Publications by authors named "Molly McNett"

72 Publications

Nurses Do Not Need an Order to Assess the Patient.

J Neurosci Nurs 2021 Jun 10. Epub 2021 Jun 10.

Questions or comments about this article may be directed to DaiWai M. Olson, PhD RN CCRN FNCS, at D.M.O. is a Professor, Department of Neurology, UT Southwestern Medical Center, Dallas, TX. Molly M. McNett.

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http://dx.doi.org/10.1097/JNN.0000000000000597DOI Listing
June 2021

Use of Continuous Glucose Monitor in Critically Ill COVID-19 Patients Requiring Insulin Infusion: An Observational Study.

J Clin Endocrinol Metab 2021 Jun 8. Epub 2021 Jun 8.

Division of Endocrinology, Diabetes and Metabolism, The Ohio State University Medical Center.

Context: The coronavirus disease 2019 (COVID-19) pandemic has created a need for remote blood glucose (BG) monitoring in the intensive care unit (ICU).

Objective: To evaluate feasibility and patient safety of a hybrid monitoring strategy of point of care (POC) BG plus continuous glucose monitor (CGM) in the ICU.

Design: Retrospective analysis.

Setting: ICU of an academic medical center.

Patients: Patients with COVID-19 on intravenous (IV) insulin.

Intervention: After meeting initial validation criteria, CGM was used for IV insulin titration and POC BG was performed every 6 hours or as needed.

Main Outcome Measures: Outcomes included frequency of POC BG, workflow, safety, and accuracy measures.

Results: The study included 19 patients, 18 with CGM data, mean age 58 years, 89% on mechanical ventilation, 37% on vasopressors, and 42% on dialysis. The median time to CGM validation was 137 minutes (interquartile range [IQR] 114-206). During IV insulin, the median number of POC values was 7 (IQR 6-16) on day 1, and declined slightly thereafter ( 71% reduction compared to standard of 24 /day). The median number of CGM values used nonadjunctively to titrate IV insulin was 11.5 (IQR 0, 15) on day 1 and increased thereafter. Time in range 70-180mg/dl was 64+/-23% on day 1 and 72+/-16% on day 2-7 while time <70 mg/dl was 1.5 +/-4.1% on day 1 and <1% on days 2-7.

Conclusions: This study provides data to support that CGM using a hybrid protocol is feasible, accurate, safe, and has potential to reduce nursing and staff workload.
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http://dx.doi.org/10.1210/clinem/dgab409DOI Listing
June 2021

Global Incidence of Neurological Manifestations Among Patients Hospitalized With COVID-19-A Report for the GCS-NeuroCOVID Consortium and the ENERGY Consortium.

JAMA Netw Open 2021 05 3;4(5):e2112131. Epub 2021 May 3.

College of Nursing, The Ohio State University, Columbus.

Importance: The COVID-19 pandemic continues to affect millions of people globally, with increasing reports of neurological manifestations but limited data on their incidence and associations with outcome.

Objective: To determine the neurological phenotypes, incidence, and outcomes among adults hospitalized with COVID-19.

Design, Setting, And Participants: This cohort study included patients with clinically diagnosed or laboratory-confirmed COVID-19 at 28 centers, representing 13 countries and 4 continents. The study was performed by the Global Consortium Study of Neurologic Dysfunction in COVID-19 (GCS-NeuroCOVID) from March 1 to September 30, 2020, and the European Academy of Neurology (EAN) Neuro-COVID Registry (ENERGY) from March to October 2020. Three cohorts were included: (1) the GCS-NeuroCOVID all COVID-19 cohort (n = 3055), which included consecutive hospitalized patients with COVID-19 with and without neurological manifestations; (2) the GCS-NeuroCOVID COVID-19 neurological cohort (n = 475), which comprised consecutive patients hospitalized with COVID-19 who had confirmed neurological manifestations; and (3) the ENERGY cohort (n = 214), which included patients with COVID-19 who received formal neurological consultation.

Exposures: Clinically diagnosed or laboratory-confirmed COVID-19.

Main Outcomes And Measures: Neurological phenotypes were classified as self-reported symptoms or neurological signs and/or syndromes assessed by clinical evaluation. Composite incidence was reported for groups with at least 1 neurological manifestation. The main outcome measure was in-hospital mortality.

