J. Spencer Dingman, PharmD, BCCCP
Neurocritical Care Pharmacy Specialist
Wesley Medical Center, Wichita, KS
Brian W. Gilbert, PharmD, BCCCP, BCPS
Emergency Medicine Pharmacy Specialist
Wesley Medical Center, Wichita, KS Brian.firstname.lastname@example.org
Time-to-intervention has become well-recognized as an important quality measure in numerous areas of medicine, including acute coronary syndromes, sepsis, trauma, and acute ischemic stroke. An increased demand for hospital beds during the COVID-19 pandemic has brought many hospitals to maximum occupancy, bringing to attention the issue of prolonged boarding in the emergency department (ED) as a potential barrier to optimized care. Delayed transfer to neurology intensive care units (ICUs) has been associated with worse outcomes in ischemic and hemorrhagic stroke patients, but there remain fewer data examining the impact of ED boarding on a broader neurocritically ill patient population. Multidisciplinary teams of specialized staff trained in neurocritical care provide more optimal care and have demonstrated improved patient outcomes, including reduced rates of infection and mortality, as well as increased rates of favorable discharge disposition. It is reasonable to assume that some of the most impactful care is provided in the acute phase of treatment in the ED. Here we aim to highlight under-recognized obstacles to high-quality care for these patients and to propose suggestions for improving care for specific populations.
Changes in Neurological Exam
In patients with ischemic and hemorrhagic stroke, the importance of acute changes in neurological exam should be emphasized as a possible indicator of worsening stroke, early hemorrhagic conversion, hydrocephalus, or increased intracranial pressure. In these cases, early recognition may be the trigger for interrupting thrombolytic therapy, initiating hyperosmolar treatment, or proceeding to emergent surgical intervention. Nursing education on the proper performance of the NIH Stroke Scale score in the ED is crucial, especially for patients who are intubated or in other circumstances in which assessment becomes more difficult or changes are subtle.
Assessment and Management of Elevated Intracranial Pressure
For patients with acute stroke or brain injury, awareness of the risk for elevated intracranial pressure (ICP) is essential for ED providers. Any patient with concern for acutely elevated ICP should have their head of bed elevated as tolerated, and attention should be paid to the position of cervical spine collars to avoid impinging venous outflow. Timely placement of ICP monitoring devices in appropriate patients can facilitate the administration of life-saving hyperosmolar therapy in the ED, although staff must be trained in the safe use of both the devices and the medications. When ICP monitoring is not available for patients at risk for elevated ICP, empiric treatment should be considered based on neurological exam, imaging, and an assessment of risks and benefits. Given the time-sensitive nature of treating an ICP crisis, urgent orders for hypertonic saline or mannitol should be expedited, with careful attention paid to the rate of infusion and type of intravenous access available. As most patients in the ED will lack central venous access, rescue administration of highly concentrated products (e.g., 23.4% sodium chloride) may be considered contraindicated, though a growing body of literature supports the peripheral administration of 3% sodium chloride and mannitol through medium- and large-bore intravenous sites.
Early Recognition of Seizure Activity
In patients admitted with seizures or at high risk for the development of seizures, early recognition of seizure activity in the ED is critical. While electroencephalography capabilities will be limited in many EDs, consideration for nonconvulsive seizure activity as an explanation for altered mental status in a postictal or otherwise encephalopathic patient may prompt faster reevaluation and treatment. Emphasizing the importance of airway protection may also identify respiratory failure in a deteriorating patient and allow for timely intubation when needed.
Blood Pressure Management
Timely blood pressure control is foundational to the acute treatment of many neurological emergencies, including intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury. Its importance should therefore be emphasized among ED providers, with a focus on appropriate medication selection based on individual patient-level factors, titration according to national and institutional guidelines, and close monitoring for safety events, especially considering the dynamic nature of patients with neurocritical illness.
Targeted Temperature Management
In patients undergoing targeted temperature management (TTM) after cardiac arrest, achieving temperature control can be difficult in the ED, especially with more aggressive targets of 32-34 degrees Celsius used in some centers. Some therapies described in the NCS guideline for implementation of TTM may translate easily to the ED (e.g., chilled saline, cooling blankets and fans), while others may require special education or training (e.g., use of advanced non-invasive systems such as Arctic Sun™, intravascular cooling systems, and pharmacotherapies intended to reduce shivering). Neurocritical Care ICU nurses and pharmacists may be useful resources for assisting with device setup or providing education on the purpose and safe use of these medications when a delay in ICU transfer is anticipated. Additionally, providing ED staff with access to advanced training such as Emergency Neurological Life Support (ENLS) certification may bolster the quality of care provided to neurocritical care patients in the ED.
