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Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01260-x.

Background The outbreak of coronavirus disease 2019 (COVID-19) rippled across the world from Wuhan, China, to the shores of the United States within a few months. Hospitals and intensive care units were suddenly faced with a “tsunami” warning requiring instantaneous implementation and escalation of disaster plans. Evidence Review An evidence-based question was developed and an extensive review of the literature was completed, resulting in a structured plan for the intensive care units to manage a surge of patients critically ill with COVID-19 in March 2020. Twenty-five sources of evidence focusing on pandemic intensive care unit and COVID-19 management laid the foundation for the team to navigate the crisis. Implementation The Critical Care Services task force adopted recommendations from the CHEST consensus statement on surge capacity principles and other sources, which served as the framework for the organized response. The 4 S’s became the focus: space, staff, supplies, and systems. Development of algorithms, workflows, and new processes related to treating patients, staffing shortages, and limited supplies. New intensive care unit staffing solutions were adopted. Evaluation Using a framework based on the literature reviewed, the Critical Care Services task force controlled the surge of patients with COVID-19 in March through May 2020. Patients received excellent care, and the mortality rate was 0.008%. The intensive care unit team had the needed respiratory and general supplies but had to continually adapt to shortages of personal protective equipment, cleaning products, and some medications. Sustainability The intensive care unit pandemic response plan has been established and the team is prepared for the next wave of COVID-19.

BACKGROUNDThe Brain Trauma Foundation has developed treatment guidelines for the care of patients with acute traumatic brain injury. The Adam Williams Initiative is a program established to provide education and resources to encourage hospitals across the United States to incorporate the guidelines into practice.OBJECTIVETo explore the relationship in hospitals between participation in the Adam Williams Initiative and adherence to the Brain Trauma Foundation guidelines for patients with acute traumatic brain injury.METHODHospitals that participated in the Adam Williams Initiative entered data into an online tracking system of patients with traumatic brain injury for at least 2 years after the initial site training. Data included baseline hospital records and daily records on hospital care of patients with traumatic brain injury, including blood pressure, intracranial pressure, cerebral perfusion pressure, oxygenation, and other data relevant to the 15 key metrics in the Brain Trauma Foundation guidelines.RESULTSThe 16 hospitals funded by the Adam Williams Initiative had good overall adherence to the 15 key metrics of the recommendations detailed in the Brain Trauma Foundation guidelines. Variability in results was primarily due to data collection methods and analysis.CONCLUSIONSThe Adam Williams Initiative helps promote adherence to the Brain Trauma Foundation guidelines for hospital care of patients with traumatic brain injury by providing a platform for developing and standardizing best practices. Participation in the initiative is associated with high adherence to clinical guidelines, a situation that may subsequently improve care and outcomes for patients with traumatic brain injury.

Article-at-a-Glance Background From 2003–2005, a comprehensive review of all cardiac/respiratory arrests at Mission Hospital (Mission Viejo, California) uncovered deficits in knowledge and judgment in the hours preceding 75% of our non-ICU patients. Nearly half of all arrests were occurring outside the ICU, with an overall mortality rate of 60%. In addition, transfers into ICU from the floor averaged 96 patients per month. Methods A multidisciplinary team met for 12 months to develop a specialized nurse-driven rapid response team (RRT) to reduce the incidence and mortality of non–ICU arrests, reduce transfers to the ICU from the floor, and provide ICU–level nursing care for emergency department (ED) patients in extremis. The team developed an RRT protocol, a methodology for rounds and calls, and a data collection system. After gaining consensus among the nursing managers, 4.2 full-time equivalent (FTE) RRT nurse positions were created by each unit contributing portions of an FTE. Results Prospective data collected demonstrated an inpatient call frequency averaging 118 calls per 1,000 discharges; 138 calls per month were in support of the ED. Floor codes were reduced from 36 to 17 per year, and the mortality rate in the floor-code patients decreased from 61% to 26%. Unanticipated transfers from the floor units to the ICU decreased significantly. Discussion The RRT initiative delivered measurable outcomes demonstrating the hospital's commitment to saving the vulnerable hospitalized patient population. In addition, the identification of critical system and clinical issues resulted in efforts to improve processes and identify patient subpopulations at risk (for example, patients with congestive heart failure, end-stage heart disease, high-dose narcotics).

