Hospital Discharge and Readmissions Before and During the COVID-19 Pandemic for California Acute Stroke Inpatients.

BACKGROUND: Acute stroke therapy and rehabilitation declined during the COVID-19 pandemic. We characterized changes in acute stroke disposition and readmissions during the pandemic. METHODS: We used the California State Inpatient Database in this retrospective observational study of ischemic and hemorrhagic stroke. We compared discharge disposition across a pre-pandemic period (January 2019 to February 2020) to a pandemic period (March to December 2020) using cumulative incidence functions (CIF), and re-admission rates using chi-squared. RESULTS: There were 63,120 and 40,003 stroke hospitalizations in the pre-pandemic and pandemic periods, respectively. Pre-pandemic, the most common disposition was home [46%], followed by skilled nursing facility (SNF) [23%], and acute rehabilitation [13%]. During the pandemic, there were more home discharges [51%, subdistribution hazard ratio 1.17, 95% CI 1.15-1.19], decreased SNF discharges [17%, subdistribution hazard ratio 0.70, 95% CI 0.68-0.72], and acute rehabilitation discharges were unchanged [CIF, p<0.001]. Home discharges increased with increasing age, with an increase of 8.2% for those ≥85 years. SNF discharges decreased in a similar distribution by age. Thirty-day readmission rates were 12.7 per 100 hospitalizations pre-pandemic compared to 11.6 per 100 hospitalizations during the pandemic [p<0.001]. Home discharge readmission rates were unchanged between periods. Readmission rates for discharges to SNF (18.4 vs. 16.7 per 100 hospitalizations, p=0.003) and acute rehabilitation decreased (11.3 vs. 10.1 per 100 hospitalizations, p=0.034). CONCLUSIONS: During the pandemic a greater proportion of patients were discharged home, with no change in readmission rates. Research is needed to evaluate the impact on quality and financing of post-hospital stroke care.

Mechanical ventilation in aneurysmal subarachnoid hemorrhage: systematic review and recommendations.

OBJECTIVE: Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation. DATA SOURCES: PubMed was queried for publications with the Medical Subject Headings (MeSH) terms "mechanical ventilation" and "aneurysmal subarachnoid hemorrhage" published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest. STUDY SELECTION: Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies. DATA EXTRACTION: Articles were reviewed by one team member, and interpretation was verified by a second team member. DATA SYNTHESIS: Thirty-one articles met the inclusion criteria for this review. CONCLUSIONS: We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.

EEG dynamical correlates of focal and diffuse causes of coma.

BACKGROUND: Rapidly determining the causes of a depressed level of consciousness (DLOC) including coma is a common clinical challenge. Quantitative analysis of the electroencephalogram (EEG) has the potential to improve DLOC assessment by providing readily deployable, temporally detailed characterization of brain activity in such patients. While used commonly for seizure detection, EEG-based assessment of DLOC etiology is less well-established. As a first step towards etiological diagnosis, we sought to distinguish focal and diffuse causes of DLOC through assessment of temporal dynamics within EEG signals. METHODS: We retrospectively analyzed EEG recordings from 40 patients with DLOC with consensus focal or diffuse culprit pathology. For each recording, we performed a suite of time-series analyses, then used a statistical framework to identify which analyses (features) could be used to distinguish between focal and diffuse cases. RESULTS: Using cross-validation approaches, we identified several spectral and non-spectral EEG features that were significantly different between DLOC patients with focal vs. diffuse etiologies, enabling EEG-based classification with an accuracy of 76%. CONCLUSIONS: Our findings suggest that DLOC due to focal vs. diffuse injuries differ along several electrophysiological parameters. These results may form the basis of future classification strategies for DLOC and coma that are more etiologically-specific and therefore therapeutically-relevant.

Sleeping with one cerebrum open: patient and staff perceptions of sleep quality and quantity on an inpatient neurology unit.

STUDY OBJECTIVES: This study sought to investigate perceptions of sleep disruptions among patients and staff in the inpatient neurology setting. The objectives were to explore the differences between these groups regarding factors that impact sleep, identify the most significant sleep disruptions, and examine the barriers and opportunities suggested to improve inpatient sleep. METHODS: A survey-based observational study was conducted on a 25-bed inpatient neurology unit at an academic medical center. Staff and patients completed the Potential Hospital Sleep Disruptions and Noises Questionnaire, and focus groups were held to gather qualitative data. Patient-reported sleep measures were collected for additional assessment. Responses were dichotomized for comparison. Regression models were used to assess associations between disruptors and patient-reported sleep measures. Qualitative thematic analyses were performed. RESULTS: Forty-nine inpatient staff and 247 patients completed sleep surveys. Top primary patient diagnoses included stroke, epilepsy, autoimmune diseases, and psychogenic nonepileptic attacks. Medical interventions, environmental factors, patient-related factors, and unit workflows emerged as key themes related to sleep disruptions. Patient-reported sleep efficiency was significantly reduced when pain, anxiety, stress, temperature, and medication administration disrupted sleep. Staff perspectives highlighted medical interventions as most disruptive to sleep, while patients did not find them as disruptive as expected. CONCLUSIONS: Differing perspectives on sleep disruption exist between staff and patients in the inpatient neurology setting. Medical interventions may be overstated in staff perceptions and inpatient sleep research, as pain, anxiety, and stress had the most significant impact on patient-reported sleep efficiency. CITATION: Kadura S, Poulakis A, Roberts DE, et al. Sleeping with one cerebrum open: patient and staff perceptions of sleep quality and quantity on an inpatient neurology unit. J Clin Sleep Med. 2024;20(4):619-629.

