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BACKGROUND A change in the pupillary light reflex (PLR) is a sensitive indicator for detecting expanding intracranial lesions. Changes in PLR may be a prognostic marker for patients with intracranial lesions. The purpose of this analysis was to explore how PLR readings, size, constriction velocity (CV), dilation velocity (DV), Neurologic Pupil Index (NPi), and latency predict clinical outcome in patients with subarachnoid hemorrhage. METHODS This is a secondary analysis of prospectively collected multicenter registry data. The within-subject standard deviation (WSD) of PLR values, NPi, size, CV, DV, and latency were explored as predictors of discharge modified Rankin Scale (mRS) in patients with subarachnoid hemorrhagic. RESULTS Among 4403 pupillary readings from 82 patients with a diagnosis of subarachnoid hemorrhage, with a mean age of 57.7 years, the admission Glasgow Coma Scale median score was 14 (eye, 4; verbal, 4; motor, 6), and the mRS median was 0 on admission and 4 at discharge. Correlation between standard deviation of PLR values and discharge mRS was moderate and negative (r = -0.3 to -0.47, P < .01). The standard deviations for NPi, size, CV, and DV were significant for predicting discharge mRS (r = 0.23-0.28, P < .05) after controlling for admission Glasgow Coma Scale. CONCLUSION Patients with higher WSD PLR values showed better outcomes (ie, lower mRS at discharge), suggesting that patients with narrower WSD PLR are at a higher risk for poor outcomes.

To enhance nursing staff retention and ensure a consistently high standard of care, a study was conducted to determine an appropriate nurse staffing model for a neurocritical care unit. In addition to being critically ill, these patients often require extensive diagnostic testing to determine treatment. Nurses traveling with patients leave higher nurse-patient ratios remaining on the unit.Prospective observation was used to assess relationships between neurologic assessment, documentation, and the amount of time spent traveling with patients. Patient acuity and nursing experience were also measured.Over the 30-day study period, more than 226 hours were spent traveling, equivalent to approximately 38% of a single nurse's shift. There was no correlation between the experience of nurses and the time necessary to perform a neurologic assessment. When controlling for acuity, a relationship was found between nursing experience and the time needed to chart an assessment.Significant time was spent every day off the floor, in addition to the documentation and performance of frequent assessments. These results advocate for a staffing position without a dedicated patient assignment but to assist with traveling and high-acuity patients so that safe and attentive care can be consistently given.

The field of neurointerventional radiology (NIR) therapy, including acute ischemic stroke intervention, endovascular intracranial aneurysm management, and treatment of intra- and extracranial large-vessel disease, has evolved over the past 18 years. To support this specialized advanced care requires nursing standards of care for staff to provide direct patient care in NIR suites and intensive management of this high-risk patient population. The intent of this paper is to provide a complementary document for the Stroke Interventional Laboratory Consensus (SILC) statement that will specifically address the nursing standards of care for patients in an NIR suite.

Targeted temperature management (TTM) is often used in neurocritical care to minimize secondary neurologic injury and improve outcomes. TTM encompasses therapeutic hypothermia, controlled normothermia, and treatment of fever. TTM is best supported by evidence from neonatal hypoxic-ischemic encephalopathy and out-of-hospital cardiac arrest, although it has also been explored in ischemic stroke, traumatic brain injury, and intracranial hemorrhage patients. Critical care clinicians using TTM must select appropriate cooling techniques, provide a reasonable rate of cooling, manage shivering, and ensure adequate patient monitoring among other challenges. The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacotherapy to form a writing Committee in 2015. The group generated a set of 16 clinical questions relevant to TTM using the PICO format. With the assistance of a research librarian, the Committee undertook a comprehensive literature search with no back date through November 2016 with additional references up to March 2017. The Committee utilized GRADE methodology to adjudicate the quality of evidence as high, moderate, low, or very low based on their confidence that the estimate of effect approximated the true effect. They generated recommendations regarding the implementation of TTM based on this systematic review only after considering the quality of evidence, relative risks and benefits, patient values and preferences, and resource allocation. This guideline is intended for neurocritical care clinicians who have chosen to use TTM in patient care; it is not meant to provide guidance regarding the clinical indications for TTM itself. While there are areas of TTM practice where clear evidence guides strong recommendations, many of the recommendations are conditional, and must be contextualized to individual patient and system needs.

The pupillary light reflex (PLR) describes the response when light hits the retina and sends a signal (cranial nerve II) to the Edinger-Westphal Nucleus which via cranial nerve III results in pupillary constriction. The Neurological Pupil indexTM (NPi) and pupil constriction velocity (CV) are two distinct variables that can be observed and measured using a pupillometer. We examine NPi and CV in 27,462 pupil readings (1,617 subjects). NPi values

The National Trust owns and opens to the public historic houses containing an enormous quantity and range of decorative arts. Conserving these features in ways that enhance visitors' enjoyment through their experience of the conservation work is now as important an objective of conservation in the National Trust as improving these features' state of conservation. This paper takes as an example the conservation of the early eighteenth-century Baroque wall paintings decorating the staircase of Hanbury Hall (Worcestershire, UK) which presented considerable challenges not only in conservation but also in enabling the visiting public to experience the work. Evaluation of visitors' response is presented and discussed in the context of evaluations of other ‘conservation in action’ projects across the National Trust.

