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To investigate the pandemic's impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, 'PUI'). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.

Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01260-x.

Several recent studies across the field of medicine have indicated gender disparity in the reception of prestigious awards and research grants, placing women in medicine at a distinct disadvantage. Gender disparity has been observed in neurology, critical care medicine and within various professional societies. In this study, we have examined the longitudinal trends of gender parity in awards and grants within the Neurocritical Care Society (NCS). A retrospective analysis was conducted of all available data longitudinally from 2004, when NCS first granted awards through 2019. We used self-identified gender in the membership roster to record gender for each individual. For individuals without recorded gender, we used a previously validated double verification method using a systematic web-based search. We collected data on six awards distributed by the NCS and divided these awards into two main categories: (1) scientific category: (a) Christine Wijman Young Investigator Award; (b) Best Scientific Abstract Award; (c) Fellowship Grant; (d) INCLINE Grant; and (2) non-scientific category: (a) Travel Grant; and (b) Presidential Citation. Available data were analyzed to evaluate longitudinal trends in awards using descriptive statistics and simple or multiple linear regression analyses, as appropriate. A total of 445 awards were granted between the years 2004 and 2019. Thirty-six awards were in the scientific category, while 409 awards were in the non-scientific category. Only 8% of women received NCS awards in the scientific awards category, whereas 44% of women received an award in the non-scientific category. Most notable in the scientific category are the Best Scientific Abstract Award and the Fellowship Grant, in which no woman has ever received an award to date, compared to 18 men between both awards. In contrast, women are well represented in the non-scientific awards category with an average of 5% increase per year in the number of women awardees. Our data reveal gender disparity, mainly for scientific or research awards. Prompt evaluation of the cause and further actions to address gender disparity in NCS grants and recognition awards is needed to establish gender equity in this area.

Background DNP programs should follow the Academic-Practice Partnership guiding principles developed by the AACN-AONE Task Force of Academic Practice Partnerships (2012) to support students educational and practice experiences. This paper outlines the collaboration between a college of nursing (CON) and academic medical center in establishing a formal process for identification and vetting of student DNP projects. Methods A collaborative committee called DNP Project Oversight Committee (DNPPOC) was formed. DNPPOC members outlined a number of processes to facilitate DNP project review, key stakeholder input, and developed several tools to accomplish the committee's goals. A survey was sent to DNPPOC members to solicit their feedback on meeting the committees overall goals. Results Medical center leadership reported improvements in the collection of key DNP project information and the distribution of DNP projects across facilitators and geographic locations. There was also report of perceived improvement in the overall quality of student learning opportunities, strategic direction of DNP projects, and alignment between CON and healthcare system goals. Conclusions Processes developed by the DNPPOC have allowed the organization to handle the increase in DNP projects and maximize organizational resources. The DNPPOC structure has ensured high-quality DNP projects and that DNP students are prepared to be leaders in quality improvement.

Several studies in critical care and neurology demonstrate women under-representation in professional societies; representation trends within the Neurocritical Care Society (NCS) are unknown. We examined longitudinal gender parity trends in membership and leadership within NCS. A retrospective study of NCS membership and leadership rosters was conducted. To determine gender, self-reported binary gender was extracted. For individuals without recorded gender, a systematic Web-based search to identify usage of gender-specific pronouns in publicly available biographies was performed. According to previously published methods, available photographs were utilized to record presumed gender identification in the absence of available pronoun descriptors. We analyzed available data longitudinally from 2002 to 2019 and performed descriptive statistical and linear regression analyses. In overall membership, the proportion of women members demonstrated an average 11% increase between 2005 and 2018 (95% confidence interval (CI) − 8.1 to 30.1, p = 0.08). The proportion of women Board of Directors (BOD) members increased significantly over time to 50% in 2019. There was an increase in women Officers from 0% in the first 3 years (2002–2004) to 40% in 2019, with two women Presidents out of 17 from 2002 to 2019. For available Executive Committee rosters, there was a statistically significant nearly 3% increase per year (95% CI 1.5–4; p = 0.0007) in the proportion of women members. Rosters for Committee members and chairpersons were also incomplete, but in an analysis of the available data, there was a statistically significant increase of 5% per year analyzed (95% CI 0.5–9.7; p = 0.04) in the proportion of women Committee members. We also found a statistically significant 4.3% increase per year analyzed (95% CI 2.4–6.1; p = 0.003) in the proportion of women Committee chairpersons. This is the first study of longitudinal gender parity trends within neurocritical care. We report that from 2002 to 2019, the NCS has undergone a significant increase in women representation in general membership, committee membership, and leadership positions.

