Neurology Inpatient Service Research Articles

Optimizing Neurology Inpatient Documentation: A Pilot Study of a Novel Discharge Documentation EHR Tool.

Clinical documentation of patient acuity is a major determinant of payer reimbursement. This project aimed to improve case mix index (CMI) by incorporating a novel electronic health record (EHR) discharge documentation tool into the inpatient general neurology service at the University of California, Los Angeles (UCLA) Medical Center. We used data from Vizient AMC Hospital: Risk Model Summary for Clinical Data Base (CBD) 2017 to create a discharge diagnosis documentation tool consisting of dropdown menus to better capture relevant secondary diagnoses and comorbidities. After implementation of this tool, we compared pre- (July 2017-June 2019) and post-intervention (July 2019-June 2021) time periods on mean expected length of stay (LOS) and mean CMI with two sample T-tests and the percentage of encounters classified as having Major Complications/Comorbidities (MCC), with Complication/Comorbidity (CC), and without CC/MCC with tests of proportions. Mean CMI increased significantly from 1.2 pre-intervention to 1.4 post-intervention implementation (P < .01). There was a pattern of increased MCC percentages for "Bacterial infections," "Other Disorders of Nervous System", "Multiple Sclerosis," and "Nervous System Neoplasms" diagnosis related groups post-intervention. This pilot study describes the creation of an innovative EHR discharge diagnosis documentation tool in collaboration with neurology healthcare providers, the clinical documentation improvement team, and neuro-informaticists. This novel discharge diagnosis documentation tool demonstrates promise in increasing CMI, shifting diagnosis related groups to a greater proportion of those with MCC, and improving the quality of clinical documentation.

The impact of headache disorders: a prospective analysis of headache referrals to outpatient and inpatient neurology and emergency services in an Irish University teaching hospital

BackgroundHeadache represents a significant proportion of disability globally in general practice, neurology outpatient settings, and emergency departments. There is scant literature regarding the impact of headache on healthcare services in Ireland.AimsWe aimed to investigate headache burden across the emergency department, inpatient stays, and neurology outpatient department referrals in an Irish University teaching hospital.MethodsWe prospectively collected data regarding emergency department presentations, inpatient neurology consultations, and neurology outpatient referrals for patients with headache between 13th January and 8th March 2020. Data were analyzed using descriptive statistics.ResultsThere were 180 emergency department attendances, 50 inpatient consultations, and 76 outpatient referrals with headache. Neurological examinations were often incomplete; neuroimaging was commonly employed. Migraine was the most frequent headache diagnosis at discharge in the emergency department and among inpatients after neurology review. Diagnostic uncertainty was identified—33% of patients left the emergency department with no diagnosis, and “unknown/unspecified headache” was recorded on 49% of outpatient referrals and 30% of inpatient consult requests. Medication overuse headache coexisted with migraine in nine patients in the inpatient group. Prophylaxis had been trialed in 56% of patients with migraine referred to outpatients.ConclusionsPrimary headache disorders have a large impact on hospital services. Diagnostic uncertainty is common; neuroimaging is relied upon. Appropriate care pathways, education, and resource allocation should be prioritized.

Inpatient Neurology Deaths and Factors Associated With Discharge to Hospice.

The Neurology Mortality Review Committee at our institution identified variability in location of death for patients on our inpatient neurology services. Hospice may increase the number of patients dying in their preferred locations. This study aimed to characterize patients who die on inpatient neurology services and explore barriers to discharge to hospice. This retrospective study was completed at a single, quaternary care medical center that is a Level I Trauma Center and Comprehensive Stroke Center. Patients discharged by an inpatient neurology service between 6/2019-1/2021 were identified and electronic medical record review was performed on patients who died in the hospital and who were discharged to hospice. 69 inpatient deaths and 74 discharges to hospice occurred during the study period. Of the 69 deaths, 54 occurred following withdrawal of life sustaining treatment (WLST), of which 14 had a referral to hospice placed. There were 88 "hospice-referred" patients and 40 "hospice-eligible" patients. Hospice-referred patients were less likely to require the intensive care unit than hospice-eligible patients. Hospice-referred patients had their code status changed to Do Not Intubate earlier and were more likely to have advanced directives available. Our data highlight opportunities for further research to improve discharge to hospice including interhospital transfers, advanced directives, earlier goals of care discussions, palliative care consultations, and increased hospice bed availability. Importantly, it highlights the limitations of using in-hospital mortality as a quality indicator in this patient population.

