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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.

Background Delirium is a common neuropsychiatric diagnosis in intensive care units and often leads to extended hospital stays and an increased rate of complications. Delirium can be classified as hypoactive, hyperactive, or mixed. Hyperactive delirium is often accompanied by agitation, which is a predictive factor for unplanned extubation. Hypoactive delirium does not include outward agitation; its incidence and relationship to ventilatory outcomes, specifically unplanned extubation and duration of mechanical ventilation, are relatively unexplored. Objective To determine the occurrence rate of each delirium type in the first 7 days after intensive care unit admission and explore the relationship between delirium type and ventilatory outcomes. Methods This was a retrospective cohort study that enrolled adult patients consecutively admitted to a medical intensive care unit over 12 months. Data were abstracted on patient demographic variables, daily clinical variables (morning and evening delirium, coma, and sedation scores), and outcome variables (unplanned extubation, length of stay, and duration of mechanical ventilation). Results We enrolled 171 patients in the study. Hypoactive delirium occurred in up to 44% of patients. Of 25 instances of unplanned extubation, up to 74% of patients had hypoactive delirium. Delirium was not a predictor of unplanned extubation; smoking history, chronic obstructive pulmonary disease, and failed breathing trials best predicted unplanned extubation (odds ratios = 3.2, 5.2, and 12.6, respectively; P < .05). Conclusions Hypoactive delirium is common among intensive care unit patients and may precede unplanned extubation. Patient history and comorbidities remain the strongest predictors of unplanned extubation.

ContextThe coronavirus disease 2019 (COVID-19) pandemic has created a need for remote blood glucose (BG) monitoring in the intensive care unit (ICU).ObjectiveTo evaluate feasibility and patient safety of a hybrid monitoring strategy of point-of-care (POC) BG plus continuous glucose monitor (CGM) in the ICU.DesignRetrospective analysis.SettingICU of an academic medical center.PatientsPatients with COVID-19 on IV insulin.InterventionAfter meeting initial validation criteria, CGM was used for IV insulin titration and POC BG was performed every 6 hours or as needed.Main Outcome MeasuresOutcomes included frequency of POC BG, workflow, safety, and accuracy measures.ResultsThe study included 19 patients, 18 with CGM data, mean age 58 years, 89% on mechanical ventilation, 37% on vasopressors, and 42% on dialysis. The median time to CGM validation was 137 minutes (interquartile range [IQR] 114-206). During IV insulin, the median number of POC values was 7 (IQR 6-16) on day 1, and declined slightly thereafter (71% reduction compared with standard of 24/day). The median number of CGM values used nonadjunctively to titrate IV insulin was 11.5 (IQR 0, 15) on day 1 and increased thereafter. Time in range 70 to 180 mg/dL was 64 ± 23% on day 1 and 72 ± 16% on days 2 through 7, whereas time ConclusionsThis study provides data to support that CGM using a hybrid protocol is feasible, accurate, safe, and has potential to reduce nursing and staff workload.

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.

Neurocritical care is a rapidly growing specialty of complex care for the critically ill patient with neurological injury. This rapid growth has led to an increase in the number of important clinical trials to guide clinical practice and evidence-based care of the critically ill patient with neurological injury. Specialty-trained critical care nurses and advanced practice providers are integral members of neurocritical care teams and must remain informed about pivotal trials shaping practice recommendations. This article presents a summary of recent trials that have affected current practice and influenced care recommendations in the neurocritical care setting.

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.

Objective: Overtriage (OT) of helicopter emergency medical services (HEMS) poses significant burden to multiple stakeholders. The project aims were to identify the following: 1) associated factors, 2) downstream effects, and 3) focus areas for change. Methods: We undertook a failure mode and effects analysis (FMEA) to evaluate our HEMS interfacility transport process. Data were collected from organizational finances and 3 key stakeholder groups: 1) interfacility patients transferred by HEMS in 2017 who were discharged from the receiving facility within 24 hours (n = 149), 2) flight registered nurses (n = 19), and 3) referring emergency medicine providers (EMPs) (n = 30) from the top HEMS users of 2017. The completed FMEA identified failure modes, the frequency and severity of effects, and unique risk profile numbers (RPNs). Results: Twelve failure modes were identified with 30 potential causes. Leading failure modes included inappropriate HEMS requests by EMPs (RPN = 343), inappropriate activation by EMS for interfacility transport (RPN = 343), and minimizing patient/family involvement in decision making (RPN = 315). Significant burdens to organizational finances and flight registered nurse satisfaction were identified. Conclusion: Associated factors for interfacility HEMS OT, downstream effects, and areas for change were identified. EMP and emergency medical services practices, HEMS processes, and shared decision making may affect regional OT rates.

