How to merge caregivers' corporate cultures.

Mergers and acquisitions combine sets of employees, as well as corporate entities. These steps show how facilities can proactively address joining corporate cultures for a successful transition.     

Indications for computed tomography in patients with minor head injury

BACKGROUND: Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury who do not need to undergo CT. METHODS: In the first phase of the study, we recorded clinical findings in 520 consecutive patients with minor head injury who had a normal score on the Glasgow Coma Scale and normal findings on a brief neurologic examination; the patients then underwent CT. Using recursive partitioning, we derived a set of criteria to identify all patients who had abnormalities on CT scanning. In the second phase, the sensitivity and specificity of the criteria for predicting a positive scan were evaluated in a group of 909 patients. RESULTS: Of the 520 patients in the first phase, 36 (6.9 percent) had positive scans. All patients with positive CT scans had one or more of seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3 percent) had positive scans. In this group of patients, the sensitivity of the seven findings combined was 100 percent (95 percent confidence interval, 95 to 100 percent). All patients with positive CT scans had at least one of the findings. CONCLUSIONS: For the evaluation of patients with minor head injury, the use of CT can be safely limited to those who have certain clinical findings.     

Vision,Aphasia, Neglect Assessment to Predict Neurosurgical Intervention in Patients with Nontraumatic Intracerebral Hemorrhage

Background and PurposeThe Vision, Aphasia, and Neglect (VAN) screening tool is a simple bedside test developed to identify patients with large vessel occlusion stroke. In the setting of intracerebral hemorrhage (ICH), there are very few bedside predictors of need for neurosurgical interventions other than age and Glasgow Coma Scale (GCS). We aimed to assess the utility of the VAN screening tool in predicting the need for neurosurgical intervention in patients with ICH.MethodsWe accessed sensitivity, specificity, positive predictive value, negative predictive value (NPV), and area under receiver operating characteristics curve of VAN for identifying ICH patients who require neurosurgical intervention.ResultsAmong 228 ICH patients, 176 were VAN positive and 52 were VAN negative. On unadjusted analyses, VAN positive patients had a significantly higher ICH volume, GCS score, and National Institutes of Health Stroke Scale score (P < .001 for all). As compared to VAN negative patients, significantly higher proportion of VAN positive ICH patients (15.4% versus 32.4%) underwent a neurosurgical procedure such as external ventricular drain (EVD) and/or hematoma evacuation with craniotomy or craniectomy. The VAN screening tool had high sensitivity and NPV (100%) in predicting the need for craniectomy or hematoma evacuation, but had lower sensitivity (87.7%) for any neurosurgical procedure, as 15.4% of VAN negative patients received EVD.ConclusionsOur study suggests that VAN screening tool can identify high-risk ICH patients who are more likely to undergo craniotomy or craniectomy but is less sensitive to rule out need for EVD.     

Conversion disorder presenting as hemiplegia and hemianesthesia with loss of neurologic reflexes: a case report

Conversion disorders can present with a variety of sensorimotor signs and symptoms. We present the case of a young woman who presented with sudden onset hemiplegia and hemianesthesia including unilateral loss of deep tendon reflexes, Babinski reflex, and loss of rectal tone with bladder incontinence. The loss of rectal tone, loss of deep tendon reflexes, and a flaccid Babinski reflex are unusual signs in conversion disorders. A thorough medical workup including x-rays, CT scans, and magnetic resonance imaging revealed no organic causes for the neurologic deficits. Before the onset of symptoms, the patient was emotionally upset during an argument, which may have provided the psychologic stressor necessary for a conversion disorder. The young woman gradually regained full neurologic function over the next 14 hours. Conversion disorders should be considered when the neurologic findings do not correspond to known anatomic or physiologic pathways, although a thorough medical investigation must be performed to search for organic causes.     

Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms

STUDY OBJECTIVE: Indications for computed tomography (CT) in children with minor head injury remain controversial. The objective of this preliminary study is to determine whether a clinical decision rule developed for adults could be used in children aged 5 years and older. METHODS: A prospective questionnaire was completed on all patients who were aged 5 to 17 years with major mechanisms of injury resulting in minor head injury (defined as normal Glasgow Coma Scale or modified coma scale in infants, plus normal brief neurologic examination) and loss of consciousness. The questionnaire documented 6 clinical variables: headache, emesis, intoxication, seizure, short-term memory deficits, and physical evidence of trauma above the clavicles. CT was obtained for all patients, findings were compared with the results of the questionnaires, and the sensitivity and specificity of the decision rule were determined. RESULTS: Throughout a 30-month period, 175 patients were enrolled, with a mean age of 12.8 years. Fourteen (8%) patients had intracranial injury or depressed skull fracture on CT. The presence of any of the 6 criteria was significantly associated with an abnormal CT scan result (P<.05) and was 100% (95% confidence interval 73% to 100%) sensitive for identifying patients with intracranial injury. CONCLUSION: In this preliminary study, CT use in pediatric patients with minor head injury could have been safely reduced by 23% by using a clinical decision rule previously validated in adults.