The Completion of a PGY-1 Neurology Bootcamp Leads to Increased Trainee Knowledge and Confidence in Neurologic Emergencies Management and Procedural Skills (P2-2.001)

<h3>Objective:</h3> To evaluate the impact of an end-of-the-year, post-graduate year 1 (PGY-1) simulation-based neurology bootcamp on trainee knowledge, self-confidence, and skill independence regarding acute neurologic emergencies management and bedside procedural skills. <h3>Background:</h3> The post-graduate year 2 (PGY-2) neurology resident is often the first line of triage for evaluation of acute neurologic deterioration on the inpatient neurology service, requiring autonomy and responsibility. We implemented and evaluated a bootcamp prior to this critical training period. <h3>Design/Methods:</h3> In this prospective cohort study, 14 rising PGY-2 neurology residents attended a two-day bootcamp with a simulation-based curriculum led by neurology faculty practicing cerebrovascular, critical care, and inpatient neurology medicine. Pre- and postbootcamp, trainees completed multiple-choice knowledge assessments and via Likert scales, self-reported confidence in managing neurologic emergencies. Faculty observed and rated trainee ability to independently perform five neurologic procedures (lumbar puncture, external ventricular drain [EVD] management, botulinum toxin injection for migraine, digital fundoscopy, and pupillometry), with residents additionally reporting their own perceived degree of independence. <h3>Results:</h3> Proportion of trainees demonstrating independence per faculty rating significantly increased for all five procedural skills post-bootcamp (for all, p &lt; .05). Trainee self-reported independence of EVD management, pupillometry, and fundoscopy skills also increased postbootcamp (for all, p &lt; .05), with &lt; 25% of trainees reporting total independence pre-bootcamp to 50%, 86%, and 79% post-bootcamp, respectively. Knowledge assessment scores increased from a pre-bootcamp mean of 54% of questions correct to mean 70% correct (p = 0.002), driven by increases in vascular neurologic emergency and procedural knowledge. On a 5-point Likert scale, trainee self-reported confidence in emergency management increased from median 2.5 (a little confident) to median 4 (fairly confident) (p &lt; .001) <h3>Conclusions:</h3> A simulation-based, two-day bootcamp with focus on acute cerebrovascular neurologic emergencies and neurologic procedural skills showed significant improvements in trainee knowledge along with faculty-observed and self-reported confidence and independence. <b>Disclosure:</b> An immediate family member of Dr. Swetlik has received personal compensation for serving as an employee of Pfizer. Dr. Buletko has nothing to disclose. Dr. Marquardt has nothing to disclose. Dr. Higgins has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Organon. Ms. Hassett has nothing to disclose.

Evaluating Barriers and Tools to Optimize Resident Call Scheduling on Neurology In-Patient Services (P8-7.006)

Evaluating Barriers and Tools to Optimize Resident Call Scheduling on Neurology In-Patient Services (P8-7.006)

Adding Nocturnal Advanced Practice Providers to an Academic Inpatient Neurology Service Improves Residents' Educational Experience.

Background and Objectives: In the inpatient academic medical center, increased demand for clinical services often equates to an increased workload for trainees, which could have a positive or negative impact on their educational experience. In 2020, our academic medical center hired Advanced Practice Providers (APPs) to provide continuous additional overnight coverage for our neurology ward teaching service. We hypothesized that adding APPs and reducing overnight clinical workload for residents would have a positive impact on resident education. Methods: We performed a mixed-methods, prospective study that included needs-assessments by residents, semi-structured interviews with both residents and APPs, and surveys to residents and nursing staff. In addition, we collected quantitative data such as hours of sleep, number of admissions, and number of pages to capture the impact of APPs on resident overnight shifts. Results: The addition of APPs overnight increased the median hours of sleep overnight from 1 hour to 3 hours (P < .001) and decreased the median number of pages overnight from 31.5 to 17 (P < .001). The median number of patients the resident was responsible for cross-covering overnight decreased from 24 patients to 14 patients (P < .001). The majority of resident responses (94%) agreed that the addition of APPs benefited their education by reducing workload and increasing time allotted to reading and formulating plans for overnight admissions. 88% of residents agreed that the addition of APPs improved quality of life and reduced risk of burnout. Conclusion: Advanced Practice Providers significantly reduced resident workload, leading residents to report improvements in the educational experience overnight and reduced perceived risk of burnout.