Key Points Question What are the incidence of and outcomes associated with neurologic manifestations in patients with COVID-19? Findings In this cohort study of 3744 patients in 2 large consortia, neurological manifestations were found in approximately 80% of patients hospitalized with COVID-19; the most common self-reported symptoms included headache (37%) and anosmia or ageusia (26%), whereas the most common neurological signs and/or syndromes were acute encephalopathy (49%), coma (17%), and stroke (6%). Presence of clinically captured neurologic signs and/or syndromes was associated with increased risk of in-hospital death. Meaning These findings suggest that neurological manifestations are prevalent among patients hospitalized with COVID-19 and are associated with higher in-hospital mortality., This cohort study investigates the neurological phenotypes, incidence, and outcomes among adults hospitalized with COVID-19., Importance The COVID-19 pandemic continues to affect millions of people globally, with increasing reports of neurological manifestations but limited data on their incidence and associations with outcome. Objective To determine the neurological phenotypes, incidence, and outcomes among adults hospitalized with COVID-19. Design, Setting, and Participants This cohort study included patients with clinically diagnosed or laboratory-confirmed COVID-19 at 28 centers, representing 13 countries and 4 continents. The study was performed by the Global Consortium Study of Neurologic Dysfunction in COVID-19 (GCS-NeuroCOVID) from March 1 to September 30, 2020, and the European Academy of Neurology (EAN) Neuro-COVID Registry (ENERGY) from March to October 2020. Three cohorts were included: (1) the GCS-NeuroCOVID all COVID-19 cohort (n = 3055), which included consecutive hospitalized patients with COVID-19 with and without neurological manifestations; (2) the GCS-NeuroCOVID COVID-19 neurological cohort (n = 475), which comprised consecutive patients hospitalized with COVID-19 who had confirmed neurological manifestations; and (3) the ENERGY cohort (n = 214), which included patients with COVID-19 who received formal neurological consultation. Exposures Clinically diagnosed or laboratory-confirmed COVID-19. Main Outcomes and Measures Neurological phenotypes were classified as self-reported symptoms or neurological signs and/or syndromes assessed by clinical evaluation. Composite incidence was reported for groups with at least 1 neurological manifestation. The main outcome measure was in-hospital mortality. Results Of the 3055 patients in the all COVID-19 cohort, 1742 (57%) were men, and the mean age was 59.9 years (95% CI, 59.3-60.6 years). Of the 475 patients in the COVID-19 neurological cohort, 262 (55%) were men, and the mean age was 62.6 years (95% CI, 61.1-64.1 years). Of the 214 patients in the ENERGY cohort, 133 (62%) were men, and the mean age was 67 years (95% CI, 52-78 years). A total of 3083 of 3743 patients (82%) across cohorts had any neurological manifestation (self-reported neurological symptoms and/or clinically captured neurological sign and/or syndrome). The most common self-reported symptoms included headache (1385 of 3732 patients [37%]) and anosmia or ageusia (977 of 3700 patients [26%]). The most prevalent neurological signs and/or syndromes were acute encephalopathy (1845 of 3740 patients [49%]), coma (649 of 3737 patients [17%]), and stroke (222 of 3737 patients [6%]), while meningitis and/or encephalitis were rare (19 of 3741 patients [0.5%]). Presence of clinically captured neurologic signs and/or syndromes was associated with increased risk of in-hospital death (adjusted odds ratio [aOR], 5.99; 95% CI, 4.33-8.28) after adjusting for study site, age, sex, race, and ethnicity. Presence of preexisting neurological disorders (aOR, 2.23; 95% CI, 1.80-2.75) was associated with increased risk of developing neurological signs and/or syndromes with COVID-19. Conclusions and Relevance In this multicohort study, neurological manifestations were prevalent among patients hospitalized with COVID-19 and were associated with higher in-hospital mortality. Preexisting neurological disorders were associated with increased risk of developing neurological signs and/or syndromes in COVID-19.

Aim To describe nurse-specific and patient risk factors present at the time of a patient fall on medical surgical units within an academic public health care system. Background The incidence of falls can be devastating for hospitalized patients and their families. Few studies have investigated how patient and nurse-specific factors can decrease the occurrence of falls in hospitals. Method In this retrospective cohort study, data were gathered on all patients who experienced a fall during January 2012 to December 2013. Results Falls were reduced dramatically when the number of nurses on the unit increased to five or six. Patient falls occurred most often when either the least experienced or most experienced nursing staff were providing care. Conclusion Patient falls in hospitals can be influenced not only by patient-specific factors, but also by nurse staffing and experience level. Implications for nursing management Findings from this study highlight factors which may contribute to hospital-based falls prevention initiatives and are amenable to nursing management decisions.

