Search

Background: Literature on the impact of patient-satisfaction metrics on nursing staff is scarce and limits nurses’ ability to understand the impact these metrics have on their daily practice. Aim: The aim of this qualitative study is to explore nurses’ perceptions of patient satisfaction surveys on their daily practice when working with patients with acute neurological changes. Method: A content analysis approach was used to analyze interviews with six neurosurgical nurses. The analysis was conducted throughout the interview and analysis process, and guided interviews and rigor processes. Results: Among the surveyed nurses, there was unified agreement that the current tool for obtaining the metrics did not accurately reflect the performance of the registered nurse. Themes that emerged from interview analysis included “anxiety”, “frustration”, “uncertainty”, and “workarounds”. Interviews uncovered a disconnect between clinical nurses and leadership, as well as how feedback is presented to nurses by patients, which drove many of the themes listed above. The nurses felt that the metrics should not be linked to individual performance feedback. Conclusion: Nurses report that patient satisfaction surveys do not represent an ideal metric for quality of nursing care and impact their daily practice negatively. These results could be applied to improving the registered nurse performance evaluation tools utilized in neurological units.

External ventricular drains (EVDs) provide a temporary egress for cerebrospinal fluid (CSF) in patients with symptomatic hydrocephalus following aneurysmal subarachnoid hemorrhage. Before EVD removal, a wean trial, which involves clamping the EVD, is typically attempted to ensure that CSF self-regulation is achieved. Automated infrared pupillometry (AIP) has been shown to detect early neurologic decline. We sought to explore the use of AIP to detect early EVD clamping trial failure.This prospective observational pilot study enrolled aneurysmal subarachnoid hemorrhage patients before an EVD clamp trial. On initiating the clamp trial, nurses included hourly AIP assessment in documentation. Clamp trial outcome was based on neurologic examination and neuroimaging. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) models were constructed to explore computed tomography (CT) versus AIP as predictors of clamp trial outcome.Among the 30 subjects enrolled, there were 38 clamping trials and 22 successful EVD removals. CT scan as a predictor of clamp trial was found to have a sensitivity of 68.8% and specificity of 89.5% (PPV = 84.6%, NPV = 77.3%). AIP assessment as a predictor of wean trial outcome was found to have a sensitivity of 58.3% and specificity of 100% (PPV = 100%, NPV = 63.2%).The pilot study data support that Neurological Pupil index3 is a potential indicator of early clamp trial failure, but a CT scan has a higher sensitivity and NPV for predicting successful EVD removal. This finding suggests the benefits of including AIP assessments during clamping trials.

BACKGROUND: Automated infrared pupillometry (AIP) has been shown to be helpful in the setting of aneurysmal subarachnoid hemorrhage and stroke as an indicator of imminent irreversible brain injury. We postulated that the early detection of pupillary dysfunction after light stimulation using AIP may be useful in patients with traumatic brain injury (TBI). METHODS: We performed a retrospective review of the Establishing Normative Data for Pupillometer Assessment in Neuroscience Intensive Care database, a prospectively populated multicenter registry of patients who had AIP measurements taken during their intensive care unit admission. The primary eligibility criterion was a diagnosis of blunt TBI. Ordinal logistic modeling was used to explore the association between anisocoria and daily Glasgow Coma Scale scores and discharge modified Rankin Scale scores from the intensive care unit and from the hospital. RESULTS: Among 118 subjects in the who met inclusion, there were 6187 pupillometer readings. Of these, anisocoria in ambient light was present in 12.8%, and that after light stimulation was present in 9.8%. Anisocoria after light stimulation was associated with worse injury severity (odds ratio [OR], 0.26 [95% confidence interval (CI), 0.14-0.46]), lower discharge Glasgow Coma Scale scores (OR, 0.28 [95% CI, 0.17-0.45]), and lower discharge modified Rankin Scale scores (OR, 0.28 [95% CI, 0.17-0.47]). Anisocoria in ambient light showed a similar but weaker association. CONCLUSION: Anisocoria correlates with injury severity and with patient outcomes after blunt TBI. Anisocoria after light stimulation seems to be a stronger predictor than does anisocoria in ambient light. These findings represent continued efforts to understand pupillary changes in the setting of TBI.