Two-Year Profile of Preventable Errors in Hospital-Based Neurology.

Medical errors are estimated to cause 7,000 deaths and cost 17-29 billion USD per year, but there is a lack of published real-world data on preventable errors, in particular in hospital-based neurology. We sought to characterize the profile of errors that occur on the inpatient neurology services at our institution to inform strategies on future error prevention. We reviewed all cases of preventable errors occurring on the inpatient neurology services from July 1, 2018, to June 30, 2020, logged in institutional error reporting systems and reviewed at departmental morbidity and mortality conferences (M&MC). Each case was characterized by primary category of error, level of harm as determined by the Agency for Healthcare Research & Quality Common Format Harm Scale version 1.2, primary intervention, and recurrence within 1 year, with a final censoring date of June 30, 2021. Of 72 cases, 43 (60%) were attributed to errors in clinical decision making and 20 (28%) to systems or electronic health record-related errors. The majority of cases resulted in in-conference education on systems-based errors (29%) at departmental M&MCs followed by in-conference education on clinical neurology (25%). Among errors classified primarily as clinical, 28% were addressed via systems-based interventions including in-conference education on systems issues and changes in written protocol. In 23 cases (32%), a similar error recurred within 1 year of the presentation. In total, 7 cases (10%) resulted in a change in written protocol, none with recurrences. Systems-based interventions may reduce both clinical and systems-based errors, and protocol changes are effective when feasible. Given the important goal of optimizing care for every patient, quality leaders should conduct continuous audits of preventable errors and quality improvement systems in their clinical areas.

Feasibility and Potential Value of TMS for Upper Extremity Motor Assessment at the Bedside During Acute Stroke Hospitalization

<h3>Research Objectives</h3> To assess the feasibility of collecting transcranial magnetic stimulation (TMS) measures at the bedside during acute stroke hospitalization and to associate TMS neurophysiology with upper extremity (UE) behavioral measures. <h3>Design</h3> The Stroke Motor reHabilitation and Recovery sTudy (SMaHRT; https://www.clinicaltrials.gov/ct2/show/NCT03485040?term=NCT03485040&draw=2&rank=1) is a prospective, observational cohort study <h3>Setting</h3> Inpatient neurology service, Massachusetts General Hospital, a large academic medical center. <h3>Participants</h3> Twenty-seven individuals (65.44 ± 12.52 years) with first-ever stroke resulting in UE weakness, who were 18 years or older, could follow simple commands in English and had no contraindications to receiving ipsilesional TMS were eligible for and included in this study. TMS was performed within 5.2 ± 2.2 days of stroke. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Feasibility of collecting TMS measures including motor evoked potentials (MEPs), resting motor threshold (RMT), cortical silent period (cSP) and ipsilateral silent period (iSP) at the hospital bedside was assessed. The main behavioral measures collected included upper extremity Fugl-Meyer Assessment (FMA-UE), grip strength, shoulder abduction finger extension (SAFE) score and 9-hole peg test. <h3>Results</h3> MEPs, RMT, cSP and iSP were collected in at least one hemisphere for 26/42 participants, of whom 15 participants did not receive testing due to medical and discharge factors. A mobile TMS cart facilitated efficient equipment transport. Additionally, coordination with nursing and use of hospital-bed or bedside chair positioning features maximized successful testing. Patients' whose lesioned hemisphere was MEP+ compared to MEP- at acute hospitalization had better affected FMA-UE, SAFE, 9HPT and grip strength scores (p<0.01). Lower RMT values were also associated with better affected FMA-UE (rho=-0.6, p<0.05), SAFE (rho=-0.5, p=0.07), and Grip Strength (rho=-0.4, p=0.23) scores. There were no clear linear trends between cSP or iSP and any behavioral outcome. <h3>Conclusions</h3> Several TMS measures are feasible to perform during acute stroke hospitalization. Interdisciplinary coordination, a mobile TMS cart, and participant positioning are essential to successful TMS testing at the hospital bedside. In addition to MEP, RMT has added value for relating to UE motor behavior during acute stroke hospitalization. <h3>Author(s) Disclosures</h3> See "Faculty Disclosures" task tab

Fast Neuro: A Care Model to Expedite Access to Neurology Clinic.