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

Background Intracranial pressure is a frequent target for goal-directed therapy to prevent secondary brain injury. In critical care settings, nurses deliver many interventions to patients having intracranial pressure monitored, yet few data documenting the immediate effect of these interventions on intracranial pressure are available. Objective To examine the relationship between intracranial pressure and specific nursing interventions observed during routine care. Methods Secondary analysis of prospectively collected observational data. Results During 3118 minutes of observation, 11 specific nursing interventions were observed for 28 nurse-patient dyads from 16 hospitals. Family members talking in the room, administering sedatives, and repositioning the patient were associated with a significantly lower intracranial pressure. However, intracranial pressure was sometimes higher, lower, or unchanged after each intervention observed. Conclusion Response of intracranial pressure to nursing interventions is inconsistent. Most interventions were associated with inconsistent changes in intracranial pressure at 1 or 5 minutes after the intervention. Language: en

The aim of this study was to compare predictive ability of hospital Glasgow Coma Scale (GCS) scores and scores obtained using a novel coma scoring tool (the Full Outline of Unresponsiveness [FOUR] scale) on long-term outcomes among patients with traumatic brain injury. Preliminary research of the FOUR scale suggests that it is comparable with GCS for predicting mortality and functional outcome at hospital discharge. No research has investigated relationships between coma scores and outcome 12 months postinjury.This is a prospective cohort study. Data were gathered on adult patients with traumatic brain injury admitted to urban level I trauma center. GCS and FOUR scores were assigned at 24 and 72 hours and at hospital discharge. Glasgow Outcome Scale scores were assigned at 6 and 12 months.The sample size was n = 107. Mean age was 53.5 (SD = ±21, range = 18-91) years. Spearman correlations were comparable and strongest among discharge GCS and FOUR scores and 12-month outcome (r = .73, p.000; r = .72, p.000). Multivariate regression models indicate that age and discharge GCS were the strongest predictors of outcome. Areas under the curve were similar for GCS and FOUR scores, with discharge scores occupying the largest areas.GCS and FOUR scores were comparable in bivariate associations with long-term outcome. Discharge coma scores performed best for both tools, with GCS discharge scores predictive in multivariate models.

Ventilator-associated pneumonia (VAP) is a leading nosocomial infection in pediatrics. Little research has investigated the risk factors or effectiveness of interventions for pediatric VAP prevention. The purposes of this study were to identify the risk factors associated with VAP in pediatric patients and describe current VAP prevention practices. Data were gathered retrospectively on ventilated patients admitted to the pediatric intensive care unit over 12 months. No variables were found to be predictive of VAP. Review of practices indicates that better documentation is needed of all interventions. Findings provide information to guide the implementation of VAP bundles. Implementation should focus on adequate documentation of VAP prevention efforts.

Agitation occurs in 70% of patients hospitalized with traumatic brain injury (TBI) and has adverse effects on length of stay and functional outcomes. Treatment involves pharmacological and behavioural interventions. Much research on TBI agitation has been conducted in intensive care or rehabilitation settings. This study aimed to identify agitation prevalence, treatment and outcomes among patients with TBI on acute care wards.Data abstracted from the trauma registry and medical records of adult patients with TBI admitted to an acute care ward within a Level I trauma centre over 12 months.From 219 patients, at least one agitation behaviour was present in 41% (n = 90) of patients. Clinically significant agitation was present in 8% (n = 18) of patients. Agitation behaviours included impulsiveness (30%), pulling at devices (21%) and decreased attention span (16%). Common interventions were reorientation (33%), constant supervision (32%) and benzodiazepines (30%). Agitated patients had longer length of stay (p 0.001) and were less likely to be discharged home. Physical restraints, constant supervision, redirection, reorientation and environmental modifications were associated with agitation (p 0.001).Management of agitation among patients with TBI on acute care wards can present challenges to healthcare staff. Innovative approaches are needed to promote outcomes using available resources.