BACKGROUND: Information on nurse satisfaction and unit acuity is scarce in the literature. The purpose of this study is to evaluate the effect of the MATRIX Staffing Grid (MSG) on nurse assignment satisfaction in a 20-bed inpatient rehabilitation facility. METHODS: Prospective systematic implementation study of the MSG occurred in 5 phases: development, baseline, run-in, implementation, and sustainability. Pretest/posttest nursing satisfaction data were analyzed using Wilcoxon-Mann-Whitney tests. RESULTS: Analysis of 128 satisfaction surveys demonstrated that the median total satisfaction score increased by 35% after MSG implementation (P < .05), with no change in patient satisfaction or adverse event rates. CONCLUSION: A systematic approach to implementation of the MSG evidence-based practice significantly improved nursing satisfaction with patient assignment in a way that addressed specific needs. The MSG has now been adopted into practice at our institution. The MSG may be feasible for implementation in inpatient rehabilitation units to improve staffing satisfaction.

Objectives Sleep disturbances may contribute to the development of delirium, prolonged ICU stay, and increased mortality. There is conflicting data on the effectiveness of earplugs and eye masks for sleep promotion in the ICU. This study evaluates the impact of earplugs and eye masks on sleep quality in postoperative surgical ICU patients at risk for frequent awakenings. Design Prospective randomized controlled trial. Setting Surgical ICU within the University of Texas Southwestern Medical Center. Patients Adult, female patients admitted to the surgical ICU requiring hourly postoperative assessments following breast free flap surgery between February 2018 and October 2019. Interventions Patients were randomized into an intervention group or a control group. The intervention group received earplugs and eye masks in addition to standard postoperative care, whereas the control group received standard postoperative care. Measurements and main results The primary outcome was overall sleep quality assessed via the Richards-Campbell Sleep Questionnaire. Secondary outcomes of patient satisfaction and rates of ICU delirium were assessed with a modified version of the Family Satisfaction in the ICU survey and the Confusion Assessment Method for the ICU. After a planned interim analysis, the study was stopped early because prespecified criteria for significance were attained. Compared with the control group's average Richards-Campbell Sleep Questionnaire total score of 47.3 (95% CI, 40.8-53.8), the intervention group's average Richards-Campbell Sleep Questionnaire total score was significantly higher at 64.5 (95% CI, 58.3-70.7; p = 0.0007). There were no significant between-group differences for Confusion Assessment Method for the ICU scores or modified Family Satisfaction in the ICU survey scores. Conclusions These results suggest that earplugs and eye masks are effective in improving sleep quality in ICU patients undergoing frequent assessments. The results strengthen the evidence for nonpharmacologic sleep-promoting adjuncts in the ICU.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes.We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied.Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (3) and was predictive of intervention (Fisher exact test; P0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention.AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.

Background Clinical registries provide insight on the quality of patient care by providing data to identify associations and patterns in diagnosis, disease, and treatment. This has led to a push toward using large data sets in healthcare research. Nurse researchers are developing data registries, but most are unaware of how to manage a data registry. This article examines a neuroscience nursing registry to describe a quality control and data management process. Data quality process Our registry contains more than 90 000 rows of data from almost 5000 patients at 4 US hospitals. Data management is a continuous process that consists of 5 phases: screening, data organization, diagnostic, treatment, and missing data. These phases are repeated with each registry update. Discussion The interdisciplinary approach to data management resulted in high-quality data, which was confirmed by missing data analysis. Most technical errors could be systematically diagnosed and resolved using basic statistical outputs, and fixed in the source file. Conclusion The methods described provide a structured way for nurses and their collaborators to clean and manage registries.

Introduction: Several AHA Guidelines recommend inpatient rehabilitation facility (IRF) care to enhance post-stroke recovery. We evaluated the IRF treatment effect on modified Rankin scale (mRS) score change at 90 days in ischemic stroke (IS) patients. Methods: Using prospectively collected data from Get With the Guidelines-Stroke, the Uniformed Data System for Medical Rehabilitation registry and the electronic medical record, we identified IS patients with discharge disposition of home or IRF between 1/1/2018-12/31/2020. Sociodemographics, clinical variables and IS treatment rates were summarized. IRF outcomes, including length of stay (LOS), improvement in mobility and self-care scores and discharge disposition were compared in thrombectomy vs no thrombectomy groups. mRS at IRF discharge was calculated with a Cronbach interrater score of 0.88; shift analyses of mRS at hospital discharge and 90 days were completed for IS patients in the Home and IRF care groups. Results: Among 738 patients, 499 went home, 239 went to IRF. IRF patients were more likely to have Medicare insurance (49.2 vs 28.9%), undergo thrombectomy (16.3 vs 4.6%) have increased LOS (12.7 vs 4.8 days) and stroke severity (mean NIHSS 7.8 vs 4.8; mean mRS 3.1 vs 1.7) compared to Home (Table 1). At IRF, 39 patients previously underwent thrombectomy, 200 did not. Both groups had a IRF LOS >14 days and considerable recovery in the self-care and mobility domains (Table 2). Shift analysis of mRS at hospital discharge compared to 90 days yielded significant improvements in mRS of 0-2 and lower mortality in the IRF group compared to home group (Figure). Conclusion: In ischemic stroke patients with higher disease severity, IRF treatment is a catalyst for improved functional recovery.