We set out to improve outpatient neurology access while reducing patient volume in the emergency department (ED) for nonemergent neurologic complaints. We created a rapid access model, University of California Los Angeles (UCLA) Fast Neuro, for patients referred from affiliated EDs to outpatient neurology, enabling appointments within 1 week of referral. Rapid access appointments were also available to established neurology patients with urgent concerns. Fast Neuro was built to reduce nonemergent neurologic care in the ED, improve outpatient neurology access, and avoid use of inpatient neurology services for nonemergent consults. The volume of referrals and neurology consults from the ED and wait time from referral to appointment were measured. Surveys were conducted at 3 and 6 months to assess satisfaction with the model by all stakeholders. From January 2019 through January 2021, 201 patients were referred to outpatient neurology through UCLA Fast Neuro. Wait time for an outpatient neurology appointment was reduced from the prior period by 82.5% (7.0 ± 5.5 vs 40 ± 4.1 days). The number of nonemergent consults from the ED was reduced by 60% (4.1 ± 1.9/mo vs 10.3 ± 1.7/mo). Surveys showed wide acceptance of the new model with 92% of attending physicians and advanced practice providers and 89% of residents endorsing that UCLA Fast Neuro patients did not detract from their clinic experience. UCLA Fast Neuro improved ED throughput, reduced inpatient neurology consults from the ED, and decreased wait times for outpatient neurology appointments without using the inpatient neurology service for nonurgent consults. UCLA Fast Neuro was successful. Exploration of how to scale and implement the model of access more broadly is warranted.

Using cerebrospinal fluid ATN quantification to classify research subjects in a diverse clinical population

AbstractBackgroundThe ATN Framework was proposed to better classify subjects on the Alzheimer’s Disease (AD) spectrum for research purposes. The role of the MassGeneral Institute for Neurodegenerative Disease (MIND) Tissue bank is to collect cerebrospinal fluid (CSF), plasma, and associated clinical data from a diverse neurological subject population. Ab40, Ab42, p‐tau 181, and t‐tau were quantified in CSF samples from the MIND Bank and classified according to the ATN framework to assess the utility of this research framework in a clinical trial relevant, non‐cohort setting.Method750 CSF samples were collected from clinically indicated lumbar punctures at the Massachusetts General Hospital Outpatient and Inpatient Neurology Services. The CSF samples were analyzed using Eurolmmun ELISA assays on a semi‐automated TECAN FreedomEVO liquid handler to obtain ATN values. To optimize sensitivity and specificity we plotted these value across varying thresholds, and selected the value at which both were maximized. Assessment of cognitive impairment and neurological diagnosis was performed by chart review by an experienced neurologist.ResultAfter sliding threshold analysis of clear cognitively unimpaired versus AD‐Dementia cases, a threshold value for Ab42/40 Ratio (0.082, 92% sensitivity, 91% specificity), pTau (41.8 pg/mL, 91% sensitivity, 91% specificity), and tTau (280 pg/mL, 88% sensitivity, 88% specificity) was determined. 25% of the MIND bank was classified as likely AD from chart review and a similar proportion was biofluid A+T+N+. The overlap of these two subgroups was extensive but not complete. Out of the 188 A+T+N+ subjects, 152 presented clinically with a form of AD, 6 had other neurodegenerative diseases, 23 had other forms of cognitive impairment, and 7 were cognitively unimpaired. 8 of the 419 A‐T‐N‐ subjects had a clinical diagnosis of AD or mixed AD.ConclusionThe ATN framework can be used to provide an extra level of certainty with regards to diagnosis of likely AD in a clinical trial relevant subject population. Even in this population with clinical indication for LP, there is a small number of resilient cognitively unimpaired individuals that have AD positive biomarkers but no cognitive impairment.

