Health Care Disparities in Stroke Rehabilitation

Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.

Variability in the Transition of Care to Poststroke Rehabilitation During the First Wave of COVID-19

OBJECTIVE

The aim of the study is to evaluate transitions of acute stroke and inpatient rehabilitation facility care during the first wave of COVID-19.

DESIGN

This is a retrospective observational study (3 comprehensive stroke centers with hospital-based inpatient rehabilitation facilities) between January 1, 2019, and May 31, 2019 (acute stroke = 584, inpatient rehabilitation facility = 210) and January 1, 2020, and May 31, 2020 (acute stroke = 534, inpatient rehabilitation facility = 186). Acute stroke characteristics included stroke type, demographics, and medical comorbidities. The proportion of patients admitted for acute stroke and inpatient rehabilitation facility care was analyzed graphically and using t test assuming unequal variances.

RESULTS

The proportion of intracerebral hemorrhage patients (28.5% vs. 20.5%, P = 0.035) and those with history of transient ischemic attack (29% vs. 23.9%; P = 0.049) increased during the COVID-19 first wave in 2020. Uninsured acute stroke admissions decreased (7.3% vs. 16.6%) while commercially insured increased (42.7% vs. 33.4%, P < 0.001).Acute stroke admissions decreased from 116.5 per month in 2019 to 98.8 per month in 2020 ( P = 0.008) with no significant difference in inpatient rehabilitation facility admissions (39 per month in 2019, 34.5 per month in 2020; P = 0.66).In 2019, monthly changes in acute stroke admissions coincided with inpatient rehabilitation facility admissions.In 2020, acute stroke admissions decreased 80.6% from January to February, while inpatient rehabilitation facility admissions remained stable. Acute stroke admissions increased 12.8% in March 2020 and remained stable in April, while inpatient rehabilitation facility admissions decreased by 92%.

CONCLUSIONS

Acute stroke hospitalizations significantly decreased per month during the first wave of COVID-19, with a delayed effect on the transition from acute stroke to inpatient rehabilitation facility care.

Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients

OBJECTIVE

To determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients.

MATERIALS AND METHODS

This prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days.

RESULTS

Among 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05).

CONCLUSIONS

In ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.

Pilot Study of Neurologic Pupil Index as A Predictor of External Ventricular Drain Clamp Trial Failure After Subarachnoid Hemorrhage

BACKGROUND

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

The pilot study data support that Neurological Pupil index <3 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.

Creating a resident-centric rehabilitation research team

BACKGROUND

The 36-month Physical Medicine and Rehabilitation (PM&R) or Physiatry residency provides a number of multidisciplinary clinical experiences. These experiences often translate to novel research questions, which may not be pursued by residents due to several factors, including limited research exposure and uncertainty of how to begin a project. Limited resident participation in clinical research negatively affects the growth of Physiatry as a field and medicine as a whole. The two largest Physiatry organizations - the Association of Academic Physiatrists and the American Academy of Physical Medicine and Rehabilitation - participate in the Disability and Rehabilitation Research Coalition (DRRC), seeking to improve the state of rehabilitation and disability research through funding opportunities by way of the National Institutes of Health (NIH), the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) and the Patient-Centered Outcomes Research Institute (PCORI). A paucity of new Physiatry researchers neutralizes these efforts.

RESULTS

This paper details the creation of a novel, multidisciplinary Rehabilitation Resident Research program that promotes resident research culture and production. Mirroring our collaborative clinical care paradigm, this program integrates faculty mentorship, institutional research collaborates (Neuroscience Nursing Research Center, Neuroscience Research Development Office) and departmental resources (Shark Tank competition) to provide resident-centric research support.

CONCLUSIONS

The resident-centric rehabilitation research team has formed a successful research program that was piloted from the resident perspective, facilitating academic productivity while respecting the clinical responsibilities of the 36-month PM&R residency. Resident research trainees are uniquely positioned to become future leaders of multidisciplinary and multispecialty collaborative teams, with a focus on patient function and health outcomes.

Comparison of Bispectral Index Monitor Data Between Standard Frontal-Temporal Position and Alternative Nasal Dorsum Position in the Intensive Care Unit: A Pilot Study

ABSTRACT

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.

Abstract WP63: The Effect Of Inpatient Rehabilitation Facility Treatment On 90 Day Outcomes: A Shift Analysis Of Modified Rankin Scale Score In Ischemic Stroke Patients

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.

Anisocoria Correlates With Injury Severity and Outcomes After Blunt Traumatic Brain Injury

ABSTRACT

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.

Exploring the Face Validity of the Pain Numeric Rating Scale Among Healthcare Providers

ABSTRACT

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.

Admission Glasgow Coma Scale Score as a Predictor of Outcome in Patients Without Traumatic Brain 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 <8: z = -7.89, P < .001; Glasgow Coma Scale score 8-12: z = -4.17, P < .001).

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.

The "Network Effect" on Interfacility Transfers Among Regional Stroke Certified Hospitals

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.

Implementation of the MATRIX Staffing Grid Improves Nurse Satisfaction With Rehabilitation Unit Staffing

ABSTRACT

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.

Quantitative pupillometry in patients with traumatic brain injury and loss of consciousness: A prospective pilot study

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

A Qualitative Study of Nurses' Perceptions of Narcotic Administration after Subarachnoid Hemorrhage

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.

Postoperative Pain Management Is Influenced by Previous Cannabis Use in Neurosurgical Patients

ABSTRACT

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.

An operating room audit to examine for patterns of staff entry/exit: pattern sequencing as a method of traffic reduction

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.

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury

OBJECTIVE

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.

METHODS

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.

RESULTS

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; P < 0.0001). 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.

CONCLUSIONS

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.