Neurohospitalist Practice and Well-Being During the COVID-19 Pandemic

Background and Purpose

Neurohospitalists play an important role in, and have been variably affected by, the ongoing COVID-19 pandemic. In this study, we survey neurohospitalists to characterize practice changes and the impact of the pandemic on their well-being.

Methods

A 22-item survey was distributed to neurohospitalists through the Neurohospitalist Society and the American Academy of Neurology Neurohospitalist, Stroke & Vascular Neurology, and Critical Care & Emergency Neurology Sections.

Results

After 2 weeks of collection, 123 responses were received, with 57% of respondents practicing in academic settings, 23% in private practice, and 7% in community hospitals. A minority of neurohospitalists (8%) were redeployed to care for COVID-19 or non-COVID-19 medicine patients. The most common neurologic diagnoses they reported in COVID-19 patients were delirium (85%), cerebrovascular events (75%), and seizure (35%); however, most neurohospitalists (59%) had evaluated fewer than 10 patients with COVID-19. Respondents observed that fewer patients with unrelated neurological diseases were admitted to the hospital compared to before the pandemic. Neurohospitalists experienced changes in administrative (27%), educational (15%), and research duties (11%), and had overall worse well-being and work-life balance (77%).

Conclusions

The most common neurologic diagnoses seen in COVID-19 patients by neurohospitalists in this sample are delirium, cerebrovascular disease, and seizure. Though the majority of survey respondents reported not being primary frontline providers, they report key clinical and operational roles during the pandemic, and report worse well-being as compared to before the pandemic. Our data suggests that there are opportunities to improve neurohospitalists' experience through flexible work practices and providing family care support.

Cardiac and Pulmonary Disorders and the Nervous System

PURPOSE OF REVIEW

This article reviews the neurologic complications encountered with cardiac and pulmonary disorders, specifically focusing on endocarditis, cardiac arrest, heart failure, hypercapnia, hypoxia, and cystic fibrosis. As neurologic dysfunction is one of the most frequent complications of these diseases and may even be the presenting symptom, it is important to be familiar with these complications to foster early recognition and intervention.

RECENT FINDINGS

Advances have been made in the identification of which patients can safely undergo valvular surgery for treatment of infective endocarditis in the setting of stroke, which, ideally, will minimize the risk of recurrent stroke in these patients. Additionally, technologic advances are improving our ability to use a multimodal approach for prognostication after cardiac arrest.

SUMMARY

The neurologic complications from the described disorders range from cerebrovascular complications to encephalitis, cognitive impairment, sleep-disordered breathing, headache, and increased intracranial pressure leading to coma or even death. Given the severity of these symptoms, it is paramount that neurologists be closely involved in the care of patients with neurologic complications from cardiac and pulmonary disorders.

Tissue Plasminogen Activator Prescription and Administration Errors within a Regional Stroke System

BACKGROUND

Intravenous (IV) tissue plasminogen activator (tPA) utilization in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. In our regional network, we have tried to minimize tPA dosing errors. We describe the frequency and types of tPA administration errors made in our comprehensive stroke center (CSC) and at community hospitals (CHs) prior to transfer.

METHODS

Using our stroke quality database, we extracted clinical and pharmacy information on all patients who received IV tPA from 2010-11 at the CSC or CH prior to transfer. All records were analyzed for the presence of inclusion/exclusion criteria deviations or tPA errors in prescription, reconstitution, dispensing, or administration, and for association with outcomes.

RESULTS

We identified 131 AIS cases treated with IV tPA: 51% female; mean age 68; 32% treated at the CSC, and 68% at CHs (including 26% by telestroke) from 22 CHs. tPA prescription and administration errors were present in 64% of all patients (41% CSC, 75% CH, P < .001), the most common being incorrect dosage for body weight (19% CSC, 55% CH, P < .001). Of the 27 overdoses, there were 3 deaths due to systemic hemorrhage or ICH. Nonetheless, outcomes (parenchymal hematoma, mortality, modified Rankin Scale score) did not differ between CSC and CH patients nor between those with and without errors.

CONCLUSION

Despite focus on minimization of tPA administration errors in AIS patients, such errors were very common in our regional stroke system. Although an association between tPA errors and stroke outcomes was not demonstrated, quality assurance mechanisms are still necessary to reduce potentially dangerous, avoidable errors.

Abstract W MP104: tPA Administration and Dosing Errors within a Regional Stroke System

BACKGROUND: Utilization of systemic IV tPA in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. We describe the frequency and types of tPA administration errors made in a comprehensive stroke center (CSC) and at stroke receiving facilities prior to transfer. METHODS: Using a prospectively-collected stroke quality database, all patients included received IV tPA from 2010-11 either at the CSC or prior to transfer (“drip-and-ship”). Retrospective data collection included pharmacy, air transport, and nursing records. RESULTS: We identified 131 tPA-treated AIS cases: 51% female; mean age 68 years; 33% treated at CSC; and 67% treated pre-transfer (including 16% by telestroke) from 22 facilities. Treatment of stroke mimics was more common at the CSC (12% vs 9%, p=NS). Pre-tPA blood pressure was more frequently not recorded in transfers (64% vs 7%, p<0.0001). tPA dosing/administration errors were present in 49.6% of all patients (26% at CSC; 61% of transfers, p=0.0001): infusion > 60 minutes (14%), total dose >90mg (5%), suspension/discontinuation of infusion (5%), or delayed tPA delivery to bedside (4%). Body weight discrepancies between institutions were frequent among transfers (42%). Parenchymal hematomas (PH) occurred in 7.5% of all patients (or 6.2% with tPA errors, 9.1% without errors); in-hospital death occurred in 10.7% overall (or 9.2% with errors, 12.1% without errors). PH, mortality and mRS did not differ between CSC-treated patients and transferred patients nor between those with and without errors. See table. CONCLUSION: tPA errors were very common in our large, regional stroke system, particularly among patients treated as “drip-and-ships”. Though in this study errors were not associated with outcomes, CSCs should include tPA dosing/administration education and quality assurance mechanisms within their systems in order to reduce avoidable, systematic errors.

Reproducibility of ABC/2 method to determine infarct volume and mismatch percentage with CT perfusion

BACKGROUND

Our aim is to implement a simple, rapid, and reliable method using computed tomography perfusion imaging and clinical judgment to target patients for reperfusion therapy in the hyper-acute stroke setting. We introduce a novel formula (1-infarct volume [CBV]/penumbra volume [MTT] × 100%) to quantify mismatch percentage.

METHODS

Twenty patients with anterior circulation strokes who underwent CT perfusion and received intravenous tissue plasminogen activator (IV tPA) were analyzed retrospectively. Nine blinded viewers determined volume of infarct and ischemic penumbra using the ABC/2 method and also the mismatch percentage.

RESULTS

Interrater reliability using the volumetric formula (ABC/2) was very good (intraclass correlation [ICC] = .9440 and ICC = .8510) for hemodynamic parameters infarct (CBV) and penumbra (MTT). ICC coefficient using the mismatch formula (1-MTT/CBV × 100%) was good (ICC of .635).

CONCLUSIONS

The ABC/2 method of volume estimation on CT perfusion is a reliable and efficient approach to determine infarct and penumbra volumes. The 1-CBV/MTT × 100% formula produces a mismatch percentage assisting providers in communicating the proportion of salvageable brain and guides therapy in the setting of patients with unclear time of onset with potentially salvageable tissue who can undergo mechanical retrieval or intraarterial thrombolytics.