Randomized Study of Bedside vs Hallway Rounding

Over the last century, attending rounds have shifted away from the bedside. Despite evidence for greater patient satisfaction rates and improved nursing perception of teamwork with bedside presentations, residents and attending physicians are apprehensive of the bedside approach. There is lack of data to guide rounding practices within neurology, and therefore, optimal rounding methods remain unclear. The objective of this study was to compare bedside rounding with hallway rounding on an academic neurology inpatient service and assess efficiency, trainee education, and satisfaction among patients and staff. We conducted a single-center prospective randomized study of bedside vs hallway rounding on new inpatient neurology admissions over 1-week blocks. The bedside team presented patients at the bedside, whereas the hallway team presented patients outside of the patient's room. We evaluated the 2 approaches with time-motion analysis, which investigated the rounding style's effect on composition and timing of rounds (primary outcome) and surveys of patients, nurses, residents, and attending physicians on both teams (secondary outcomes). The mean rounding time per newly admitted patient in the bedside group (n = 38 patients) and hallway group (n = 41 patients) was 23 minutes and 23.2 minutes, respectively (p = 0.93). The bedside group spent on average 56.4% of patient rounding time in the patient's room, whereas the hallway group spent 39.5% of rounding time in the patient's room (p = 0.036). Residents perceived hallway rounding to be more efficient and associated it with a superior educational experience and more effective data review. Nurses had improved perception of their participation in bedside rounds. Although patients' views of bedside and hallway rounds were similar, patients who had experienced bedside rounds preferred it. In conclusion, bedside rounding was perceived less favorably by most residents but was as efficient as hallway rounding. Although bedside rounding limited the use of technology for data review, it promoted nursing participation and resulted in more time spent with the patient. CLINICAL TRIAL REGISTRATION NUMBER: Registered retrospectively per the editors' suggestion (NCT04754828).

Risk factors and outcomes of hospitalized stroke patients in Lusaka, Zambia

BackgroundLimited data exists about stroke risk factors and outcomes in sub-Saharan African countries, including Zambia. We aim to fill this gap by describing features of hospitalized stroke patients at University Teaching Hospital (UTH), the national referral hospital in Lusaka, Zambia. MethodsWe conducted a retrospective study of consecutive adults with stroke admitted to UTH's inpatient neurology service from October 2018 to March 2019. Strokes were classified as ischemic or hemorrhagic based on CT scan results and unknown if CT scan was not obtained. Chi-square analyses and t-tests were used to compare characteristics between cohorts with differing stroke subtypes. ResultsAdults with stroke constituted 43% (n = 324) of all neurological admissions, had an average age of 60 ± 18 years, and 62% of the cohort was female. Stroke subtypes were 58% ischemic, 28% hemorrhagic, and 14% unknown. Hypertension was present in 80% of all strokes and was significantly associated with hemorrhagic stroke (p = 0.03). HIV was present in 18% of all strokes and did not significantly differ by stroke subtype. Diabetes (16%), heart disease (34%), atrial fibrillation (9%), and past medical history of stroke (22%) were all significantly more common in patients with ischemic stroke (p < 0.05). In-hospital mortality was 24% overall and highest among individuals with hemorrhagic strokes (33%, p = 0.005). ConclusionsThis Zambian stroke cohort is notable for its young age, significant HIV burden, high in-hospital mortality, and high rates of uncontrolled hypertension. Our results demonstrate Zambia's substantial stroke burden, significant contribution of HIV to stroke, and the need to improve primary stroke prevention.

Abstract P301: Evaluating the Impact of a Pharmacist-Managed Hypertension Collaborative Care Model in Vascular Neurology Patients in an Inpatient Acute Care Setting

Introduction: The utility of pharmacist-managed collaborative practice agreements (CPA) in the management of hypertension is well established in the outpatient setting. There has been little evaluation of the use of CPAs in the inpatient acute care setting, and none described specifically in the vascular neurology population. Treatment of hypertension is a critical intervention for the secondary prevention of acute ischemic stroke. This quality improvement project evaluated the implementation of a CPA for the inpatient acute care management of hypertension in vascular neurology patients at University of Virginia Health. Methods: A CPA was developed between the neurosciences clinical pharmacist group and the inpatient vascular neurology service, legally vetted, and implemented in June 2019. All vascular neurology patient charts in which an electronic CPA referral was placed from June 2019 through June 2020 were reviewed. Patients were excluded if they were discharged within 24 hours of the referral being placed. The primary objective was to describe and evaluate the implementation of a pharmacist-driven hypertension management practice in the inpatient acute care setting. All patient demographic and clinical data were analyzed using descriptive statistics. Secondary safety outcomes included documented hypotensive events (SBP &lt;90) and acute kidney injury (AKI, increase in SCr by 0.3 mg/dl within 48 hours). Results: During the study period, 26 referrals were placed, and 19 patients were included for review. On average, patients were on 2 anti-hypertensive medications prior to admission. From the time of referral to discharge (mean 6 days), systolic blood pressure (SBP) was reduced on average by 36 mmHg (mean percentage reduction 20%) and diastolic blood pressure (DBP) by 12 mmHg (mean percentage reduction 7%). Ten patients (53%) met the goal of SBP &lt; 140 at discharge. There were 5 hypotensive events and 4 instances of AKI, all of which were mild and recovered prior to discharge. Conclusion: A pharmacist-managed hypertension CPA was successfully implemented in vascular neurology patients in the inpatient acute care setting. The practice demonstrated improved blood pressure control and minimal adverse outcomes.