External ventricular drain (EVD) placement is a common practice in neurocritical care units. The EVDs are the "gold" standard and the most cost-effective treatment for intracranial hypertension and hydrocephalus caused by a variety of neurological conditions. The EVD drains excess cerebrospinal fluid in an attempt to maintain balance within the cranial vault and provides intermittent monitoring of intracranial pressure. This invasive procedure, as with any other procedures, carries an increased risk of a device-related infection that can lead to devastating consequences such as meningitis, ventriculitis, and death. This article will discuss how Riverside Methodist Hospital, which is located in Central Ohio, identified an increase in the rate of EVD infections in 2007 and responded with changes in procedure and processes. The implementation of the improvement plan has resulted in 25 months without an EVD infection, a triumph for the patients, staff, and the hospital system.

PurposeThe purpose of this paper is to examine an audit that was performed of all patients referred to a liaison psychiatry inpatient consultation service which sought to establish a baseline for demographics, type of referral, and management of referrals, with a view to introducing improved evidence‐based treatments. It also aims to examine timeliness of response to referrals benchmarked against published standards.Design/methodology/approachAll inpatient referrals to a liaison psychiatry service were recorded over a six‐month period, including demographics, diagnosis, management and timeliness of response to referrals. The data were retrospectively analysed and compared against international standards.FindingsA total of 172 referrals were received in the six months. Commonest referral reasons included assessments regarding depressive disorders (23.8 per cent), delirium/other cognitive disorders (19.2 per cent), alcohol‐related disorders (18.6 per cent), anxiety disorders (14.5 per cent), and risk management (12.2 per cent). Evidence‐based practices were not utilised effectively for a number of different types of presentations. A total of 40.1 per cent of referrals were seen on the same day, 75.4 per cent by the end of the next day, and 93.4 per cent by the end of the following day.Practical implicationsUse of a hospital protocol for management of delirium may improve outcomes for these patients. Evidence‐based techniques, such as brief intervention therapies, may be beneficial for referrals involving alcohol dependence. Referrals were seen reasonably quickly, but there is room for improvement when compared with published standards.Originality/valueThis paper provides valuable information for those involved in management of liaison psychiatry consultation services, providing ideas for development and implementation of evidence based practices.

Proton magnetic resonance spectroscopy (1H MRS) is a noninvasive technique, important for investigating metabolic changes occurring in the nervous system as a result of pathology. Recent technical advances have improved spinal cord 1H MRS feasibility for preclinical and clinical studies, despite its technical challenges. This chapter will focus on the use of 1H MRS in the spinal cord in preclinical and clinical studies. We will first discuss the importance of using spinal cord 1H MRS to obtain insights into the metabolic abnormalities of neurological illnesses. We will then review the methodological challenges of this technique, followed by a brief overview of disease “models” to illustrate 1H MRS applications in spinal cord for preclinical and clinical research, including the following: multiple sclerosis, spinal cord injury, tumor, and amyotrophic lateral sclerosis. Finally, we will highlight future opportunities.

Using industry leading methods and software products, this article explores the potential for health risk adjustment in the Department of Defense (DoD) Military Health System. From an epidemiologic perspective, the study assesses whether DoD populations enrolled to and served by different provider groups exhibit sufficient variation in risk to justify changes in resource allocation, such as staffing, services, and facility modification. In addition, the study investigates whether systematic differences in risk exist between TRICARE enrollees and commercially insured enrollees. Given the interest of the DoD in managed care, risk prediction tools are shown to project future risk for individuals with sufficient accuracy to justify development of disease management programs for patients with chronic conditions. Analyses demonstrate that Military Health System data support industry requirements to perform risk grouping among a random sample of 200,000 enrollees selected from 495,941 eligible enrollees.

minimum, to NHSN benchmark rates. The team identified several factors believed to be contributing to the higher-thanaverageVAP rates, and subsequently implemented the following interventions to address these issues: 1) identification of VAP Reduction Team Champions on all shifts to reinforce VAP prevention strategies in real time to front line staff 2) reviewandreinforcementof bundleelementsduringdaily carerounds3)assignmentof chart audits tounit staff toassure documentation of head of bed elevation (HOB) and bundle compliance 4) staff re-education and audits on the use of oral care products and protocols 5) designation of separate oral and endotracheal suction set-ups to reduce environmental and hand contamination, and 6) implementation of transfer procedures for ventilated patients that included subglottic and endotracheal suctioning prior to transfer and maintaining HOB elevation.30 degrees unless contraindicated.