BackgroundIntracranial pressure (ICP) values guide treatment and diagnosis in the ICU. Lack of agreement on ICP determination reduces the validity of ICP as a predictor variable in research and clinical practice. This study explores international perspectives of interpreting an ICP tracing to document an ICP value across varying lengths of time.MethodsThis was a prospective anonymous online survey study of clinician practice of ICP measurement using patient data showing an ICP trend. Participants were shown one of three scenarios at 1-minute, 3-minute, and 5-minute ICP trends. It wasn't possible to randomized participants, however multiple reading improves precision. Paired t-test was used to explore for differences within each scenario and between each epoch.ResultsThere were a total of 332 international responses which came from 247 nurses, 43 attending physicians, 29 nurse practitioners, and 12 physicians in training. Estimates of ICP were significantly different for two of the three scenarios (p < .0001). The range of ICP values was largest during the 3-minute epoch (from 5 to 40 mmHg).ConclusionsThere is a wide and inconsistent variation in the determination of ICP with significant difference between for two of the three scenarios. Without a standardized amount of time to provide to clinicians, variability in ICP reporting will continue.

Blood pressure (BP) management is a crucial part of critical care that directly affects morbidity and mortality. While BP has become a mainstay in patient care, the accuracy and precision of BP measures across commonly used sites (left upper arm, right upper arm, etc.) and methods have not been established. This study begins to fill this gap in literature by testing the null hypothesis that BP measurement does not vary according to site. This is a prospective, non-randomized, cross-sectional study of 80 neurocritical care unit patients. Near simultaneous non-invasive blood pressure (NIBP) readings from 4 different locations (bilateral upper arm, bilateral wrist) and, when available, intra-arterial blood pressure readings (IABP) were included. Pearson correlation coefficients and one-way repeated measures ANOVA were used to observe the systolic, diastolic, and mean arterial pressure (MAP) correlations. The BP measured at the four most common sites (left upper arm, left wrist, right upper arm, right wrist) had adequate correlation coefficients but were statistically significantly different and highly unpredictable. The median inter-site systolic variability was 10 mmHg (IQR 2 to 10 mmHg). The median inter-site MAP variability was 6mmHg with an interquartile range (IQR) of 3 to 9 mmHg. As expected, the values correlated to show that patients with high BP in one site tended to have high BP in another site. However, the unpredictable inter-site variability is concerning within the clinical setting where oftentimes BP measurement site is not standardized but resulting values are nevertheless used for treatment. There is prominent inter-site variability of BP measured across the 4 most common measurement sites. The variability persists across non-invasive (NIBP) and invasive (IABP) methods of assessment.

BACKGROUND: The Bispectral (BIS) monitor is a validated, noninvasive monitor placed over the forehead to titrate sedation in patients under general anesthesia in the operating room. In the neurocritical care unit, there is limited room on the forehead because of incisions, injuries, and other monitoring devices. This is a pilot study to determine whether a BIS nasal montage correlates to the standard frontal-temporal data in this patient population. METHODS: This prospective nonandomized pilot study enrolled 10 critically ill, intubated, and sedated adult patients admitted to the neurocritical care unit. Each patient had a BIS monitor placed over the standard frontal-temporal location and over the alternative nasal dorsum with simultaneous data collected for 24 hours. RESULTS: In the frontal-temporal location, the mean (SD) BIS score was 50.9 (15.0), average minimum BIS score was 47.0 (15.0), and average maximum BIS score was 58.4 (16.7). In the nasal dorsum location, the mean BIS score was 54.8 (21.6), average minimum BIS score was 52.8 (20.9), and average maximum BIS score was 58.0 (22.2). Baseline nonparametric tests showed nonsignificant P values for all variables except for Signal Quality Index. Generalized linear model analysis demonstrated significant differences between the 2 monitor locations (P.0001). CONCLUSION: The results of this pilot study do not support using a BIS nasal montage as an alternative for patients in the neurocritical care unit.