Results: Of the 3055 patients in the all COVID-19 cohort, 1742 (57%) were men, and the mean age was 59.9 years (95% CI, 59.3-60.6 years). Of the 475 patients in the COVID-19 neurological cohort, 262 (55%) were men, and the mean age was 62.6 years (95% CI, 61.1-64.1 years). Of the 214 patients in the ENERGY cohort, 133 (62%) were men, and the mean age was 67 years (95% CI, 52-78 years). A total of 3083 of 3743 patients (82%) across cohorts had any neurological manifestation (self-reported neurological symptoms and/or clinically captured neurological sign and/or syndrome). The most common self-reported symptoms included headache (1385 of 3732 patients [37%]) and anosmia or ageusia (977 of 3700 patients [26%]). The most prevalent neurological signs and/or syndromes were acute encephalopathy (1845 of 3740 patients [49%]), coma (649 of 3737 patients [17%]), and stroke (222 of 3737 patients [6%]), while meningitis and/or encephalitis were rare (19 of 3741 patients [0.5%]). Presence of clinically captured neurologic signs and/or syndromes was associated with increased risk of in-hospital death (adjusted odds ratio [aOR], 5.99; 95% CI, 4.33-8.28) after adjusting for study site, age, sex, race, and ethnicity. Presence of preexisting neurological disorders (aOR, 2.23; 95% CI, 1.80-2.75) was associated with increased risk of developing neurological signs and/or syndromes with COVID-19.

Conclusions And Relevance: In this multicohort study, neurological manifestations were prevalent among patients hospitalized with COVID-19 and were associated with higher in-hospital mortality. Preexisting neurological disorders were associated with increased risk of developing neurological signs and/or syndromes in COVID-19.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.12131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114143PMC
May 2021

Advancing Evidence-Based Practice Through Implementation Science: Critical Contributions of Doctor of Nursing Practice- and Doctor of Philosophy-Prepared Nurses.

Worldviews Evid Based Nurs 2021 Apr;18(2):93-101

College of Nursing, Helene Fuld Health Trust National Institute for EBP, The Ohio State University, Columbus, OH, USA.

Purpose: Describe the evolution of implementation science and the roles and potential collaborations of doctorally prepared nurses to advance implementation science in practice settings.

Methods: Review of academic preparation and areas of expertise for doctorally prepared nurses as it relates to implementation science and evidence-based practice (EBP).

Findings: There have been substantial gains in the number of academic programs in healthcare that include content on EBP, resulting in healthcare teams that are motivated to align practices with best evidence. Unfortunately, many EBP initiatives stall during early stages of implementation, resulting in fragmented practices and persistent gaps between evidence and practice. Implementation science aims to bridge this gap and provides a structured, science-based approach to implementation. Few healthcare teams are familiar with implementation science, and many do not incorporate knowledge from the field when implementing EBPs. Doctorally prepared nurses are in a unique position to serve as leaders in EBP implementation due to the breadth and depth of academic preparation and their pivotal roles across practice settings.

Conclusions: Collaboratively aligning existing strengths of PhD and DNP prepared nurses with knowledge of implementation science can advance implementation of EBP across practice settings to effectively incorporate and sustain meaningful change to improve outcomes.

Linking Evidence To Action Section: Doctorally prepared nurses are in a unique position to advance and apply the science of implementation in practice settings. Nurse scientists can generate evidence on effective strategies and outcomes among healthcare teams to successfully integrate evidence based practices into routine care. Nurse leaders and educators can apply these findings and use an implementation science approach when leading clinical teams in evidence-based practice changes.
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http://dx.doi.org/10.1111/wvn.12496DOI Listing
April 2021

Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality.

Worldviews Evid Based Nurs 2021 Apr 29;18(2):76-84. Epub 2021 Mar 29.

College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia.

Background: Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence-based practice (EBP) models can guide implementation, contributing to the knowledge-to-practice gap.

Aim: This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes.

Methods: The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice.

Linking Evidence To Action: Knowledge of implementation science can help clinicians adopt high-quality evidence into their practices. Application-oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge-to-action gap.
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http://dx.doi.org/10.1111/wvn.12495DOI Listing
April 2021

Evidence-Based Practice Requires Evidence-Based Implementation.

Worldviews Evid Based Nurs 2021 04 18;18(2):74-75. Epub 2021 Mar 18.

Helene Fuld Health Trust National Institute for EBP, College of Nursing, The Ohio State University, Columbus, OH, USA.

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http://dx.doi.org/10.1111/wvn.12494DOI Listing
April 2021

Facilitators and Barriers to Nursing Implementation of Continuous Glucose Monitoring (CGM) in Critically Ill Patients With COVID-19.

Endocr Pract 2021 Apr 27;27(4):354-361. Epub 2021 Jan 27.

Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, Ohio.

Objective: We describe our implementation of a continuous glucose monitoring (CGM) guideline to support intravenous insulin administration and reduce point of care (POC) glucose monitoring frequency in the coronavirus disease 2019 medical intensive care unit (MICU) and evaluate nurses' experience with implementation of CGM and hybrid POC + CGM protocol using the Promoting Action on Research in Health Services framework.

