The Neurohospitalist

Notably absent from current practice guidelines for common neurologic diseases as stroke and seizure is the revised Centers for Disease Control (CDC) recommendation for human immunodeficiency virus (HIV) testing of all clinical encounters. During a 9-month period 2 patients with treatable stroke mimics related to HIV type 1 infection were misdiagnosed resulting in delay in beginning antiretroviral therapy and increased cost and morbidity. This study was conducted to determine the frequency of HIV-1 screening in our stroke center population and consider the implications of such testing on neurologic disease. We surveyed our stroke center database to determine the frequency of HIV screening in ischemic strokes from January 2005 through May 2011. Of 2806 ischemic strokes, 27 (0.96%) patients were HIV-tested during the 6.5-year study period. We suggest that incorporating the CDC recommendations for HIV screening into neurology practice guidelines can impact diagnosis and treatment of unsuspected HIV-related neurologic disease with reduction in cost of care and morbidity.

Delirium is an acute change in awareness and attention and is common, morbid, and costly for patients and health care systems. While hyperactive delirium is easily identifiable, the hypoactive form is more common and carries a higher mortality. Hospital systems to address delirium should consist of 3 critical steps. First, hospitals must identify patients who develop or are at intermediate or high risk for delirium. Delirium risk may be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment. Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria. Hospital systems may be useful to efficiently allocate delirium resources to prevent and manage delirium. Second, it is crucial to develop a systematic approach to prevent delirium using multimodal nonpharmacologic delirium prevention methods and to monitor all high-risk patients for its occurrence. Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium. Third, hospital systems can utilize established methods to assess and manage delirium in a standardized fashion. The key lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications. With a sustained commitment, standardized efforts to identify and prevent delirium can mitigate the long-term morbidity associated with this acute change. In the face of changes in health care funding, delirium serves as an example of a syndrome where care coordination can improve short-term and long-term costs.

In this 2 part series, analysis of the risk stratification tools that are available and definition of the scope of the problem and potential solutions through a review of the literature is presented. A systematic review was used to identify articles for risk stratification and interventions. Three risk stratification systems are discussed, STRATIFY, Morse Fall Scale, and the Hendrich Fall Risk Model (HFRM). Of these scoring systems, the HFRM is the easiest to use and score. Predominantly, multifactorial interventions are used to prevent patient falls. Education and rehabilitation are common themes in studies with statistically significant results. The second article presents a guide to implementing a quality improvement project around hospital falls. A 10-step approach to Plan-Do-Study-Act (PDSA) cycles is described. Specific examples of problems and analysis are easily applicable to any institution. Furthermore, the sustainability of interventions and targeting new areas for improvement are discussed. Although specific to falls in the hospitalized patient, the goal is to present a stepwise approach that is broadly applicable to other areas requiring quality improvement.

Neurological diseases are prevalent in the general population, and the neurohospitalist has an important role to play in the preoperative planning for patients with and at risk for developing neurological disease. The neurohospitalist can provide patients and their families as well as anesthesiologists, surgeons, hospitalists, and other providers guidance in particular to the patient’s neurological disease and those he or she is at risk for. Here we present considerations and guidance for the neurohospitalist providing preoperative consultation for the neurological patient with or at risk of disturbances of consciousness, cerebrovascular and carotid disease, epilepsy, neuromuscular disease, and Parkinson disease.