TL,DR - Improving handover through the use of an integrated electronic discharge proforma in neurocritical care

Introduction: Effective handover between treating clinical teams is an important part of communication in the care of patients leaving the intensive care environment.1 This can be even more vital in neurocritical care, where patients may be unable to communicate their own history due to neurological deficits and whose families are unable to visit due to COVID. These patients often have had complex neurosurgical interventions and ongoing complex MDT discussion due to the nature of their illness. Handover needs to represent this. Furthermore, as a specialist tertiary centre, many patients leave the unit as repatriations to other intensive care units. In these situations, it is even more important for good handover to contain the relevant and succinct information for ongoing care. Objective(s): We aim to improve the quality of handover from the intensive care team to ward teams at a specialist neurocritical care centre through the use of an electronic discharge proforma integrated into the electronic patient record (EpicCare Epic Systems Corporation). This is a system that has only recently been introduced locally and has required modification for the intensive care environment. Method(s): We performed a retrospective cohort study of documented transfer of care (TOC) summaries for patients entering the ICU in a month-long period. 67 patient admissions were identified as possible candidates with 11 cases excluded as not meeting criteria. The TOC summaries of suitable cases were compared to standards set by the Faculty of Intensive Care Medicine and Intensive Care Society and criteria tailored to the neuro-intensive care environment. Following this, we implemented a curated discharge proforma for all patients leaving intensive care. Through the use of smart lists and specific prompts, we aim to improve compliance with the guidelines and improve the quality of TOC. The project is currently ongoing and we aim to repeat the analysis in March 2022 to review if there has been improved compliance. Result(s): Compliance for the first round of discharges was variable. There was generally good quality information on the summary of stay of the patient (96%) and ongoing plan for the care of the patient (88%). However, documentation of the rehabilitation needs (32%), psychological needs (14%), communication needs (16%), safeguarding issues (4%), and resuscitation and escalation status of the patient was suboptimal (4%). Documentation of verbal handover to the parent team (25%) and critical care outreach team (45%) was mixed. Conclusion(s): Here we present the use of an electronic discharge proforma to improve the quality of handover in patients leaving the intensive care environment. While the study is ongoing, we show that currently local patient handover is often incomplete with a lack of detail in the TOC summary and poor verbal communication between teams. Through the use of this proforma, we aim to improve the quality of this handover and improve the continuity of care for patients leaving the neuro-intensive care unit.

The Embedment of Palliative Care Services on a Neuro-Surgical Unit (CS359)

Outcomes: 1. A better understanding of the benefits of embedded palliative care into a neuro surgery unit at a large academic hospital 2. An understanding of the financial impact related to embedding a palliative care APC into the neuro surgery unit at a large academic hospital Problem: Palliative care needs of patients admitted to neurology ICUs are often unmet. Patients with palliative care needs identified were more likely to die in an ICU setting or be transferred to the floor with comfort measures only. These patients were noted to have a longer length of stay. Because of the known benefits of palliative care, specifically, with this vulnerable population of patients, there was a desire to increase the palliative care presence on the neuro surgical service. Intervention(s): One APC palliative care position specific to the neuro ICU team was created. Responsibilities included symptom management, family support, medical decision making, managing conflicts over care goals, and disposition planning. Outcome(s): Outcomes included involvement in interdisciplinary rounds, increased donor opportunities, and increased billing by 28% in 2021. There was a 46% increase in palliative care consults from 2020 to 2021 and an increase in percentage of DNR/DNI orders obtained during admission from 2020 to 2021. An increase in deaths during hospitalization with active palliative care consults on comfort care was noted. Statistics were collected specific to mortality, ICU LOS, diagnosis, COVID status, social work involvement, as well as spiritual care involvement. Conclusion(s): Patients are seen earlier in their hospitalization and their medical wishes are now widely known and discussed by all interdisciplinary team members. The need for the involvement of the APC in these cases has only solidified with increased exposure to the palliative care team as consults increase. Patients are benefitting from the quality care being provided that now better aligns with their personal medical goals. Implications for nursing: There are many vulnerable patient populations for whom palliative care could be just as impactful;additional research should be completed to investigate further. Palliative care embedded on an ICU improves collaboration and increases exposure and understanding of the intent of palliative care.Copyright © 2023

