For children who enter hospitals with traumatic brain injuries (TBI), meaningful recovery that results in a long and independent life is the highest of priorities. At St. Louis Children’s Hospital, a specially designed team in the neurocritical care program steps up to that task, and their interdisciplinary collaboration and aggressive treatment are improving outcomes for patients.
The neurocritical care program is directed by Jose Pineda, MD, a Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program scholar (2009-2013) and assistant professor of pediatrics and neurology at Washington University School of Medicine. St. Louis Children’s Hospital was one of the first in the nation to implement a neurocritical care program, which relies on an interdisciplinary team of experts from critical care, neurosurgery, neurology, surgery, anesthesia, and radiology.
“We hold regular patient discussions and reach a consensus on a lot of treatment decisions before the patient even comes to us,” Pineda says. “That allows the team to really focus on what’s unique to each patient. Since we don’t have to worry about the things we know we should be doing for them, we’re more likely to catch any curve balls the patient throws at us.”
The program educates front-line staff on best clinical practices. It is overseen by a full-time clinical nurse coordinator––something unique to the neurocritical care program at St. Louis Children’s Hospital. “We felt it was important to have a clinical coordinator who could fully focus on this patient population,” Pineda says, “whose job it was to make sure these kids get the best care and that best clinical practices are really put into action.”
Pineda recently co-authored a study in Lancet Neurology that examined the hospital’s outcomes for children with TBI, before and after the neurocritical care program was implemented in 2005. The first-of-its-kind study examined 123 cases over more than 12 years.
The researchers found that patients treated after the neurocritical care program was implemented were more likely to be discharged with favorable outcomes, such as being discharged to home instead of to an inpatient rehabilitation facility or another acute care facility. Before the program launched, 52 percent of patients either died or were admitted to long-term care facilities, but only 33 percent had that outcome after the neurocritical care program was put in place.
The program also resulted in more aggressive care, the study found, which may have contributed to the better outcomes. Monitoring for intracranial hypertension––resulting from swelling of the brain––was started earlier and maintained for a longer period than before the program was implemented.
“Our data shows that outcomes might be improved by changing the process of care in a way that stably implements a cooperative program of accepted best practices … This care model exploits evidence-based best practice guidelines and complementary expertise inherent to multidisciplinary teams which achieve synergy as members work concurrently, rather than serially, on problems,” the study says.
A Two Way Street
Pineda first saw a need for better communication and standardization of care while studying how TBI unfolds at the cellular level, as part of his Harold Amos Medical Faculty Development Program research. The ICU is like a laboratory, he says, but “sometimes you can’t detect the signal you’re looking for because of all the excess noise. I knew that we had to make care more homogenous so that there would be less noise in the system.”
“We knew that streamlining care and focusing on best clinical practices would be a good thing for patients,” he adds.
The detailed training for staff on the best clinical practices is an important part of the program, but so is continuous quality improvement through evaluation and feedback, Pineda says.
“It’s always an evaluation process,” he explains. Members of the neurocritical care program are given feedback on every case, no matter the outcome. “You can’t give people materials and just expect them to apply them effectively and efficiently. It’s a two way street––you have to give them something in return. Team members enjoy when patients do well, and part of the process is making sure this important feedback is also communicated to them.”