Implementation of Tenecteplase for Acute Ischemic Stroke Treatment.

INTRODUCTION: Acute ischemic stroke is a neurologic emergency, requiring rapid recognition and treatment with intravenous thrombolysis. Since the publication of the 2019 American Heart Association/American Stroke Association Guidelines that recommend tenecteplase as an alternative agent, several centers across the United States are transitioning from alteplase to tenecteplase as the agent of choice for thrombolysis in acute ischemic stroke. METHODS: Our health system transitioned to tenecteplase for the treatment of acute ischemic stroke in 2021 due to increasing evidence for efficacy and potential for improved door-to-needle time. Herein we describe our experience and provide guidance for other institutions to implement this change. CONCLUSION: Emergency nurses are vital to the care of acute ischemic stroke patients. There are several pharmacologic and logistical differences between alteplase and tenecteplase for this indication. This paper outlines these key differences.

Streamlining the External Ventricular Drain and Intracranial Pressure Monitor Procedural Setup: A Quality Improvement Initiative.

OBJECTIVE: External ventricular drain (EVD) and intracranial pressure (ICP) monitor placements are among the most common critical care procedures for severe brain injury. Quality improvement initiatives have streamlined similar processes. The aim of the project was to decrease the time to collect supplies for EVD or ICP monitor placement by 25% by April 1, 2021. METHODS: The project followed the define-measure-analyze-improve-control 6 sigma framework. Several quality gaps were identified: equipment stored separately, delays in replacing faulty items, and wasted resources. The team defined the process using the suppliers-inputs-processes-outputs-customers + requirements method, measured time to collect supplies, and analyzed data with an Ishikawa/fishbone diagram. The improve phase included a kaizen burst to generate solutions and an impact/effort grid to evaluate options. The team concluded that the optimal plan was to stock a mobile EVD cart and an ICP monitor pole with disposable go-bags. RESULTS: The average time for nurses to collect EVD placement supplies decreased from 411 to 63 seconds (7-1 minute), and the average time for nurses to collect ICP monitor placement supplies decreased from 418 to 53 seconds (7-<1 minute). Residents decreased the time to obtain EVD placement supplies from 330 to 56 seconds (6-<1 minute) and ICP monitor supplies from 489 to 77 seconds (8-1 minute). Feedback was overwhelmingly positive and focused on improved process efficiency and reduced waste. CONCLUSIONS: The time reduction and enthusiasm are likely associated with the simplicity and comprehensiveness of the intervention design. Including key stakeholders in decision-making and succinct communications reduced resistance to change.

Sequential Pneumatic Compression in the Arm in Neurocritical Patients with a Peripherally Inserted Central Venous Catheter: A Randomized Trial.

BACKGROUND: Peripherally inserted central venous catheters (PICCs) are increasingly used for parenteral access in critically ill hospitalized patients, but they increase the incidence of upper extremity deep venous thrombosis (UE DVT). Sequential compression devices (SCDs) applied to the legs effectively reduce lower extremity DVT, but have not been tested in the arms. Our objective was to determine whether SCDs applied to the arm may reduce the risk of PICC-associated UE DVT. METHODS: This was a retrospective study of randomized, single-center, controlled clinical trial on patients hospitalized in the intensive care unit with critical neurological illness who had a PICC and were not receiving anticoagulants. Between January 2014 and October 2016, patients were randomized 1:1 to an intervention group having a custom SCD applied to the arm harboring the PICC or to a control group. The primary endpoint was ultrasound-detected UE DVT. RESULTS: Following randomization of 77 subjects, the study was terminated due to excess DVT in the treatment arm. UE DVT was detected in 18 subjects (29.0%), and it was more frequent among those in the SCD group (13/31 [41.9%] vs. the control group 5/31 [16.1%]; p = 0.049). After accounting for crossovers, the difference was still significant (12/28 [43.0%] vs. 6/34 [17.6%]; p = 0.048). Yet, symptomatic UE DVT (n = 3) and pulmonary embolism without evidence of lower extremity DVT (n = 2) were only observed in patients who were not wearing the SCD on the arm. CONCLUSIONS: Although UE DVT is commonly associated with PICC use, the results of this trial do not support the use of SCD on the arm for DVT prevention. Further research on this strategy may nonetheless be justified. TRIAL REGISTRATION: This trial was registered in ClinicalTrials.gov under the identifier NCT01670188.

Predictors of Postoperative Nausea and Vomiting in Neurosurgical Patients.

In the neurosurgery patient population, one of the most frequent complications is postoperative nausea and vomiting (PONV). The purpose of this predictive correlational study was to examine the incidence and predictors of PONV in a cohort of 519 neurosurgery patients undergoing elective spinal and intracranial procedures. Patients were interviewed, and their medical records were reviewed every 24 hours for up to 72 hours postoperatively to identify risk factors for PONV development. After summarizing univariate associations, a multivariable logistic regression model for each outcome was developed using forward and backward stepwise selection, with the p value for a variable to enter or leave the model set to .05. Women, especially those who were younger and with a history of PONV, were most likely to have PONV. In addition, those undergoing craniotomy, particularly infratentorial craniotomy, were more likely to have PONV compared with patients undergoing spine surgery. This study provides a foundation for nursing and interdisciplinary intervention studies aimed at reducing this postoperative symptom in the most susceptible patients.