An unusually fulminant case of encephalomyelitis in an 80 year old

Background: There have been reports of demyelinating syndromes in association with COVID-19 and to a much lesser extent COVID 19 vaccines. The association between demyelination and vaccines, in general, remains controversial. We review a presentation of fulminant demyelination, and discuss antecedent COVID-19 vaccination, the formulation of a broader differential diagnosis and ultimately the pathologic diagnosis. Case presentation: An 80-year-old woman presented with seizure, encephalopathy, quadriparesis and ultimately expired. She received a SARS-CoV-2 vaccine one day prior. Imaging revealed contrast enhancing cerebral lesions, longitudinally extensive transverse myelitis. CSF was markedly inflammatory. Pathologic examination of the CNS lesions revealed demyelination and inflammation beyond white matter, not restricted to a perivenular distribution. Conclusion(s): This case depicts a seemingly fulminant course of a diffuse demyelinating syndrome characterized clinicopathologically as Marburg's variant of multiple sclerosis. There are several unique aspects of this case including the extremely rapid course, the unusual evolution of CSF abnormalities, with hypoglycorrhachia and markedly elevated protein. The proximity to vaccination is a pertinent association to document, though we cannot unequivocally prove causation.Copyright © 2022 The Authors

Assessment of knowledge, practice and compliance eye care guidance in neurocritical care unit

Introduction: Ocular complications in critically ill patients is common. Up to 42% of intensive care unit patients can have signs of damage to the corneal surface of the eye (exposure keratopathy), which can lead to secondary complications and ultimately irreversible visual loss1,2 (Rosenberg and Eisen, 2008;Bird et al, 2017). Emergence of COVID-19 pandemic has meant increased number of critical care admission with inherent risk of ocular complication owing to need for non-invasive ventilation, mechanical ventilation and prone ventilation. All these factors have resurfaced need for increased awareness and adherence to national standards related to eye care in critical care3 (Royal college of Ophthalmology and Intensive Care Society joint Ophthalmic service guidance). Objectives: To study baseline knowledge and awareness of eye care practices in neuro critical care unit. To measure compliance of national eye care guidance. Methods: Structured online survey for critical care nurses. Review of hospital IT software to study snapshot of eye care compliance. Results: We ran baseline survey of neuro critical care nurses on knowledge and current practice of eye care in ICU. Eye care complications in ICU are common with 1 in 5 individual reporting > 3 ocular complications in last 3 months. Three-quarter of individuals reported to have good to very good knowledge of eye care protocol with 66% aware of current national guidance. 86% of respondents assessed lagophthalmos while 76% assessed conjunctiva and cornea routinely. On the flipside however only 60% routinely documented eye care measures in clinical practice. Importantly, 96% responded that they would benefit from education and training in eye care practices. Review of hospital records for eye care compliance and documentation validated the findings on the survey. We found 68% compliance rate for assessment of lagophthalmos in all admitted patient in neuro critical care unit. There was 100% compliance to institution of protective measures and appropriate escalation to medical staff. Graph 1: Baseline survey of knowledge and practice of Eye care in Neuro Critical Care Unit depicting a stepladder pattern in knowledge, practice and documentation of Eye care. Conclusion: Knowledge and awareness of eye care practices fall below national guidance. There is clear gap in knowledge, practice and documentation of eye care practices. Incorporation of eye care module in continuous training program and use of cognitive aids may help to further improve compliance and documentation of eye care practice in future.

Remote Virtual Reality Exposure Therapy for Post-Intensive Care Syndrome

Background: Post-intensive care syndrome (PICS) affects up to half of ICU patients and comprises neuromuscular, cognitive, and psychiatric impairments that persist up to years after discharge (Inoue, 2019). PICS is often overlooked and under-diagnosed (Rawal, 2017), without clear evidence-based strategies for management. Data supporting interventions for symptoms of anxiety, depression, and post-traumatic stress after discharge is limited (Needham, 2012). Developing high-quality, evidence-based interventions for PICS would address this critical need. Methods: Shortly before discharge, patients are recruited from our neurological ICU who have been intubated for at least 24 hours and score 24–32 on the Impact of Event Scale - Revised (which indicates likely PTSD symptoms without a true diagnosis). Baseline Beck Depression Index and Telephone Interview for Cognitive Status questionnaires are also administered to each patient. Participants are then randomly assigned either to a virtual reality exposure therapy intervention or to a control group that receives no therapeutic intervention. VRET patients are given an online 360° video of an ICU room from the perspective of an intubated patient, complete with sounds and simulated clinical scenarios (rounds, intubation, suctioning, etc.). Intervention patients have unlimited access to the videos for six months, beginning one month after discharge. Follow-up IES-R, BDI, and TICS are administered at 1, 3, and 6 months to both groups. Results/Discussion: Our IRB approved this study in March 2021. Enrollment has begun with 3–5 feasibility patients, to be followed by 30 randomized patients starting in November. Our poster features a case discussion on our first patient's experiences with VRET. Given the novelty of remote VRET for post-ICU PTSD symptoms, our results will be an important contribution with the potential to change practice. Conclusion: This will be the first remote intervention for neuropsychiatric symptoms of PICS, and has far-reaching implications for inpatient and outpatient CL psychiatrists — particularly at a time when patients have grown increasingly accustomed to virtual interventions, and when ICU survivors have multiplied due to COVID-19. Should our VRET prove successful, it will open the eyes of intensivists and CL psychiatrists to a whole realm of remote, efficient, and accessible virtual reality therapies for patients who have undergone acute care. This will improve long-term outcomes, particularly for patients who may have difficulty seeing an outpatient psychiatrist or taking medications consistently. Finally, our study will help to raise awareness of the psychiatric sequelae of acute illness, and so enhance inpatient collaboration between psychiatry and many other specialties. References: 1. Inoue S et al. Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg. 2019;(3):233-246. 2. Needham DM et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40(2):502-9. 3. Rawal G et al. Post-intensive Care Syndrome: an Overview. J Transl Int Med. 2017;5(2):90-92.

