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Use of Multimodality Monitoring Spreads—Slowly

Jane Martinsons, Staff Writer
Poll question: Do you use multimodality monitoring?
The current trend of using multimodality monitoring for patients with traumatic brain injury is spotty at best, with several large medical centers having successfully used it for years, while most others just note it on their capital-equipment wish list, pending adequate funding. It's a highly desired commodity. According to several experts who recently spoke with Synapse E-News, monitoring an array of modalities beyond cerebral intracranial pressure—including brain temperature, brain tissue oxygenation, and cerebral blood flow, as well as microdialysis—allows providers to get a far fuller and more comprehensive clinical picture of each patient's condition as well as a keener understanding of cerebral dynamics in general.
    "With a patient in coma, multimodality monitoring provides a series of clinical information that is monitored for trends with the opportunity to intervene and reverse processes before they lead to secondary brain injury," says Eileen Maloney Wilensky, MSN ACNP-BC, director of clinical research at the University of Pennsylvania Health System in Philadelphia, which instituted its multimodality monitoring program 8 years ago. "We just don't use one monitor or variable, we use them all in concert with each other—intracranial pressure, brain oxygenation, temperature, CO₂, CPP [cerebral perfusion pressure], microdialysis—and try to put into context what is occurring in the patient's brain as a result of systemic and intercerebral factors to make the best decision for that patient."
    Cindy Sullivan, MN RN ANP-C CNRN, of Forsyth Medical Center in Winston-Salem, NC, agrees that multimodality monitoring allows for more individualized and finely tuned care of patients with traumatic brain injury (TBI). "In the critical care arena, we're looking at the patient's cellular level and using modalities such as brain tissue oxygenation, microdialysis, and cerebral blood flow. We're really honing in on the person's individual makeup. Our goal is to establish how we can best maximize our treatment approach to that individual patient and thereby promote brain recovery by decreasing secondary brain injury processes like ischemia and hypoxia."
    Such monitoring also is altering treatment paradigms, says Katherine Helmick, MS CRNP CNRN, deputy director of clinical and educational affairs for the Defense and Veterans Brain Injury Center in Washington, DC. With it, "you may change your ventilator settings, or pull back on the fluids that you're giving a patient," she says, or "you may treat fever differently or more aggressively."
    The trend is being fueled in part by new evidence-based guidelines published last year by the Brain Trauma Foundation, which include a section on brain oxygen monitoring. These guidelines are having a positive impact on outcome measures. Mission Hospital Regional Medical Center in Mission Viejo, CA, for instance, implemented the guidelines in 1997, long before most other hospitals. By comparing its 6-month outcomes before and after implementing the guidelines, the hospital found that mortality had gone from 43% to 13.5% currently; they saw similar decreases in the same time period for severe disability, from 30% to 14%. In addition, the hospital's "good outcomes" was 27% for 6 months during the pre-guideline period, dating January 1994 to June 1997. Today, it is 72.5%.
    "It is about applying the evidence," says Mary Kay Bader, MSN RN CCRN CCNS CNRN, a clinical nurse specialist at Mission. Word of the hospital's positive outcomes has spread nationwide, due in no small part to a $1.3 million initiative funded by the Adam Williams Foundation, which was founded by the mother of a brain-injured patient who was successfully treated at Mission. Since 2004, the hospital has launched 22 trauma centers that use its treatment protocol.
    "Our patients stay in our hospital far longer than at other facilities around the country. Our average intensive care unit (ICU) length-of-stay is about 19 days," Bader says. "We focus on physiologic outcomes. You can't do anything about that primary injury once that happens," she says, "but you can monitor the brain for secondary injury, minimize the impact of that injury and, hopefully, maximize [patients'] recovery."
Meanwhile, these experts note other trends on the horizon in TBI. Among them:
    Microdialysis. Although federally approved and used at several centers, microdialysis is not yet a standard of care, Maloney Wilensky says. "The best thing we can do in TBI is to find those markers that indicate brain crisis (cellular injury) and then employ interventions that reverse the process before secondary injury occurs," she says.
    Neuroimaging. Helmick says that work is being conducted in neuroimaging, including PET [positron emission tomography] and SPECT [single-photon emission computed tomography] imaging, and functional magnetic resonance imaging. "All these things are trying to help us piece together what's happening in the brain from a physiological and chemical standpoint. These new high-tech modalities can better help us understand what parts of the brain get stimulated for different functions, like thinking functions and fatigue."
    Synthetic blood. Maloney Wilensky says that a federally approved synthetic blood product for treating TBI patients in the field may become a reality in coming years. At least one company is finalizing its protocol for clinical study on its product.
    As new technologies emerge, however, the family must never be overlooked. "We can't forget that they're one of our stakeholders in this," Helmick says. "We can't forget the personal touch and remembering that the family is part of that patient unit."
    In her recent keynote address at the AANN Annual Educational Meeting, Lee Woodruff—whose husband, television news reporter Bob Woodruff, sustained a brain injury caused by a roadside bomb in Iraq—stressed the important role nurses played in responding to and caring for them as a family. "Lee clearly, and very nicely, articulated the role of neuroscience nurses in caring for the family unit, providing education in small pieces," says Helmick, who consulted on the case. "The whole concept of hope is really what she was discussing."
    Bader stresses that at her hospital, "we're strong believers in advocating for family presence at the bedside—for as many hours as they want," she says. "It's about caring for the family unit, helping them understand what's going on, and having them as partners with you at the bedside. I think patients do better when their families are engaged; even when patients are in a coma I think they sense on some level that their family's there."
    Family education is key, Sullivan says. "When you are treating and caring for a patient with any sort of traumatic brain injury—mild, moderate, or severe—ongoing education is needed so that the family understands what's going on with the patient's brain," she notes. "You want to educate them about the location of the brain injury and what to anticipate with their loved one."
     As for now, "we are moving so far forward in how we address brain-injured patients," Maloney Wilensky states. "Unlike our cardiac partners, never before have we had the 'armor' that we have now to approach this disease in our monitoring tools. It's a very, very exciting time for neuroscience nurses and what they bring to the table. They are our bedside partners who are responsible for minute-to-minute 24/7 technologic monitoring, trending, and employing interventions that save patients' lives."