GLOSSARY
- AAN=
- American Academy of Neurology;
- CAUTI=
- catheter-associated urinary tract infection;
- GBS=
- Guillain-Barré syndrome;
- NCS=
- Neurocritical Care Society;
- NHS=
- Neurohospitalist Society
The emergence of inpatient neurologic specialists including neurohospitalists and neurointensivists has led to an increased focus on the quality of neurologic care delivered in the hospital. Each year, there are over 1.5 million nonsurgical neurologic hospital discharges in the United States, making neurology a large inpatient specialty even without accounting for nonadmitted emergency patients.1 National quality metrics in other non-neurologic specialties have focused primarily on inpatient care since hospitals, insurers, professional organizations, and the general public have turned their attention to outcomes achieved during and following hospitalization. Many of these metrics have been applied to neurology patients, despite their not being developed with neurology-specific patient populations or disorders in mind. This gap highlights the need for measures for neurology patients in both inpatient and emergency settings.
In 2015, the American Academy of Neurology (AAN), Neurocritical Care Society (NCS), and Neurohospitalist Society (NHS) formed an Inpatient and Emergency Neurology Work Group to review existing guidelines, current evidence, and gaps in care in order to develop a measurement set for inpatient and emergency neurology. The goal of this effort was to develop a quality measurement set, which should not be confused for a clinical practice guideline. This article is a result of a formal process that was conducted according to standards and methods created by the AAN. The same methodology has been used to develop many other quality measures that focus on other conditions and diseases within neurology. This quality measurement set aims to promote quality improvement and drive better outcomes for neurologically ill patients in inpatient and emergency settings while providing a roadmap for improving care at national, regional, and local levels.
The AAN, NCS, and NHS developed this quality measure set based on the belief that specialists should play a major role in selecting and creating measures that will drive performance improvement and possibly be used in accountability programs. The AAN, NCS, and NHS formed the Work Group with representatives from professional associations and patient advocacy organizations to ensure the developed measures represented the diverse experience, views, and skills of broad and multidisciplinary health care teams.
No single quality measure set is able to capture all the aspects of treatment needed for the diverse patients in these settings. This quality measure set is focused on measuring the quality of care provided for a variety of conditions and diseases and does not address the whole scope of each disorder, nor all of inpatient or emergency neurology. In this executive summary, we report on the quality measure set developed by the Work Group. The full quality measure set, including specifications, is available in appendix e-1 at Neurology.org.
OPPORTUNITIES FOR IMPROVEMENT
Inpatient and emergency neurology focuses on diseases that span the neurologic spectrum. Patients with these disorders are treated by both neurologists and non-neurologists. Opportunities for quality improvement were identified for a variety of these conditions based on a review of the literature that revealed both gaps in care and areas where quality measures might be used to drive improvement. This 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.
Despite the development of evidence-based guidelines for the determination of brain death by neurologic criteria (e.g., brain death), significant variability in the practice has been identified.2 A review of more than 30 major institutions' guidelines on brain death showed there was inconsistency in nearly every aspect of brain death declaration, identifying a clear opportunity for quality improvement.3
Delirium is extremely common in hospitalized patients, especially in those with preexisting neurologic conditions including cognitive impairment as well as in those with advanced age. Delirium has been associated with poor outcomes, including increased length of hospital stay, greater incidence of hospital-acquired conditions, and death, while increasing average daily costs substantially.4
Patients with GBS and patients with myasthenia gravis in crisis are frequently admitted to the hospital. These neuromuscular emergencies may be difficult to recognize, especially by non-neurologists, but they require prompt recognition and treatment in order to prevent prolonged neurologic disability.5,–,7
Status epilepticus is a neurologic emergency that affects between 50,000 and 150,000 patients annually in the United States and requires rapid treatment.8,–,10 The estimated mortality is up to 30% in adults, and rapid termination of both clinical and electrical seizure activity reduces both mortality and morbidity associated with this condition.8,9,11,12
The administration of dexamethasone prior to or concurrent with the first dose of antimicrobials is now widely accepted as standard practice in the management of acute bacterial meningitis in the industrialized world and can reduce morbidity and mortality by mitigating the brisk inflammatory reaction that can result in the meninges.13,–,16 Neurologists and non-neurologists in inpatient and emergency settings need to be aware of appropriate empiric treatment algorithms while lumbar puncture results, including cultures, are pending.