BACKGROUND Automated pupillometry is becoming widely accepted as an objective measure of pupillary function, especially in neurocritical care units. Normative reference values and thresholds to denote a significant change are necessary for integrating automated pupillometry into practice. OBJECTIVE Providing point estimates of normal ranges for pupillometry data will help clinicians intuit meaning from these data that will drive clinical interventions. METHODS This study used a planned descriptive analysis using data from a multicenter registry including automated pupillometry assessments in 2140 subjects from 3 US hospitals collected during a 3-year period. RESULTS We provide a comprehensive list of admission pupillometry data. Our data demonstrate significant differences in pupillary values for Neurological Pupil Index, latency, and constriction velocity when stratified by age, sex, or severity of illness defined by the Glasgow Coma Scale score. CONCLUSION This study provides a greater understanding of expected distributions for automated pupillometry values in a wide range of neurocritical care populations.

RESUMO Objetivo: Calcular as velocidades médias da dilatação de pupila para classificar a gravidade da lesão derivada da escala de coma de Glasgow, estratificada por variáveis de confusão. Métodos: Neste estudo, analisaram-se 68.813 exames das pupilas para determinar a velocidade normal de dilatação em 3.595 pacientes com lesão cerebral leve (13 - 15), moderada (9 - 12) ou grave (3 - 8), segundo a escala de coma de Glasgow. As variáveis idade, sexo, raça, tamanho da pupila, tempo de permanência na unidade de terapia intensiva, pressão intracraniana, uso de narcóticos, classificação pela escala de coma de Glasgow e diagnóstico foram consideradas confundidoras e controladas para análise estatística. Empregou-se regressão logística com base em algoritmo de classificação com aprendizado de máquina para identificar os pontos de corte da velocidade de dilatação para as categorias segundo a escala de coma de Glasgow. Resultados: As razões de chance e os intervalos de confiança desses fatores se mostraram estatisticamente significantes em sua influência sobre a velocidade de dilatação. A classificação com base na área sob a curva mostrou que, para o grau leve, na escala de coma de Glasgow, o limite da velocidade de dilatação foi de 1,2mm/s, com taxas de falsa probabilidade de 0,1602 e 0,1902 e áreas sob a curva de 0,8380 e 0,8080, respectivamente, para os olhos esquerdo e direito. Para grau moderado na escala de coma de Glasgow, a velocidade de dilatação foi de 1,1mm/s com taxas de falsa probabilidade de 0,1880 e 0,1940 e áreas sob a curva de 0,8120 e 0,8060, respectivamente, nos olhos esquerdo e direito. Mais ainda, para o grau grave na escala de coma de Glasgow, a velocidade de dilatação foi de 0,9mm/s, com taxas de falsa probabilidade de 0,1980 e 0,2060 e áreas sob a curva de 0,8020 e 0,7940, respectivamente, nos olhos esquerdo e direito. Esses valores foram diferentes dos métodos prévios de descrição subjetiva e das velocidades de dilatação previamente estimadas. Conclusão: Observaram-se velocidades mais lentas de dilatação pupilar em pacientes com escores mais baixos na escala de coma de Glasgow, indicando que diminuição da velocidade pode indicar grau mais grave de lesão neuronal. ABSTRACT Objective: To calculate mean dilation velocities for Glasgow coma scale-derived injury severity classifications stratified by multiple confounding variables. Methods: In this study, we examined 68,813 pupil readings from 3,595 patients to determine normal dilation velocity with brain injury categorized based upon a Glasgow coma scale as mild (13 - 15), moderate (9 - 12), or severe (3 - 8). The variables age, sex, race, pupil size, intensive care unit length of stay, intracranial pressure, use of narcotics, Glasgow coma scale, and diagnosis were considered as confounding and controlled for in statistical analysis. Machine learning classification algorithm-based logistic regression was employed to identify dilation velocity cutoffs for Glasgow coma scale categories. Results: The odds ratios and confidence intervals of these factors were shown to be statistically significant in their influence on dilation velocity. Classification based on the area under the curve showed that for the mild Glasgow coma scale, the dilation velocity threshold value was 1.2mm/s, with false probability rates of 0.1602 and 0.1902 and areas under the curve of 0.8380 and 0.8080 in the left and right eyes, respectively. For the moderate Glasgow coma scale, the dilation velocity was 1.1mm/s, with false probability rates of 0.1880 and 0.1940 and areas under the curve of 0.8120 and 0.8060 in the left and right eyes, respectively. Furthermore, for the severe Glasgow coma scale, the dilation velocity was 0.9mm/s, with false probability rates of 0.1980 and 0.2060 and areas under the curve of 0.8020 and 0.7940 in the left and right eyes, respectively. These values were different from the previous method of subjective description and from previously estimated normal dilation velocities. Conclusion: Slower dilation velocities were observed in patients with lower Glasgow coma scores, indicating that decreasing velocities may indicate a higher degree of neuronal injury.

