The Neurovascular Stroke Unit offers integrated care for patients who are primarily admitted for neurovascular-related illness.

 B4 is an integrated unit that consists of ward, Level 1 and Level 2 ICU beds.

 Patients are admitted and transferred to the appropriate level of care based on clinical acuity and care requirements.

 All reasonable efforts should be made to prioritize stroke and neurovascular patients to be admitted to B4 NVST.

Admitted stroke patients follow a stroke care pathway to ensure access to best practices, including: rapid investigation and diagnosis, post-hyperacute intervention care, secondary stroke prevention, rehab assessment, and coordination of stroke services.

A maximum total of 2 post-thrombolysis patients can be admitted on B4 Level 1 while q15min OR q30min monitoring frequency is in effect.

A maximum total of 2 post-Neuro Interventional Procedures can be admitted on B4 Level 1 while q15min OR q30min monitoring frequency is in effect.

When reasonably possible, admissions to B4 should occur before 07:00/19:00 or after 08:00/20:00.

INCLUSION CRITERIA

• Primary neurovascular diagnoses that are non-traumatic in origin and etiology;

• Patients with compensated hemodynamics (without the use of vasoactive infusions) that are deemed appropriate for routine q 4 hour monitoring.

EXCLUSION CRITERIA:

• Acute, traumatic brain and spinal cord injuries, status epilepticus, acute subdural hemorrhage

• Patients with acute neurosurgical care needs and immediate post-neurosurgical interventions (including, but not limited to craniotomy, craniectomy, EVD, lumbar drain)

• Patients with uncompensated hemodynamics that requires
  ₋ Monitoring/assessment more frequent than every 4 hours;
  ₋ Suctioning requirements more frequent than every 4 hours
  ₋ Oxygen requirements exceeding 50% FiO2
  ₋ Higher level of care (Level 1, 2, 3)

• Infection prevention and control that requires a negative pressure room

INCLUSION CRITERIA

•  Primary neurovascular diagnoses that are non-traumatic in origin and etiology with care needs that exceed the ward criteria

•  0 or 1 acute organ failure other than CNS

•  Hemodynamic condition is deemed appropriate for routine q 2 hour monitoring. Exceptions include:

  • Post-thrombolysis for ischemic stroke that are hemodynamically stable and do not require continuous IV anti-hypertensive medications or vasopressors. A total maximum of 2 post-thrombolysis patients can be admitted on B4 Level 1 while q15- or q30- minute monitoring frequency is in effect.

  • Post-Neuro Intervention for underlying neurovascular diagnosis (e.g. cerebral angiography, cerebral embolization). A total maximum of 2 post-neuro IR patients can be admitted on B4 Level 1 while q15- or q30- minute monitoring frequency is in effect.

•  Intermittent IV medications that require cardiac monitoring (e.g. labetolol, hydralazine, phenytoin)

•  *Increased oxygen/ ventilation demands secondary to neurovascular conditions, which require non-invasive ventilation (e.g., HFNC, BiPAP, CPAP)

EXCLUSION CRITERIA:

•  Acute, traumatic brain and spinal cord injuries, status epilepticus, acute subdural hemorrhage

•  Patients with acute neurosurgical care needs and immediate post-neurosurgical interventions (including, but not limited to craniotomy, craniectomy, EVD, lumbar drain)

•  Suctioning requirements that is more frequent than every 2 hours

•  Patients that meet inclusion criteria for Level 2 care including:

  • High risk for imminent airway compromise (E.g., GCS less than 8 AND not protecting their airway)

  • Continuous vasoactive infusion for hemodynamic support

  • Invasive hemodynamic monitoring (e.g., arterial line)

•  Infection prevention/ control that requires a negative pressure room

NVL1 - Special Considerations and Points:

 We will admit patients to NVL1 when there is an available bed or an expected bed available within 4 hours of admission orders.

 Admission to NVL1 is contingent on NVL1 Staff acceptance - if a non-neurovascular patient is going to be admitted to NVL1, they must be discussed with the NVL1 staff first for the appropriate designation of MRP

 *For NIV (non-invasive ventilation): In cases where a patient has a primary neurovascular diagnosis with concomitant short-term need for BiPAP (12-48Hrs), BiPAP can be used for conditions such as COPD, OSA, CHF (with Rapid Response consultation if needed, based on disease trajectory). For HFNC, depending on etiology and patient trajectory, HFNC patients can be accepted to NVL1, with the ability to transfer to a higher level of care (via Rapid Response consultation) if escalating FiO2 needs or progression of disease.

 No Direct from Ward to NVL1 for deteriorating patients - Rapid Response consultation first for deteriorating Ward patients with subsequent Rapid Team/ICU Team-NVL1 staff discussion for admission to NVL1