Consistently Exploring Nurse Staffing and Neurocritical Care Unit Turnover.

ABSTRACT: BACKGROUND: Staffing models within nursing units have long been a hot topic of discussion. The COVID-19 pandemic exacerbated this discussion by straining the national nursing environment and workforce. Before the pandemic, the neuroscience intensive care unit (NSICU) primarily used an acuity-adjusted staffing model and aimed for a nurse-to-patient ratio of 1:1.5. During and after the pandemic, the NSICU was forced to primarily use a centralized staffing model because of the increased turnover in the hospital at large and a rise in patient census. METHODS : Unit census data in an NSICU were tracked before, during, and after the pandemic alongside utilization of a centralized staffing model in the hospital at large. RESULTS : During this time, the NSICU saw a statistically significant increase in average nurse-to-patient ratio and incidences of both floating and tripled assignments. The NSICU simultaneously saw a 180% increase in nursing turnover. CONCLUSION : Although we cannot prove that a centralized staffing model is directly responsible for higher nursing turnover, its utilization led to greater incidence of poor staffing-reflected in deviation from the nurse-to-patient ratio goal of the unit. Nurse staffing concerns play a large role in nurse satisfaction in the workforce: staffing shortages have been described both as a precursor to and as a consequence of increased nursing turnover.

Exploring Plan of Care Communication With a Multidisciplinary Rounding Plan to Nursing Care Plans.

ABSTRACT: BACKGROUND: The nursing care plan (NCP) was developed approximately 100 years ago as a teaching tool for nursing students. Our neuroscience intensive care unit (NSICU) uses a multidisciplinary rounding plan (MDRP) that may provide more relevant and up-to-date information than the standard NCP. METHODS: In this prospective single-blind randomized pilot study, we examined nurses' abilities to respond to 7 clinical scenarios common to the NSICU. The NCPs and MDRPs from 70 patients were randomly assigned to 14 nurses (10 per nurse) who answered each of the 7 questions using only data from an NCP or data from an MDR. RESULTS: The MDRP mean score of 4.51 (1.50) correct answers was statistically significantly higher than the NCP mean score of 0.31 (0.71) correct answer (P < .0001). CONCLUSION: The MDRP was designed to address the modern-day communication needs of NSICU staff by leveraging technological advances. Data from this study suggest that the MDRP may have advantages over the NCP in providing contextually relevant information. Additional research is warranted to develop the MDRP as a replacement for the NCP in the NSICU setting.

Patient and Spine Surgeon Perceptions on Shared Decision-Making in the Treatment of Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity.

STUDY DESIGN: Retrospective. OBJECTIVE: To understand patients' and spine surgeons' perspectives about decision-making around surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA: Surgery for correction of adult spinal deformity is often beneficial; however, in over 20% of older adults (≥ 65 yrs of age), outcomes from surgery are less desirable. MATERIALS AND METHODS: We conducted semistructured, in-depth interviews with six patients and five spine surgeons. Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes. RESULTS: Patients themes: 1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; 2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; 3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and 4) patients felt that pain management was the most difficult part of recovery from surgery. Surgeons themes: 1) surgeons varied substantially in their interpretations of shared decision-making; 2) surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; 3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and 4) surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration. CONCLUSION: Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery. These findings highlight the need for improved understanding of both sides of shared decision-making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness. LEVEL OF EVIDENCE: 3.

Cultural Perspectives on Pain Assessment and Opioid Use: International Neuroscience Nursing Research Symposium Conference Proceedings.

ABSTRACT: INTRODUCTION: In August of 2020, the 4th International Neuroscience Nursing Research Symposium was held. The purpose of the symposium was to share neuroscience nursing research from around the world. One of the topics thought most notable that stimulated a crucial conversation was how different countries assessed pain and their use of opioids for pain management. BACKGROUND: Neuroscience nurses are global. What is not known is their experience with and what challenges exist with pain management for human beings in their country. Crossing geographic and cultural boundaries, pain affects all human beings. Each culture has unique values and beliefs regarding pain. Patient barriers, pivotal in this article, included poverty, poor health literacy, opioid phobia, and cultural as well as social beliefs. RESULTS: Neuroscience nurses from Australia, Brazil, Germany, Singapore, India, Ghana, Kenya, Philippines, South Africa, and the United States each collaborated to provide a short summary of assessing pain and use of opioids for pain management for the neuroscience patient. CONCLUSION: Neuroscience patients have varying degrees of pain based on many factors. Various countries have religious, spiritual, and cultural traditions that influence the reporting and management of pain. Pain assessment and management can be challenging, especially for the neuroscience nurses around the world.

Alleviating Care Partner Poststroke Stress Through Education.