Effect of COVID-19 pandemic on outcomes in intracerebral hemorrhage.

OBJECTIVES: Patients with severe intracerebral hemorrhage (ICH) often suffer from impaired capacity and rely on surrogates for decision-making. Restrictions on visitors within healthcare facilities during the pandemic may have impacted care and disposition for patient with ICH. We investigated outcomes of ICH patients during the COVID-19 pandemic compared to a pre-pandemic period. MATERIALS AND METHODS: We conducted a retrospective review of ICH patients from two sources: (1) University of Rochester Get With the Guidelines database and (2) the California State Inpatient Database (SID). Patients were divided into 2019-2020 pre-pandemic and 2020 pandemic groups. We compared mortality, discharge, and comfort care/hospice. Using single-center data, we compared 30-day readmissions and follow-up functional status. RESULTS: The single-center cohort included 230 patients (n = 122 pre-pandemic, n = 108 pandemic group), and the California SID included 17,534 patients (n = 10,537 pre-pandemic, n = 6,997 pandemic group). Inpatient mortality was no different before or during the pandemic in either cohort. Length of stay was unchanged. During the pandemic, more patients were discharged to hospice in the California SID (8.4% vs. 5.9%, p<0.001). Use of comfort care was similar before and during the pandemic in the single center data. Survivors in both datasets were more likely to be discharged home vs. facility during the pandemic. Thirty-day readmissions and follow-up functional status in the single-center cohort were similar between groups. CONCLUSIONS: Using a large database, we identified more ICH patients discharged to hospice during the COVID-19 pandemic and, among survivors, more patients were discharged home rather than healthcare facility discharge during the pandemic.

Association of Do-Not-Resuscitate orders and in-hospital mortality among patients undergoing cranial neurosurgery.

BACKGROUND: Previous studies identified pre-existing DNR orders as a predictor of mortality after surgery. We sought to evaluate mortality of patients receiving cranial neurosurgery with DNR orders placed at the time of, or within 24 h of admission. METHODS: We performed a retrospective cohort study using the California State Inpatient Database, January 2018 to December 2020. We used International Classification of Diseases, 10th Revision (ICD-10) codes to identify emergent hospitalizations with principal diagnosis of brain injury, including traumatic brain injury [TBI], ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], or malignant brain tumor [mBT]. We used procedure and Diagnosis Related Group codes to identify cranial neurosurgery. Patients with DNR were one-to-one matched to non-DNR controls based on diagnosis (exact matching), age, sex, Elixhauser comorbidity index, and organ failure (coarsened matching). The primary outcome was inpatient mortality. RESULTS: In California, 30,384 patients underwent cranial neurosurgery, 2018-2020 (n = 3,112, 10% DNR). DNR patients were older, more often female, more often White, with greater comorbidity and organ system dysfunction. There were 2,505 patients with DNR orders 1:1 matched to controls. Patients with DNR had greater inpatient mortality (56% vs. 23%, p < 0.001; Hazard Ratio 3.11, 95% CI 2.50-3.86), received tracheostomy (Odds Ratio [OR] 0.37, 95% CI 0.24-0.57) and gastrostomy less (OR 0.48, 95% CI 0.39-0.58) compared to controls. Multivariable analysis of the unmatched cohort demonstrated similar results. CONCLUSION: Patients undergoing cranial neurosurgery with early or pre-existing DNR have high inpatient mortality compared to clinically similar non-DNR patients; 1 in 2 died during their hospitalization.

Reversal of Advanced Directives in Neurologic Emergencies.

