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To Sleep or Not to Sleep: The Unasked Question of Hourly Neuro Checks

By Currents Editor posted 18 days ago

  
Diane McLaughlin, DNP, UF Health Jacksonville, Department of Neurology and Kimberly McPhearson, DO, Mayo Clinic Jacksonville, Department of Critical Care

Neurological checks (neuro checks) are brief, serial bedside exams performed by nursing to evaluate for changes in clinical status or neurological function. Historically conducted hourly in the neuroscience intensive care unit (NSICU), patients undergo these evaluations regardless of the time of day. A typical neuro check often includes assessment for pupillary response and level of consciousness, most often rated via the Glasgow Coma Scale (GCS) score, which assesses a patient’s ability to open their eyes and remain alert throughout the examination, answer orientation questions, and follow commands. The FOUR score may also be used in conjunction with or in place of GCS for comatose patients.  As part of a neuro check, nurses also evaluate patients’ motor strength in all four extremities, which helps screen for new focal motor deficits. The National Institutes of Health Stroke Scale (NIHSS) is commonly used to objectively measure symptom severity in stroke patients, especially in those who have suffered an ischemic stroke and received thrombolytics—these patients require frequent NIHSS exams for the first 24 hours according to national guidelines. 


The goal of serial neuro checks is to detect impending neurological deterioration early enough to facilitate timely intervention. However, there is limited evidence to support the hourly frequency of neuro checks. Historically, early recommendations included indefinite GCS observation every 10-15 minutes1; neuro checks every 15 minutes for the first hour, every 30 minutes for an hour, and then every hour2; and a maximum of one hour between neuro checks.3 None of these early recommendations came with any stated rationale. Guidelines for the neurological observation of patients with a head injury from the National Institute for Clinical Excellence (NICE) suggested neurological observation every 30 minutes until a GCS of 15 was achieved, then every hour for two hours, followed by every two hours thereafter4.  Many patients may never achieve a GCS of 15. Meanwhile, many other guidelines do not recommend specific time intervals at all.  Therefore, many institutions continue hourly neuro checks throughout their ICU stay or until these orders are questioned by nursing.

Both the utility and duration of hourly examinations have recently come under some scrutiny.  A 2005 study of 100 consecutive patients with a head injury found that these protocols were not followed in any patient, bringing the feasibility of these guidelines into question.5 Another study in patients with TBI found that patients that remained on hourly neuro checks for an excess of 4 days had greater lengths of stay compared to other patients, and that only two of these patients ultimately required neurosurgical intervention after 48 hours (both for chronic subdural hematomas).6 The first 12 hours after admission for intracranial hemorrhage have been described as the maximum period of neurologic instability with subsequent diminution of yield in neuro checks,7 while a prospective study in a heterogeneous population of neurocritical care patients showed that 63% of neurological deterioration occurred within the first 48 hours, with later deterioration less likely to be actionable and more likely related to delirium.8 Another large-scale study of 8,936 patients found that the duration of hourly neuro checks was shortest for neurosurgery and longest for neurocritical care service lines, and also found that over the course of the year, prolonged hourly neuro checks became less common.9  Most recently, a study of 231 acute ischemic stroke patients over the first 72 hours of admission found that neurological deterioration was only discovered on a scheduled neuro check 45% of the time, while other events were found outside of a scheduled neuro check 26% of the time and not detected at all in 29% of cases.10

The controversy over neuro checks and their frequency has real-world implications. There has been increasing awareness regarding the importance of sleep in the critically ill.  Negative effects from sleep deprivation can occur after just one night of missed sleep, 11 with potential impacts to all organ systems. Neurologically, patients are at increased risk for seizures, stroke, and dementia, while psychiatric manifestations include delirium, decreased attention, irritability, impaired judgement, and addictive behaviors.12-14 Respiratory effects include weakened inspiratory muscle strength and difficulty weaning from ventilator support, while cardiac effects may result from increased catecholamine activity and sympathetic surge leading to increased heart rate and blood pressure.13,14 Sleep deprivation has also been linked to endocrine disorders and immunosuppression.13,14  To combat the negative sequelae of sleep deprivation, many critical care units have enacted sleep hygiene protocols. However, neurocritical care patients are typically excluded from these protocols due to the concern that they require hourly neurological examinations. With the average sleep cycle lasting approximately 90-100 minutes, hourly neurological examinations inherently cause sleep cycle disturbances and sleep deprivation.11 All of these factors can further confound neurological assessment, making it more difficult to ascertain the true meaning of a change in exam. 