Pressure ulcer formation related to positioning while in the OR increases the length of hospital stay and hospital costs, but there is little evidence documenting how positioning devices used in the OR influence pressure ulcer development when examined with traditional risk factors. The aim of this prospective cohort study was to identify the prevalence of and risk factors associated with pressure ulcer development among patients undergoing surgical procedures lasting longer than three hours. Participants included all adult same-day admission patients scheduled for a three-hour surgical procedure during an eight-month period (N = 258). Data were gathered preoperatively, intraoperatively, and postoperatively on pressure ulcer risk factors. Bivariate analyses indicated that the type of positioning (ie, heels elevated) (χ(2) = 7.897, P = .048), OR bed surface (ie, foam table pad) (χ(2) = 15.848, P = .000), skin assessment in the postanesthesia care unit (χ(2) = 41.652, P = .000), and male gender (χ(2) = 6.984, P = .030) were associated with pressure ulcer development. Logistic regression analyses indicated that the use of a foam pad (β = 2.691, P = .024) and a lower day-one Braden score (β = .244, P = .003) were predictive of pressure ulcers.

BackgroundMany patients admitted to medical intensive care units require mechanical ventilation to assist with respiratory management. Unplanned extubations of these patients are associated with poor outcomes for patients and organizations. No previous research has investigated the role of standardized protocols in unplanned extubations when examined in conjunction with traditional risk factors.ObjectiveTo identify risk factors associated with unplanned extubation among patients receiving mechanical ventilation and determine degree of compliance with pain, sedation, and weaning protocols.MethodsA prospective cohort study design was used. Data on all patients admitted to the medical intensive care unit who required mechanical ventilation were gathered daily. Additional data were gathered on those patients who experienced unplanned extubation. Descriptive, correlational, and regression analyses were performed.ResultsWeaning protocols were a significant predictor of unplanned extubation: patients who had weaning protocols ordered and followed were least likely to experience unplanned extubation. Only 10% of the 190 patients in the study required reintubation, resulting in a significantly shorter ventilation time and unit length of stay among the unplanned extubation group.ConclusionsWeaning protocols were associated with decreased incidence of unplanned extubation. Use of standardized protocols was feasible, as compliance among health care providers was high when protocols were medically prescribed. The reintubation rate in this study was low and associated with a significantly shorter ventilatory period and unit length of stay in the unplanned extubation group.

The Glasgow Coma Scale (GCS) is a routine component of a neurological exam for critically ill traumatic brain injury (TBI) patients, yet has been criticized for not accurately depicting verbal status among intubated patients or including brain stem reflexes. Preliminary research on the Full Outline of UnResponsiveness (FOUR) Scale suggests it overcomes these limitations. Research is needed to determine correlations with patient outcomes. The aims of this study were to: (1) examine correlations between 24 and 72 h FOUR and GCS scores and functional/cognitive outcomes; (2) determine relationship between 24 and 72 h FOUR scores and mortality. Prospective cohort study. Data gathered on adult TBI patients at a Level I trauma center. FOUR scores assigned at 24, 72 h. Functional outcome measured by functional independence measure scores at rehabilitation discharge; cognitive status measured by Weschler Memory Scale scores 3 months post-injury. n = 136. Mean age 53.1. 72 h FOUR and GCS scores correlated with functional outcome (r s = 0.34, p = 0.05; r s = 0.39, p = 0.02), but not cognitive status. Receiver operating characteristic curves were comparable for FOUR and GCS at 24 and 72 h for functional status (24 h FOUR, GCS = 0.625, 0.602, respectively; 72 h FOUR, GCS = 0.640, 0.688), cognitive status (24 h FOUR, GCS = 0.703, 0.731; 72 h FOUR, GCS = 0.837, 0.674), and mortality (24 h FOUR, GCS = 0.913, 0.935; 72 h FOUR, GCS = 0.837, 0.884). FOUR is comparable to GCS in terms of predictive ability for functional status, cognitive outcome 3 months post-injury, and in-hospital mortality.

Nurse residency programs (NRPs) are an effective mechanism for transitioning newly licensed registered nurses (NLRNs) to practice. No studies have investigated how experienced nurses view NLRN performance after NRPs. The purpose of this quality initiative was to identify experienced nurses' satisfaction with NLRN proficiency before and after implementation of an NRP using the Nursing Practice Readiness Tool. Findings indicate that experienced nurses are more satisfied with the performance of NLRNs after the new nurse participated in an NRP.

Critically ill spinal cord injury (SCI) patients are at high risk for pressure ulcers. Research is needed to identify risk factors for pressure ulcers. The aim of this study was to investigate risk factors and outcomes of pressure ulcers in critically ill SCI patients. This is a retrospective cohort study. Data were gathered from medical records of adult patients with SCI admitted to surgical intensive care units. Ninety-four SCI patients participated in this study. Clinical variables associated with pressure ulcers were as follows: fecal management systems, incontinence, acidosis, support surfaces, steroids, and additional equipment. Hypotension was the strongest predictor of pressure ulcers. Nursing interventions may address risk factors and improve patient outcomes.