NeuroICU Orientation

Rounds in the NeuroICU are multidisciplinary. Nurses and pharmacists are critical to the team and included in rounding activities, but teamwork also requires RTs, PT/OT/SLPs and more. There is not another unit that heavily relies upon bedside nurses to understand and recognize subtle differences and changes in the neurologic exam that may be critical in patient care. For this reason, the bedside nurses present patients at rounds, describing their known diagnosis, exam, thresholds for Na, blood pressure, I/Os ventilator settings, lines and more. The role of the student and resident is the listen, assimilate this information with that they have already collected and determine their assessment and plan which they will detail after the nurse is done presenting. 

Comatose vs Conscious

General Aspects to Patient Exams

• Always address patient and acknowledge them (they may be able to hear but not respond)

• Assess awareness, orientation if you can

• Avoid yes/no questions to assess language function, comprehension

• Screen for delirium

• Identify barriers to exam including severe headache, meningismus, nausea & vomiting, visual and langauge problems

Coma Exam

• Focused brainstem reflexes

• Work your way down the brainstem

  • Pupillary light reflex -- Corneal reflex -- Gag/cough 

• Then obtain motor exam from less to more stimulation as necessary

  • Dont start with noxious stimulation if they respond to light touch

  • Noxious stimulation (ie sternal rub, cough) can produce motor response (extensor posturing) in severely brain injured patients

• Look for localizing signs of injury vs general dysfunction

  • Purposeful motor response (spontaneous, following, localizing, withdrawal from pain) vs non-purposeful or reflexive motor reponse (flexion, extension or even triple flexion spinal reflex in lower extremities)

Conscious Exam

• More focused on neurologic problem or location/type of injury

  • Examples

    • Dermatomes and individual strength for spinal cord injury

    • LOC, orientation, generalized motor for encephalopathy

    • NIHSS for ischemic stroke patients (may abreviate when demonstrated)

    • Cerebellar tests in patient with tumor or hemorrhage

Additional Tips

Address the patients as if they are your family

Do not enter rooms and start pinching, sternal rubs without assessing LOC

You need to ensure you perform an adequate physical exam for all body systems on your patients!

Below is a helpful algorithm to guide your exam in the NSICU!

Morning signout begins at 630AM 7 days a week, night signout begins at 630PM

This is located in the provider conference room just inside the unit on 8East (H831/829)

Be considerate and do not be late (if you need list plan to print before)

Be prepared, know the patients and exams, reading straight off list is not helpful

Deliver concise but complete one liner. Presume the overnight NP does not know the patient

• Mr. Smith is a 40 yo M w aneurysmal SAH from a right pcom aneurysm that was coiled and is post bleed day 5. 

• Mrs. Johnson is a 54 yo F with acute left MCA stroke from M1 occlusion. She did not receive tPA, but did have thrombectomy. 

Deliver exam with focus on LOC, brainstem (if comatose) and motor

• On exam, Mr Smith would awaken only to verbal stimulation, state his name, month and go back to sleep, otherwise he would follow commands antigravity equally, but not keep them up long.

Deliver important details from the day and plans is suspecting worsening

• Mr. Smith's TCDs have been more and more elevated and today were in the 200s in bilateral MCAs. If he stops waking to voice our plan was give 1L bolus, obtain CTA and start pressors for MAP goal increase by 20.

Some patients are complicated and may need a few summary sentences that if you know your patients you should be able to deliver.

• Mr. Smith is a 40 yo M that suffered an aneurysmal SAH from right pcom aneurysm. This was coiled and initially he was doing well, but developed severe cerebral vasospasm and delayed cerebral ischemia requiring several endovascular treatments. He suffered several left MCA territory strokes and now remains aphasic with dense right hemiplegia on exam. He required tracheostomy and PEG, and was treated for MSSA pneumonia for 7 days. He now has significant AKI and developed DVT so we are waiting for IVC filter placement tomorrow.

• Ms. Johnson is a 68 yo F with encephalopathy after status epilepticus. She initially presented with convulsive status and was treated with lorazepam, levetiracetam load, fosphenytoin load and then burst suppression with propofol. She had 2 seizures after burst suppression, but no more since. She had a workup for new onset seizures, and was found to have normal CSF studies, no severe metabolic or toxic issues and her MRI demonstrating prior right temporal stroke, which was felt to be her etiology of status. She is not on EEG anymore, and has been seizure free for 5 days. Despite no further seizures she has no awoken and on exam has brainstem reflexes intact and withdrawals from pain in all extremities. We are waiting on family to decide about tracheostomy and PEG. 

