Date of Award


Document Type

Open Access Dissertation


College of Nursing


Nursing Practice

First Advisor

Nathaniel Bell


Traumatic brain injury (TBI) is a leading cause of death and permanent disability worldwide. The American College of Surgeon’s Trauma Quality Improvement Program (TQIP) has developed a set of recommendations for the management of trauma-related injuries, including TBI. The objective of this evidenced-based practice project was to implement provider- and workflow-based strategies to improve adherence to TQIP recommended guidelines for the placement of intracranial pressure (ICP) monitors. The primary outcome measured was number of ICP monitors placed post-intervention.

The author reviewed available literature and found six articles pertaining to guideline implementations. Analysis of the literature was performed utilizing Melynk and Fineout-Overholt’s evidence table formatting and classified using the Johns Hopkins evidence level and quality guide. Utilized articles encompassed meta- and systematic reviews of quasi-experimental studies and qualitative studies. The results supported the implementation of multiple strategies that would affect both provider actions and workflow processes.

Following literature analysis, a provider- and workflow-based strategy for TQIP guideline adherence was evaluated by the trauma team at a Level I trauma center. This was done using a pre-post implementation study on eligible TBI patients, aged 16 years and older utilizing TQIP inclusion and exclusion criteria. Patient record analysis for the retrospective cohort was conducted from October 2010 through September 2015, and the post-implementation cohort from October 2015 through September 2016. Patient information obtained included age, race, gender, ED GCS score, AIS head score, insurance type, ISS score, and ETOH level. Clinical data collected included initial head computed tomography (CT) findings, hyperosmolar agent used (if any), plan of care upon initial exam by neurosurgery, ICU LOS, and hospital LOS.

A total of 563 cases were reviewed for study participation, but only 305 patients met TQIP TBI inclusion criteria in both pre- and post-implementation cohorts. After adjustment for confounding variables, the odds of receiving ICP monitoring in the post-implementation group was 76% lower than in the pre-implementation cohort (AOR 0.24 [95% CI 0.07-0.82], p 0.023). However, the post-implementation was 92% more likely to receive hypertonic saline infusion than pre-implementation cohort (AOR 0.08 [95% CI 0.04 – 0.20], p <0.0001). Mortality was not found to be significantly associated with provider or workflow-strategy implementation.

End results conclude that the provider and workflow-strategies were not statistically significantly related to increasing TQIP guideline adherence in the placement of ICP monitors. Recommendations for future practice include more robust inter-departmental communication, administrative advocacy for best practice guidelines, and expanding departmental scope of practice.