Effect of Implementing Initial Neuroprotective Nursing Care on Outcomes of Traumatic Brain Injury Patients

: Background : Traumatic brain injury (TBI) is the most leading cause of mortality and disability worldwide, with long-term complication. Implementing initial neuro-protective nursing care could improve the results for TBI patients. Aim : The study aimed to assess the effect of implementing initial neuroprotective nursing care on outcomes of TBI patients . Method : This study was carried out at the emergency department of the Emergency Hospital, Mansoura University, using a quasi-experimental research method . 78 patients composed of a convenience sample, 39 of whom were in the study group and 39 of whom were in the control group, of both genders who aged more than or equal 18 years, and admitted to the previously setting were included. Data was gathered using a single tool of initial traumatic brain injury patients’ assessment tool. Results : it revealed a significant improvement in the GCS of the study group (8.48± 1.50) after the implementation of the intervention than that of the control group (7.35±1.47) also there was a statistically significant differences between both studied TBI groups post-intervention as regards pupil equality (P <0.001), pupil size (P =0.026), and the pupil reaction to light (P<0.001) and all physiological parameters (P≤0.001) . Recommendations : It is recommended to integrate initial neuro-protective nursing care on the emergent care of TBI patient. Additionally, evaluation of the long-term effects on TBI patients in varied contexts of the initial neuro-protective nursing care.


Introduction
There is a significant public health burden associated with traumatic brain injury (TBI), which has the highest prevalence of all common neurological disorders. TBI is becoming more and more well-documented as a chronic disease with long-term effects, including an elevated risk of late-onset neurodegeneration, in addition to an acute condition (Andrew, et al., 2022). According to research, between 3.2 and 5.3 million Americans (or even more than 1.1% of all US residents) were admitted as a result of a mild to severe TBI, and approximately 40% of those individuals experience protracted impairment. Patients with severe TBI have bad prognosis and need effective initial care for enhancing patients' survival. Therefore, providing these patients with high-quality care by nurses can enhance their neurological outcomes. To reduce secondary brain injury and enhance outcomes for TBI patients, multidisciplinary teams, regular close monitoring, and effective therapies are required. Different ways are used to manage TBI, which obviously requires the assistance of bedside nurses as well as the other of the ER's medical staff.
Although such management might be challenging, nurses should be competent in the delivery of healthcare and possess the necessary knowledge and skills (Varghese, Chakrabarty, Menon, 2017

Aim of the study:
The purpose of the study is to evaluate the effect of implementing initial neuroprotective nursing care on outcomes of traumatic brain injury patients.

Hypothesis
Patients who will receive initial neuroprotective nursing care will have an improvement on their outcomes as (physiological

Sample
The study involved a convenience sampling of 78 patients aged > 18 years of both genders who were admitted to the previously mentioned setting.
The patients classified into two equal groups, study, and control group, 39 patients in each group and they were included in this study according to the following criteria:

Inclusion criteria
Patients aged >18 years with GCS < 12 were included in this study.

Exclusion criteria
Patients who experienced cardiovascular disorders, metabolic disorders and previous history of neurological disorders or had a history of addiction were excluded from this study.

Data Collection Tool
One tool was used in this study to collect data.

Assessment tool
This tool was developed by researchers after reviewing recent pertinent literature. It consisted of three parts as follows: -

Part I: Patient's Demographic Data
This part was used to address the patient's personal profile at admission as age, gender, marital status, and occupation.

Part II: Patient's Health Profile Data
This part focused on the patient's past medical history, type of trauma, cause of injury, GCS categories, revised trauma score, CT diagnosis, physiological parameters at admission such as (HR, respiratory rate (RR), temperature, Systolic blood pressure (SBP), mean arterial pressure (MAP), oxygen saturation, and ETCO2), pupil size, pupil equality and reactivity.

Part III: Patient's Outcome Evaluation data
This part was used to evaluate the effect of implementing the initial neuroprotective nursing care on the outcome of TBI patients. This part included the patient's physiological parameters, GCS, Revised trauma score, temperature, pupil size, equality and reaction, and survival until discharge from the ED.

Validity and Reliability
Experts from Mansoura University's Critical

Pilot Study
An evaluation of the clarity, viability, and applicability of the data collecting tool was conducted in a pilot study with 10 % of the total sample from the emergency department at the Emergency Hospital of Mansoura University. The study sample did not include those patients.

Ethical Considerations
Ethical approval will be obtained from the The next of kin were made aware that participation in the study was entirely voluntary and that they had the option of approving or rejecting their loved ones' involvement.
Additionally, they were made aware of their unrestricted ability to remove their patients from the study at any time. Furthermore, they received assurances that the patients' private information would be kept private because there was no connection between the names of the patients and the data acquired.

Data Collection Process
It included three phases as follows: -

Preparation phase
The administrative authorities of the

Intervention phase
During this phase, the researchers began screening all patients admitted to the ED to ensure they did not meet the exclusion criteria. Following this, part I and part II of the tool were used to collect the patients' demographic and health profile data. Additionally, the patients were assigned using a lottery randomization procedure by selecting one of two cards with the labels "group A" (the study group) or "group B" (the control group) on them.
The study group patients received the initial neuroprotective nursing care in the initial four hours from admission to the ED. Implementation of the initial neuroprotective nursing care lasted for the first four hours for each patient admission.
This intervention was adopted from Promlek, Currey, Damkliang, and Considine (2020)   No statistically significant differences were noted between the studied groups regarding their health profile data.     Thereby, these differences between patients in both groups who are still alive are statistically significant as a result.     P-value between two successive measurements t**=5.16 P ≤0.001* t**=1.43 P =0.160 t** paired t test, t*: Independent t-test * Statistically significant at p < 0.05. P-value between two successive measurements t**=5.14 P ≤0.001* t**=1.78 P =0.083 t** paired t test, t*: Independent t-test * Statistically significant at p < 0.05.   The initial GCS is an important predictor of neurological prognosis and survival in TBI patients. A greater fatality rate was observed in TBI patients with a lower baseline GCS at admission (Algethamy, 2020). Moreover, it is very useful because low GCS scores correlate well with TBI severity (Tenovuo et al., 2021).
The current study results revealed a significant improvement in the GCS was observed in the study group after the implementation of the intervention than that of the control group; the difference was statistically significant. This outcome is consistent with another study by

Conclusion and Recommendation
The integration of the initial neuro-protective nursing care improves TBI patients' outcomes, including physiological parameters, GCS, pupil size and reactivity, and survival. After patients are admitted to the ICU, the mortality rate is reduced by the early application of the initial neuro-protective nursing care. Additionally, we proposed that utilizing the initial neuro-protective nursing care facilitates the implementation of patient care. Future research is needed to determine the long-term impact of the initial neuroprotective nursing care on TBI patients in various settings.