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Cencer S, Tubergen T, Packard L, Gritters D, LaCroix H, Frye A, Wills N, Zachariah J, Wees N, Khan N, Min J, Dejesus M, Combs J, Khan M. Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis Is Safe and Reduces Length of Stay for Minor Stroke Patients. Neurohospitalist 2022; 12:504-507. [DOI: 10.1177/19418744211048014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The current standard of practice for patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator (tPA) requires critical monitoring for 24-hours post-treatment due to the risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of this standard 24-hour ICU monitoring period compared with a shorter 12-hour ICU monitoring period for minor stroke patients (NIHSS 0-5) treated with tPA only. Stroke mimics and those who underwent thrombectomy were excluded. The primary outcome was length of hospital stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and favorable functional outcome defined as modified Rankin scale (mRS) of 0-2 at 90 days. Of the 122 patients identified, 77 were in the 24-hour protocol and 45 were in 12-hour protocol. There was significant difference in length of hospital stay for the 24-hour ICU protocol (2.8 days) compared with the 12-hour ICU protocol (1.8 days) ( P < 0.001). Although not statistically significant, the 12-hour group had favorable rates of sICH, 30-day readmission rates, favorable discharge disposition and favorable functional outcome. Rates of DVT, PE and aspiration pneumonia were identical between the groups. Compared with 24-hour ICU monitoring, 12-hour ICU monitoring after thrombolysis for minor acute ischemic stroke was not associated with any increase in adverse outcomes. A randomized trial is needed to verify these findings.
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Affiliation(s)
- Samantha Cencer
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Tricia Tubergen
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Laurel Packard
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | | | - Hattie LaCroix
- Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Angela Frye
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Nicole Wills
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Joseph Zachariah
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nabil Wees
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nadeem Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jiangyong Min
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Michelle Dejesus
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jordan Combs
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Muhib Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
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LaBuzetta JN, Hirshman BR, Malhotra A, Owens RL, Kamdar BB. Practices and Patterns of Hourly Neurochecks: Analysis of 8,936 Patients With Neurological Injury. J Intensive Care Med 2021; 37:784-792. [PMID: 34219542 DOI: 10.1177/08850666211029220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients experiencing acute neurological injury often receive hourly neurological assessments ("neurochecks") to capture signs of deterioration. While commonly utilized in the intensive care unit (ICU) setting, little is known regarding practices (i.e., variations by age and ordering services) and patterns (i.e., duration and post-discontinuation plans) of hourly neurochecks. To inform future quality improvement intervention efforts, we performed an analysis of hourly neurochecks using an electronic health record-based dataset. STUDY DESIGN AND METHODS Our 75-month retrospective dataset consisted of all health system ICU patients who received hourly neurochecks. Variables included age, admission diagnosis category, ordering provider, post-discontinuation order, and discharge destination. Multivariable Cox regression was used to evaluate factors associated with hourly neurocheck duration. RESULTS We evaluated 9,513 first admission hourly neurocheck orders in 8,936 patients. The trauma, neurosurgery, and neurocritical care services were responsible for 4,067 (43%), 2,071 (22%) and 1,697 (18%) hourly neurocheck orders, respectively. Median (interquartile range) hourly neurocheck duration was 1.09 (0.69, 2.35) days, and was greater than 3 and 7 days, respectively, for 1,773 (19%) and 640 (7%) patients. Median hourly neurocheck duration ranged from 0.87 (0.65, 1.68) to 1.60 (0.83, 2.97) days for neurosurgical and non-neurological ICU services, respectively. Upon discontinuation, 2,225 (23%) of hourly neurochecks were transitioned to no neurochecks. CONCLUSION Substantial differences exist between ICU services and practice patterns surrounding hourly neurochecks. Understanding these differences will help inform intervention efforts aimed at streamlining hourly neurocheck practices and outcomes for patients with acute neurological injury.
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Affiliation(s)
- Jamie Nicole LaBuzetta
- Division of Neurocritical Care, Department of Neurosciences, UC San Diego Health, La Jolla, CA, USA
| | - Brian R Hirshman
- Department of Neurosurgery, UC San Diego Health, La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, UC San Diego Health, La Jolla, CA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, UC San Diego Health, La Jolla, CA, USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, UC San Diego Health, La Jolla, CA, USA
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Faigle R, Butler J, Carhuapoma JR, Johnson B, Zink EK, Shakes T, Rosenblum M, Saheed M, Urrutia VC. Safety Trial of Low-Intensity Monitoring After Thrombolysis: Optimal Post Tpa-Iv Monitoring in Ischemic STroke (OPTIMIST). Neurohospitalist 2019; 10:11-15. [PMID: 31839859 DOI: 10.1177/1941874419845229] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose At present, stroke patients receiving intravenous thrombolysis (IVT) undergo monitoring of their neurological status and vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and every hour thereafter up to 24 hours post-IVT. The present study sought to prospectively evaluate whether post-IVT stroke patients with low risk for complications may safely be cared for utilizing a novel low-intensity monitoring protocol. Methods In this pragmatic, prospective, single-center, open-label, single-arm safety study, we enrolled 35 post-IVT stroke patients. Adult patients were eligible if their NIH Stroke Scale (NIHSS) was less than 10 at the time of presentation, and if they had no critical care needs by the end of the IVT infusion. Patients underwent a low-intensity monitoring protocol during the first 24 hours after IVT. The primary outcome was need for a critical care intervention in the first 24 hours after IVT. Results The median age was 54 years (range: 32-79), and the median pre-IVT NIHSS was 3 (interquartile range [IQR]: 1-6). None of the 35 patients required transfer to the intensive care unit or a critical care intervention in the first 24 hours after IVT. The median NIHSS at 24 hours after IVT was 1 (IQR: 0-3). Four (11.4%) patients were stroke mimics, and the vast majority was discharged to home (82.9%). At 90 days, the median NIHSS was 0 (IQR: 0-1), and the median modified Rankin Scale was 0 (range: 0-6). Conclusion Post-IVT stroke patients may be safely monitored in the setting of a low-intensity protocol.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jaime Butler
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Juan R Carhuapoma
- Division of Neurosciences Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth K Zink
- Department of Neuroscience Nursing, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Tenise Shakes
- Department of Neuroscience Nursing, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Melissa Rosenblum
- Department of Neuroscience Nursing, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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