BACKGROUND: Those who provide assistance to persons who have experienced stroke (care partners) become exposed to new situation and paradigms that may produce stress. Providing adequate information and training before discharge may reduce care partner stress. METHODS: This prospective longitudinal pilot study examined whether tailored poststroke discharge education would reduce care partner stress. Stress was measured via survey at baseline and at 30 and 60 days after discharge with the modified Caregiver Strain Index (mCSI), where a higher mCSI indicates a higher level of stress. RESULTS: There was no significant difference between the mCSI scores at baseline (9.73), 30 days (9.59), and 60 days (10.26; P = .94). DISCUSSION: Education is an important part of predischarge care for both patients and care partners. However, education alone or education only delivered once before discharge may not be sufficient to significantly reduce care partner stress. CONCLUSION: A single postdischarge education session does not reduce care partner stress. Further research is needed to determine whether an altered session or a repeated education session can assist in alleviating care partner stress.

Elevated blood pressure after craniotomy: A prospective observational study.

PURPOSE: Close hemodynamic monitoring after craniotomy is routine given risk for post-operative hypertension, systemic and neurological complications. Patient and peri-operative variables associated with increased risk of post-craniotomy hypertension and complications are not well understood. Our analysis aims to estimate the incidence and prevalence of post-craniotomy hypertension, its time course, contributing factors, and post-craniotomy complications. MATERIAL AND METHODS: This is a prospective study of patients admitted to the Neurosurgical Intensive Care Unit after an elective craniotomy. Variables associated with pre-surgical risk, demographics, and post-operative care were analyzed. RESULTS: A total of 282 patients were included in the final analysis, 44% had pre-existing hypertension. Post-craniotomy hypertension was seen in 21%, with a higher incidence in patients with pre-existing hypertension (p < .001), smaller craniotomies (p = .0035), and increased use of analgesic medications (p < .001). History of hypertension was the only independent risk factor for post-craniotomy hypertension in a multivariate regression model. Patients who developed post-craniotomy hypertension, showed a significant increase in length of stay, number and duration of antihypertensive treatment. However, post-craniotomy hypertension was not associated with a higher incidence of other post-operative complications. CONCLUSIONS: Development of hypertension after craniotomy is multi-factorial. In this prospective study, a prior history of hypertension was the only associated independent risk factor.

Methods for Cleaning and Managing a Nurse-Led Registry.

BACKGROUND: Clinical registries provide insight on the quality of patient care by providing data to identify associations and patterns in diagnosis, disease, and treatment. This has led to a push toward using large data sets in healthcare research. Nurse researchers are developing data registries, but most are unaware of how to manage a data registry. This article examines a neuroscience nursing registry to describe a quality control and data management process. DATA QUALITY PROCESS: Our registry contains more than 90 000 rows of data from almost 5000 patients at 4 US hospitals. Data management is a continuous process that consists of 5 phases: screening, data organization, diagnostic, treatment, and missing data. These phases are repeated with each registry update. DISCUSSION: The interdisciplinary approach to data management resulted in high-quality data, which was confirmed by missing data analysis. Most technical errors could be systematically diagnosed and resolved using basic statistical outputs, and fixed in the source file. CONCLUSION: The methods described provide a structured way for nurses and their collaborators to clean and manage registries.

Efficacy of Using Available Data to Examine Nurse Staffing Ratios and Quality of Care Metrics.

BACKGROUND: Nurse staffing ratios impact both the quality and safety of care on a particular unit. Most hospitals have access to a large volume of nurse-sensitive outcomes. We hypothesized that these data could be used to explore the impact of changing the nurse-to-patient ratio on patient-reported outcomes, nurse satisfaction scores, and quality of care metrics. METHODS: Retrospective data from hospital resources (eg, Press Ganey reports) were linked to daily staffing records (eg, assignment sheets) in a pre-post study. Before September 2017, the nurse-to-patient ratio was 1:1.75 (pre); afterward, the ratio was reduced to 1:1.5 (post). RESULTS: Press Ganey National Database of Nursing Quality Indicators scores were improved, staffing turnover rates were reduced, and falls were linked to periods of high nurse-to-patient ratios. CONCLUSION: This study shows the efficacy of using readily available metrics to explore for associations between nurse staffing and nurse-sensitive outcomes at the nursing care unit level. This provides a unique perspective to optimize staffing ratios based on personalized (unit-level) metrics.

Distributions and Reference Ranges for Automated Pupillometer Values in Neurocritical Care Patients.

BACKGROUND: Automated pupillometry is becoming widely accepted as an objective measure of pupillary function, especially in neurocritical care units. Normative reference values and thresholds to denote a significant change are necessary for integrating automated pupillometry into practice. OBJECTIVE: Providing point estimates of normal ranges for pupillometry data will help clinicians intuit meaning from these data that will drive clinical interventions. METHODS: This study used a planned descriptive analysis using data from a multicenter registry including automated pupillometry assessments in 2140 subjects from 3 US hospitals collected during a 3-year period. RESULTS: We provide a comprehensive list of admission pupillometry data. Our data demonstrate significant differences in pupillary values for Neurological Pupil Index, latency, and constriction velocity when stratified by age, sex, or severity of illness defined by the Glasgow Coma Scale score. CONCLUSION: This study provides a greater understanding of expected distributions for automated pupillometry values in a wide range of neurocritical care populations.