Background The Glasgow Coma Scale was developed in 1974 as an injury severity score to assess and predict outcome after traumatic brain injury. The tool is now used to score depth of impaired consciousness in patients with and without traumatic brain injury. However, evidence supporting the use of the Glasgow Coma Scale in the latter group is limited. Objective To assess Glasgow Coma Scale score on hospital admission as a predictor of outcome in patients without traumatic brain injury. Methods This was a secondary analysis of prospectively collected data from 3507 patients admitted to 4 hospitals between October 2015 and October 2019. Patients with a primary diagnosis of traumatic brain injury were excluded from this study. Results The mean age of the 3507 participants in the study was 57 years. Participants were primarily female (52%), White (77%), and non-Hispanic (89%). On admission, 90% of patients had a modified Rankin Scale score of 0 to 3 and 72% had a Glasgow Coma Scale score of 13 to 15 (mild injury). Generalized estimating equation modeling indicated that admission Glasgow Coma Scale score did not predict modified Rankin Scale score at discharge in patients not diagnosed with traumatic brain injury (Glasgow Coma Scale score Conclusions The Glasgow Coma Scale is not recommended for use in patients without traumatic brain injury; clinicians should use a more appropriate and validated clinical assessment instrument for this patient population.

BACKGROUND: Healthcare providers (HCPs) use the numeric rating scale (NRS) under the assumption that it provides reliable information from which to make decisions regarding analgesic administration. METHODS: We explored the face validity of the NRS using a prospective single-blinded observational design. Pre and post NRS scores were obtained from HCPs who submerged their hand in a bucket of ice water (pain stimulus). RESULTS: Despite a consistent similar pain source, individual HCPs rated their pain very differently (range, 2-10), and there was a significant difference in self-estimated pain tolerance (μ = 7.06 [SD, 1.43]) and actual pain scores (μ = 6.35 [SD, 2.2]; t = 4.08, P < .001). CONCLUSION: The findings indicate a limitation in the face validity of the NRS. The high variance in NRS scores reaffirms the subjectivity of pain perception and brings into question the utility of using NRS scores when determining analgesic dosages.

To evaluate the effect of a physiatry-led stroke consult service on access and time to intensive postacute rehabilitation.Prospective observational study.Urban Joint Commission Comprehensive Stroke Center.Adult (older than 18 years) acute stroke hospital discharges between January 1, 2018, and December 31, 2020 (N=1190).Weekday huddle rounds were interdisciplinary, which created a pathway to ensure patients with stroke received comprehensive rehabilitation care followed by a virtual rounding tool, allowing clinicians to evaluate plan of care facilitation using the electronic medical record.Proportion of acute stroke discharges to home, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF) and onset days to IRF transfer.During the 3-year study period, sociodemographic characteristics, stroke severity at admission, and mortality rates did not change significantly. Discharges of patients with acute stroke patient to IRFs increased 5.9%, from 24.2% in 2018 to 30.1% in 2020. A total of 11% of patients were discharged to SNF in 2018 compared with 8.7% in 2020. Proportion of patients with acute stroke discharged to home decreased 4.9%, from 49.6% in 2018 to 44.7% (P=.0325). For patients with ischemic stroke, the average onset days to IRF transfer decreased 7.5% between 2018 and 2020, from 8 days to 7.4 days. For patients with hemorrhagic stroke, the average onset days decreased 17.5%, from 12 days in 2018 to 9.9 days in 2020. The decrease in onset days were not statistically significant for either stroke type (P=.3794).Implementation of huddle rounds and a virtual rounding tool by a physiatry-led stroke consult service significantly increased referrals to IRFs, with a concomitant decrease in referrals to SNFs or directly home. Next steps include validating model efficacy, with the goal of implementation at stroke centers in the United States.