The Neurocritical Care Society and the Society of Critical Care Medicine have worked together to create a perspective regarding the Standards of Neurologic Critical Care Units (Moheet et al. in Neurocrit Care 29:145-160, 2018). The most neurologically ill or injured patients warrant the highest standard of care available; this supports the need for defining and establishing specialized neurological critical care units. Rather than interpreting the Standards as being exclusionary, it is most appropriate to embrace them in the setting of team-based care. Since there are many more patients than there are highly specialized beds, collaborative care and appropriate transfer agreements are essential in promoting excellent patient outcomes. This viewpoint addresses areas of clarification and emphasizes the need for collegiality and partnership in delivering the best specialty critical care to our patients.

Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care. The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form. A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care. This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.

The Fifth Neurocritical Care Research Network (NCRN) Conference held in Boca Raton, Florida, in September of 2018 was devoted to challenging the current status quo and examining the role of the Neurocritical Care Society (NCS) in driving the science and research of neurocritical care. The aim of this in-person meeting was to set the agenda for the NCS’s Neurocritical Care Research Central, which is the overall research arm of the society. Prior to the meeting, all 103 participants received educational content (book and seminar) on the ‘Blue Ocean Strategy®,’ a concept from the business world which aims to identify undiscovered and uncontested market space, and to brainstorm innovative ideas and methods with which to address current challenges in neurocritical care research. Three five-member working groups met at least four times by teleconference prior to the in-person meeting to prepare answers to a set of questions using the Blue Ocean Strategy concept as a platform. At the Fifth NCRN Conference, these groups presented to a five-member jury and all attendees for open discussion. The jury then developed a set of recommendations for NCS to consider in order to move neurocritical care research forward. We have summarized the topics discussed at the conference and put forward recommendations for the future direction of the NCRN and neurocritical care research in general.

Critical care nursing involves the specialised nursing care of critically ill patients who are vulnerable and may be unable to voice their needs or have their human rights recognized or addressed. The World Federation of Critical Care Nurses (WFCCN) accepts and supports the Universal Declaration of Human Rights and the need for critically ill patients to be cared for with humanity, and to advocate for the rights of their families and communities. In the above context, WFCCN determined the need to create a document that was focused more specifically on the rights of critically ill patients. To this end, in August 2007, the WFCCN released its first Position Statement on the Rights of the Critically Ill Patient - The Declaration of Manila (WFCCN, 2007). The fundamental aim of this Declaration was to inform and assist critical care nursing associations, health services, educational facilities, and other interested parties to realize the rights of critically ill patients. Due to changes in critical care worldwide, as well as increased global migration, the WFCCN Board of Directors commissioned a review of the 2007 Declaration. As a result of this review, revisions were undertaken. This document represents the 2019 revised WFCCN Position Statement on the Rights of the Critically Ill Patient.

Ischemic stroke remains the fifth leading cause of death in the United States. Nurses play a pivotal role in the care of patients throughout the continuum. With the advances in stroke care, including mechanical thrombectomy, the American Heart Association/American Stroke Association charged the writing panel to complement the 2009 clinical practice guideline, “Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient,” with current evidence-based nursing care. This update is 1 of a 3-part series focusing on emergency medical services/emergency care, endovascular/intensive care unit care, and postacute care. The aim of this scientific statement is to review and present current evidence, complications, best practices, and clinical practice strategies to provide current comprehensive scientific information for nursing care in the neuroendovascular area and intensive care unit in conjunction with medical treatments, including intravenous thrombolysis and mechanical thrombectomy.