Catheter-associated urinary tract infection (CAUTI) is regarded as one of the most common health care–associated infections and a variety of efforts have been initiated nationally to reduce their frequency. Overuse of indwelling urinary tract catheters is particularly common in hospitalized neurologic patients with stroke or dementia, increasing CAUTI rates in these conditions.17,18
Patients admitted to the hospital for neurologic emergencies have a high risk of mortality and often face important choices regarding life-sustaining therapies. However, it is estimated that only about 1 in 5 seriously ill patients have documented advanced directives; increasing the use of these advanced directives and documentation of discussions regarding goals of care with patients and families could improve patient satisfaction and outcomes while assuring our patients' wishes are respected at the end of life.19
METHODS
The AAN, NHS, and NCS formed a cross-specialty and multidisciplinary expert work group of diverse key stakeholders from physician and nonphysician associations, patient and caregiver advocacy organizations, and payers. Details of the full measure development process are available online (Quality and Safety Subcommittee, American Academy of Neurology Quality Measurement Manual 2014 Update, January 2015; available at: aan.com/uploadedFiles/Website_Library_Assets/Documents/3.Practice_Management/2.Quality_Improvement/1.Quality_Measures/2.About_Quality_Measures/2015%2002%2011%20Process%20Manual%20Final.pdf). The formation of the work group began with a nomination process from each organization, which led to a 23-member final work group, which is listed at the conclusion of the article.
All work group members were required to disclose potential conflicts of interest and completed applications summarizing their experiences and interests. The co-chairs and facilitators independently selected members from the pool of qualified specialists and expert nominees. The selection was based on the nominee's clinical activities and experience with performance measures and quality improvement.
The measure development process included the following: (1) performing an evidence-based literature search; (2) drafting candidate measures and technical specifications; (3) establishing a multidisciplinary work group adhering to the AAN conflict of interest policy; (4) convening the work group in person to review candidate measures; (5) refining and discussing the candidate measures; (6) soliciting public comments on approved measures during a 30-day period; (7) refining the final measures according to input received during the public comment period and corresponding technical specifications; and (8) obtaining approvals from the work group, AAN Quality and Safety Subcommittee, AAN Practice Committee, AAN Institute Board of Directors, NHS Board of Directors, and NCS Board of Directors.
The work group sought to develop evidence-based measures to support the delivery of high-quality care and to improve patient outcomes. The co-chairs and facilitators, guided by a medical librarian, conducted a comprehensive literature search identifying 1,595 abstracts relevant to the potential measures. This search included 16 guideline documents representing a core feature of the evidence base for the measures developed.
Prior to the work group meeting, the leadership group put forth a set of candidate measures for work group review and discussion. The work group met on August 28, 2014, developing and approving 12 candidate measures. Following the development of draft measure concepts during the in-person meeting, a public comment period resulted in 115 comments from 16 individuals. Following a review of these public comments, which were incorporated into the measurement set, the work group ultimately approved 12 revised measures for inclusion in the AAN 2016 Inpatient and Emergency Neurology Quality Measurement Set.
The AAN, NHS, and NCS plan to provide resources to update these measures every 3 years. Thus, this measure set aims to provide a working framework for measurement and refinement, rather than a long-term mandate.
RESULTS: INPATIENT AND EMERGENCY NEUROLOGY QUALITY MEASUREMENT SET
Potential gaps in care quality span all neurologic conditions that bring patients to inpatient and emergency hospital settings. This measure set aims to address some of these gaps, particularly where clinical evidence exists to support measure development. The measures were not intended to address all such conditions or all complications of neurologic disease. Instead, they were chosen and developed to affect large, broad neurologic populations, cutting across many neurologic conditions. If broadly adopted, some of these measures would also affect non-neurologic patients (table).
2016 Inpatient and emergency care measurement set
Brain death determination remains an important and common task in the neurologist's domain. Adhering to published guidelines may lead to improved communication with families, reduced hospital costs, and increased rates of successful organ donation. Apnea testing should be performed in all patients when possible and documented clearly per established guidelines to assure hospitals and the public that this important determination is being performed carefully and with great accuracy. When apnea testing is not possible or there are potential confounders, appropriate ancillary testing should be utilized and documented.
In the last decade, delirium has been increasingly recognized as an important complication in hospitalized patients, disproportionately affecting patients with primary neurologic diagnoses and those of advanced age. Patients at risk for delirium can be identified through a host of validated bedside instruments and standardized clinical assessments; prevention efforts can then be initiated to reduce the rate of hospital-acquired delirium in these high-risk patients. Once delirium is newly identified in the hospital, evidence-based management includes multicomponent and multidisciplinary efforts in which nonpharmacologic interventions should typically occur before medications such as antipsychotics are initiated.
Neuromuscular emergencies, such as GBS or myasthenic crisis, can be challenging diagnostically, and definitive immunosuppression therapy can therefore be delayed. The panel recognized that there is strong evidence for the usage of plasmapheresis or IV immunoglobulin in these conditions and that their timely initiation can reduce the duration of acute hospitalization and may avoid the need for mechanical ventilation. These therapies should be available in hospitals that serve this patient population, and if not available, patients should be transferred to hospitals with these capabilities.