Methods: A multidisciplinary team created a guideline providing criteria for establishing initial sensor-meter agreement within each individual patient followed by hybrid use of CGM and POC. POC measures were obtained hourly during initial validation, then every 6 hours. We conducted a focus group among MICU nurses to evaluate initial implementation efforts with content areas focused on initial assessment of evidence, context, and facilitation to identify barriers and facilitators. The focus group was analyzed using a qualitative descriptive approach.

Results: The protocol was integrated through a rapid cycle review process and ultimately disseminated nationally. The Diabetes Consult Service performed device set-up and nurses received just-in-time training. The majority of barriers centered on contextual factors, including limitations of the physical environment, complex device set-up, hospital firewalls, need for training, and CGM documentation. Nurses' perceived device accuracy and utility were exceptionally high. Solutions were devised to maximize facilitation and sustainability for nurses while maintaining patient safety.

Conclusion: Outpatient CGM systems can be implemented in the MICU using a hybrid protocol implementation science approach. These efforts hold tremendous potential to reduce healthcare worker exposure while maintaining glucose control during the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.eprac.2021.01.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7839794PMC
April 2021

A Scoping Review of Implementation Science in Adult Critical Care Settings.

Crit Care Explor 2020 Dec 16;2(12):e0301. Epub 2020 Dec 16.

College of Nursing, The Ohio State University, Columbus, OH.

Objectives: The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation.

Data Sources: A librarian-assisted search was performed using three electronic databases.

Study Selection: Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included.

Data Extraction: Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system.

Data Synthesis: Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes.

Conclusions: The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.
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http://dx.doi.org/10.1097/CCE.0000000000000301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746210PMC
December 2020

The European Academy of Neurology COVID-19 registry (ENERGY): an international instrument for surveillance of neurological complications in patients with COVID-19.

Eur J Neurol 2020 Nov 21. Epub 2020 Nov 21.

Department of Neurology, Inselspital, University of Bern, Bern, Switzerland.

The COVID-19 pandemic is a global public health issue. Neurological complications have been reported in up to one-third of affected cases, but their distribution varies significantly in terms of prevalence, incidence and phenotypical characteristics. Variability can be mostly explained by the differing sources of cases (hospital vs. community-based), the accuracy of the diagnostic approach and the interpretation of the patients' complaints. Moreover, after recovering, patients can still experience neurological symptoms. To obtain a more precise picture of the neurological manifestations and outcome of the COVID-19 infection, an international registry (ENERGY) has been created by the European Academy of Neurology in collaboration with European national neurological societies and the Neurocritical Care Society and Research Network. ENERGY can be implemented as a stand-alone instrument for patients with suspected or confirmed COVID-19 and neurological findings or as an addendum to an existing registry not targeting neurological symptoms. Data are also collected to study the impact of neurological symptoms and neurological complications on outcomes. The variables included in the registry have been selected in the interests of most countries, to favour pooling with data from other sources and to facilitate data collection even in resource-poor countries. Included are adults with suspected or confirmed COVID-19 infection, ascertained through neurological consultation, and providing informed consent. Key demographic and clinical findings are collected at registration. Patients are followed up to 12 months in search of incident neurological manifestations. As of 19 August, 254 centres from 69 countries and four continents have made requests to join the study.
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http://dx.doi.org/10.1111/ene.14652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753513PMC
November 2020

Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus.

Intensive Care Med 2020 12 11;46(12):2397-2410. Epub 2020 Nov 11.

School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.

Purpose: To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI).

Methods: An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1-3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75-85%, and < 75% of panellists, respectively, agreed with a statement.

Results: The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts.

Conclusions: This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches.
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http://dx.doi.org/10.1007/s00134-020-06283-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655906PMC
December 2020

A Prospective Study of Neurologic Disorders in Hospitalized Patients With COVID-19 in New York City.

Neurology 2021 01 5;96(4):e575-e586. Epub 2020 Oct 5.

From the New York University Grossman School of Medicine (J.A.F., S.S., R.L., T.F., B.F., P.M.-V., T.S., S.B., D.Y., A.G., N.M., P.P., J.G., K.M., S.A., M.B., A.A., E.V., M.O., A.K., K.L., Daniel Friedman, David Friedman, M.H., J.H., S.T., J.H., N.A.-F., P.K., A.L., A.S.L., T.Z., D.E.K., B.M.C., J.T., S.Y., K.I., E.S., D.P., M.L., T.W., A.B.T., L.B., S.G.), New YorkUniversity of Pittsburgh School of Medicine (S.H.-Y.C., E.L.F.), PAThe Ohio State University (M.M., S.M.), ColumbusMedical University of Innsbruck (R.H.), AustriaThe Johns Hopkins University School of Medicine (C.R., J.I.S., W.Z.), Baltimore, MDUniversity of Utah School of Medicine (M.S., A.d.H.), Salt Lake CityUniversity of Cambridge (D.M.), UK.

