• Pilot Implementation Project of the FOUR Score in a Neurocritical Care Unit

      Aparicio, Johanna (2017)
      Introduction: The neurological exam is performed and monitored closely by clinicians to trend, intervene, and improve patient outcomes. The Full Outline of UnResponsiveness Score (FS) is a novel, reliable, and validated tool that can be used to trend neurological exams in critical care settings. The FS assesses brainstem function, can be used among intubated comatose patients, and can detect subtle neurologic changes. Background: The Neurocritical Care Unit (NCCU) in a large urban academic medical center currently uses the Glasgow Coma Scale (GCS) for neurological exam monitoring. However, the medical providers were interested trialing the FS. The purpose of this project was to determine the feasibility for the adoption of the FS into routine practice. A pilot implementation project was conducted with the Advanced Practice Providers (APPs) [i.e. Nurse Practitioners (NP) and Physician Assistants (PA)] to determine if the APPs would use the FS and discuss the FS during rounds. The adoption of the FS should improve neurological exam trending and may also improve provider confidence in making treatment decisions and prognostication. Methods: APPs performed the FS once per shift for four weeks on each patient in the 10-bed East NCCU. Daily FS compliance and discussions during rounds were measure. The APPs experience with the FS was measured at the end of the project with the User Experience Questionnaire (UEQ). Results: Eleven APPs completed the project. Overall, weekly compliance decreased (76% to 25%) along with daily discussion during rounds (95%-55%). APP experience with the FS tool was excellent for perspicuity (ease of learning to use the product; M=2.32; SD=0.60; 95% CI=1.96-2.68) and efficiency (ease and speed of use; M=2.16, SD=0.71, 95% CI=1.74-2.58) and average on all other UEQ scales. Conclusions: Although compliance rates were low, the FS was well received by the APPs. The APPs rated their experience with the FS tool as excellent, practical, easy to learn and easy to use. The FS adoption into practice is feasible however a longer implementation period is needed to further explore compliance factors affecting adoption and sustainability. Lessons learned from this project will assist in a revised implementation plan for adoption of the FS under development at the practice site with the goal to transition away from the GCS and to the FS during the next 1-2 years.