Several recent studies across the field of medicine have indicated gender disparity in the reception of prestigious awards and research grants, placing women in medicine at a distinct disadvantage. Gender disparity has been observed in neurology, critical care medicine and within various professional societies. In this study, we have examined the longitudinal trends of gender parity in awards and grants within the Neurocritical Care Society (NCS).A retrospective analysis was conducted of all available data longitudinally from 2004, when NCS first granted awards through 2019. We used self-identified gender in the membership roster to record gender for each individual. For individuals without recorded gender, we used a previously validated double verification method using a systematic web-based search. We collected data on six awards distributed by the NCS and divided these awards into two main categories: (1) scientific category: (a) Christine Wijman Young Investigator Award; (b) Best Scientific Abstract Award; (c) Fellowship Grant; (d) INCLINE Grant; and (2) non-scientific category: (a) Travel Grant; and (b) Presidential Citation. Available data were analyzed to evaluate longitudinal trends in awards using descriptive statistics and simple or multiple linear regression analyses, as appropriate.A total of 445 awards were granted between the years 2004 and 2019. Thirty-six awards were in the scientific category, while 409 awards were in the non-scientific category. Only 8% of women received NCS awards in the scientific awards category, whereas 44% of women received an award in the non-scientific category. Most notable in the scientific category are the Best Scientific Abstract Award and the Fellowship Grant, in which no woman has ever received an award to date, compared to 18 men between both awards. In contrast, women are well represented in the non-scientific awards category with an average of 5% increase per year in the number of women awardees.Our data reveal gender disparity, mainly for scientific or research awards. Prompt evaluation of the cause and further actions to address gender disparity in NCS grants and recognition awards is needed to establish gender equity in this area.

Several studies in critical care and neurology demonstrate women under-representation in professional societies; representation trends within the Neurocritical Care Society (NCS) are unknown. We examined longitudinal gender parity trends in membership and leadership within NCS.A retrospective study of NCS membership and leadership rosters was conducted. To determine gender, self-reported binary gender was extracted. For individuals without recorded gender, a systematic Web-based search to identify usage of gender-specific pronouns in publicly available biographies was performed. According to previously published methods, available photographs were utilized to record presumed gender identification in the absence of available pronoun descriptors. We analyzed available data longitudinally from 2002 to 2019 and performed descriptive statistical and linear regression analyses.In overall membership, the proportion of women members demonstrated an average 11% increase between 2005 and 2018 (95% confidence interval (CI) - 8.1 to 30.1, p = 0.08). The proportion of women Board of Directors (BOD) members increased significantly over time to 50% in 2019. There was an increase in women Officers from 0% in the first 3 years (2002-2004) to 40% in 2019, with two women Presidents out of 17 from 2002 to 2019. For available Executive Committee rosters, there was a statistically significant nearly 3% increase per year (95% CI 1.5-4; p = 0.0007) in the proportion of women members. Rosters for Committee members and chairpersons were also incomplete, but in an analysis of the available data, there was a statistically significant increase of 5% per year analyzed (95% CI 0.5-9.7; p = 0.04) in the proportion of women Committee members. We also found a statistically significant 4.3% increase per year analyzed (95% CI 2.4-6.1; p = 0.003) in the proportion of women Committee chairpersons.This is the first study of longitudinal gender parity trends within neurocritical care. We report that from 2002 to 2019, the NCS has undergone a significant increase in women representation in general membership, committee membership, and leadership positions.

Head-of-bed (HOB) elevation is the standard of care for patients with intracranial pressure monitoring at risk for intracranial hypertension. Measurement of cerebral perfusion pressure (CPP) based on HOB elevation and arterial transducer position has not been adequately studied.This is a planned secondary analysis of prospectively collected data in which paired, serial arterial blood pressure (ABP), intracranial pressure, and CPP measures were obtained once per day for 3 days, with measures leveled at the tragus (Tg) and the phlebostatic axis (PA). The HOB position was recorded for all paired readings.From 136 subjects, ABP and CPP values were lower when the transducer was leveled at the Tg, compared with the PA (P.001); these differences persisted regardless of HOB position.The difference in CPP when ABP is referenced at the Tg versus PA is not consistently attributed to HOB elevation.