Objective: To determine the prevalence and associated mortality of well-defined neurologic diagnoses among patients with coronavirus disease 2019 (COVID-19), we prospectively followed hospitalized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients and recorded new neurologic disorders and hospital outcomes.

Methods: We conducted a prospective, multicenter, observational study of consecutive hospitalized adults in the New York City metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between patients with COVID-19 with and without neurologic disorders.

Results: Of 4,491 patients with COVID-19 hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were reverse transcriptase PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all < 0.05). After adjusting for age, sex, SOFA scores, intubation, history, medical complications, medications, and comfort care status, patients with COVID-19 with neurologic disorders had increased risk of in-hospital mortality (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.17-1.62, < 0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63-0.85, < 0.001).

Conclusions: Neurologic disorders were detected in 13.5% of patients with COVID-19 and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.
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http://dx.doi.org/10.1212/WNL.0000000000010979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905791PMC
January 2021

Using Radiofrequency Technology to Prevent Retained Sponges and Improve Patient Outcomes.

AORN J 2020 10;112(4):345-352

Retained items (eg, sponges, sharps) after surgical procedures are reportable errors that can result in patient harm or death and increased patient and health care system costs. Perioperative use of radiofrequency (RF) technology may decrease the number of retained sponges and reduce hospital costs. We sought to determine whether the use of RF technology may be associated with fewer retained sponges, improved patient outcomes, and decreased hospital costs. We completed a retrospective evaluation of incident reports before and after implementing the use of an RF system for retained surgical sponges. We found that using RF technology was associated with fewer retained sponges and improved outcomes at our facility. We also determined that mortality rates before and after RF technology implementation were similar, and we estimated that our hospital's costs were reduced.
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http://dx.doi.org/10.1002/aorn.13171DOI Listing
October 2020

The Global Consortium Study of Neurological Dysfunction in COVID-19 (GCS-NeuroCOVID): Development of Case Report Forms for Global Use.

Neurocrit Care 2020 12 18;33(3):793-828. Epub 2020 Sep 18.

Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, Pittsburgh, PA, USA.

Since its original report in January 2020, the coronavirus disease 2019 (COVID-19) due to Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection has rapidly become one of the deadliest global pandemics. Early reports indicate possible neurological manifestations associated with COVID-19, with symptoms ranging from mild to severe, highly variable prevalence rates, and uncertainty regarding causal or coincidental occurrence of symptoms. As neurological involvement of any systemic disease is frequently associated with adverse effects on morbidity and mortality, obtaining accurate and consistent global data on the extent to which COVID-19 may impact the nervous system is urgently needed. To address this need, investigators from the Neurocritical Care Society launched the Global Consortium Study of Neurological Dysfunction in COVID-19 (GCS-NeuroCOVID). The GCS-NeuroCOVID consortium rapidly implemented a Tier 1, pragmatic study to establish phenotypes and prevalence of neurological manifestations of COVID-19. A key component of this global collaboration is development and application of common data elements (CDEs) and definitions to facilitate rigorous and systematic data collection across resource settings. Integration of these elements is critical to reduce heterogeneity of data and allow for future high-quality meta-analyses. The GCS-NeuroCOVID consortium specifically designed these elements to be feasible for clinician investigators during a global pandemic when healthcare systems are likely overwhelmed and resources for research may be limited. Elements include pediatric components and translated versions to facilitate collaboration and data capture in Latin America, one of the epicenters of this global outbreak. In this manuscript, we share the specific data elements, definitions, and rationale for the adult and pediatric CDEs for Tier 1 of the GCS-NeuroCOVID consortium, as well as the translated versions adapted for use in Latin America. Global efforts are underway to further harmonize CDEs with other large consortia studying neurological and general aspects of COVID-19 infections. Ultimately, the GCS-NeuroCOVID consortium network provides a critical infrastructure to systematically capture data in current and future unanticipated disasters and disease outbreaks.
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http://dx.doi.org/10.1007/s12028-020-01100-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500499PMC
December 2020

The Curing Coma Campaign: Framing Initial Scientific Challenges-Proceedings of the First Curing Coma Campaign Scientific Advisory Council Meeting.

Neurocrit Care 2020 08;33(1):1-12

Department of Neurology, Neuro-ICU, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France.