Management of Sedation in Mechanically Ventilated Patients
The ability to rapidly assess a patient’s neurological exam is vital in patients with neurocritical sequelae. However, rapidly deteriorating patients frequently require intubation and subsequent sedation. It is of utmost importance that ED personnel be cognizant of appropriate sedation strategies as they pertain to neurocritically ill patients. In many instances it is advantageous to select analgesic or sedative agents that allow for frequent interruption to obtain serial neurological exams: medications such as propofol, ketamine, and fentanyl offer predictably rapid onset and offset with minimal accumulation over short durations. Dexmedetomidine, which confers a light depth of sedation and fairly short duration of effect, does not offer the same pharmacodynamic profile as sedatives such as propofol or benzodiazepines, and therefore may not be the agent of choice in patients requiring a decrease in cerebral metabolic demand or ICP reduction. Lastly, agents with more prolonged half-lives, such as benzodiazepines, should be utilized only after direct consultation with the neurocritical care team to ensure that deep levels of sedation are warranted and more frequent neurological exams will not be needed while boarding in the ED.
Other ED Considerations
- Among patients with neurocritical illness, minimization of stimulation may be indicated but made more difficult in the fast-moving environment of the ED. Such patients should ideally be admitted to private rooms with doors rather than semi-private rooms with curtains and placed in quieter areas of the department, while visitation should be limited as necessary.
- Nurses caring for patients with suspected CNS infections should clarify the intended timing of antibiotic and steroid administration in relation to plans for lumbar puncture to avoid unnecessary delays. Adapting hospital policy to allow for intravenous push administration of antibiotics such as beta-lactams can reduce time to administration and overcome compatibility issues with the limited intravenous access present in many ED patients. Finally, if an ED typically utilizes one-time rather than standing medication orders, doses can be missed or delayed if a patient is held for a prolonged time before ICU transfer.
- Incorporation of ED pharmacists with neurocritical care training may help with prevention of medication errors, appropriate medication reconciliation, and facilitating time-sensitive therapies. Additionally, a multidisciplinary evaluation of existing institutional practices to reduce operational barriers to pharmacotherapy can be helpful. Emerging data support the safety of minimally diluted intravenous push administration of antibiotics and anti-epileptic medications, and adding time-sensitive medications to the inventory of automated dispensing cabinets can reduce the delay between order and administration.
Our Local Experience
Locally, our institution has felt the impact of increased hospital census and has made use of a variety of personnel and practice changes to accommodate this demand. Operationally, the introduction of push-dose antibiotics and antiepileptic medications has reduced hands-on nursing time requirements and made more infusion pumps available for other medications or other patients. ED stroke alert response has been spearheaded by neurocritical care advanced practice providers, as well as remote teleneurologists evaluating patients via real-time video services. Nurse educators have played a critical role in developing new staff or cross-training resource ICU nurses to provide care in the ED when critical patients require it.
Prolonged boarding has also introduced the opportunity to reassess disposition after a patient’s initial hours in the ED and to determine if a different level of care may now be more appropriate (potentially reserving an ICU bed for another patient or allowing for more optimal staffing ratios). Multidisciplinary collaboration across departments and an open mind to new practice models has yielded improved results for our clinicians and our patients at a time they need it most. Lastly, prior to the COVID-19 pandemic, ENLS courses were offered biannually to staff within our institution. Numerous ED personnel, including physicians, pharmacists, and nursing, have all become ENLS-certified, improving the overall care provided to the neurocritically ill patients even during times of extreme boarding.
From left-to-right: Christopher Cassidy, J. Spencer Dingman, Sean Di Paola, and Brian Gilbert
In summary, delivering optimized patient care while a patient awaits transfer to the neurocritical care unit can be difficult. Multidisciplinary efforts and coordinated education can help to prioritize and navigate the variety of challenges encountered during prolonged emergency department stays. While a general consensus exists that prolonged boarding puts patients at risk for worse outcomes, more data are needed to evaluate the true impact this has amongst neurocritically ill patients. Once barriers are identified, institutions can take appropriate process-oriented steps to optimize care for boarding neurocritical care patients.
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