Influence of Autoimmune Antibody Testing on the Use of Immunotherapy on an Inpatient Neurology Service.

To determine the frequency of autoimmune antibody testing in an inpatient neurology setting and its influence on immunotherapy use on an inpatient neurology service. A retrospective descriptive cohort study of patients admitted to the neurology inpatient service at a large tertiary academic medical center who had autoimmune and/or paraneoplastic antibody testing performed between 10/1/2017 and 10/1/2018. Characteristics of patients' initial clinical presentation, antibody testing results, test timing in relation to initiating immunotherapy, and final diagnosis using consensus criteria were extracted and analyzed. Case reports of patients with positive antibody panels are presented. Of 1,604 patients, 50 patients (3.1%) had an antibody panel sent. Tests resulted after an average of 17 days (range 7-27). The most common clinical presenting symptom in those with a panel sent was encephalopathy. There were 5 (10%) positive serum panels and no positive CSF panels. Only one of these 5 patients had autoimmune encephalitis and was treated with immunotherapy. Of those with negative serum and CSF panels, 15 were treated acutely with empiric immunotherapy and the remainder with supportive care. Of those treated with immunotherapy, 14/15 (93%) were treated before the panel tests resulted. Four patients who had negative panels but were empirically treated met consensus criteria for an autoimmune-mediated neurologic process. Our study suggests that the results of antibody testing did not influence inpatient neurologists' decision to treat with immunotherapy as most treatments began prior to final results being available.

Patient Characteristics Associated With Readmission to 3 Neurology Services at an Urban Academic Center.

Hospital 30-day readmissions in patients with primary neurological problems are not well characterized. We sought to determine patient characteristics associated with readmission across 3 different inpatient neurology services at New York University Langone Hospital. We retrospectively reviewed all 30-day readmissions from the General Neurology, Epilepsy, and Stroke services at NYULH Brooklyn and Manhattan campuses from 2016-2017 and compared them to a random sample of non-readmitted neurology patients. We used univariate analyses to compare demographics, clinical characteristics, disease specific metrics, and discharge factors of non-readmitted and readmitted groups and binomial logistic regression to examine specific variables with adjustment for confounders. We included 284 patients with 30-day readmissions and 306 control patients without readmissions matched by discharge location and service. After adjusting for confounders, we found that the following factors were associated with increased readmission risk: a recent hospital encounter increased risk for all services, increased number of medications at discharge, intensive care unit stay, higher length of stay, and prior history of seizure for the General Neurology Service, increased number of medications at discharge for the Epilepsy Service, and active malignancy and higher discharge modified Rankin Scale score for the Stroke Service. This study identifies potential risk factors for readmission in patients across multiple neurology services. Further research is needed to establish whether these risk factors hold across multiple institutions.

Keeping the team together: Transformation of an inpatient neurology service at an urban, multi-ethnic, safety net hospital in New York City during COVID-19

The COVID-19 pandemic dramatically affected the operations of New York City hospitals during March and April of 2020. This article describes the transformation of a neurology division at a 450-bed tertiary care hospital in a multi-ethnic community in Brooklyn during this initial wave of COVID-19. In lieu of a mass redeployment of staff to internal medicine teams, we report a novel method for a neurology division to participate in a hospital’s expansion of care for patients with COVID-19 while maintaining existing team structures and their inherent supervisory and interpersonal support mechanisms.