No prospective studies have compared neuro check frequency, although existing studies show a decreased yield of high-frequency neuro checks over the course of a patient’s hospitalization. As a result, there should be clinical equipoise for future prospective studies, which are needed to determine the optimal frequency and duration of these neuro checks. However, efforts at some centers to formally study less than hourly neuro checks have unfortunately stalled, as regulatory bodies have indicated it to be a significant deviation from standard of care.

In the meantime, the necessity of frequent neuro checks should be considered on a daily basis for each patient, with a thoughtful discussion of potential risks and benefits. Nursing performs more neuro checks than any other member of the patient team and should therefore feel empowered to introduce these discussions. Indeed, the most frequent intervention following nursing notification of a change in exam is provider reassessment of that same patient. A greater emphasis on expanding nursing knowledge and improving bedside examinations may ultimately lead to higher yield examinations which can be performed less frequently. This could negate the need for prolonged duration of frequent checks after the patient is out of the high-risk period of neurological decline. However, more work is needed in this understudied topic to more definitively inform clinical practice. 

References

  1. Frawley P (1990) Neurological observations. Nursing Times 86(35): 29-34.
  2. Boylan, A., Brown P (1985) Neurological observations. Nursing Times 81(27); 36-40.
  3. Edwards, S. (2001). Using the Glasgow Coma Scale: analysis and limitations. British journal of nursing, 10(2): 92-101.
  4. National Institute for Clinical Excellence. Head Injury: triage, assessment, investigation and early management of head injury in infants, children and adults. London: National Institute for Clinical Excellence, 2021.
  5. Qureshi, A., Mulleady, V., Patel, A. and Porter, K. (2005). Are we able to comply with the NICE head injury guidelines? Emergency Medicine Journal 22: 861-862.
  6. Stone, J., Childs, S., Smith, L., Battin, M., Papadakos, P. and Huang, J. (2014). Hourly neurological examinations for traumatic brain injury in the ICU. Neurological Research 36(2); 164-9.
  7. De Leon Benedetti AM, Bhatia R, Ancheta SR, Romano JG, Koch S. How Well Do Neurochecks Perform After Stroke? Stroke. 2021 Mar;52(3):1094-1097. doi: 10.1161/STROKEAHA.120.032303. Epub 2021 Jan 28. PMID: 33504183.
  8. Maas, M., Berman, M., Guth, J., Liotta, E., Prabhakaran, S., and Naidech, A. (2015). Neurochecks a biomarker of the temporal profile and clinical impact of neurologic changes after intracerebral hemorrhage. Journal of Stroke and Cerebrovascular Diseases: 1-6.
  9. McLaughlin DC, Hartjes TM, Freeman WD. Sleep deprivation in neurointensive care unit patients from serial neurological checks. J Neurosci Nurs. (2018) 50:205–10. doi: 10.1097/JNN.0000000000000378LaBuzetta JN, Hirshman BR, Malhotra A, Owens RL, Kamdar BB. Practices and Patterns of Hourly Neurochecks: Analysis of 8,936 Patients with Neurological Injury. Journal of Intensive Care Medicine. July 2021. doi:10.1177/08850666211029220
  10. Drouot, X. and Quentin, S. (2015). Sleep neurobiology and critical care illness. Critical Care Clinics, 31: 379 – 391.
  11. Palma, J., Urrestarazu, E. and Iriarte, J. (2013). Sleep loss as risk factor for neurologic disorders: A review. Sleep Medicine, 14: 229-236.
  12. Chang, V.A., Owens, R.L. & LaBuzetta, J.N. Impact of Sleep Deprivation in the Neurological Intensive Care Unit: A Narrative Review. Neurocrit Care 32, 596–608 (2020). https://doi.org/10.1007/s12028-019-00795-4
  13. Kishore K, Cusimano MD. The Fundamental Need for Sleep in Neurocritical Care Units: Time for a Paradigm Shift. Front Neurol. 2021;12:637250. Published 2021 Jun 17. doi:10.3389/fneur.2021.637250

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