Loss of consciousness (LOC) is a hallmark feature in Traumatic Brain Injury (TBI), and a strong predictor of outcomes after TBI. The aim of this study was to describe associations between quantitative infrared pupillometry values and LOC, intracranial hypertension, and functional outcomes in patients with TBI.We conducted a prospective study of patients evaluated at a Level 1 trauma center between November 2019 and February 2020. Pupillometry values including the Neurological Pupil Index (NPi), constriction velocity (CV), and dilation velocity (DV) were obtained.Thirty-six consecutive TBI patients were enrolled. The median (range) age was 48 (range 21-86) years. The mean Glasgow Coma Scale score on arrival was 11.8 (SD = 4.0). DV trichotomized as low (0.5 mm/s), moderate (0.5-1.0 mm/s), or high (1.0 mm/s) was significantly associated with LOC (P = .02), and the need for emergent intervention (P .01). No significant association was observed between LOC and NPi (P = .16); nor between LOC and CV (P = .07).Our data suggests that DV, as a discrete variable, is associated with LOC in TBI. Further investigation of the relationship between discrete pupillometric variables and NPi may be valuable to understand the clinical significance of the pupillary light reflex findings in acute TBI.

Introduction and purpose Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth (DFW) Metroplex (19 counties, 9,286 sq mi, > 7.7 million people), by hospital network and stroke center status. Methods We conducted a North Central Texas Trauma Regional Advisory Council (NCTTRAC) Stroke Regional Care Survey at all 44 centers involved in the treatment of MT-eligible ischemic stroke patients between June-September 2019, with a response rate of 100%. All hospitals identified network status, stroke designation – Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Comprehensive Stroke Center (CSC) - and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest CSC was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package. Results Of the 44 facilities, 6 were ASRHs, 27 were PSCs, 11 were CSCs. Seventy-seven percent (n=34) belonged to one of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. There was significant heterogeneity in inter-facility transfer patterns with no regional standardization. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers using ground transportation via EMS. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9 miles). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8 miles). Conclusions Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy.

Background: Music as a therapeutic intervention for critically ill stroke patients has not been adequately researched. This may be related to a limited number of tools being available to measure the hypnotic response when patients cannot respond verbally. This pilot study examines the feasibility of bispectral index (BIS) monitoring to study music as a stress-reduction intervention in the neurocritical care setting. Methods: This prospective, randomised, crossover, pilot study enrolled 30 patients. On each of two consecutive days, patients were randomised to either 1 hour of silence followed by a crossover to 1 hour of music, or the reverse (music then silence). BIS values were recorded to evaluate stress and agitation before, during and after the 2-hour study period. Results: There were no reported adverse events, supporting feasibility of this pilot intervention. BIS values were sampled once every 6 seconds during the 2-hour study period. There was a statistically significant difference in BIS scores between the music and no music group (pConclusion: The use of neurofunction monitors to assess response to music is feasible during the critical care phase for patients with stroke. Additional studies should focus on genre, timing and route of delivery for music as an intervention.

BACKGROUND: Cannabis use for medical and recreational purposes is growing. Cannabis may have drug-drug interactions for managing pain, anxiety, and seizures. The research regarding cannabis use in patients with craniotomy surgeries is sparse and often conducted in states where cannabis use is legal. This study compared 24-hour postoperative craniotomy pain levels in patients who reported cannabis use in a state where cannabis is not yet legal. METHODS: This is an observational prospective, nonrandomized, pilot study of postoperative craniotomy patients. Patients were consented and given a one-time self-report questionnaire regarding postoperative pain, pain management method, type of pain medication used at home (including cannabis), route of administration, and frequency of use. Subjects scored pain on both the numeric rating scale and the visual analog scale. Demographic data were collected from the electronic medical record. RESULTS: Forty-five patients with a mean age of 57 years, 62% female, participated in this study. There were 33% who reported previous cannabis use. One-way analysis of variance showed a significant difference in the mean postoperative pain scores for the cannabis users (4.58) and nonusers (3.89; P = .0056). There was no significant difference between age (P = .1894) and adequacy of pain control (P = .6584) between users and nonusers. CONCLUSION: In this pilot study, a one-time survey in critical care on the sensitive topic of cannabis use is feasible and seems to generate honest responses. One-third of patients reported home use of cannabis in a state where cannabis is illegal.