Rush University Medical Center (Rush) is nationally recognized as a neurosciences center of excellence. The neuroscience programs at Rush offer treatment options for a broad and comprehensive spectrum of complex neurological diseases. Rush's significant investment and programs of clinical distinction in neurology and neurosurgery (collectively referred to as "neurosciences") did not occur without a significant long-term strategic plan and organizational investment. Rush University Medical Center is a 700-bed academic medical center, located in the urban downtown area of Chicago, Illinois. Rush first achieved Magnet designation (American Nurses Credentialing Center) in 2002, and most recently achieved the fourth designation in 2016. Rush has a long history of caring for highly complex patients, and stakeholders throughout the organization were intent on leveraging Rush's established strengths to aid in the development of a neurosciences center of excellence. Toward this end, several tactics emerged—including plans to invest significantly in technology, infrastructure, physician resources, marketing and outreach, and business development (Table 1).

Monitoring cerebral perfusion pressure (CPP) is recommended by a number of clinical practice guidelines and is a routine function performed by critical care neuroscience nurses. However, several studies highlight theoretical and practice variations in the measurement of CPP regarding the location of the arterial pressure transducer during measurement. Agreement on the technique and process for obtaining valid measurements is lacking. This article identifies the challenges associated with CPP measurement and highlights opportunities for standardizing CPP measurement to improve consistency in care and findings reported in the research literature. The challenges associated with practice variations impact multiple nursing domains, including the environment, patient treatment, and team communication; all ultimately impacting nursing workflow. The practice variation and impact on nursing workflow have significant implications for further research, electronic health record development, and refining monitoring technology.

Within healthcare systems, quality improvement (QI) methodologies and implementation science (IS) techniques are used to identify optimal processes to improve care delivery. Nurses remain at the forefront of care delivery, and must understand the basic components of QI and IS in order to advocate for improved efficiencies, address challenges to evidence-based practice utilization, and monitor incremental changes to positively impact benchmarks and patient outcomes.

Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care.The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form.A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care.This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.

Introduction Falls in the emergency department pose an important challenge for patient safety. Multifactorial fall prevention bundles have been associated with a reduction in patient falls in the inpatient setting. The purpose of this project was to tailor and implement a comprehensive fall prevention bundle in our emergency department. Methods Fall bundle components for this intervention were selected on the basis of a review of fall prevention research and included fall risk assessment, safe ambulation, safe toileting, staff communication, early warning, and patient education. The fall risk assessment was tailored to the emergency department through an appraisal of select inpatient fall risk assessments, literature search for ED-specific fall risk factors, and a site-specific chart review, after which pertinent fall risk factors were integrated into a modified screening. Fall prevention materials that were both practical and applicable to the emergency department and facilitated patient safety along each bundle domain were selected for implementation at our site. Results The tailored fall prevention bundle was championed by the interdisciplinary ED Fall Prevention Team and implemented over the course of 5 months in 1 emergency department. Education on fall prevention equipment was delivered in a peer-to-peer format, and an online module was designed to guide staff through the new fall risk assessment. The fall prevention bundle was adopted into clinical practice after staff education was completed, and the fall risk screening was merged into the electronic medical record. Discussion ED fall prevention requires a comprehensive bundled approach, which includes a fall risk screening and multifactorial interventions that are tailored to the ED setting. Successful implementation relies on the involvement of front-line staff from the design through the delivery of the bundled fall prevention measures. Continued inquiry and innovation in ED fall prevention will help provide a safer health care environment and improve patient outcomes.

Background: Post–intensive care syndrome (PICS) is a constellation of cognitive, physical, emotional, or psychiatric impairments that begins during or immediately after intensive care unit (ICU) hospitalization and persists beyond discharge. This executive review summarizes literature on PIC

Although technology over the past several decades has enabled improved neuroimaging and advanced noninvasive and invasive neuromonitoring, the role of the bedside nurse conducing ongoing neurologic examination is still a foundational element of neuromonitoring. Ongoing neurologic monitoring by the bedside nurse in the neuroscience intensive care unit is variable and guided by little evidence or data. When neurologic monitoring through clinical examination is possible, data obtained from multimodal monitoring should be interpreted in the context of the neurologic examination. The bedside nurse plays a crucial role in conducting ongoing neurologic examinations.