Coma and disordered consciousness are common manifestations of acute neurological conditions and are among the most pervasive and challenging aspects of treatment in neurocritical care. Gaps exist in patient assessment, outcome prognostication, and treatment directed specifically at improving consciousness and cognitive recovery. In 2019, the Neurocritical Care Society (NCS) launched the Curing Coma Campaign in order to address the "grand challenge" of improving the management of patients with coma and decreased consciousness. One of the first steps was to bring together a Scientific Advisory Council including coma scientists, neurointensivists, neurorehabilitationists, and implementation experts in order to address the current scientific landscape and begin to develop a framework on how to move forward. This manuscript describes the proceedings of the first Curing Coma Campaign Scientific Advisory Council meeting which occurred in conjunction with the NCS Annual Meeting in October 2019 in Vancouver. Specifically, three major pillars were identified which should be considered: endotyping of coma and disorders of consciousness, biomarkers, and proof-of-concept clinical trials. Each is summarized with regard to current approach, benefits to the patient, family, and clinicians, and next steps. Integration of these three pillars will be essential to the success of the Curing Coma Campaign as will expanding the "curing coma community" to ensure broad participation of clinicians, scientists, and patient advocates with the goal of identifying and implementing treatments to fundamentally improve the outcome of patients.
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http://dx.doi.org/10.1007/s12028-020-01028-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392933PMC
August 2020

Global Consortium Study of Neurological Dysfunction in COVID-19 (GCS-NeuroCOVID): Study Design and Rationale.

Neurocrit Care 2020 08;33(1):25-34

Departments of Critical Care Medicine, Neurology, and Neurosurgery, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background: As the COVID-19 pandemic developed, reports of neurological dysfunctions spanning the central and peripheral nervous systems have emerged. The spectrum of acute neurological dysfunctions may implicate direct viral invasion, para-infectious complications, neurological manifestations of systemic diseases, or co-incident neurological dysfunction in the context of high SARS-CoV-2 prevalence. A rapid and pragmatic approach to understanding the prevalence, phenotypes, pathophysiology and prognostic implications of COVID-19 neurological syndromes is urgently needed.

Methods: The Global Consortium to Study Neurological dysfunction in COVID-19 (GCS-NeuroCOVID), endorsed by the Neurocritical Care Society (NCS), was rapidly established to address this need in a tiered approach. Tier-1 consists of focused, pragmatic, low-cost, observational common data element (CDE) collection, which can be launched immediately at many sites in the first phase of this pandemic and is designed for expedited ethical board review with waiver-of-consent. Tier 2 consists of prospective functional and cognitive outcomes assessments with more detailed clinical, laboratory and radiographic data collection that would require informed consent. Tier 3 overlays Tiers 1 and 2 with experimental molecular, electrophysiology, pathology and imaging studies with longitudinal outcomes assessment and would require centers with specific resources. A multicenter pediatrics core has developed and launched a parallel study focusing on patients ages <18 years. Study sites are eligible for participation if they provide clinical care to COVID-19 patients and are able to conduct patient-oriented research under approval of an internal or global ethics committee. Hospitalized pediatric and adult patients with SARS-CoV-2 and with acute neurological signs or symptoms are eligible to participate. The primary study outcome is the overall prevalence of neurological complications among hospitalized COVID-19 patients, which will be calculated by pooled estimates of each neurological finding divided by the average census of COVID-19 positive patients over the study period. Secondary outcomes include: in-hospital, 30 and 90-day morality, discharge modified Rankin score, ventilator-free survival, ventilator days, discharge disposition, and hospital length of stay.

Results: In a one-month period (3/27/20-4/27/20) the GCS-NeuroCOVID consortium was able to recruit 71 adult study sites, representing 17 countries and 5 continents and 34 pediatrics study sites.

Conclusions: This is one of the first large-scale global research collaboratives urgently assembled to evaluate acute neurological events in the context of a pandemic. The innovative and pragmatic tiered study approach has allowed for rapid recruitment and activation of numerous sites across the world-an approach essential to capture real-time critical neurological data to inform treatment strategies in this pandemic crisis.
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http://dx.doi.org/10.1007/s12028-020-00995-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7243953PMC
August 2020

One Team's Experience with Integrating Flexible Visitation in the Medical Intensive Care Unit.

Crit Care Nurs Clin North Am 2020 Jun 27;32(2):253-264. Epub 2020 Mar 27.

Clinical Nursing, Implementation Science Core, The Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing & Healthcare, College of Nursing, The Ohio State University, 760 Kinnear Road, Columbus, OH 43212, USA.

Integration of flexible visitation into a large health system requires concentrated effort. Evaluating impact on patient, family, and staff outcomes is important to facilitate changes and ensure visiting policy success. The medical intensive care unit staff participated in a collaborative quality improvement effort to encourage flexible visitation. The integration of flexible visitation spanned an 18-month period, timed to accompany a transition to a new setting with rooms designed to support visitor presence. This article details these efforts, outcomes, and important gaps for future work evaluating integration of flexible visitation in critical care.
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http://dx.doi.org/10.1016/j.cnc.2020.02.007DOI Listing
June 2020

Relationship Between Delirium and Ventilatory Outcomes in the Medical Intensive Care Unit.

