Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review.

OBJECTIVES: The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population. DATA SOURCES: We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed. STUDY SELECTION AND DATA EXTRACTION: Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes. DATA SYNTHESIS: Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival. CONCLUSIONS: These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.

Sustainability of a nurse-driven early progressive mobility protocol and patient clinical and psychological health outcomes in a neurological intensive care unit.

OBJECTIVES: To determine sustainable impact of an early progressive mobility protocol on mobility level and clinical outcomes. DESIGN/METHODS: Prospective, longitudinal, comparative study using three time points (pre-, immediate post-intervention and 12-month post-intervention sustainability). Analyses included comparative statistics and multivariable modelling. Data were collected by clinical nurses, from administrative databases. Psychological health data were collected using a valid, reliable tool. SETTING: Patients treated in a 22-bed Neurological Intensive Care Unit of a quaternary-care medical centre. OUTCOME MEASURES: Highest mobility level, length of stay, mortality, discharge disposition, quality metrics and psychological profile including depression, anxiety, and hostility. RESULTS: Amongst 260 pre-intervention, 377 post-implementation, and 480 twelve-month post-implementation patients (N = 1117) walking increased post-implementation and was sustained at the eight-month assessment, p < .001. After multivariable adjustment, unit and hospital length of stay and psychological distress were reduced compared to the pre-early mobility programmes (all p < .001). There were no differences in discharge disposition (i.e., home vs skilled nursing facility), mortality or quality metrics. CONCLUSION: Ongoing implementation of an early mobility programme in a neurological intensive care environment led to sustained improvement in patients' level of mobility, length of unit and hospital stay, depression, anxiety and hostility levels.

Teleneurocritical care and telestroke.

Telestroke and teleneurologic intensive care units (teleneuro-ICUs) optimize the diagnosis and treatment of neurologic emergencies. Establishment of a telestroke or teleneuro-ICU program relies on investment in experienced stroke and neurocritical care personnel as well as advanced telecommunications technologies. Telemanagement of neurologic emergencies can be standardized to improve outcomes, but it is essential to have a relationship with a tertiary care facility that can use endovascular, neurosurgical, and neurocritical care advanced therapies after stabilization. The next stage in telestroke/teleneuro-ICU management involves the use of mobile stroke units to shorten the time to treatment in neurocritically ill patients.