Abstract WP472: Improving Neurologic Follow-Up After Stroke Utilizing a Nurse Practitioner

Background: Patients who experience acute ischemic stroke are at increased risk for a secondary vascular event. Risk factor management as well as review of the medication regimen are important components to secondary prevention. Neurologic follow-up is an essential step during transitions of care to ensure these components are addressed. For a variety of reasons, stroke patients do not always complete follow up appointments. The literature suggests that such patients are at increased risk for readmission. Purpose: The purpose of this project was to improve access to neurologic follow-up for patients diagnosed with acute ischemic stroke after discharge from an acute care or rehabilitation setting. The secondary goal was to decrease readmission rates. Methods: A nurse practitioner (NP) was added to the inpatient stroke neurology service. The model of care was redesigned with the NP performing subsequent assessments after the initial evaluation was completed by the neurologist. The NP also organized the plan of care, including appropriate post discharge follow-up. Over time, due to challenges with access to appointments, the NP started an outpatient stroke clinic. Data were entered into Get With The Guidelines®-Stroke to identify the patients who had a neurology provider appointment scheduled prior to hospital discharge, regardless of discharge disposition. Results: Between the first quarter of 2018 and the second quarter of 2019, the percentage of patients with a neurologic follow-up appointment scheduled prior to hospital discharge improved from 23% to 61%. During this same time period, the readmission rates decreased from 14% to 9%. Conclusions: Adding the NP position to an inpatient stroke neurology service and using this role to lead an outpatient stroke clinic improves the percentage of patients who have appointments scheduled prior to hospital discharge. Improving access to follow-up care influences readmission rates.

The prevalence and utility of screening for urinary tract infection at the time of presumed multiple sclerosis relapse

BackgroundMethods of screening for infections at the time of suspected relapse in people with multiple sclerosis (MS) vary across physicians. People with multiple sclerosis (MS) are at an increased risk of urinary tract infection (UTI). Data evaluating the utility of screening for potential UTI at the time of suspected relapse and whether there are key subgroups of patients in which screening would be most effective are sparse. ObjectivesTo evaluate demographic and clinical predictors of UTI in the context of a suspected acute relapse in (1) a retrospective hospital admission cohort and (2) a prospectively-enrolled, ambulatory care-based cohort, and to determine an approximate number needed to screen to detect one UTI in both healthcare settings. MethodsFor the hospital admissions cohort, we included individuals with a known or new diagnosis of MS or clinically isolated syndrome who were admitted at least once to the Johns Hopkins Neurology Inpatient Service (March 2012 to December 2014). We considered those screened via urinalysis. Possible UTI was defined as leukocyte esterase OR nitrite positive. For the ambulatory population, we enrolled a cohort of RRMS patients aged 18–65 who were suspected of suffering from an acute MS relapse who either called or came into clinic. Participants were screened via urinalysis; possible UTI was similarly defined. Participants also completed questionnaires (disability, history of Uhthoff's-type phenomenon, recent sexual intercourse, and new urologic symptoms). For both cohorts, we calculated an approximate number needed to screen, and tested if demographic and patient characteristics were associated with possible UTI using logistic regression models. ResultsFor the hospital admissions cohort, we included 158 individuals; 48 (30.4%) were identified as possibly having a UTI. For possible UTI, the approximate number needed to screen in order to detect 1 possible UTI is 3 (95% CI: 2, 6). Female sex was the only factor associated with increased odds of UTI (odds ratio [OR]: 3.90; 95% CI: 1.59–9.61; p = 0.003). For the ambulatory cohort, we included 50 participants; 10 (20.0%) with possible UTI. The approximate number needed to screen in order to detect 1 possible UTI was 5 (95% CI: 3, 11) in this cohort. Foul-smelling urine was positively associated with UTI (OR: 5.36; 95% CI: 1.10, 26.17; p = 0.04); no men had a possible UTI in this cohort, so we could not estimate odds ratios associated with sex. ConclusionUTIs at the time of a suspected MS relapse are relatively uncommon. Female sex is a strong risk factor for UTI in people with MS; foul-smelling urine is a potential predictor of UTI in people with MS. Larger studies are needed to comprehensively evaluate the utility of screening and risk factors for UTI at the time of suspected MS relapse.

The Impact of a Dedicated Emergency Department Neurology Resident on the Inpatient Neurology Service (P2.9-014)

The Impact of a Dedicated Emergency Department Neurology Resident on the Inpatient Neurology Service (P2.9-014)

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

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. 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. 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). 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.