In this issue of JNN, authors from Denmark report on the prevalence of nurse-sensitive indicators among patients with severe traumatic brain injury (TBI) over a 5-year period.1 Findings establish important preliminary benchmarks for how often these complications occur, specifically among patients with brain injury. In this edition of "Research Bytes," we will break down what the study found and what it means for clinical practice.

Background

Nursing-sensitive indicators are measurement indices that reflect quality of nursing care provided on a unit or in a hospital. Common indices include falls, pain assessment, pressure ulcers (PUs), restraint use, deep vein thromboses (DVTs), and nosocomial infections, such as urinary tract infections (UTIs), pneumonias, and catheter-associated bloodstream infections. These are all patient factors directly influenced by nursing interventions and care. Depending on the database, other measures of nursing-sensitive indicators may be recorded, such as nurse satisfaction, turnover, and education or certification. On an international level, nursing-sensitive indicators are not universally agreed upon. However, there is a general consensus that specific patient-level clinical factors are directly impacted by the quality of nursing care provided. In Denmark, these included UTIs, pneumonia, PUs, joint contractures, and DVTs. These nursing-sensitive indicators were abstracted directly from a national database of severe TBI patients in subacute rehabilitation facilities. Although estimates of nursing-sensitive indicators are widely reported, few studies have looked specifically at the prevalence of these indicators among a cohort of severe TBI patients, particularly during the rehabilitation phase. Severe TBI patients are at a high risk of complications, and baseline benchmarks of nursing-sensitive indicators are an important first step toward ensuring high quality nursing care and optimizing patient outcomes. Therefore, the purpose of this study was to provide prevalence estimates for nursing-sensitive indicators specifically among a cohort of severe TBI patients admitted to subacute rehabilitation and up to 1 year post injury.

Methods

For this study, data were abstracted form the Danish Head Trauma database among patients over the age of 15 years with severe TBI, admitted to subacute rehabilitation. Data are recorded up to 1 year post injury; for this study, individuals who died before 1 year were excluded from the analysis. Thus, the total sample size over a 5-year period for this study was N = 455. Investigators calculated period prevalence, point prevalence, and overall prevalence specifically during the rehabilitation phase and up to 1 year post injury. Period prevalence was calculated as the number of patients with the complication that either is present on admission or developed over the course of rehabilitation divided by the total number of patients. In contrast, point prevalence was calculated as the number of patients with the complication at a specific time point (on admission, at discharge, or at 1 year post injury) divided by the total number of patients at that time.

It is important to note the differences between prevalence and incidence. Prevalence refers to how widespread the complications are, whereas incidence refers to patient risk of developing the complication. For this study, the focus was on prevalence or how often these complications occurred among severe TBI patients in rehabilitation. The different types of prevalence were calculated to capture specifically which complications were present overall (period prevalence), compared with those that were present at key time points (admission, discharge, and 1 year post injury).

Results

Findings on period prevalence (from admission throughout rehabilitation) indicate that the most common complications were UTIs (52.85%) and pneumonia (32.3%). When investigating specifically the presence of these complications on admission, compared with development over the course of rehabilitation, approximately 36.7% of UTIs and 11.7% of pneumonia developed during the course of rehabilitation. The period prevalences for PU, joint contractures, and DVT indicate that these occurred less often (18.5%, 18.1%, and 3.9%, respectively), and only 5% of these complications developed during rehabilitation. Age was a determining factor for prevalence, as those over the age of 35 years were more likely to experience these complications.

When looking at point prevalence at admission, UTI (13.9%), pneumonia (19%), and PU (14%) were again most common. These estimates shifted upon discharge, as no subjects at discharge had a UTI, only 0.6% had pneumonia, and only 3.2% had PUs. However, the point prevalence of joint contractures increased from admission (12.5%) to discharge (16.2%). When looking at point prevalence data at 1 year post injury, again, no subjects had UTIs, only 3.2% had pneumonia, and 3.3% had PUs. Contractures had decreased slightly over the year to 13.4%. Throughout all point prevalence estimates (admission, discharge, and 1 year post injury), the presence of a DVT remained low, ranging from 1% to 2%.

Relevance to Clinical Practice

Study findings provide important initial estimates for both period and point prevalences of nursing-sensitive indicators among severe TBI patients on rehabilitation units. Although these patients are at a high risk for complications, delivery of high-quality nursing care can positively impact outcomes at discharge and up to 1 year post injury.

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