Introduction: Standard monitoring of severe traumatic brain injury patients (TBI) by intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring fails to recognize episodes of cerebral oxygen desaturation. We found and characterized frequent episodes of desaturation of jugular venous oxygen (SjO2) in the face of normal ICP and CPP. Methods: Fifty six patients with severe TBI had SjO2 and ICP monitors placed. The charts were retrospectively reviewed and all episodes of desaturation were recorded and characterized. Results: Nineteen patients had episodes of desaturation with normal ICP and CPP. The average GCS score was 5.8. 63% of desaturations occurred in the first 24 hours, 17% of desaturations occurred in 24-48 hours, and 20% occurred in 48-72 hours. The depth of desaturation was 50-54% in 50% of instances, 45-49% in 37% of instances, and 40-44% in 13% of in- stances. The duration of the desaturation episodes was less than 10 minutes in 47%, 10-30 minutes in 17%, 30-60 minutes in 23%, and greater than 50 minutes in 13%. Treatment of the desaturation was elevation of FIO2 in all patients, elevation of pCO2 in 15 patients, volume expansion in 9 patients, pressors in 9 patients, and Propofol in 5 patients. Conclusions: The monitoring of severe TBI patients with ICP and CPP alone is insufficient to recognize cerebral oxygen de- saturation episodes in 34% of patients. The monitoring of SjO2 facilitates the recognition and treatment of these episodes.

Cessation of circulation during cardiac arrest causes critical end-organ ischemia. Although the neurological consequences of cardiopulmonary arrest can be catastrophic, an aggressive “push fast and push hard” resuscitation technique maintains blood flow until the return of spontaneous circulation. However, reperfusion to the cerebrum leads to cellular chaos and further neurological injury. Use of moderate hypothermia after cardiac arrest mediates these cellular and chemical processes, reducing the impact of the arrest and reperfusion phenomena. A 43-year-old man had 2 asystolic arrests with 20 minutes of cardiopulmonary resuscitation as a result of massive, multiple pulmonary emboli. After the cardiac arrest, the patient was comatose and posturing. The 2005 American Heart Association guidelines for cardiopulmonary resuscitation were used along with moderate hypothermia in an attempt to minimize the neurological consequences of the cardiopulmonary arrest and to optimize the patient’s outcome.

Patients with severe traumatic brain injury resulting in increased intracranial pressure refractory to first-tier interventions challenge the critical care team. After exhausting these initial interventions, critical care practitioners may utilize barbiturate-induced coma in an attempt to reduce the intracranial pressure. Titrating appropriate levels of barbiturate is imperative. Underdosing the drug may fail to control the intracranial pressure, whereas overdosing may lead to untoward effects such as hypotension and cardiac compromise. Monitoring for a therapeutic level of barbiturate coma includes targeting drug levels and using continuous electroencephalogram monitoring, considered the gold standard. New technology, the Bispectral Index monitor, utilizes electroencephalogram principles to monitor the level of sedation and hypnosis in the critical care environment. This technology is now being considered for targeting appropriate levels of barbiturate coma.

Trauma teams strive to provide care based on best practice. Exploring the clinical outcomes of patients sustaining severe traumatic brain injury (TBI) at our trauma centre from 1994–97 we found that the outcomes were marginal at best: 43% of our patients expired and 30% suffered severe disability. These results were consistent with those of some studies on TBI published in the 1980s. Researchers in the past decade have used new technology for monitoring the effects of secondary brain injury and examined the effects of various treatment modalities on the outcomes of patients with TBI. In 1995, the American Association of Neurological Surgeons (AANS) evidence-based clinical guidelines for managing severe TBI were published.1 The guidelines recommended changes in the care of patients with TBI and challenged caregivers to evaluate their practices and examine the clinical outcomes of this high risk group. Motivated by the new practice recommendations and the potential for greatly affecting patient outcomes, Mission Hospital Regional Medical Center’s (MHRMC) multidisciplinary neurotrauma team convened in 1997 to begin performance improvement. Current practice was examined and new hospital based clinical guidelines were developed. Numerous changes were recommended as the team dismantled current practice patterns and constructed new care priorities. The result was a series of algorithms with established outcomes at every phase of the patient’s hospital course. Four years after integrating the changes in practice, the team evaluated prospectively collected data to determine outcomes for patients with severe TBI. Current outcomes (2001 data) indicated that 72.8% of patients had a good outcome (no disability to moderate disability), 13.6% had severe disability to persistent vegetative state, and 13.6% died. We will present a FOCUS-PDCA performance improvement approach to show the processes used to apply national scientific guidelines to the clinical setting. Statistical analysis using an ordinal regression model will show outcome …

BackgroundTraumatic brain injury poses a serious public health challenge. Treatment paradigms have dramatically shifted with the introduction of the American Association of Neurologic Surgeons (AANS) Guidelines for the Management of Severe Head Injury. Implementation of the AANS guidelines positivel

The treatment options and management of ischemic and hemorrhagic stroke are expanding. Neuroradiologic interventions are being used in acute care settings to change the course of these devastating processes. These interventions include the injection of intra-arterial urokinase for ischemic stroke, use of coils to secure aneurysms, and balloon angioplasty for increasing the lumen of spastic cerebral arteries in patients with cerebral vasospasm. Using a case study approach, these three options for managing stroke patients will be integrated, and nursing strategies for delivering care to the stroke patient will be profiled.

