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ObjectiveTo determine the prevalence and associated mortality of well-defined neurologic diagnoses among patients with coronavirus disease 2019 (COVID-19), we prospectively followed hospitalized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–positive patients and recorded new neurologic disorders and hospital outcomes.MethodsWe conducted a prospective, multicenter, observational study of consecutive hospitalized adults in the New York City metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between patients with COVID-19 with and without neurologic disorders.ResultsOf 4,491 patients with COVID-19 hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were reverse transcriptase PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all p < 0.05). After adjusting for age, sex, SOFA scores, intubation, history, medical complications, medications, and comfort care status, patients with COVID-19 with neurologic disorders had increased risk of in-hospital mortality (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.17–1.62, p < 0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63–0.85, p < 0.001).ConclusionsNeurologic disorders were detected in 13.5% of patients with COVID-19 and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.

Serial pupil examinations remain a mainstay of neurological assessments performed by neuroscience nurses. Integration of pupillometer technology has increased in recent years, because of its ability to address limitations of manual examinations and to evaluate trended data over time. Preliminary research has linked pupillometer values to intracranial pressure (ICP) values, but data on pupillary changes in the setting of increased ICP remain sparse. The purpose of this study was to determine trends in pupillometer values in the setting of increased ICP among critically ill patients with neurological injury. This is a secondary analysis of data where serial pupillometer and ICP readings were recorded hourly on adult patients with neurological injury necessitating critical care management. More than 2100 paired serial pupillometer and ICP readings were obtained from 76 subjects, with a total of 2107 paired readings for the left eye and 2175 for the right eye. There were statistically significant differences in pupillometry values in the setting of increased ICP. Time series analysis indicates that spikes in ICP values resulted in corresponding variations in pupillometer values. Use of automated pupillometry remains a value adjunct to traditional invasive therapies. Evaluation of trended data may provide insight into ICP elevations in the absence of invasive monitoring and warrants additional research.

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.

In 2018, the American Association of Neuroscience Nurses will celebrate its 50th anniversary as the premier member organization for neuroscience nurses. In recent decades, one of the highest rated member benefits has been the ability for members to join special focus groups (SFGs). The SFGs were initiated to allow an avenue for information sharing and communication for neuroscience nurses in a variety of subspecialties. In this anniversary edition, the neurotrauma SFG presents a review of trends in the publication of articles in the Journal of Neuroscience Nursing related to neurotrauma. Findings from this article illustrate how these publications have impacted the nursing care of patients who have sustained traumatic injuries of the central and peripheral nervous system and the integral role of neuroscience nurses throughout the decades.

Falls remain an important benchmarking indicator for hospitals. Research identifies factors associated with falls among hospitalized patients in general. Similarly, the stroke literature outlines fall risk factors in the inpatient rehabilitation and community setting.The aim of this study was to identify prevalence and risk factors for falls among acute, hospitalized AIS patients within an urban public healthcare system. Secondary aims were to identify activities present at the time of the fall and outcomes associated with falling.This is a retrospective case-control study. Data were abstracted and merged from hospital stroke and fall registries and matched with medical records from 2013 to 2015 among all adult patients admitted for AIS.The study included 856 patients with AIS, with 2.3% experiencing a fall during the acute care hospitalization period. Falls among patients with AIS accounted for 1.4% of all hospitalized adult falls. Bivariate analysis indicate that a higher proportion of falls occurred among male patients when compared with female patients (75% male; χ = 3.964, P.05) and among patients with a history of previous myocardial infarction or renal insufficiency (χ = 5.260, P.05; χ = 11.116, P.001, respectively). Multivariate analyses identify previous myocardial infarction (OR, 2.5; 95% confidence interval, 1.0-6.3; P = .04) and renal insufficiency (odds ratio, 4.2; 95% confidence interval, 1.5-12.2; P = .008) as strongest predictors of falls. The occurrence of a fall resulted in increased hospital length of stay (7.1 vs 4.0 days, P.000) and slightly decreased functional outcome at discharge. Most falls occurred during the day shift while toileting, despite implementation and adherence to fall prevention programs.Fall rates among hospitalized patients with AIS are low, which may be reflective of increased vigilance among providers and widespread integration of fall prevention strategies. Consistent with the fall literature among other populations, the occurrence of a fall in the inpatient setting can substantially increase length of stay.

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.