BackgroundDue to changes in critical care worldwide, the World Federation of Critical Care Nurses Board of Directors commissioned a review of its 2005 Declaration of Buenos Aires: Position Statement on the Provision of a Critical Care Nursing Workforce.AimTo provide international recommendations to inform and assist critical care nursing associations, health services, governments, and other interested stakeholders in the development and provision of an appropriate critical care nursing workforce.MethodsAn international review group was established, comprised of critical care nurse clinicians, leaders, and researchers. A literature search was undertaken, which informed the revision of the 2005 Declaration, which is contained in the 2019 Position Statement.PositionThe position is supported by six central principles, and is comprised of eight key statements: A critical care unit should have a dedicated nurse leader; Each shift should have at least one registered nurse (RN) designated as the team leader; The majority of RNs providing patient care should hold a recognized post-registration qualification or certification in critical care; Critical care RN staffing should be assessed on a shift-by-shift basis according to patient acuity, the staffing profile, and unit need; An additional critical care RN, not counted in RN-to-patient ratios or allocated a patient load, may provide additional hands-on assistance in patient care, and coordinate other patient-related activities; Support staff (such as nursing and allied health assistants, nursing aides, and care assistants) should work only under the direct supervision of a critical care RN, and never in place of a critical care RN; Where institutionally supported, and in accordance with local legislation, a critical care RN may provide expert critical care consultancy; A critical care unit should be staffed to provide at least one senior nurse, who holds a recognized post-registration critical care qualification or certification, and ideally further qualifications in education.

Neurocritical care is a distinct subspecialty focusing on the optimal management of acutely ill patients with life-threatening neurologic and neurosurgical disease or with life-threatening neurologic manifestations of systemic disease. Care by expert healthcare providers to optimize neurologic recovery is necessary. Given the lack of an organizational framework and criteria for the development and maintenance of neurological critical care units (NCCUs), this document is put forth by the Neurocritical Care Society (NCS). Recommended organizational structure, personnel and processes necessary to develop a successful neurocritical care program are outlined. Methods: Under the direction of NCS Executive Leadership, a multidisciplinary writing group of NCS members was formed. After an iterative process, a framework was proposed and approved by members of the writing group. A draft was then written, which was reviewed by the NCS Quality Committee and NCS Guidelines Committee, members at large, and posted for public comment. Feedback was formally collated, reviewed and incorporated into the final document which was subsequently approved by the NCS Board of Directors.

The road to Comprehensive Stroke Center (CSC) certification is challenging and requires full integration of neurological, neurosurgical, neurointerventional, and neurocritical care and rehabilitation services across the entire continuum of care. To successfully achieve this level of certification, centers must coordinate significant resources and services into an organized program. This paper is the first in a three-part series outlining common pitfalls facing many organizations during their journey to initial CSC certification and re-certification and offers a roadmap and pearls for success on this journey. Setting the vision for certification is a key first step in the certification process. This includes fully understanding the certification standards, requirements, and supporting documents. Program leadership must then conduct a thorough gap analysis and build a business plan to support the program as it transitions to a CSC. These key steps should inform the timeline for certification application.

Cerebral perfusion pressure (CPP) is a key parameter in management of brain injury with suspected impaired cerebral autoregulation. CPP is calculated by subtracting intracranial pressure (ICP) from mean arterial pressure (MAP). Despite consensus on importance of CPP monitoring, substantial variations exist on anatomical reference points used to measure arterial MAP when calculating CPP. This study aimed to identify differences in CPP values based on measurement location when using phlebostatic axis (PA) or tragus (Tg) as anatomical reference points. The secondary study aim was to determine impact of differences on patient outcomes at discharge. This was a prospective, repeated measures, multi-site national trial. Adult ICU patients with neurological injury necessitating ICP and CPP monitoring were consecutively enrolled from seven sites. Daily MAP/ICP/CPP values were gathered with the arterial transducer at the PA, followed by the Tg as anatomical reference points. A total of 136 subjects were enrolled, resulting in 324 paired observations. There were significant differences for CPP when comparing values obtained at PA and Tg reference points (p

Purpose of review Neurocritical care has matured as a field and there is now a growing body of literature on the subject of quality improvement in neurocritically ill patients. This review will highlight major recent contributions in this field and discuss future directions. Recent findings Articles published in the past 18 months have evaluated neurocritical care unit staffing, structure, and disease-specific protocols including subarachnoid hemorrhage and severe traumatic brain injury management. An assessment of current quality improvement practices in neurocritical care was also conducted. A neurocritical care-specific metric bundle is being proposed. Summary The quality improvement movement is gaining momentum in neurocritical care with evaluation of general medical and surgical critical care quality improvement approaches in this specific patient population. Future work should focus on improving systems of neurocritical care delivery through iterative evaluation of structure, staffing, minimizing unnecessary variation, and evaluation of neurocritical care-specific metrics.

