nursing sensitive indicators in Neuro ICU

  • Neurological assessment compliance
  • Pupil reaction and GCS monitoring accuracy
  • ICP monitoring compliance
  • Seizure precaution compliance
  • Timely recognition and escalation of neuro changes-BEFAST
  • Swallowing assessment before oral intake
  • Pain and spasticity assessment
  • EVD pressure monitoring and bundle compliance
  • Patient comfort and quality of care
  • Counselling by the nurses
  • Motor function assessment
  • Discharge readiness/education score

Conclusion

Neuro nursing care is a tailored made where acuity levels of each patient differs. Key components include continuous neurological monitoring, managing symptoms like pain, preventing complications, patient education, and interdisciplinary collaboration. Skill set of nurses in neuro ICU are highly recommended to manage and monitor clinical parameters, which contribute to the better clinical outcomes thereby to quality indicators.

References

[1] Vanja C Douglas, A Proposed Roadmap for Inpatient Neurology Quality Indicators, PMCID: PMC3726101 PMID: 23983832

[2] Adam B Cohen, Quality measures for neurologists, PMCID: PMC3613219 PMID: 23634383

[3] Certification standard for stroke centre, NABH

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