Background: Understanding the factors impacting recovery after stroke is a critical step in developing interventions to optimize stroke outcomes. Previous work from Ohio Coverdell Program suggested that race may be independently associated with reduced odds of improvement in the first 30 days after stroke. Purpose: To determine if race, household income, and insurance status are independently associated with improvement in disability in the first 90 days after hospital discharge in patients admitted to comprehensive stroke centers (CSC) who received acute intervention. Methods: Retrospective cohort study of patients entered into the GWTG-Stroke from 7 Ohio Coverdell CSCs from 1/1/2015 to 7/16/2018 who received IV tPA and/or acute catheter-based intervention and had a mRS score at discharge and 90 days. Multivariable linear regression was performed to examine the association of race, household income estimated by ZIP code, and insurance on improvement in mRS between discharge and 90 days after adjusting for discharge mRS, clinical characteristics and hospital management. Results: There were 1,140 patients in the cohort who had mean age 66.7 yrs (SD 15.0). Estimated median income was $51,190 (SD $18,050); 18.3% were nonwhite. Of the socioeconomic variables assessed, only Medicaid insurance was associated with less recovery in the first 90 days post-discharge (β = -0.40; 95% CI -0.67, -0.14).Other variables associated with recovery were discharge mRS, hospital, premorbid ambulatory status, admission NIHSS, discharge destination, and length of stay. (see Table) Conclusion: Race and household income were not associated with recovery in the first 90 days post-discharge in stroke patients admitted to CSCs receiving acute interventions. Patients with Medicaid insurance had reduced probability of improvement. Further evaluation is indicated to determine if the worse recovery in Medicaid patients is due to socioeconomic status or premorbid health status.

It is important for neuroscience nurses to have a solid understanding of the instruments they use in clinical practice. Specifically, when reviewing reports of research instruments, nurses should be knowledgeable of analytical terms when determining the applicability of instruments for use in clinical practice. The purpose of this article is to review 3 such analytical terms: sensitivity, specificity, and receiver operating characteristic curves. Examples of how these terms are used in the neuroscience literature highlight the relevance of these terms to neuroscience nursing practice. As the role of the nurse continues to expand, it is important not to simply accept all instruments as valid but to be able to critically evaluate their properties for applicability to nursing practice and evidence-based care of our patients.

Fall Risk Factors among Hospitalized Acute Post-Ischemic Stroke Patients in an Urban Public Healthcare System Background: Falls remain an important benchmarking indicator for hospitals. The incidence of falls is a nursing-sensitive indicator, amenable to preventable measures. Research indicates factors associated with falls, but few studies specifically identify factors among hospitalized patients with acute ischemic stroke (AIS). Purpose: Identify prevalence and risk factors for falls among acute, hospitalized AIS patients within an urban safety net hospital. Methods: Retrospective cohort study. Data abstracted from stroke and fall registries, and medical records from 2013-2015 among all adult patients admitted for AIS. Variables included traditional risk factors for falls, as well as stroke-specific factors (NIHSS score, functional status, stroke location and vessel, administration of tPA). Results: N=683 AIS stroke patients, with 1.6% fall rate. Falls among AIS patients accounted for 6% of all hospital falls. AIS patients who experienced an inpatient fall had a mean age of 67 (range 46-86), were mostly male (82%), and ambulating independently prior to arrival (91%). Mean NIHSS scores upon admission were higher among those who experienced a fall, when compared to AIS patients who did not fall (mean=8.73, 7.01, respectively). Most patients who experienced a fall demonstrated weakness and/or paresis upon initial exam (90%), with 64% experiencing small vessel ischemic changes, and 36% MCA strokes. Administration of tPA was not associated with increased falls. LOS was significantly increased among AIS patients who experienced a fall (7.7 vs. 4.8, respectively, p Conclusions: Fall rates among hospitalized AIS patients may be lower than earlier reports, reflecting increased vigilance among providers and widespread integration of fall prevention strategies. Elevated NIHSS scores and weakness/paresis upon initial exam may be important predictors of falls among newly diagnosed AIS patients who had previously been able to ambulate independently. Consistent with fall literature among other populations, the occurrence of a fall in the inpatient setting can substantially increase length of stay.

Trarumatic brain injuries (TBIs) affect more than 1.4 million Americans annually. Trauma nurses caring for these patients routinely perform serial neurologic assessments, including pupillary examinations. While trauma nurses are likely familiar with basic components of the pupillary examination, some confusion about more specific aspects of the examination and the physiologic basis of the pupillary response may still remain, particularly as it pertains to patients with TBI. Therefore, the purpose of this article is to identify the key components of a pupillary examination and its associated physiologic response. A case study is provided to illustrate the application of this information among patients with TBI.