Objective: Patients with advanced directives or Medical Orders for Life-Sustaining Treatment (MOLST), including "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI), may be candidates for procedural interventions when presenting with acute neurologic emergencies. Such interventions may limit morbidity and mortality, but typically they require MOLST reversal. We investigated outcomes of patients with MOLST reversal for treatment of neurologic emergencies. Methods: We conducted a retrospective chart review from July 1, 2019 to April 30, 2021 of patients with MOLST reversal treated in our NeuroMedicine Intensive Care Unit. Variables collected include neurologic disease, MOLST reversal decision maker, procedural interventions, and outcomes. Results: Twenty-seven patients (18 female, median age 78 years (IQR 73-85 years), median baseline modified Rankin score 1 [IQR 0-2.5] were identified with MOLST reversal. The most common pre-procedural MOLST was DNR/DNI (n=22, 81%), and 93% (n=25) pre-procedural MOLSTs were completed by the patient. MOLSTs were reversed by surrogates in n=23 cases (85%). The median time from MOLST completion to MOLST reversal was 603 days (IQR 45 days to 4 years). The most common neurologic emergency was ischemic stroke (n=14, 52%). Most patients died (n=14, 52%), 26% (n=7) were discharged to skilled nursing, and 22% (n=6) returned to home or assisted living. Conclusions: In neurologic emergencies, urgent shared decision making is needed to ensure goal-concordant care, which may result in reversal of existing advanced directives. Outcomes of patients with MOLST reversal were heterogeneous, emphasizing the importance of deliberate patient-centered care weighing the risks and benefits of each intervention.

Risk factors and associated complications with unplanned intubation in patients with craniotomy for brain tumor.

Patients undergoing surgical resection of a brain tumor have the potential risk for beingintubated post-operatively, which may be associated with significant morbidity and/or mortality after surgery. This study was analyzed various preoperative patient characteristics, postoperative outcomes, and complications to identify risk factors for unplanned intubation (UI) in adult patients undergoing craniotomy for a brain tumor and created a risk score framework for that cohort. Patients undergoing surgery for a brain tumor were identified according to primary Current Procedural Terminology codes, and information found in The American College of Surgeons (ACS) National Surgical Quality Improvement Project (NSQIP) database from 2012 to 2015 was reviewed. A total of 18,642 adult brain tumor patients were included in the ACS-NSQIP. The rate of unplanned intubation in this cohort was 2.30% (4 2 8). The mortality rate of patients who underwent UI after surgical resection of brain tumor was 24.78% compared to an overall mortality of 2.46%. During the first 30 days after surgery, 33% of patients who underwent UI had an unplanned reoperation, compared to 4.76% of patients who did not undergo unplanned intubation. Bivariate and multivariate analyses identified several predictors and computed a risk score for UI. A risk score based on patient factors for those undergoing a craniotomy for a brain tumor predicts the postoperative UI rate. This could aid in surgical decision-making by identify patients at a higher risk of UI, while modifying perioperative management may help prevent UI.

Post-acute care discharge delays for neurology inpatients: Opportunity to improve patient flow.

BACKGROUND: Hospital stays for patients discharged to post-acute care are longer and more costly than routine discharges. Issues disrupting patient flow from hospital to post-acute care facilities are an underrecognized strain on hospital resources. We sought to quantify the burden of medically unnecessary hospital days for inpatients with neurologic illness and planned discharge to post-acute care facilities. METHODS: We conducted a retrospective evaluation of hospital discharge delays for patients with neurologic disease and plans for discharge to post-acute care. We identified 100 sequential hospital admissions to an academic neurology inpatient service that were medically ready for discharge from December 4, 2017, to January 25, 2018. For each patient, we quantified the number of medically unnecessary hospital days, or all days in the hospital following the determination of medical discharge readiness. RESULTS: Among 100 patients medically ready for discharge with plans for post-acute care disposition (47 female, mean age 72.5 years, mean length of stay 12.3 days), 50 patients were planned for discharge to skilled nursing, 37 to acute rehabilitation, 10 to hospice/palliative care, and 3 to other facilities. There was a total of 1,226 patient-days, and 480 patient-days (39%) occurred following medical readiness for discharge. Medically unnecessary days ranged from 0 to 80 days per patient (mean 4.8, median 2.5, interquartile range 1-5 days). CONCLUSION: Unnecessary hospital days represent a large burden for patients with neurologic illness requiring post-acute care on discharge. These discharge delays present an opportunity to improve hospital-wide patient flow.

Evaluation of Long-Term Cryostorage of Brain Tissue Sections for Quantitative Histochemistry.

Storage of tissue sections for long periods allows multiple samples, acquired over months or years, to be processed together, in the same reagents, for quantitative histochemical studies. Protocols for freezer storage of free-floating frozen sections using sucrose with different additives have been reported and assert that storage has no effect on histochemistry, but no quantitative support has been provided. The present study analyzed the efficacy of long-term storage of brain tissue sections at -80C in buffered 15% glycerol. To determine whether histochemical reactivity is affected, we analyzed 11 datasets from 80 monkey brains that had sections stored for up to 10 years. For processing, sections from multiple cases were removed from storage, thawed, and batch-processed at the same time for different histochemical measures, including IHC for neuronal nuclear antigen, parvalbumin, orexin-A, doublecortin, bromodeoxyuridine, the pro-form of brain-derived neurotrophic factor, and damaged myelin basic protein as well as a histochemical assay for hyaluronic acid. Results were quantified using stereology, optical densitometry, fluorescence intensity, or percent area stained. Multiple regression analyses controlling for age and sex demonstrated the general stability of these antigens for up to a decade when stored in 15% glycerol at -80C.