Stressors Experienced by Primary Caregivers of Severe Acute Brain Injury Patients Recovering from Coma in Neurointensive Care Units: Preliminary Findings from a Multicenter Qualitative Study

Objective: To understand the psychosocial stressors reported by caregivers of severe acute brain injury (SABI) patients recovering from coma in neuroICUs. Background: Caregivers of SABI patients are at risk of developing long-term adverse psychological outcomes following neuroICU discharge, particularly those of patients admitted in a comatose state and remaining disabled. Understanding the top psychosocial stressors reported by these caregivers is critical for design of interventions to improve psychological outcomes. Design/Methods: At the time of neuroICU discharge, we conducted semi-structured, recorded interviews with 15 primary caregivers of SABI patients, all of whom were comatose for greater than 24 hours and needed tracheostomy and/or feeding tube placement. Participants were recruited as a convenience sample from 6 US centers. A codebook for psychosocial stressors was developed from open coding of the first 5 interview transcripts amongst 9 study team members. Using NVivo software, two team members then independently coded each transcript, refined the codebook, and resolved coding discrepancies. Results: Fourteen of 15 caregivers provided demographic data: 13 (92.9%) were female, 5 (35.7%) were racial minorities, and 9 (64.3%) reported fewer than 4 years of college. Six of the 15 (40.0%) patients had recovered to a Glasgow Coma Scale of 9 or higher at the time of interview. The psychosocial stressors most commonly reported by participants were: navigation of the healthcare system, including hospital visitor restrictions due to COVID-19;uncertainty about prognosis;communication with healthcare providers;juggling of practical matters beyond the hospitalization;and navigation of social relationships. Caregivers also referenced challenges with direct caregiving responsibilities, changes to the relationship dynamic with the hospitalized patient, and loss of normality. Conclusions: Across multiple US centers, caregivers of SABI patients in various stages of coma recovery at time of neuroICU discharge share a wide variety of psychosocial stressors. Interventions designed to improve psychological outcomes will need to acknowledge these stressors directly.

Red light record: Advancing collaborative communication through technology

BACKGROUND AND PURPOSE: The onset of COVID resulted in stricter visitation policies and greater communication challenges between the care team and families. These challenges represent barriers to delivering great values-based, patient-centered care. In this , we describe the care team-family communication experience in a large, open NeuroICU and a software communication tool, Medical Memory, which is intended improve the efficiency of delivering information. METHODS: Medical Memory (MM) is a smartphone or tablet software application that allows the delivery of HIPAA compliant recordings via email. Before implementing MM, the Neurocritical Care nursing staff was surveyed to quantitatively and qualitatively gauge perception of communication strengths, challenges, effectiveness, and processes. Simultaneously, MM virtual training sessions were completed within the Neurocritical care practice group and a structured video update was created. Patients' family members were identified (preferred email contacts) for receiving video updates with a goal of one message per day. Family members can provide feedback via a brief survey after viewing the message. RESULTS: The pre-implementation survey had a response rate of over 80% (N=83). Approximately half of the nurses report at least 3 calls a day spending more than 15-30 minutes giving care updates. Over a 3rd of respondents spent more than 45 minutes a day. Qualitatively, nursing staff feel that they play an important role in communication, but provider communication was often reported to be inadequate by family members. MM is currently in use with a post-implementation survey scheduled after a 12-month pilot period. CONCLUSIONS: Even in the aftermath of the COVID pandemic, telehealth and communication technology will remain a vital component of delivering and communicating patient care. Software like Medical Memory may help with information delivery via improved efficiencies thus increasing satisfaction of both care teams and patients' families.