Background: Screening is a valuable tool in emergency medicine for triaging, activation of protocols, and resource allocation. The Dallas Emergency Department Screening Tool to Identify Stroke (DESTINY) was developed to screen for all stroke subtypes, with improved sensitivity for posterior circulation stroke and large vessel occlusion (LVO). The main purpose of this study was to evaluate how reliably the tool could be taught and used by ED Nurses. Methods: This is Phase 1 of a multi-phase study to evaluate the DESTINY tool. A vascular neurologist retrospectively reviewed 409 stroke code activations between January and December of 2018. Thirty descriptive vignettes were composed: right anterior circulation stroke (n=5), left anterior circulation stroke (n=5), posterior circulation stroke (n=5), TIA and stroke mimic (n=6), non-LVO stroke (n=5), and hemorrhagic stroke (n= 4). Fifteen emergency medicine registered nurses used the DESTINY tool to screen the vignettes following the stroke education and DESTINY training module. Results: Individual Pearson Correlation Coefficients (PCC) were calculated for each nurse compared to the vascular neurologist (range: 0.43860 to 0.96966; mean: 0.8746 ± 0.1484). All individual PCC were statistically significant except for one [PCC of 0.43860 (p = 0.0153)]. Cronbach’s Alpha scores were very similar across multiple raters (standardized alpha for nurse raters: 0.9853). Omnibus test to compare DESTINY scores by stroke type demonstrated left anterior LVO and mimic/TIA stroke had few outlier observations, however, poorly differentiated hemorrhagic from ischemic stroke Conclusion: As demonstrated by high interrater reliability, the DESTINY tool can be effectively taught to ED nurses using clinical vignettes. The DESTINY tool is good at differentiating non-LVO, anterior LVO, mimics, and TIAs; while the ability to distinguish between anterior LVO/posterior LVO and ischemic/hemorrhagic stroke was sub-optimal. Utilizing the lessons learned in the early version of the DESTINY screening tool we expect that the high-reliability scores will continue to improve in future prospective studies.

Background Nearly every patient admitted to a neuroscience intensive care unit (ICU) will experience pain and nurses are tasked with analgesic administration. Within the setting of the ongoing opioid epidemic it is not well understood how nurses meet the need to alleviate pain while individualizing analgesic administration. Aims This qualitative study used a phenomenological approach to determine nurses’ perceptions in pain management of patientswith subarachnoid hemorrhage (SAH). Design Prospective qualitative inquiry using phenomenology Setting The study was conducted in a neuroscience intensive care unit at a university hospital. Participants Nine neuroscience intensive care unit nurses were enrolled using snowball sampling. Methods Saturation was reached after nine individual nurse interviews. Hermeneutic cycling analysis was used throughout interviews and codes and themes were developed throughout the interview process. Rigor was established using triangulation, rich and thick descriptions, and member checks. Results Emerging themes included discernment and hesitation. Discernment is supported by codes such as: “nursing judgement” and “follow the orders.” Hesitation is supported by codes such as “clouded exam” and “over sedation.” Eight nurses made references to hesitation of administering opioids due to the perception that it would cause a poorer neurological exam. All nurses described a reliance on education, experience, or intuition to guide their decision to administer opioids along with using approved pain scales. Themes were confirmed by member checks, which prompted slight modifications to coding. Conclusions Results of this study support that nurses do express apprehension in administering opioids to patients with (SAH). This apprehension leads to hesitation to administer the medication and a thought out discernment process.

Background: Surgical site infections (SSIs) are estimated at over 16,000 annually and cost hospitals an estimated $1.6 billion per year. Therefore, most operating rooms (ORs) seek methods to reduce the risk of SSI, especially during the intraoperative period. Prior work has established a link between excess traffic through the OR and increased microbial counts, which create a higher risk for SSIs. Aim/Objectives: To identify patterns of staff entry into the OR to further reduce the risk of SSIs after total joint arthroplasties. Methods: Researchers directly observed 31 total joint arthroplasties, recording every instance the door to the OR suite opened and the personnel, reason for opening and timing during surgical incision. Researchers then utilised the sequential data analysis to search for patterns. Results: Despite expected patterns in staff movement during the patterned surgery, researchers found no significant patterns to staff movement during total joint arthroplasty. Discussion: This study’s results suggest purposeful education targeted to circulating registered nurses could induce purposeful creation of traffic flow patterns to further decrease traffic and risk of SSI. Conclusion: There is no singular pattern to entering and exiting the OR during surgery. Thus, a single-solution approach is not recommended.

