Lithium-Induced Neurotoxicity: A Case Study BACKGROUND In patients presenting with neurological deficits, identifying the cause can be challenging. METHODS This case study discusses a condition that is not commonly seen. DISCUSSION Although lithium toxicity syndrome is not as familiar as other causes of neurological issues, this should be considered for any patient who presents with unexplained neurological deficits and a history of taking this medication. CONCLUSION If toxicity is not recognized early, the patient can be left with irreversible neurological symptoms, also known as syndrome of irreversible lithium-effectuated neurotoxicity, which impacts quality of life or can even cause death.

Validity and Reliability of the Responses to Ischemic Stroke Symptoms Questionnaire BACKGROUND Prehospital delay remains an important reason for low intravenous tissue plasminogen activator administration rates. Study of ischemic stroke patients' responses to stroke onset may be hampered by lack of a questionnaire designed specifically to examine their cognitive, emotional, and behavioral responses to symptoms. METHODS We provide evidence for content validity and reliability for the Responses to Ischemic Stroke Symptoms Questionnaire (RISQ) through, expert panel review and calculation of a content validity index and a study to examine stability reliability among hospitalized acute ischemic stroke patients. RESULTS Expert panel review demonstrated agreement on the relevance of questionnaire items and an overall content validity index of 0.97. The study to examine stability reliability demonstrated acceptable stability of the items on the RISQ over the short term in a sample of white and black stroke patients. CONCLUSION Preliminary evidence was gathered to support the content validity and stability reliability of the RISQ. Study of the RISQ with other population groups is needed.

Pain Control and Positioning in Children Following Selective Dorsal Rhizotomy Surgery BACKGROUND A practice was changed to elevate the head of bed from day 1 to day 3 on children after selective dorsal rhizotomy (SDR) surgery to improve pain control. Multiple methods to address pain post SDR include a continuous epidural infusion, medication administration, and repositioning/distraction. The length of time for the patient to remain flat was increased to potentially improve pain management. However, no studies in the literature were found to support the practice change. Nurses inquired whether this change resulted in optimal pain control. The primary research aim was to determine whether the change in positioning resulted in a difference in pain control. METHODS A retrospective cohort design was used to compare pain medication administered before and after the practice change. Patients between the ages of 2 and 15 years and admitted to the neuroscience unit after SDR surgery were included. Data were electronically retrieved to record the amount of medications given for pain. Descriptive and univariate statistics were used to detect differences. RESULTS The retrospective component of the study analyzed a total of 385 patients. There were no statistically significant differences between the number of intermittent doses of medication administered for pain between the 2 groups (P = .661). DISCUSSION Results support return to practice of 1 day of flat time. Nurses perceive that lying flat contributes to child and parent anxiety and limits options for distraction; therefore, decreasing flat time may lower anxiety without affecting pain control. These results are limited to postsurgical SDR patients but have implications for postoperative positioning and pain management. On the basis of these results, the neurosurgeon changed practice to zero days of flat time.

Effect of a Passive Intervention on Carers of Stroke Survivors During the Early Poststroke Period BACKGROUND Care partners of stroke survivors are often characterized by high burden levels and depression. Passive and active interventions have been proposed to help reduce burden and depression. The aim of this quality improvement report was to evaluate the effects of a single passive intervention on reported burden and depression in carers of stroke survivors. METHODS A quality improvement report was conducted on carers who participated in a short passive intervention (n = 56) and a control group (n = 44). The Family Strain Questionnaire–Short Form (FSQ-SF) and the Beck Depression Inventory II were administered in both groups at patients' admission and before discharge, with the intervention taking place between the 2 data collection periods. RESULTS No significant difference between groups was observed in FSQ-SF score and prevalence of depression at admission and in FSQ-SF at discharge. However, compared with admission, FSQ-SF at discharge was significantly reduced only in the intervention group (pre: 14, and interquartile range, 12–15; post: 9, and interquartile range, 9–13; P < .01). Moreover, a smaller proportion of carers classified as “depression” was found at discharge in the intervention group compared with controls (4% vs 28%, respectively; P < .01). CONCLUSION Results encourage the development and use of short passive intervention to reduce burden and depression in care partners of stroke survivors.

