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The Neurointensive Care Nursery and Evolving Roles for Nursing

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The Neurointensive Care Nursery and Evolving Roles for Nursing The Neurointensive Care Nursery and Evolving Roles for Nursing Susan Peloquin, RN, MS, PNP Annette Carley, DNP, NNP, PNP Sonia L. Bonifacio, MD Hannah C. Glass, MDCM, MAS Disclosure ABSTRACT The authors have no relevant financial interest or affiliations Neonatal neurocritical care is an emerging subspecialty that combines the expertise of critical care with any commercial interests medicine and neurology with that of nursing and other providers in an interprofessional team related to the subjects discussed approach to care.1,2 Neurocritical care of the neonate has roots in adult and pediatric practice. It within this article. has been demonstrated that adults with acute neurologic conditions who are treated in a specialized No commercial support or neurocritical care unit have reduced morbidity and mortality, as well as decreased length of stay, lower sponsorship was provided for this educational activity. costs, and reduced need for neurosurgical procedures. In pediatrics, neurocritical care has focused on various primary and secondary neurologic conditions complicating critical care that also contribute to mortality, morbidity, and duration of hospitalization. However, the concept of neurocritical care as a subspecialty in pediatric practice is still evolving, and evidence demonstrating improved outcomes is lacking.3–5 In the neonatal intensive care nursery, neurocritical care is also evolving as a subspecialty concept to address both supportive and preventive care and optimize neurologic outcomes for an at-risk neonatal patient population. To enhance effectiveness of this care approach, nurses must be prepared to appropriately recognize acute changes in neurologic status, implement protocols that specifically address neurologic conditions, and carefully monitor neurologic status to help prevent secondary injury. The complexity of this team approach to brain-focused care has led to the development of a specialized role: the neurocritical care nurse (neonatal intensive care nursery [NICN] nurse). This article will review key concepts related to neonatal neurocritical care and the essential role of nursing. It will also explore the emerging role of the NICN nurse in supporting early recognition and management of at-risk infants in this neonatal subspecialty practice. Keywords: neonatal; neurology; neurocritical care; nurse EO NATAL NEUROCRITICAL CARE Is than a distinct care setting or unit.4 Brain Na rapidly emerging subspecialty injury is common in pediatrics, and primary building on adult and pediatric critical care neurologic disorders and neurologic sequelae practice experience and combining expertise of critical illness often complicate care. As is in neurology and critical care medicine.1,2,3,6 the case with adults, pediatric intensive care It has been shown that adults with acute patients experiencing neurologic complica- neurologic conditions treated in a special- tions have greater mortality and long-term ized neurocritical care unit have reduced morbidity, as well as increased duration of morbidity and mortality, as well as short- hospital stay.4 However, data demonstrat- ened length of hospital stay, lower costs, and ing the impact of neuroprotective care on reduced need for neurosurgical procedures.7 patients are lacking, and researchers recog- In the pediatric population, neurocritical nize the need to generate data that support care has been expressed as a care focus to the contribution of this care focus in terms support neuroprotective concepts, rather of improved outcomes.4,5 Accepted for publication October 2015. N EONATAL N ETWORK VOL. 35, NO. 2, MARCH/APRIL 2016 © 2016 Springer Publishing Company 87 http://dx.doi.org/10.1891/0730-0832.35.2.87 I n neonatal critical care, the development of neurocriti- initial person to recognize infants who display findings of cal care as a subspecialty focus is recent, and preventive and brain dysfunction or injury, and nurses educated to recog- supportive practices are continually being developed and nize the clinical aspects of common neurologic illnesses tested. In 2008, UCsF Benioff Children’s Hospital rec- can help optimize care of all neonates with or at risk for ognized the need to establish a neonatal neurocritical care neurologic impairment.10,11 In addition to sustained train- subspecialty practice and established the Neuro-Intensive ing of a core team of NICN nurses who are the primary Care Nursery (NICN).8 The goal of this subspecialty prac- nursing care providers for neurologic patients, all nursing tice, integrated into the NICU, was to manage neonates staff receive education in preventive and early-recognition affected by or at risk for neurologic injury. The