A couple months ago we did a column on adverse events in neurological inpatients (see our August 2017 What's New in the Patient Safety World column “”), noting that there has been a relative paucity of studies on patient safety issues in neurological patients.
In that column we noted neurological conditions that require hospitalization have a number of features that predispose to a variety of potential adverse events. For example, many are associated with neurogenic bladder dysfunction that may be a factor in high rates of catheter-associated urinary tract infections (CAUTI’s). Many of the conditions are associated with reduced mobility, increasing the risk for pressure ulcers and DVT and venous thromboembolism. Some (eg. stroke, Parkinson’s) may be associated with disordered swallowing that predisposes to aspiration and pneumonia. Impairment of balance and/or righting reflexes may lead to falls. Those neurological conditions that impair cognition may also predispose to delirium when other medical insults occur. And several neurological conditions may be associated with obstructive sleep apnea, which may increase the risk of respiratory depression in relation to opioids or other drugs that depress respiration. So we would expect neurological inpatients would have relatively high rates of adverse events while hospitalized.
Now the American Academy of Neurology (AAN) has established a set of quality measures for inpatient and emergency care for neurological patients (Josephson 2017).
The AAN inpatient and emergency care quality measurement set “focuses on brain death, urinary catheters, delirium, Guillain-Barré syndrome (GBS), myasthenic crisis, status epilepticus, bacterial meningitis, advanced directives, and goals of care.” We are happy to see a few of our favorite topics appearing in the new measurement set (reduction of urinary catheters used in neurologic patients, delirium risk factor screening and preventive protocol, nonpharmacologic treatment of delirum). And we’re also happy to see the braindeath documentation measure and immunosuppressive treatment of Guillain-Barre Syndrome measure (since we co-authored New York State’s original guideline on braindeath determination and co-authored a text on Guillain-Barre Syndrome). Rounding out the quality measures are several measures regarding status epilepticus, EEG, coma, bacterial meningitis, discussion and documentation of advanced directives, and discussion and documentation of goals of care.
The accompanying editorial (Vespa 2017) explains how the quality measures were selected and the challenges encountered. It notes that they were selected not only for demonstrating how often appropriate care is delivered but also for highlighting areas in which opportunities to improve care are present. For example, they note that documentation of braindeath determination is known to be suboptimal so it was selected as a measure.
It should be noted that many other quality measures involving neurological inpatients are captured in other data sets (eg. measures regarding falls, pressure ulcers, and DVT prophylaxis are captured in multiple data sets and quality measures for stroke care are also found in several data sets).
Josephson SA, Ferro J, Cohen A, et al. Quality improvement in neurology: Inpatient and emergency care quality measure set: Executive summary. Neurology 2017; 89: 730-735; published ahead of print July 21, 2017
Vespa PM, Ferro J, Josephson SA. Inpatient quality metrics in neurology: A grand challenge. Neurology 2017; 89: 646-649; published ahead of print July 21, 2017