Systematic Reduction of Neuro Checks for Post-stroke Delirium at a Comprehensive Stroke Center
Elizabeth Smolenski1, Charles Palmer1, Emma Wetmore1, Kevin Jacks1, Christina Blake1, Sarah Creed1, Jamie Folsom1, Kimberly Ohlund1, Chirantan Banerjee1, Christine Holmstedt1, Benjamin Kalivas1
1Medical University of South Carolina
Objective:
This pilot study introduces overnight holds on neuro checks in clinically stable stroke patients to reduce rates of delirium and improve patient outcomes.
Background:
Post-stroke delirium is a common complication during acute hospitalization. It is standard to perform neuro checks every 1-4 hours for acute stroke patients to ensure neurologic stability until discharge. Potentially related to overnight neuro checks, patients’ circadian rhythms are fragmented, which has been implicated in the pathogenesis of delirium. Consequently, acute stroke patients affected by delirium are more likely to develop dementia, have longer hospitalizations, and be discharged to assisted care.
Design/Methods:
Patients were assessed at least 24 hours after admission to determine stability per expert clinical judgment. In stable patients, neuro checks were discontinued between 8pm-4am. Patients were reevaluated daily for changes in stability that would alter neuro check frequency. The Confusion Assessment Method (CAM) was performed each shift to determine delirium status. Primary outcome was delirium rate. Secondary outcomes included rates of reimaging, mental status changes requiring restraints or medication or infectious workup, length of stay, and discharge destination.
Results:
Over a period of 12 months, 290 patients were analyzed. 157 were pre-intervention and 133 were post-intervention with no significant difference between each groups’ demographics. The delirium rate (positive on CAM) decreased from 34% to 23% (p=0.017) after introducing the intervention. Hospitalization length shortened form 6.6 days to 5.1 days (p=0.024). There was no significant change to modified Rankin scale (p=0.38) or NIHSS (p=0.97). Evaluation also included cost of care, use of restraints or neuroleptic agents, infection/thrombosis rates, discharge destination, and stroke etiology.
Conclusions:
Clinically stable stroke patients may experience lower rates of delirium and shorter hospital stays without overnight interruptions to sleep in the form of neuro checks. Further study of patient outcomes is required to better characterize the effects and safety of withholding overnight neuro checks.