Semester

Summer

Date of Graduation

2025

Document Type

Dissertation

Degree Type

DNP

College

School of Nursing

Department

Anesthesiology

Committee Member

Rachel Lumbus

Committee Member

Heather Carter-Templeton

Committee Member

Angela Jeffries

Committee Member

Amanda Foster

Abstract

ABSTRACT

Reassessing Hourly Neurological Assessments: A Quality Improvement Initiative

Haley Lynne Johnson, BSN, RN

Background: Stroke and brain injuries remain among the leading causes of mortality in the United States, accounting for 162,890 deaths in 2021 (Centers for Disease Control and Prevention [CDC], 2021). Although frequent neurological assessments are essential for monitoring patient status, limited evidence supports the prolonged use of hourly neuro-checks (LaBuzetta et al., 2022). Excessive neuro-check frequency has been linked to sleep deprivation, an increased risk of delirium, and inefficient resource utilization (Kishore et al., 2021).

Purpose: This project aimed to assess the impact of a nurse-driven neuro-check protocol in the Neurocritical Care Unit (NCCU) by decreasing the frequency of neuro-checks and reducing patient disruptions to help mitigate ICU delirium and enhance workflow efficiency.

Methods: This project was conducted in the NCCU at J.W. Ruby Memorial Hospital, a Level 1 trauma center and Joint Commission-certified Comprehensive Stroke Center. Participants included adult patients requiring neuro-checks and NCCU nursing staff. Data on total patients with hourly neuro-check orders, protocol adherence, usage, patient length of stay (LOS) averages, CAM-ICU delirium scores, and staff workload satisfaction were collected before and after the intervention. Quantitative data were analyzed using Epic’s SlicerDicer software and Excel software, while staff perspectives were assessed through Qualtrics surveys. [HT1]

Interventions: A nurse-driven neuro-check protocol was introduced, allowing for a stepwise reduction in neuro-check frequency, starting with hourly assessments, transitioning to every two hours, and eventually every four hours, depending on patient stability after 48 hours of admission. Patients were eligible if they had an unchanging GCS motor score and were hemodynamically appropriate, as determined in collaboration with NCCU providers. Exclusion criteria targeted patients with spontaneous subarachnoid hemorrhage (SAH) due to the unpredictable risk of rebleeding within 14 days of the initial injury. The protocol was reinforced through comprehensive staff education, Epic integration, and interdisciplinary collaboration to ensure safe and effective implementation.

Results: Hourly neuro-check orders decreased by 19.1% (from 372 to 301) following implementation. CAM-ICU delirium scores showed an 8.1 percentage point drop, with pre-intervention delirium rates at 39.8% and post-intervention rates at 31.7%, indicating a 35.6% relative reduction. The distribution of length of stay (LOS) shifted, showing fewer patients with the shortest (2 days) and prolonged hospital stays (9 days), along with an increase in intermediate stays (5–7 days). Additionally, staff surveys indicated greater confidence in patient safety and improved workflow efficiency.

Conclusions: These findings indicate that a structured neuro-check protocol may decrease assessment frequency, reduce patient interruptions, and lower delirium rates while ensuring patient safety. The results are consistent with research supporting nurse-driven neuro-monitoring methods to enhance sleep hygiene and lessen ICU delirium. Given its practicality and positive effects, the protocol could be sustainable for ongoing use and scalable across critical care environments. Future research might include investigating long-term impacts of decreased neuro checks on cognitive recovery and patient outcomes in ICU settings at multiple hospital sites.

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