The authors note that there is a discrepancy between the text of the paper and Table 2 regarding physician subspecialty certification requirements in neurocritical care for Level II centers.

Stroke is the fourth leading cause of death and the leading cause of significant, long-term disability in the United States. Clinicians’ knowledge and use of evidence to guide the care of patients with ischemic stroke are paramount to improving patient outcomes. The recently updated “Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association” provides clinicians with evidence-based, expert consensus to guide the recognition and early management of patients with acute ischemic stroke. The guideline provides 115 recommendations for the management of patients with acute ischemic stroke, including 24 new recommendations and 51 revised recommendations divided into 14 major topic areas. This article reviews the recommendations and related literature and provides suggestions for use and implementation of the guideline within a stroke program of care.

Background: Stroke coordinators (SC) are key stroke program personnel. However, little is known about the SC role or barriers to practice. We designed a role study to better understand barriers to SCs practice and contributors to burnout and and turnover. Methods: a role survey was developed using Dillman’s Tailored Design Methods and addressed orientation to role, mentoring and barriers to practice. The voluntary survey was distributed by email through three stroke organizations in Illinois and targeted SCs and advanced practice nurses (APN) with stroke program responsibilities. Results: 40 participants from 33 different facilities responded to the role survey. 65% of respondents identified as SC, 30% as stroke program manager/director, 20% as an APN. 17% had worked at other facilities previously as a stroke coordinator or similar role. 46% of respondents reported not having adequate resources to perform duties as stroke coordinator. Top reported moderate or extreme barriers to success in the role were lack of time (78%), lack of role clarity by supervisor (32%), lack of role definition as stroke coordinator (30%), lack of mentorship (27%), lack of on-the-job training (22%), and lack of formal education (19%). SCs and APNs with program coordination responsibilities report to a variety of different supervisor roles, including nursing management (38%), quality department (27%), other hospital administration (14%), service line management (8%), a physician (5%), other (6%). 70% of respondents reported they had not been mentored by anyone at their facility once hired into the role and 16% of coordinators reported they were considering leaving their position in the next year. Conclusions: While stroke coordinators and APNs with programmatic oversight are viewed as integral to program success, many are struggling with lack of role clarity, time management, adequate resources, and lack of mentorship. These factors may be contributing to turnover and burnout.

The aging of the US population poses complex management issues for the health care provider in the acute and subacute setting. Although management guidelines exist to guide the treatment of individual disease processes, addressing goals of care in an aging patient with multiple comorbidities requires conversations unique to each patient and family. This case study examines the care of a patient with Parkinson's disease, dementia, and pneumonia admitted to the intensive care unit for altered mental status and metabolic encephalopathy. The pathophysiology and management of Parkinson's disease, dementia, community-acquired pneumonia, and dysphagia will be reviewed.