Clinical registries provide insight on the quality of patient care by providing data to identify associations and patterns in diagnosis, disease, and treatment. This has led to a push toward using large data sets in healthcare research. Nurse researchers are developing data registries, but most are unaware of how to manage a data registry. This article examines a neuroscience nursing registry to describe a quality control and data management process.Our registry contains more than 90 000 rows of data from almost 5000 patients at 4 US hospitals. Data management is a continuous process that consists of 5 phases: screening, data organization, diagnostic, treatment, and missing data. These phases are repeated with each registry update.The interdisciplinary approach to data management resulted in high-quality data, which was confirmed by missing data analysis. Most technical errors could be systematically diagnosed and resolved using basic statistical outputs, and fixed in the source file.The methods described provide a structured way for nurses and their collaborators to clean and manage registries.

Objectives There is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity. Methods This study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher’s Exact X2, and multivariate modeling with constructed MAX-R models. Results Data were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r2 = 0.48, p Conclusion ICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.

Background and Purpose: Blood pressure (BP) management is a vital part of acute stroke care. Both over- and under-correction of BP are associated with increased morbidity and mortality. Non-invasive BP (NIBP) and intra-arterial BP (ABP) measurements are commonly used, yet both methods yield inconsistent results. Measurement error can hinder optimal clinical management in neurological conditions where BP directly affects cerebral perfusion pressures. Discrepancy in clinical decision-making associated with BP measurement is rarely reported. This prospective, non-randomized, cross-sectional study aims to address the gap by correlating simultaneous within-subject BP readings from multiple sites. Methods: NIBP was simultaneously measured from 4 sites (both arms, both wrists) and ABP (when available) in 80 intensive care unit subjects. Correlation matrices and repeated measures ANOVA were used to explore for differences in BP by measurement site. Results: Of 80 subjects, 41 were male, mean age = 52.8, and mean BMI = 30. Pearson Correlation Coefficients for SBP ranged from 0.67 to 0.83; DBP from 0.77 to 0.84; and MAP from 0.76 to 0.88. (Figure 1). SBP differences ranged from 0 to 57 mmHg and MAP differences ranged from 0 to 36 mmHg. One-way repeated measures ANOVA revealed significantly different values for SBP (p=0.0319); DBP (p=0.0002); and MAP (p=0.0001). Conclusions: BP values vary significantly when measured simultaneously in different sites. Unpredictable inter-site comparisons of BP warrant significant research in larger prospective trials. Nurses should consider standardizing a measurement site for consistent BP readings and better clinical decision-making.

Introduction: Hand-held automated pupillometry reliably evaluates the pupillary light reflex (PLR) at the bedside and there is growing interest in studying its ability to detect midline shift and mass effect. We hypothesized that intracerebral hemorrhage (ICH) volume would correlate with objective measures of PLR, specifically the Neurological Pupil index (NPi). Methods: This was a retrospective study of ICH patients with serial pupillometer readings admitted to the Neurocritical Care Unit and enrolled in the END-PANIC registry. CT images were examined to measure hematoma volume using the simplified ABC/2 method, midline shift, hydrocephalus score, and Graeb score to measure interventricular hemorrhage. Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher’s Exact X 2 , and multivariate modeling with constructed MAX-R models. Results: Of 44 subjects, 50% were male and the mean age was 65.4 years. ICH location was deep in 56.8% and lobar in 43.2%. There was a significant correlation between ICH volume and NPi of the pupil ipsilateral (r 2 =0.48, p2 =0.39, p2 =0.25, p=0.0006], contralateral[r 2 =0.15, p=0.0106]), as did shift of the pineal gland (ipsilateral[r 2 =0.21, p=0.0017], contralateral[r 2 =0.11, p=0.0328]). No statistically significant correlation was found between hydrocephalus score or Graeb score and NPi. ICH volume was the most predictive of abnormal NPi (Figure 1). Conclusions: The NPi correlates with ICH volume and shift of midline structures. Abnormalities in NPi can be predicted by hematoma volume. Future studies should explore the role of NPi in detecting hematoma expansion and worsening midline shift.