Characterization, Implementation, and Impact of Low Stimulation Precautions in Acute Neurological Injury
Abstract
Recommendations provided by clinical and professional organizations that encourage providing patients with a low stimulation environment following acquired brain injury are prevalent but supported by expert opinion only. Such recommendations are based on extrapolation of what is known about physiological response to environmental stimuli, however such findings are not specific to the patients with acquired brain injury. Recommendations for low stimulation environments lack guidance for their application and implementation of precautions, and there have been no studies investigating their effectiveness at improving clinical outcomes.
The objective of this study is to determine what patient characteristics are associated with prescription of low stimulation environments in an acute hospital setting, to determine if the precautions are effective at reducing environmental stimulation, and to determine if the implementation of the precautions contribute to improved patient outcomes. To answer these questions, retrospective review of patients admitted to the ICU with a stroke or TBI diagnosis was first conducted. Descriptive statistics were utilized to evaluate the patterns related to the ordering of low stimulation precautions, while logistic regression was used to determine correlation between clinical factors and the prescription of low stimulation precautions. Next, observational data was collected on light and sound levels, as well as the frequency with which people entered a patient’s room in order to quantify the levels of stimulation in low stimulation rooms on the neurological ICU, non-low stimulation rooms on the neurological ICU, and general ICU rooms. Finally, the relationship between low stimulation precautions orders and the clinical outcomes of change in GCS score, ICU and total length of stay, and discharge disposition in the retrospective cohort are analyzed through regression analysis.
Predictive indicators of low stimulation precautions included an admitting stroke diagnosis, benzodiazepine use, and a plan of care involving the Severe TBI order set identified. There were no significant differences in the stimulation levels of general ICU, low stimulation, and non-low stimulation rooms. Significant relationships between change in GCS score and discharge disposition were identified, however these associations were weak and thought to lack clinical significance.
The findings of this study indicate that application and implementation of low stimulation precautions is inconsistent and is not systematically guided by clinical indicators. In their current state, they are also ineffective at reducing environmental stimuli. Not surprisingly, clinical outcomes suggest that there is little clinical benefit to their use at the research setting, in which application was inconsistent. However, further studies are warranted to examine the posed questions in the context of a structured protocol that is systematically utilized for patients with ABI.