Rapid identification and treatment of status epilepticus improves patient outcomes. The panel identified this as an important metric, but many uncertainties were identified, including the optimum treatment strategy, timing of EEG, treatment of nonconvulsive seizures, and differences in treatment approach based on patient age. These uncertainties reflect the lack of robust data that define best current practice. Nonetheless, the treatment of convulsive status epilepticus in the adult patient appears to have strong evidence, and the panel endorsed the rapid identification and treatment of this disorder. This metric is likely to become refined and more specific as future studies clarify the optimal timing of testing and treatment.
Although neurologists do not always provide primary or initial management for adults with acute bacterial meningitis, some encounter such patients in the emergency and inpatient settings and therefore proper rapid acute treatment should be recognized. This treatment not only includes antibacterials but also the prompt administration of corticosteroids before or with the first dose of antibiotics whenever the diagnosis is suspected. Early administration of corticosteroids reduces morbidity, and possibly mortality, with certain forms of bacterial meningitis.
Urinary tract infection is one of the most common health care–associated infections, often occurring after the placement of an indwelling catheter. Between 21% and 56% of such catheters are placed without a clear medical indication.20 Nearly half a million CAUTIs occur annually, at a cost of about $1,000 per admission.21 As a result of an apparent excess of iatrogenic CAUTIs, Medicare no longer reimburses hospitals for hospital-acquired CAUTI-associated costs. Nevertheless, this policy change resulted only in a small decrease (1%) in CAUTI rates.22 Increasing efforts have focused on CAUTI rate reduction in neurology patients primarily through reducing catheter use in this population during the hospitalization.23,–,25 Neurologists can work with hospitals to develop protocols for rational catheter use in those patients with neurologic illness with the hopes of reducing CAUTI rates.
Inpatient and emergency neurologic patient populations are increasingly complex and have a high severity of illness, increasing their mortality risk and that of long-term disability. Many such populations harbor conditions for which prospective planning, in the form of an advanced directive and a health care proxy, could help avoid futile care and unnecessary suffering. Such conditions include malignant brain tumors and end-stage neurodegenerative disorders, but also span a wide range of conditions that affect the nervous system. While prehospital discussions of prognosis, quality of life, long-term needs, and goals of care are critical to the quality of care in these patients, many patients have not had such discussions and can take the opportunity to do so during the hospitalization. An early hospital-based discussion may also be necessary to define the goals of care for the current hospitalization, especially for critically ill patients in the intensive care unit setting.
DISCUSSION
Increased scrutiny on quality and safety in hospitals nationwide has led to the development of multiple metrics for inpatients across a variety of specialties. While some attention to readmission rates and nosocomial infections naturally involves patients with neurologic illness, few quality metrics exist specifically for disorders of the nervous system.25,26 Rather than allow insurers or non-neurologists to define quality across neurologic conditions, this effort aimed to garner neurologic expertise by defining measures that were supported by evidence and were relevant to the practicing neurologist. This new quality measure set is based on a rigorous and careful process. It is important to reiterate that these quality measures are not clinical practice guidelines. Many important unanswered questions exist surrounding best practices, which require further research. However, it is incumbent upon neurologists to set forth a practical and clear quality measure set in the current era. Continued evolution of these metrics, as well as the addition of new metrics, is expected as further evidence emerges.
Implementation of quality metrics remains a difficult task across medicine. Many of the metrics defined here require a multidisciplinary approach, with some of these elements not being completely controlled by the practicing neurologist (e.g., out-of-hospital advanced directive discussions) or involving conditions where a neurologist may not always be consulted (e.g., meningitis, delirium). As a result, neurologists' involvement in the implementation of these metrics will be institution-specific. For example, at a local level, a neurologist may assist in the development of pathways or guidelines in concert with a team of physicians, nurses, pharmacists, allied health professionals, and hospital staff. It is essential for neurology as a specialty to take the lead in these initiatives rather than allow quality in neurologic care to be defined by others less interested or knowledgeable in the care of neurologic patients.
Measurement of many of these metrics will be difficult for a single practicing neurologist to accomplish. Health care systems will need to invest in resources for data acquisition and management in order for neurologists to be able to quantify their adherence rates. This type of investment will not be trivial but will allow individual hospitals and health systems to demonstrate excellence in emergency and inpatient neurologic care to providers and the public at large, who increasingly have choices where to seek care even in emergent situations.
While the era of quality measures in neurologic care remains in its infancy, this partnership among the AAN, NCS, and NHS serves as an example of the type of collaborative effort required to advance the field. We look forward to continued refinement and discussion of these quality metrics as they are implemented.