Crit Care Nurse 2020 Apr;40(2):24-31

Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and the medical step-down unit, MetroHealth Medical Center, Cleveland, Ohio. Jessica Zangmeister is a clinical nurse in the medical intensive care unit, MetroHealth Medical Center. Molly McNett is Professor of Clinical Nursing and Assistant Director of Implementation Science, College of Nursing, The Ohio State University, Columbus, Ohio.

Background: Delirium is a common neuropsychiatric diagnosis in intensive care units and often leads to extended hospital stays and an increased rate of complications. Delirium can be classified as hypoactive, hyperactive, or mixed. Hyperactive delirium is often accompanied by agitation, which is a predictive factor for unplanned extubation. Hypoactive delirium does not include outward agitation; its incidence and relationship to ventilatory outcomes, specifically unplanned extubation and duration of mechanical ventilation, are relatively unexplored.

Objective: To determine the occurrence rate of each delirium type in the first 7 days after intensive care unit admission and explore the relationship between delirium type and ventilatory outcomes.

Methods: This was a retrospective cohort study that enrolled adult patients consecutively admitted to a medical intensive care unit over 12 months. Data were abstracted on patient demographic variables, daily clinical variables (morning and evening delirium, coma, and sedation scores), and outcome variables (unplanned extubation, length of stay, and duration of mechanical ventilation).

Results: We enrolled 171 patients in the study. Hypoactive delirium occurred in up to 44% of patients. Of 25 instances of unplanned extubation, up to 74% of patients had hypoactive delirium. Delirium was not a predictor of unplanned extubation; smoking history, chronic obstructive pulmonary disease, and failed breathing trials best predicted unplanned extubation (odds ratios = 3.2, 5.2, and 12.6, respectively; P < .05).

Conclusions: Hypoactive delirium is common among intensive care unit patients and may precede unplanned extubation. Patient history and comorbidities remain the strongest predictors of unplanned extubation.
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http://dx.doi.org/10.4037/ccn2020697DOI Listing
April 2020

Impact of intensive leadership training on nurse manager satisfaction and perceived importance of competencies.

Nurs Manage 2020 01;51(1):34-42

At The MetroHealth System in Cleveland, Ohio, Kelly Seabold is the director of nursing excellence, Wendy Sarver is the director of nursing research, and Melissa Kline is the senior vice president of patient care services/CNO. At The Ohio State University Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare, Molly McNett is a clinical nursing professor and assistant director, implementation science core.

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http://dx.doi.org/10.1097/01.NUMA.0000580592.92262.40DOI Listing
January 2020

Critical Care Helicopter Overtriage: A Failure Mode and Effects Analysis.

Air Med J 2019 Nov - Dec;38(6):408-420. Epub 2019 Sep 19.

College of Nursing, The Ohio State University, Columbus, Ohio.

Objective: Overtriage (OT) of helicopter emergency medical services (HEMS) poses significant burden to multiple stakeholders. The project aims were to identify the following: 1) associated factors, 2) downstream effects, and 3) focus areas for change.

Methods: We undertook a failure mode and effects analysis (FMEA) to evaluate our HEMS interfacility transport process. Data were collected from organizational finances and 3 key stakeholder groups: 1) interfacility patients transferred by HEMS in 2017 who were discharged from the receiving facility within 24 hours (n = 149), 2) flight registered nurses (n = 19), and 3) referring emergency medicine providers (EMPs) (n = 30) from the top HEMS users of 2017. The completed FMEA identified failure modes, the frequency and severity of effects, and unique risk profile numbers (RPNs).

Results: Twelve failure modes were identified with 30 potential causes. Leading failure modes included inappropriate HEMS requests by EMPs (RPN = 343), inappropriate activation by EMS for interfacility transport (RPN = 343), and minimizing patient/family involvement in decision making (RPN = 315). Significant burdens to organizational finances and flight registered nurse satisfaction were identified.

Conclusion: Associated factors for interfacility HEMS OT, downstream effects, and areas for change were identified. EMP and emergency medical services practices, HEMS processes, and shared decision making may affect regional OT rates.
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http://dx.doi.org/10.1016/j.amj.2019.07.012DOI Listing
September 2020

Transitions of Care for Patients with Neurologic Diagnoses Transition from the Intensive Care Unit to the Floor.

Nurs Clin North Am 2019 09 12;54(3):347-355. Epub 2019 Jun 12.

Neurocritical Care and Neurosurgery, The MetroHealth System, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Attn: Nursing Business Office, Cleveland, OH 44109, USA.

Transition of care from the intensive care unit to acute care units after critical neurologic injury includes the consideration of a variety of factors to ensure safe and effective care, and promote ongoing neurologic recovery. Assessment of effectiveness of deescalation techniques, agitation management, and risk factor mitigation are important strategies to enhance the success of transitions. Clear and consistent interdisciplinary communication between teams during hand-off between units is imperative to decrease the risk of complications and errors, and to streamline discharge processes.
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http://dx.doi.org/10.1016/j.cnur.2019.04.005DOI Listing
September 2019

Impact of level of nurse experience on falls in medical surgical units.