An important aspect of nursing care is to assist patients in the process of adaptation as proposed by Roy. An individual's response to the diagnosis of stroke and the everchanging environment affords the nurse a tremendous opportunity to assess the patient and factors that may ultimately influence quality of living. Given the devastating consequences of stroke, the efforts directed at improving patient compliance are well placed. Nurses have the opportunity to teach those patients under their direct care as well as those individuals in the community setting. Nurses can also play an instrumental role in health promotion strategies, incorporating lifestyle modifications as well as information based on medication therapy. Taking advantage of professional organizations such as the National Stroke Association, the American Heart Association, and the multiple neuroscience organizations who have developed the Brain Attack Coalition, materials can be accessed and used for acute care and community health education programs. Acute care nurses interact with a variety of women on a daily basis. Each patient presents with her unique physiology and associated risk factors. Acute care nurses must be attuned to these factors and be ready to intervene with assessment, education, and collaboration with the health care team in order to reduce the incidence of stroke in women.

Managing the critical neuroscience patient population challenges practitioners because of both the devastating injury involved and the complexity of care required. Emerging technology provides the neuroscience intensive care unit team with better information on the intricate physiology and dynamics inside the cranium. In particular, the team is better able to detect changes in pressure, oxygen, and blood flow. With improved data in hand, the team can intervene to optimize intracranial dynamics, possibly reducing disability and death among such patients.

This article describes the potential application of brain tissue oxygen monitoring technology in the care of patients who have sustained traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH). To accomplish this objective, a review of the intracranial dynamics that are created by primary and secondary brain injury, and the challenges of optimizing oxygen delivery to the injured brain are presented. Furthermore, interventions that facilitate cerebral oxygen supply and reduce oxygen consumption are identified. Finally, application of this technology is highlighted by using case vignettes of patients who have TBI or SAH.

New neurointerventional procedures affect patient outcomes following stroke. Intraarterial thrombolysis, cerebral angioplasty, coils placed inside aneurysms, and vessel occlusion with embolic agents serve as options for stroke patients with conditions not as amenable to traditional surgical or medical management. By understanding these new neurointerventional therapies, critical care nurses can utilize a focused neurological assessment to intervene and maintain perfusion to the brain following the procedures.

Ruptured intracerebral aneurysm causes instantaneous neurologic chaos and is associated with high morbidity ad mortality. The event initiates a cascade of physiologic and structural changes that manifest themselves in a variety of clinical symptoms. The critical care team of nurses, physicians, and therapists must rapidly identify the cause; understand the pathology; and use advanced assessment techniques, medications, and interventions to stabilize the patient and to counter the horrendous effects of the injury. Interventions that include endovascular aneurysm coiling and cerebral angioplasty are providing new options for isolating the aneurysm and countering the effects of vasospasm. Through an integrated team approach, recovery from ruptured aneurysm will be maximized.

Background: Trauma teams strive to provide care based on best practice. Examining the outcomes of patients sustaining severe traumatic brain injury (TBI) at our trauma center from 1994–1997, we discovered that at 6 months, 43% of the patients had expired and 30% sustained severe disability. The outcomes were consistent with some studies published on TBI in the 1980s and early 1990s. Research in the past decade on resuscitation efforts and new technology for monitoring the effects of secondary brain injury has produced improved outcomes in managing these patients. In 1995, evidence-based clinical guidelines for treating severe TBI were published recommending changes in the care of these patients. The guidelines challenged hospitals to evaluate their care practices and examine the clinical outcomes of this high-risk group. Approach: Motivated by the new practice recommendations and the potential for impacting patient outcomes, the neuro clinical nurse specialist (CNS) formed a multidisciplinary team to begin the process of performance improvement. Patient management practices were examined and relevant research evaluated. The team melded the national guidelines and supporting literature into hospital-based clinical guidelines with a series of care algorithms directing the care of these patients from admission, through the operative period, to the intensive care (ICU) phase. Prospective data were collected, and care patterns were analyzed on an annual basis. The team reconvened as needed every 12 to 18 months to discuss issues, review new literature, and alter the clinical guidelines. A vital issue emerged in 2000, which was brought to the neuro CNS by several families. Although liberal family presence was supported in the ICU, this practice was not present on the floor or rehab areas. A team of practitioners and former patients and families collaborated in August of 2000 exploring the patient-family experiences during the hospitalization. Supporting evidence-based nursing literature was reviewed, which led to the adoption of family-centered care throughout patients' hospitalization. Findings: Seven years after integrating these changes, the 6-month outcomes have improved dramatically: 72.1% showed good outcome/moderate disability, 13.6% showed severe disability to persistent vegetative state, and 14.3% died. In addition, families have become a vital force in our team's care. With key hospital team members, the families have developed a TBI family manual and formed a “call-back program” to provide support to new TBI families. The TBI families have donated more than $3 million in gifts/money to support the program. Discussion: This presentation will utilize a performance improvement approach revealing the actions used by the team to apply evidence-based guidelines and literature to the clinical setting. Statistical analysis using an ordinal regression model will provide outcome data emphasizing the positive aspects of applying evidence-based guidelines/literature to practice.