Assessment of Adherence to Status Epilepticus Treatment Guideline after Initiation of Status Epilepticus Order Set 

OBJECTIVE An order set was created to optimize the time to administration and ensure proper dosing of benzodiazepine and anti-seizure medications in patients with status epilepticus (SE).BACKGROUND The Neurocritical Care Society and American Academy of Neurology have developed expert consensus guidelines and quality measures on management of acute SE which recommend that upon seizure onset, benzodiazepines and anti-seizure medications should be administered rapidly (within 5 and 10 minutes, respectively per NCS guidelines) with appropriate weight- based dosing.DESIGN/METHODS A SE order set was designed in an electronic health record which included pre-determined loading dosages of anti-seizure medications and benzodiazepines in accordance with current guidelines. Education regarding status epilepticus and order set was given to emergency medicine, neurology, neurosurgery, and neurocritical care divisions prior to order set availability in July 2023. We tracked use of the order set in all patients with the diagnosis of SE from July 1, 2023 to October 10, 2023. Our goal was to track the proportion of patients who received benzodiazepines within 5 minutes and anti-seizure medication within 10 minutes of seizure detection, and appropriate first dose of benzodiazepine and anti-seizure medication, before and after order set implementation.RESULTS The recommended loading dose was used 100% of the time (8/8) with order set use compared to 18% (8/44) without the order set. Recommended benzodiazepine dose was used 50% of the time (2/4) with the order set compared to 64% (28/44) without. Average time to anti-seizure medication administration with the order set was 33 minutes compared to 61 minutes without. Average time to benzodiazepine medication administration was 5 minutes with order set use compared to 9 minutes without.CONCLUSIONS Our initiative shows there can be improvement in adherence to status epilepticus guideline execution in dosage and time to administration of benzodiazepines and anti-seizure medications with implementation of a standardized SE order set

Massage therapy in the neurologic intensive care unit

Massage therapy in the NICU appears to be safe, feasible, and improves patient pain self-assessment without vital sign instability

Massage Therapy May be Safe and Reduce Pain in Critically Ill Patients with Acute Neurological Injury: a Case Control Study.

PURPOSE: Massage therapy is an important adjunctive treatment for physiologic and psychologic symptoms and has been shown to benefit patients among a wide variety of patient populations. SETTING: Few studies have investigated the utility of massage therapy in the general ICU setting, and even fewer have done so in the neurological ICU (NeuroICU). RESEARCH DESIGN: If massage therapy was determined to improve objective outcomes-or even subjective outcomes in the absence of harm-massage may be more readily employed as a complementary therapy, particularly in the ICU setting or in patients with acute neurological injury. INTERVENTION: This pilot study aimed to assess the safety of massage in the neurocritical care unit and its impact on patient vital signs, subjective pain assessment, and other clinical outcomes. PARTICIPANTS: Twenty-one patients who received massage therapy during admission to the neurocritical care service were compared to matched controls in a retrospective case control study design. RESULTS: We found a statistically significant reduction in pain scores among patients with acute neurological injury who received massage therapy. There was no statistical difference in hospital length of stay, discharge destination, in-hospital mortality, adverse events, or incidence/duration of delirium between patients who received massage therapy and those who did not. No adverse events were ascribed to the massage therapy when evaluated by blinded neurocritical care specialists. CONCLUSION: This study found that massage therapy may be safe for many patients in the NeuroICU and may offer additional subjective benefits

Use of Accelerometry for Long Term Monitoring of Stroke Patients.

Stroke patients are monitored hourly by physicians and nurses in an attempt to better understand their physical state. To quantify the patients' level of mobility, hourly movement (i.e. motor) assessment scores are performed, which can be taxing and time-consuming for nurses and physicians. In this paper, we attempt to find a correlation between patient motor scores and continuous accelerometer data recorded in subjects who are unilaterally impaired due to stroke. The accelerometers were placed on both upper and lower extremities of four severely unilaterally impaired patients and their movements were recorded continuously for 7 to 14 days. Features that incorporate movement smoothness, strength, and characteristic movement patterns were extracted from the accelerometers using time-frequency analysis. Support vector classifiers were trained with the extracted features to test the ability of the long term accelerometer recordings in predicting dependent and antigravity sides, and significantly above baseline performance was obtained in most instances ([Formula: see text]). Finally, a leave-one-subject-out approach was carried out to assess the generalizability of the proposed methodology, and above baseline performance was obtained in two out of the three tested subjects. The methodology presented in this paper provides a simple, yet effective approach to perform long term motor assessment in neurocritical care patients

Massage Therapy May be Safe and Reduce Pain in Critically Ill Patients with Acute Neurological Injury: a Case Control Study