Objective: To reduce the hospital-acquired pneumonia rate in stroke patients. Background: The hospital-acquired pneumonia rate for stroke patients at our institution was 6.2% in 2014. This is the 39th percentile for the Joint Commission Comprehensive Stroke Centers in the University HealthSystem Consortium. Our goal was to achieve top decile performance by reducing our hospital-acquired pneumonia rate for stroke patients to 3.0%. Methods: A multidisciplinary team was assembled with representation from administration, coding, nursing, resident physicians, and attending physicians from stroke, neurocritical care and infectious disease. The team analyzed benchmarking data and decided to use chart review to validate the data. The team decided to use the CDC’s definition and clinical criteria for hospital-acquired pneumonia. Further chart review was performed to find information on swallow evaluations, incentive spirometer use, oral care, and head of bed elevation. A coding manager reviewed the documentation and the coding decision for each patient. After results were presented, the team decided on a course of action. Results: Review of stroke patients with hospital-acquired pneumonia showed 44% of the patients coded with pneumonia did not meet the clinical definition on physician review. When reviewed by a coding manager, all coding was found to be correct based on the documentation in the chart. To solve this documentation problem, attending physicians discharging stroke patients were informed of these results about unclear pneumonia documentation and were asked to clarify documentation if the diagnosis was not appropriate. After this change, the hospital acquired pneumonia rate in stroke patients fell from 6.2% prior to the changes from April 2014 to March 2015 to 1.9% after the changes were implemented from April to June 2015. Conclusion: Our facility was able to reduce the rate of hospital-acquired pneumonia in stroke patients from 6.2% to 1.2% through a multidisciplinary approach to achieve more accurate documentation and coding. The widespread over-documentation showed it is clinically difficult to make a diagnosis of pneumonia in this population. Therefore, the rate of hospital-acquired pneumonia is not a valid measure of quality of care.

Effective methods of monitoring the status of patients with neurological injuries began with non-invasive observations and evolved during the past several decades to include more invasive monitoring tools and physiologic measures. The monitoring paradigm continues to evolve, this time back toward the use of less invasive tools. In parallel, the science of monitoring began with the global assessment of the patient’s neurological condition, evolved to focus on regional monitoring techniques, and with the advent of enhanced computing capabilities is now moving back to focus on global monitoring. The purpose of this session of the Second Neurocritical Care Research Conference was to collaboratively develop a comprehensive understanding of the state of the science for global brain monitoring and to identify research priorities for intracranial pressure monitoring, neuroimaging, and neuro-electrophysiology monitoring.

As a result of both foundational and recent work, a call to action to urgently redesign global care systems to enhance quality and improve patient safety has become a priority. This chapter will overview the structure, process, and outcome measures that can be applied to NeuroCritical Care to enhance patient safety and optimize quality of care.

Thank you for your thoughtful review. We appreciate the additional nursing consideration points related to the care of the patient after decompressive craniectomy (DC). Both points highlight the importance of considering nursing care implications when evaluating medical therapy and measuring complications associated with any therapy. In our extensive review of the literature on complications associated with DC and care priorities after DC, train of 4 monitoring …

Multi-modal monitoring has become an integral part of neurointensive care. However, our approach is at this time neither standardized nor backed by data from randomized controlled trials. The goal of the second Neurocritical Care Research Conference was to discuss research priorities in multi-modal monitoring, what research tools are available, as well as the latest advances in clinical trial design. This section of the meeting was focused on how such a trial should be designed so as to maximize yield and avoid mistakes of the past.

Background and Purpose: Stroke is the leading cause of adult disability in the United States. Compliance with the stroke quality indicators reinforces that a stroke center is adhering to the evidence based standards of care in acute stroke patients. Hardwiring a process in the delivery of care during hospitalization will ensure improved compliance of these quality indicators. Methods: A core multidisciplinary team was formed that included neurointensivists, neurologist, neurointerventional radiologist, pharmacist, emergency room and neuro intensive care staff along with neuroscience administration staff. Directors of the various services impacted by the stroke patients were invited on an ad hoc basis. Retrospective chart reviews were performed to collect data on a monthly basis for the following quality indicators: DVT prophylaxis Discharged on antithrombotics Patients with a-fib receiving anticoagulation Thrombolytic therapy administration Antithrombotic by end of day 2 Discharged on cholesterol meds Dysphagia screening Stroke education Smoking cessation education Assessed for Rehab Overall compliance with these indicators was on target but areas for improvement were noted in the following areas: stroke education, discharged on statin, thrombolytic therapy administration and patients with a-fib receiving anticoagulation. Aggressive action plans for each of these areas were developed and implemented. Initiatives included standardized electronic order sets, electronic admission, consult, history and physical templates with the quality indicators listed. Presentation of compliance results with a review of outliers were part of monthly section meetings. In order to understand process deviations further discussions with section chiefs resulted in investigation and resolution of issues that led to the variances. Hiring of a research registered nurse and a stroke coordinator were added to the existing stroke service team. Results: Dramatic improvement was achieved with no indicator falling below Conclusions: A cohesive project team was able to identify barriers, recommend process changes and ensure the implementation of change within the institution. Data collection and process revision is ongoing

As patients with sickle cell anemia (SCA) are living longer, health care practitioners increasingly manage the chronic effects of the disease. Although significant strides in management of children with SCA over the past decade resulted in decreased mortality, less research exists to guide the care of the adult with complications from the disease. This case study reviews the care of a young woman with SCA admitted to the hospital for vaso-occlusive crisis with subsequent acute chest syndrome and acute respiratory distress syndrome. The pathophysiology and management of SCA, vaso-occlusive crisis, and pulmonary and neurologic complications of the disease are discussed.