J Nurs Manag 2019 May 9;27(4):833-839. Epub 2019 Jan 9.

The MetroHealth System, Cleveland, Ohio.

Aim: To describe nurse-specific and patient risk factors present at the time of a patient fall on medical surgical units within an academic public health care system.

Background: The incidence of falls can be devastating for hospitalized patients and their families. Few studies have investigated how patient and nurse-specific factors can decrease the occurrence of falls in hospitals.

Method: In this retrospective cohort study, data were gathered on all patients who experienced a fall during January 2012 to December 2013.

Results: Falls were reduced dramatically when the number of nurses on the unit increased to five or six. Patient falls occurred most often when either the least experienced or most experienced nursing staff were providing care.

Conclusion: Patient falls in hospitals can be influenced not only by patient-specific factors, but also by nurse staffing and experience level.

Implications For Nursing Management: Findings from this study highlight factors which may contribute to hospital-based falls prevention initiatives and are amenable to nursing management decisions.
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http://dx.doi.org/10.1111/jonm.12742DOI Listing
May 2019

Pupillometry Trends in the Setting of Increased Intracranial Pressure.

J Neurosci Nurs 2018 Dec;50(6):357-361

Questions or comments about this article may be directed to Molly McNett, PhD RN CNRN FNCS, at She is Director, Nursing Research and Evidence Based Practice, The MetroHealth System, Cleveland, OH. Cristina Moran, MSN RN CCRN, is Clinical Nurse, Surgical Intensive Care Unit, The MetroHealth System, Cleveland, OH. Dawnetta Grimm, MSN CCNS RN, is Clinical Nurse Specialist, Trauma/Critical Care/Burns, The MetroHealth System, Cleveland, OH. Anastasia Gianakis, MSN RN CCRN, is Nurse Manager, Surgical Trauma Intensive Care Unit, The MetroHealth System, Cleveland, OH.

Serial pupil examinations remain a mainstay of neurological assessments performed by neuroscience nurses. Integration of pupillometer technology has increased in recent years, because of its ability to address limitations of manual examinations and to evaluate trended data over time. Preliminary research has linked pupillometer values to intracranial pressure (ICP) values, but data on pupillary changes in the setting of increased ICP remain sparse. The purpose of this study was to determine trends in pupillometer values in the setting of increased ICP among critically ill patients with neurological injury. This is a secondary analysis of data where serial pupillometer and ICP readings were recorded hourly on adult patients with neurological injury necessitating critical care management. More than 2100 paired serial pupillometer and ICP readings were obtained from 76 subjects, with a total of 2107 paired readings for the left eye and 2175 for the right eye. There were statistically significant differences in pupillometry values in the setting of increased ICP. Time series analysis indicates that spikes in ICP values resulted in corresponding variations in pupillometer values. Use of automated pupillometry remains a value adjunct to traditional invasive therapies. Evaluation of trended data may provide insight into ICP elevations in the absence of invasive monitoring and warrants additional research.
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http://dx.doi.org/10.1097/JNN.0000000000000401DOI Listing
December 2018

The Impact of Head-of-Bed Positioning and Transducer Location on Cerebral Perfusion Pressure Measurement.

J Neurosci Nurs 2018 Dec;50(6):322-326

Sarah Livesay, DNP ACNP FNCS, is Associate Professor, Rush University, Chicago, IL. Susan Yeager, MS ACNP FNCS, is Nurse Practitioner Lead, Wexner Medical Center, The Ohio State University, Columbus, OH. Cristina Moran, MSN RN CCRN, is Clinical Nurse, The MetroHealth System, Cleveland, OH. Erin Supan, MSN RN, is Clinical Nurse Specialist, Neurosciences, University Hospitals Cleveland Medical Center, Cleveland, OH. Stefany Ortega, MSc RN, is Assistant Professor, Universidad del Norte, Barranquilla, Colombia. DaiWai M. Olson, PhD RN CCRN FNCS, is Professor of Neurosurgery and Neurotherapeutics, University of Texas Southwestern, Dallas, TX.

Introduction: Head-of-bed (HOB) elevation is the standard of care for patients with intracranial pressure monitoring at risk for intracranial hypertension. Measurement of cerebral perfusion pressure (CPP) based on HOB elevation and arterial transducer position has not been adequately studied.

Methods: This is a planned secondary analysis of prospectively collected data in which paired, serial arterial blood pressure (ABP), intracranial pressure, and CPP measures were obtained once per day for 3 days, with measures leveled at the tragus (Tg) and the phlebostatic axis (PA). The HOB position was recorded for all paired readings.

Results: From 136 subjects, ABP and CPP values were lower when the transducer was leveled at the Tg, compared with the PA (P < .001); these differences persisted regardless of HOB position.