Rapid Response Electroencephalography for Urgent Evaluation of Patients in Community Hospital Intensive Care Practice INTRODUCTION Limited access to specialized technicians and trained neurologists results in delayed access to electroencephalography (EEG) and an accurate diagnosis of patients with critical neurological problems. This study evaluated the performance of Ceribell Rapid Response EEG System (RR-EEG), which promises fast EEG acquisition and interpretation without traditional technicians or EEG-trained specialists. METHODS The new technology was tested in a community hospital intensive care unit in Northern California. Three physicians (without previous training in EEG) were trained by the manufacturer of the RR-EEG and acquired EEG without the help of any EEG technicians. Time needed from order to EEG acquisition was noted. Quality of EEG and diagnostic information obtained with the new EEG technology were evaluated and compared with the same information from conventional clinical EEG system. RESULTS Ten patients were tested with this new EEG technology, and 6 of these patients went on to have conventional EEGs when the EEG technicians arrived at the site. In these cases, the conventional EEG was significantly delayed (11.2 ± 3.6 hours) compared with RR-EEG (5.0 ± 2.4 minutes; P < .005). Use of RR-EEG helped clinicians rule out status epilepticus and prevent overtreatment in 4 of 10 cases. RR-EEG and conventional EEG systems yielded similar diagnostic information. CONCLUSION RR-EEG can be set up by nurses, and diagnostic information about the presence or absence of seizures can be appreciated by nurses. The RR-EEG system, compared with the conventional EEG, did not require EEG technologists and enabled significantly faster access to diagnostic EEG information. This report confirms the ease of use and speed of acquisition and interpretation of EEG information at a community hospital setting using an RR-EEG device. This new technology has the potential to improve emergent clinical decision making and prevent overtreatment of patients in the intensive care unit setting while empowering nursing staff with useful diagnostic information in real time and at the bedside.

Development of a Joint Commission Disease-Specific Care Certification Program for Parkinson Disease in an Acute Care Hospital BACKGROUND Patients with Parkinson disease (PD) admitted to the hospital for any reason are at a higher risk of hospital-related complications. Frequent causes include delays in administering PD medications or use of contraindicated medications. The Joint Commission Disease-Specific Care (DSC) program has been used to establish a systematic approach to the care of specific inpatient populations. Once obtained, this certification demonstrates a commitment to patient care and safety, which is transparent to the public and can improve quality of care. METHODS We formalized our efforts to improve the care of hospitalized patients with PD by pursuing Joint Commission DSC. An interprofessional team was assembled to include nurses, therapists, physicians, pharmacists, performance improvement specialists, and data analysts. The team identified quality metrics based on clinical guidelines. In addition, a large educational campaign was undertaken. Application to the Joint Commission for DSC resulted in a successful June 15, 2018 site visit. To our knowledge, this is the first DSC program in PD in an acute care hospital. CONCLUSION Using the established platform of DSC certification from the Joint Commission, we developed a program based on relevant metrics that aims to address medication management of patients with PD admitted to the hospital. Our hope is to improve the care of this vulnerable patient population.

Development and Validation of the Self-care in Motor Neuron Disease Index OBJECTIVE The aim of this study was to develop and psychometrically test the properties of the Self-care in Motor Neuron Disease (SCMND) Index. METHODS This instrument development and validation study was conducted in 3 phases. The first is to identify self-care behaviors in people with motor neuron disease (MND), and the second is to evaluate the content validity of the SCMND Index. Then, between March 2017 and March 2018, the tool was administered to 107 people with MND for psychometric tests. RESULTS The SCMND Index was developed based on the middle-range theory of self-care of chronic illness, including 15 self-care behaviors related to respiration, nutrition, mobility, medication, medical visits, and complication management. Content validity was excellent. Data analysis suggests that the instrument has a good internal consistency in all 3 domains and excellent reproducibility. Increased self-care behaviors' median values were associated with mechanical ventilation, cough assistance, and dysphagia. Domains differed significantly based on access (maintenance), hospital admissions (monitoring and management), and respiratory infection (management). CONCLUSIONS Self-care is a patient-centered outcome, and it is a key point of healthcare. Results suggest that the SCMND Index is useful for both clinicians and researchers to evaluate self-care in MND.

Testing Feasibility of a Mobile Application to Monitor Fatigue in People With Multiple Sclerosis BACKGROUND Fatigue is a significant and burdensome symptom for patients with multiple sclerosis and is associated with other symptoms, signs, and decreased quality of life. METHODS A prospective pilot study was conducted with a convenience sample (n = 34) of patients with relapsing-remitting multiple sclerosis using a phone application, FatigueApp.com, to collect data on patient-reported outcome measures (Patient-Reported Outcomes Measurement Information System [PROMIS]). RESULTS FatigueApp feasibility was good, with the ability to collect data on self-reported fatigue and other symptoms using PROMIS measures. CONCLUSIONS This study showed that using a phone application with PROMIS may be useful in the future to provide estimates of fatigue and other variables to facilitate clinical monitoring of fatigue for neurology clinic settings.

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.