What are the key management strategies for inpatient neurology?

Key Management Strategies for Inpatient Neurology

The most effective inpatient neurology management requires specialized stroke units with dedicated interdisciplinary teams, standardized protocols for rapid assessment and treatment, and systematic quality improvement programs to optimize patient outcomes and reduce mortality. 1

Specialized Stroke and Neurovascular Care Units

• Dedicated stroke units staffed by experienced interdisciplinary teams significantly reduce morbidity and mortality, with benefits comparable to intravenous rtPA administration 1
• Core elements of comprehensive stroke care include:
  • Specialized care for patients with ischemic stroke, intracerebral hemorrhage, and TIA 1
  • Dedicated stroke team with expertise in neurology, nursing, neurosurgery, physiatry, rehabilitation, and pharmacy 1
  • Clustered model where stroke patients are cared for on the same hospital ward by trained staff 1
  • Access to 24/7 imaging and interventional neuroradiology expertise 1
  • Emergent neurovascular surgery access 1

In-Hospital Stroke Management

• Five core elements to optimize in-hospital stroke care:

  • Deliver stroke training to all hospital staff, including activation protocols 1
  • Create rapid response teams with dedicated stroke training and immediate neurological expertise 1
  • Standardize evaluation with physical assessment and imaging protocols 1
  • Address barriers to treatment, including interfacility transfer when needed 1
  • Establish quality oversight programs with data-driven performance feedback 1

• In-hospital strokes are often procedure-related and occur frequently in cardiovascular services, requiring specialized recognition and management protocols 1

Acute Management Protocols

• Standardized stroke orders or integrated pathways improve adherence to best practices 1
• Frequent neurological assessments and vital sign monitoring during the first 24 hours after admission 1
• Early mobilization to prevent complications like pneumonia, deep vein thrombosis, and pressure sores 1
• Swallowing assessment before oral intake to prevent aspiration, as impaired swallowing increases mortality risk 1

Management of Specific Neurological Emergencies

Intracerebral Hemorrhage (ICH)

• ICH requires immediate diagnosis and management due to high risk of early deterioration 1
• Key emergency department actions include:
  • Rapid neuroimaging (CT or MRI) to identify hemorrhage 1
  • Immediate neurosurgical consultation for potential hematoma evacuation 1
  • Management of intracranial pressure and blood pressure 1
  • Reversal of coagulopathy when present 1

Diffuse Axonal Injury (DAI)

• MRI is indicated when CT results are normal but unexplained neurological findings persist 2
• Management focuses on preventing secondary brain injury as there is no specific treatment for primary axonal damage 2
• Regular multidisciplinary case reviews are recommended for patients with severe DAI 2

Neurological Monitoring for Special Populations

• Patients on extracorporeal membrane oxygenation (ECMO) require specialized neurological monitoring due to high risk of acute brain injury 1
• For patients with perceived devastating brain injury, a shared decision-making approach between clinical staff and family should be adopted 1

Prevention and Management of Complications

• Patients are at high risk for medical complications during hospitalization, requiring proactive management 1
• Early dysphagia screening protocols should be implemented to prevent aspiration pneumonia 1
• Early discharge planning and coordination with rehabilitation services improves transitions of care 1

Quality Improvement and Governance

• Identify a lead clinician responsible for management of neurological patients within each hospital 1
• Conduct prospective audits of neurological patients and regularly review cases in multidisciplinary meetings 1
• Monitor quality metrics including response times, imaging acquisition times, treatment rates, and outcomes 1
• Develop clear communication and referral pathways with regional neuroscience centers 1

Common Pitfalls to Avoid

• Delayed recognition of in-hospital strokes despite being in a monitored environment 1
• Inadequate stroke training for hospital staff leading to missed or delayed diagnoses 1
• Lack of standardized protocols for neurological emergencies 1
• Insufficient communication between departments during patient transitions 1
• Failure to establish clear time goals for imaging completion and result reporting 1