Introduction The American Heart Association’s quality improvement initiative, Target Stroke, is designed to reduce door-to-needle (DTN) times for IV r-tPA to improve patient outcomes. One of the quality indicators is time-to-CT scan and interpretation. Although, we were already meeting the recommended target, we sought to further enhance efficiency of this process in our institution. Method We performed a retrospective chart review of patients with CT Brain Acute Stroke protocol orders from January to December 2010, which represents a one-year period after instituting changes to our CT protocol. Some of the changes included: improved emergency medical service communication, streamlined patient registration and emergency department (ED) training on time-sensitive stroke care elements. CT scan times were analyzed based on time ordered, time of completion, and radiology interpretation. Our review included DTN for IV r-tPA administration for acute stroke patients during the same time period. Results Of the 571 acute stroke patients admitted through the ED during the study period, 12% received IV r-tPA. Of these, 79% received IV r-tPA within 60 minutes, with a mean (±SD) DTN time of 52 (±27) minutes. The relative efficiency of thrombolysis was attributed in part due to our fast-track CT head protocol process. The mean time from CT order to completion was 12 minutes and CT completion to verbal reporting to the ordering physician was 6 minutes. Conclusion Using a multi-disciplinary approach for quality improvement in CT acquisition and interpretation times, we were able to enhance the efficiency of our overall DTN time. We believe that our protocol is easily adaptable in any Neurointensivist led stroke service, and would benefit patients on a national level to allow for more rapid administration of IV r-tPA by reducing delays in the CT head protocol. Developing a strong infrastructure that is hard-wired and part of the institutional culture resulted in decreased CT times along with 79% of stroke patients receiving r-tPA in less than 60 minutes. Are efforts have paid off; our hospital has been designated on the Target Stroke Honor Roll.

Background and Purpose: Stroke is the third leading cause of death and leading cause of long term disability in the USA. Intravenous administration of tissue plasminogen activator (t-PA) is the only FDA approved medical therapy for treatment of patients with acute ischemic stroke. It is recommended by the American Heart Association that earlier treatment with t-PA within 90 minutes of symptoms may result in a more favorable patient outcome. Initiating t-PA for ischemic stroke patients within 60 minutes after Emergency Department (ED) triage is an indicator tracked by the Get With The Guidelines database. The purpose of our project was to increase the number of ischemic stroke patients receiving t-PA within 60 minutes after triage. Methods: The Six Sigma® process model was applied in order to develop an understanding of variations in the times of triage to initiation of IV t-PA data. We assembled a multidisciplinary team to develop and measure aspects of our current protocols, analyze data, investigate and identify the causes of delays and form action plans to enhance our new process. We tracked the patient flow from first responder contact to thrombolysis time. As a result the team acknowledged that it was imperative to impact the early recognition of ischemic stroke patients in the field. This led to local and regional stroke educational programs. Our neuroscience team of physicians and nurses proceeded to educate over 850 emergency responders. Results: Initial analysis of the baseline data showed that 56 % (5 of 9) of the ischemic stroke patients received intravenous t-PA within 60 minutes of triage. Once the stroke code process was implemented, 79 % (15 of 19) of ischemic stroke patients received intravenous t-PA within 60 minutes after triage. These results were obtained within 9 months of process implementation. Specific process changes included the use of a standard time clock, shorter CT scan turn around times, dedicated 24/7 ED pharmacists, quicker availability of medication administration pumps and ongoing feedback by all team members on the acute stroke process. Conclusions: The stroke team was able to identify barriers, institute process changes and ensure the implementation of change from the prehospital community setting to the acute inhospital care.