AUTHOR CONTRIBUTIONS
Dr. Cohen contributed to study concept and design, acquisition of data, analysis or interpretation of data, drafting/revising the manuscript, critical revision of the manuscript for important intellectual content, and study supervision. Dr. Ferro contributed to study concept and design, acquisition of data, analysis or interpretation of data, drafting/revising the manuscript, critical revision of the manuscript for important intellectual content, and study supervision. Dr. Josephson contributed to study concept and design, acquisition of data, analysis or interpretation of data, drafting/revising the manuscript, critical revision of the manuscript for important intellectual content, and study supervision. E. Lee contributed to study concept and design, acquisition of data, analysis or interpretation of data, drafting/revising the manuscript, critical revision of the manuscript for important intellectual content, and study supervision. Dr. Vespa contributed to study concept and design, acquisition of data, analysis or interpretation of data, drafting/revising the manuscript, critical revision of the manuscript for important intellectual content, and study supervision. Dr. Webb contributed to study concept and design, acquisition of data, analysis or interpretation of data, drafting/revising the manuscript, critical revision of the manuscript for important intellectual content, and study supervision.
STUDY FUNDING
No targeted funding reported.
DISCLOSURE
S. Josephson receives personal compensation as Editor-in-Chief of JAMA Neurology and in an editorial capacity for Continuum. J. Ferro and A. Cohen report no disclosures relevant to the manuscript. A. Webb has received compensation for consulting and speaking activities from Bard Medical. E. Lee is an employee of the American Academy of Neurology. P. Vespa reports research funding from NINDS, DOD, and State of California; industry research funding from SAGE and EDGE; speaker for Zoll, Intouch Health and SAGE; and stock equity for Intouch Health. Go to Neurology.org for full disclosures.
ACKNOWLEDGMENT
The authors thank the Inpatient and Emergency Neurology Quality Measurement Set Work Group members for their dedication, time, energy, contributions, and work that supported the development of this manuscript: John Ferro, MD, MS, FAAN (co-chair) (American Academy of Neurology); S. Andrew Josephson, MD, FAAN (co-chair) (Neurohospitalist Society); Paul Vespa, MD, FAAN (co-chair) (Neurocritical Care Society); Rohit Das, MD, MPH (American Academy of Neurology); David Gloss, MD (American Academy of Neurology); David Jones, MD (American Academy of Neurology); William Mack, MD, MS, FAANS, FAHA (American Association of Neurological Surgeons; Congress of Neurological Surgeons); Virginia Prendergast, PhD, NP-C (American Association of Neuroscience Nurses); Chip Truwit, MD (American College of Radiology/American Society of Neuroradiology); Paul Van Ness, MD (American Epilepsy Society); Michael Perskin, MD (American Geriatrics Society); Sanjeev Sockalingam, MD, FRCPC (American Psychiatric Association); Charlotte Jones, MD, PhD, MSPH (Child Neurology Society); Kevin Sheth, MD, FAAN, FNCS, FAHA (Neurocritical Care Society); Navaz Karanjia, MD (Neurocritical Care Society); Salvador Cruz-Flores, MD, MPH, FAAN (Neurocritical Care Society); Corey Fehnel, MD, MPH (Neurocritical Care Society); John Probasco, MD (Neurohospitalist Society); Mark Rubin, MD (Neurohospitalist Society); Jennifer Simpson, MD (Neurohospitalist Society); Jana Wold, MD (Neurohospitalist Society); Adam Cohen, MD (American Academy of Neurology facilitator); Adam Webb, MD (American Academy of Neurology facilitator); Amy Bennett, JD (American Academy of Neurology staff); Gina Gjorvad (American Academy of Neurology staff); Erin Lee (American Academy of Neurology staff); Becky Schierman, MPH (American Academy of Neurology staff).
Footnotes
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Approved by the AAN Quality and Safety Subcommittee on August 29, 2016; by the AAN Practice Committee on September 16, 2016; by the Neurohospitalist Society Board of Directors on September 30, 2016; by the Neurocritical Care Society Board of Directors on October 26, 2016; and by the AAN Board of Directors on November 3, 2016.
Supplemental data at Neurology.org
Editorial, page 646
- Received November 21, 2016.
- Accepted in final form April 10, 2017.
- © 2017 American Academy of Neurology
REFERENCES
Disputes & Debates: Rapid online correspondence
REQUIREMENTS
If you are uploading a letter concerning an article:
You must have updated your disclosures within six months: http://submit.neurology.org
Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment.
If you are responding to a comment that was written about an article you originally authored:
You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid
and apply to letter.
Submission specifications:
- Submissions must be < 200 words with < 5 references. Reference 1 must be the article on which you are commenting.
- Submissions should not have more than 5 authors. (Exception: original author replies can include all original authors of the article)
- Submit only on articles published within 6 months of issue date.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- Submitted comments are subject to editing and editor review prior to posting.