Purpose: Massage therapy is an important adjunctive treatment for physiologic and psychologic symptoms and has been shown to benefit patients among a wide variety of patient populations. Setting: Few studies have investigated the utility of massage therapy in the general ICU setting, and even fewer have done so in the neurological ICU (NeuroICU). Research Design: If massage therapy was determined to improve objective outcomes—or even subjective outcomes in the absence of harm—massage may be more readily employed as a complementary therapy, particularly in the ICU setting or in patients with acute neuro-logical injury. Intervention: This pilot study aimed to assess the safety of massage in the neurocritical care unit and its impact on patient vital signs, subjective pain assessment, and other clinical outcomes. Participants: Twenty-one patients who received massage therapy during admission to the neurocritical care service were compared to matched controls in a retrospective case control study design. Results: We found a statistically significant reduction in pain scores among patients with acute neurological injury who received massage therapy. There was no statistical difference in hospital length of stay, discharge destination, in-hospital mortality, adverse events, or incidence/duration of delirium between patients who received massage therapy and those who did not. No adverse events were ascribed to the massage therapy when evaluated by blinded neurocritical care specialists. Conclusion: This study found that massage therapy may be safe for many patients in the NeuroICU and may offer additional subjective benefits

Use of Accelerometry for Long Term Monitoring of Stroke Patients.

Stroke patients are monitored hourly by physicians and nurses in an attempt to better understand their physical state. To quantify the patients' level of mobility, hourly movement (i.e. motor) assessment scores are performed, which can be taxing and time-consuming for nurses and physicians. In this paper, we attempt to find a correlation between patient motor scores and continuous accelerometer data recorded in subjects who are unilaterally impaired due to stroke. The accelerometers were placed on both upper and lower extremities of four severely unilaterally impaired patients and their movements were recorded continuously for 7 to 14 days. Features that incorporate movement smoothness, strength, and characteristic movement patterns were extracted from the accelerometers using time-frequency analysis. Support vector classifiers were trained with the extracted features to test the ability of the long term accelerometer recordings in predicting dependent and antigravity sides, and significantly above baseline performance was obtained in most instances ([Formula: see text]). Finally, a leave-one-subject-out approach was carried out to assess the generalizability of the proposed methodology, and above baseline performance was obtained in two out of the three tested subjects. The methodology presented in this paper provides a simple, yet effective approach to perform long term motor assessment in neurocritical care patients

Heterozygous congenital Factor VII deficiency with the 9729del4 mutation, associated with severe spontaneous intracranial bleeding in an adolescent male

BackgroundIn congenital Factor (F) VII deficiency bleeding phenotype and intrinsic FVII activity levels don't always correlate. Patients with FVII activity levels <30% appear to have a higher bleeding propensity, but bleeding can also occur at higher FVII activity levels. Reasons for bleeding at higher FVII activity levels are unknown, and it remains challenging to manage such patients clinically.CaseA 19year old male with spontaneous intracranial hemorrhage and FVII activity levels of 44%, requiring emergent surgical intervention and a strategy for FVII replacement. Genotyping showed the rare heterozygous FVII 9729del4 mutation. Bleed evacuation was complicated by epidural abscess requiring craniectomy, bone graft procedures, and prolonged administration of recombinant human (rh) activated FVII (FVIIa). The patient recovered without neurological deficits, and remains on prophylactic low dose treatment with rhFVIIa in relation to risky athletic activities.ConclusionFor clinicians, it is important to recognize that effects of rhFVIIa within these pathways are independent of its contribution to blood clot formation and cannot be assessed by clotting assays. Reduced FVII levels should therefore not be dismissed, as even a mild reduction may result in spontaneous bleeding. Treatment of mild FVII deficiency requires a careful case-by-case approach, based on the clinical scenario

Optimizing Scarce Resource Allocation During COVID-19: Rapid Creation of a Regional Health-Care Coalition and Triage Teams in San Diego County, California.

Successful management of an event where health-care needs exceed regional health-care capacity requires coordinated strategies for scarce resource allocation. Publications for rapid development, training, and coordination of regional hospital triage teams to manage the allocation of scarce resources during coronavirus disease 2019 (COVID-19) are lacking. Over a period of 3 weeks, over 100 clinicians, ethicists, leaders, and public health authorities convened virtually to achieve consensus on how best to save the most lives possible and share resources. This is referred to as population-based crisis management. The rapid regionalization of 22 acute care hospitals across 4500 square miles in the midst of a pandemic with a shifting regulatory landscape was challenging, but overcome by mutual trust, transparency, and confidence in the public health authority. Because many cities are facing COVID-19 surges, we share a process for successful rapid formation of health-care care coalitions, Crisis Standard of Care, and training of Triage Teams. Incorporation of continuous process improvement and methods for communication is essential for successful implementation. Use of our regional health-care coalition communications, incident command system, and the crisis care committee helped mitigate crisis care in the San Diego and Imperial County region as COVID-19 cases surged and scarce resource collaborative decisions were required