complexity strategies during general orientation and continuing educa- of care needs for these at-risk infants, including specialized tion activities. use of therapies such as therapeutic hypothermia, bedside Many neurologic conditions can benefit from NICN brain activity monitoring, and pharmacologic interventions care. Neonatal encephalopathy is estimated to complicate demanded creation of an expert, interprofessional team. 2/1,000 births. Although relatively uncommon, it is a major Under the direction of a neonatal medical director, pediatric cause of neonatal mortality and long-term disability in survi- neurologist, and neurocritical care nursing coordinator, the vors.12 specific disorders in the term and preterm infant that NICN provides care for infants with primary and second- may benefit from NICN care include seizures, HIE, stroke, ary neurologic conditions such as stroke, hypoxic-ischemic intra- and extracerebral hemorrhage, central nervous system encephalopathy (HIE), seizures, and brain malformations, (CNs) infections, vascular malformations such as vein of as well as those at risk for neurologic complications.9 Among Galen malformations, developmental brain anomalies such the goals of the NICN are (1) provide brain-focused care as holoprosencephaly, neonatal-onset epilepsies, and genetic using an interprofessional team approach, (2) provide rapid and metabolic disorders. seizure response through early recognition and reduced Neonates with neurologic conditions may have multi- time to treat, (3) support long-term follow-up care needs organ system dysfunction. Thus, the approach to effective for infants at risk for or recuperating from neurologic injury, comprehensive care for NICN patients must extend beyond and (4) generate and disseminate cutting-edge research the brain to other organ systems as well. The hypoxia related to neurocritical care.9 since it was established, the and/or ischemia that contributes to the development of NICN has evaluated and/or cared for more than one thou- HIE, for example, may also manifest in multisystem dys- sand patients. function of the pulmonary, cardiovascular, gastrointestinal, hematologic, and renal systems.13 An interprofessional team approach to care that can adequately address multisystem PATIENTS WHO MAY BENEFIT needs is essential to provide effective anticipatory care to FROM NEUROCRITICAL CARE at-risk populations. Both bedside nurses and NICN nurses A dvances in critical care practices have improved survival confident in the ability to recognize and intervene early with in critically ill newborns; however, rates of neurologic com- neurocritical care support will contribute to effective care plications in survivors are high. It has been estimated that practice. As an example, infants with acute symptomatic sei- one-quarter of infants admitted to referral nurseries have zures or with benign or malignant neonatal-onset epilep- a neurologic complication or injury. These patients with sies will likely benefit from efficient recognition and prompt acute, subacute, or chronic neurologic conditions are likely management of seizures. to benefit from focused neurocritical care and the expertise Beyond management of neurologic injury that has already of a specially trained neurocritical care team that includes occurred, there is a role of the NICN in establishing care nursing.1,2 recommendations for preventive brain-focused care that can T he neonatal population served by the neurocritical care be integrated into the neonatal intensive care nursery prac- focus of the NICN currently includes critically ill infants tice for other at-risk populations. Preterm infants, especially with confirmed neurologic injury such as HIE, stroke, or those born ,28 weeks gestational age or ,1,500 g birth intra/extracerebral hemorrhage, as well as infants at risk weight have increased rates of short-term and long-term for injury. To support ongoing development and delivery neurologic complications including intraventricular hemor- of both supportive and preventive NICN care practice, staff rhage (IVH) and poor neurodevelopmental outcomes. The including neonatal nurses need training, targeted educa- incidence of IVH increases as gestational age decreases, and tion, and practice experiences. since 2008, a core team that severe IVH complicates 12–15 percent of very low birth now totals 38 NICN nurses at our institution have received weight infants ,1,500 g at birth.14 CThe NI N nurses, specialized education and training in elements of neuro- nursing staff, and other members of the NICN care team critical care practice including common neurologic condi- have the opportunity to develop and institute supportive tions in the newborn, hands-on mentored performance of care practices that can likely moderate the clinical course of neurologic exams, and use of neuromonitoring tools
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