A Standardized Checklist Improves the Transfer of Stroke Patients from the Neurocritical Care Unit to Hospital Ward.

BACKGROUND AND PURPOSE: The transfer of patients with ischemic stroke from the intensive care unit (ICU) to noncritical care inpatient wards involves detailed information sharing between care teams. Our local transfer process was not standardized, leading to potential patient risk. We developed and evaluated an "ICU Transfer Checklist" to standardize communication between the neurocritical care team and the stroke ward team. METHODS: Retrospective review of consecutive patients with ischemic stroke admitted to the neurocritical care unit who were transferred to the stroke ward was used to characterize transfer documentation. A multidisciplinary team developed and implemented an ICU Transfer Checklist that contained a synthesis of the patient's clinical course, immediate "to-do" action items, and a system-based review of active medical problems. Postintervention checklist utilization was recorded for 8 months, and quality metrics for the postintervention cohort were compared to the preintervention cohort. Providers were surveyed pre- and postintervention to characterize perceived workflow and quality of care. RESULTS: Patients before (n = 52) and after (n = 81) ICU Transfer Checklist implementation had similar demographic and clinical characteristics. In the postchecklist implementation period, the ICU Transfer Checklist was used in over 85% of patients and median hospital length of stay (LOS) decreased (8.6 days vs 5.4 days, P = .003), while ICU readmission rate remained low. The checklist was associated with improved perceptions of safety and decreased time needed to transfer patients. CONCLUSIONS: Use of the standardized ICU Transfer Checklist was associated with decreased hospital LOS and with improvements in providers' perceptions of patient safety.

Brainstem opioidergic system is involved in early response to experimental SAH.

Subarachnoid hemorrhage (SAH) is a form of stroke with high rates of mortality and permanent disability for patients who survive the initial event. Previous research has focused on delayed cerebral vasospasm of large conduit arteries as the cause of poor long-term outcomes after SAH. New evidence suggests that acute failure to restore cerebral blood flow (CBF) after SAH may be setting the stage for delayed ischemic neurological deficits. Our lab previously demonstrated that the rostral ventromedial medulla (RVM), an autonomic and sensorimotor integration center, is important for maintaining CBF after experimental SAH. In this study, we have demonstrated that ablation of µ-opioid receptor containing cells with dermorphin conjugates in the RVM results in a high mortality rate after experimental SAH and, in survivors, causes a dramatic decrease in CBF. Further, locally blocking the µ-opioid receptor with the antagonist naltrexone attenuated the reduction in CBF secondary to experimental SAH. Saturating µ-opioid receptors with the agonist [D-Ala(2),NMe-Phe(4),Gly-ol(5)]-encephalin (DAMGO) had no effect. Taken together, these results suggest that SAH activates opioidergic signaling in the RVM with a resultant reduction in CBF. Further, cells in the RVM that contain µ-opioid receptors are important for survival after acute SAH. We propose that failure of the RVM µ-opioid receptor cells to initiate the compensatory CBF response sets the stage for acute and delayed ischemic injury following SAH.

Using a 2-variable method in radionuclide shuntography to predict shunt patency.

OBJECT: Radionuclide shuntography interpretation is uncertain when the tracer fails to enter the ventricles but quickly drains distally or when the tracer enters the ventricles but takes longer than 15 minutes to drain distally. The purpose of this study was to aid in the clinical interpretation of a variety of shuntography results and to determine the applicability of shuntography in different patient populations. METHODS: The results of 259 shuntograms were reviewed. Chi-square analysis was performed to evaluate the relationship between clinical variables and shuntography results. Two-by-two binary classification analyses were performed to determine the sensitivity, specificity, positive predictive value, and negative predictive value for 4 different combinatorial types of shuntography results based on 2 variables: ventricular tracer entry and distal tracer drainage. RESULTS: Median patient age was 19 years, and 51% of patients were male. The most common presentation in patients undergoing shuntography was headache (169/254, 66.5%) with radiographically stable ventricle size. Of 227 patients with available imaging data, 163 (71.8%) presented with the same ventricle size as shown on a previous asymptomatic scan, 43 (18.9%) had larger ventricles, and 21 (9.2%) had smaller ventricles. Within 30 days of shuntography, 74 of 259 patients (28.6%) underwent surgical shunt exploration: 65 were found to have an obstructed shunt and 9 were found to have a patent shunt. Of those patients not undergoing surgery, the median length of benign clinical follow-up was 1051 days. Clinical variables were not significantly associated with shuntography results, including valve type (p = 0.180), ventricle size (p = 0.556), age (p = 0.549), distal drainage site (p = 0.098), and hydrocephalus etiology (p = 0.937). Shuntography results of patients with myelomeningocele were not dissociable from those of the group as a whole. Sensitivity to diagnose shunt failure was lowest (37.5%) but specificity was highest (97.2%) when the definition of a "normal" shuntogram included any tracer movement into the distal site within 45 minutes. Conversely, sensitivity was highest (87.5%) and specificity was lowest (51.4%) when the definition was limited exclusively to tracer entry into the ventricles and distal drainage within 15 minutes. CONCLUSIONS: Even with a stringent definition of a "normal" shuntogram, sensitivity and specificity were relatively low for a diagnostic test. Clinical variables such as valve type, ventricle size, patient age, distal drainage site, and etiology of hydrocephalus were not associated with shuntography results.