Giving a complete but concise signout is critical to every field of medicine and you should continually work to improve this skill

Neurosurgery Admissions

The Neurosurgery resident should be notified when new patients arrive and will write H&P on their patients

We should evaluate the patient ourselves and offer to write admission orders

ICH/SAH need to use diagnosis specific evidence based order set found in EPIC

All other diagnoses can use Neuroscience ICU Admission Order set

Critical patients should prompt attending notification immediately for evaluation, stable patients can have orders entered and a plan determined to then detail to the NeuroICU attending

Neurology Admissions

Stroke and General Neurology patients often are admitted through the ED. The Neurology resident should write the H&P and enter initial admission orders

Some patients may be directly admitted to the NeuroICU, these patients will need H&P entered and admission orders

Stroke patients require evidence based admission order sets to be utilized

Stroke patients should have stroke H&P used

All other patients (seizures, encephalopathy, etc) can use Neurocritical Care H&P template and Neuroscience ICU Admission Order set

If you have questions about an admission ask the attending or NP as they are often called regarding admissions and have some information

Transfer Notes

Should be started on the first day the patient is in the ICU with admission information and presenting details and shared until a bed assignment on floor is determined

Providers should update this daily with events that occur

• Day 2 or 3/12/21 - No change in neurologic exam, but TCDs increasing. Started ceftriaxone for empiric UTI coverage after UA.

• Day 16 or 3/13/21 - More somnolent today, but received tracheostomy and PEG w sedation. No seizures and taken off EEG today. Finished cefepime for pneumonia.

Don't leave this undone for your co-resident to have to fill out the weekend they are on call

Transfers out of the Unit

Don't enter transfer orders until you know a patient has been assigned a floor bed 

• Sometimes patients can wait for > 24 hours requiring constant re-updating of all orders

Ensure that notes are done including transfer summary and that you have completed the ADT transfer with medication reconciliation.

Please go through all orders and clean up what is not necessary

• Removal all ICU protocols, electrolyte order sets, prns medications not used, prior nursing communications that are not currently applicable

Neurosurgery patients, you need to let the resident for the team know they are coming out, but they often well and know a detailed plan so you really need to highlight non-surgical or medical plans

• Attending will stay the same as while in unit

Neurology patients, you need to call the resident for stroke or general neurology. On the weekends after mid-morning this is the after hours (AH) resident on simon. You will need to given a concise history, exam and current plan

• Stroke and general neurology attending are new attendings assigned to patient

• Ensure that stroke patients have detailed neurologic exam/NIHSS in the transfer summary

• Please call the neurology resident when a bed is placed so that they can come and see the patient (daytime team)

The daily progress note can be accessed by using 'neurocritical care progress note' in the smart text box in epic notes

Aim to be done with your note before rounds, the plan does not have to be exactly what the attending wants, this is your plan

Please be sure to update the entire note, exams, checklists, plans

Avoid words such as today, tomorrow and yesterday as these are often carried forward and then incorrect

Students are allowed to write notes for clinical and critical care in our unit. Be sure that you are reviewing and editing these notes, not just saying so. After you sign these notes, you are verifying that all of the documentation is correct

• Use appropriate cosign for students

Note Specifics for Stroke Patients (Ischemic stroke, ICH, SAH)

There are tabs within the daily progress note that should be filled out if your patient has one of these diagnoses

This information is for clinical documentation and joint commission review

Ischemic Stroke Documentation

NIHSS on progress notes for at least first 2 days inpatient

Hemorrhagic transformation (HT) when present on CT/MRI needs to be detailed if symptomatic vs asymptomatic (≥4 change in NIHSS)

Hemoglobin A1C and lipids

Aspirin and statin for stroke prevention, and if not why

Intracerebral Hemorrhage Documentation

ICH score on admission (should be done on Neurosurgery H&P)

If coagulpathy present on admission that reversal was given (mostly INR)

Subarachnoid Hemorrhage Documentation

Hunt & Hess score on admission (should be done on Neurosurgery H&P)

Aneurysm location

Post-bleed day