Conclusion: The difference in CPP when ABP is referenced at the Tg versus PA is not consistently attributed to HOB elevation.
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http://dx.doi.org/10.1097/JNN.0000000000000398DOI Listing
December 2018

Differentiate the Source and Site of Intracranial Pressure Measurements Using More Precise Nomenclature.

Neurocrit Care 2019 04;30(2):239-243

UT Southwestern Medical Center, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX, 75390-8897, USA.

Background: Intracranial pressure (ICP) monitoring is fundamental for neurocritical care patient management. For many years, ventricular and parenchymal devices have been available for this aim. The purpose of this paper is to review the published literature comparing ICP recordings via an intraventricular catheter or an intraparenchymal (brain tissue) catheter.

Methods: Literature search of Medline, CINAHL, Embase, and Scopus was performed in which manuscripts discussed both ICP monitoring via an intraventricular catheter and ICP monitoring through intraparenchymal (brain tissue) catheter. Keywords and MeSH terms used include critical care, intracranial pressure, ICP, monitoring, epidural catheter, intracranial hypertension, ventriculostomy, ventricular drain, external ventricular drain, and physiologic monitoring.

Results: Eleven articles met inclusion criteria. The published literature shows differences in simultaneously recorded ICP between the intraventricular and intraparenchymal sites.

Conclusions: We propose two new terms that more accurately identify the anatomical site of recording for the referenced ICP: intracranial pressure ventricular (ICP-v) and intracranial pressure brain tissue (ICP-bt). Further delineation of the conventional term "ICP" into these two new terms will clarify the difference between ICP-v and ICP-bt and their respective measurement locations.
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http://dx.doi.org/10.1007/s12028-018-0613-xDOI Listing
April 2019

Evidence-Based Review of Clinical Trials in Neurocritical Care.

AACN Adv Crit Care 2018 ;29(2):195-203

Molly McNett is Director, Nursing Research and Evidence-Based Practice, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Dr, Cleveland, OH 44109 Cristina Moran is Clinical Nurse, Trauma Surgical Intensive Care Unit, MetroHealth Medical Center, Cleveland, Ohio. Halee Johnson is Advanced Practice Registered Nurse, Department of Neurosurgery, The MetroHealth System, Cleveland, Ohio.

Neurocritical care is a rapidly growing specialty of complex care for the critically ill patient with neurological injury. This rapid growth has led to an increase in the number of important clinical trials to guide clinical practice and evidence-based care of the critically ill patient with neurological injury. Specialty-trained critical care nurses and advanced practice providers are integral members of neurocritical care teams and must remain informed about pivotal trials shaping practice recommendations. This article presents a summary of recent trials that have affected current practice and influenced care recommendations in the neurocritical care setting.
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http://dx.doi.org/10.4037/aacnacc2018200DOI Listing
January 2019

Nursing-Sensitive Outcomes After Severe Traumatic Brain Injury: A Nationwide Study.

Authors:
Molly McNett

J Neurosci Nurs 2018 06;50(3):155-156

Questions or comments about this article may be directed to Molly McNett, PhD RN CNRN, at She is Director, Nursing Research, The MetroHealth System, Cleveland, OH.

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http://dx.doi.org/10.1097/JNN.0000000000000377DOI Listing
June 2018

Challenges of Cerebral Perfusion Pressure Measurement.

J Neurosci Nurs 2017 Dec;49(6):372-376

Questions or comments about this article may be directed to Sarah L. Livesay, DNP RN ACNP-BC ACNS-BC, at She is an Associate Professor, Department of Adult and Gerontological Nursing, Rush University College of Nursing, Chicago, IL. Molly M. McNett, PhD RN, is Director, MetroHealth, Cleveland, OH. Monica Keller, BSN RN, is Staff Nurse, UT Southwestern, Dallas, TX. DaiWai M. Olson, PhD RN, is Associate Professor, Department of Neurology, Neurotherapeutics, and Neurological Surgery, UT Southwestern, Dallas, TX.

Monitoring cerebral perfusion pressure (CPP) is recommended by a number of clinical practice guidelines and is a routine function performed by critical care neuroscience nurses. However, several studies highlight theoretical and practice variations in the measurement of CPP regarding the location of the arterial pressure transducer during measurement. Agreement on the technique and process for obtaining valid measurements is lacking. This article identifies the challenges associated with CPP measurement and highlights opportunities for standardizing CPP measurement to improve consistency in care and findings reported in the research literature. The challenges associated with practice variations impact multiple nursing domains, including the environment, patient treatment, and team communication; all ultimately impacting nursing workflow. The practice variation and impact on nursing workflow have significant implications for further research, electronic health record development, and refining monitoring technology.
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http://dx.doi.org/10.1097/JNN.0000000000000321DOI Listing
December 2017