Let Them Sleep: The Case for Less Neuro Checks

In Florence Nightingale’s 1859 Notes on Nursing, she wrote, “Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing.” Sleep as an essential element of healing and good health is widely recognized. Yet one aspect of care in Neuro ICUs makes restorative sleep near impossible.

Neuro checks, in which bedside nurses assess signs of neuroworsening, are typically hourly for neurocritical patients. That’s an improvement from 30 years ago, when neuro checks were recommended as frequently as every 15 minutes.

Yet hourly neuro checks have come under a lot of scrutiny in new research that suggests they are performed longer than necessary and that the sleep disruption does more harm than good.

Clinicians and researchers are calling for a paradigm shift in use of hourly neuro checks. “The most important first step to changing practice is addressing the lack of awareness pertaining to the magnitude of the problem,” researchers write in a recent article in Frontiers of Neurology. “Healthcare provider anxiety contributes to the frequency of neuro checks for prolonged periods of time, and there is an inherent resistance among staff to diminish the frequency of these neuro checks.”

Current Use of Hourly Neuro Checks

To uncover neuro check practice and patterns, researchers at UC San Diego Health performed a 75-month retrospective dataset analysis of 8,936 patients with neurological injury at a tertiary care academic setting.

Using electronic health records, they looked at hourly neuro check orders for patients in ICU care for acute brain injury or spinal cord injury, those requiring postoperative monitoring following intradural manipulation or dural compromise, and those at risk for cerebral hemodynamic changes.

Their analysis revealed that:

• • 19% of patients had hourly neuro checks for 3 or more days
  • 7% received hourly neuro checks for 7 or more days
  • 50% of patients received hourly neuro checks for 30% of their entire hospitalization
  • Patients admitted with coma, increased ICP, and subarachnoid hemorrhage tended to experience hourly neuro checks for the longest duration

Perhaps most notably, in almost 25% of patients, hourly neuro checks were transitioned to no neuro checks instead of less frequent ones. The authors surmise this could indicate that the hourly checks weren’t being reassessed and optimized for patients’ needs.

“While some of these prolonged neuro checks may have been necessary (i.e., for neurocritical care patients experiencing vasospasm and/or cerebral edema as part of acute brain injury evolution), the majority were likely the byproduct of an order (e.g., 1 placed in the emergency department or based on a consultant recommendation) that unintentionally went unnoticed and/or lacked a corresponding discontinuation order or recommendation,” they write, “a theory supported by the large proportion of such orders that transitioned directly from hourly to no neuro checks.”

While the above found that nearly 30% of Neuro ICU patients received hourly checks for 72-plus hours, prior research indicates that the ideal time frame is shorter. For example, a study of patients with spontaneous intracerebral hematoma revealed hourly neurological assessment was most needed in the first 12 hours. In a study of neurosurgical patients, the majority of neuro deterioration occurred within 48 hours.

The Seriousness of Sleep Deprivation

Some of the same UC San Diego Health researchers also published a 2019 review discussing the specific impact of sleep deprivation in the neurological intensive care units.  These patients experience fragmented sleep that is off cycle of circadian rhythms, with patients getting 50% of their sleep during the day.

Because sleep research on ICU patients is sparse, Chang et al. looked at literature on obstructive sleep apnea patients, whose fragmented sleep patterns they believe most resemble that of patients in ICUs.

Some of the specific impacts they cited are:

Cardiovascular

Even one night of disturbed sleep may have hypertensive effects, which is particularly concerning for Neuro ICU patients, they note, who have strict blood pressure parameters. It is also correlated with increased blood pressure variability.

Pulmonary

Chang et al. reference studies that found lack of sleep may impact inspiratory muscle endurance, ventilator response and respiratory motor plasticity.

Immune System

Sleep has been linked to cell function and recovery that impact the body’s response to viruses and infections.

Neuropsychological Effects

“There is significant overlap in the risk factors, pathophysiology, and presentation of sleep deprivation and delirium,” they write, “particularly the hypoactive subtype which is characterized by lethargy and sedation.” In addition to delirium, they cite that sleep deprivation has major impacts on cognitive function, psychiatric status and perception of pain.