Multi-Modal Monitoring in the Neuro ICU

Podcast Transcript

Intro: Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Multimodal monitoring in the intensive care unit is utilized in patients with devastating neurologic injuries. The practice is recognized as an extension of the clinical exam and cognitive skillset of the clinician, and has been advocated as an important feature of neuro critical care. The goal is to detect early neurologic, or physiologic changes, before irreversible damage takes place.

In today's episode of Neuro Pathways, we're discussing the latest in multimodal monitoring in the neuro intensive care unit. I'm your host Glen Stevens, a neurologist neuro-oncologist in Cleveland Clinic's Neurological Institute. And today, I'm pleased to be joined by Dr. Christopher Newey. Dr. Newey is Medical Director of Multimodal Monitoring at Cleveland Clinic and the Medical Director of the Neuroscience Intensive Care unit at Cleveland Clinic Akron General. Chris, welcome to Neuro Pathways.

Christopher Newey, DO: Thank you for having me, Dr. Stevens.

Glen Stevens, DO, PhD: First, I'd like to thank you and your colleagues for all your hard work on the front lines during the COVID pandemic. My first question is really a two-part question. As a lead into today's conversation, can you start off by describing to our listeners the current patient population seen in the neuro intensive care unit, perhaps pre-SARS-COVID-2 pandemic, and amidst the current pandemic. And as a second part, what are the challenges you and your team are facing in the care of these patients on a daily basis?

Christopher Newey, DO: Prior to COVID our neuro ICU patient population mostly consisted of patients with strokes, whether it is a hemorrhagic stroke, or ischemic stroke. Patients with status epilepticus, patients with brain tumors. Perhaps some hydrocephalus, where the water in the head is accumulating. As well as anybody with neural critical care needs, such as a stroke patient with say sepsis or a stroke patient who needs some respiratory care. We also see neuromuscular patients, as well as patients with encephalitis.

So, after the pandemic, our patient population is pretty much the same. Now, that we're dealing with COVID-19 patients, we are seeing some patients who present with ischemic strokes who are COVID-19 positive. Sometimes we don't know they're even COVID-19 positive until after they're in the ICU, and we diagnose it at that point. So, we have seen somewhat of a shift in patients. Interestingly, we have also seen a decrease in our stroke patients when the COVID-19 pandemic initially came out. In the last few months, our numbers have increased, but we did see a drop in our stroke numbers.

Glen Stevens, DO, PhD: So, Chris, where does multimodal monitoring fit into the equation? And what is your team's approach?

Christopher Newey, DO: Yeah, that's a really good question. So multimodal monitoring is really a buzzword just describing all the monitoring that we do in the neuro ICU and how can we integrate this monitoring to provide the best patient care we can? So, the problems that we really have right now with the way the monitoring is, is we have a low frequency data where nurses may do every one hour checks, whether it be neuro checks, or monitoring blood pressure, ICP. So, there's opportunities that we may be missing to intervene. There's also missing opportunities to review the data for a process improvement.

One problem with not having a multimodal monitoring program is that you lack the understanding of concordant time lock data, meaning that our data is not synced. For example, let's say you walk into a patient's room. Over in the left-hand side, you see the EKG. Over on the right side, you see the systolic blood pressure, the blood pressure. Over on the bed, the bottom of the bed, you may see urine output. Top of the bed you may see respiratory rate, and over on the very behind the screen behind the EKG, well, you may see the temperature. That would be unacceptable if we had that in our ICUs. Luckily we don't have that. We have telemetry monitors that have everything on one screen. Everything's time locked. And you walk in, you say, "What happened at 9:13 in the morning?" You know the blood pressure might have dropped at that time with the change of heart rate, change of respirations.

However, in neuro critical care, we do face this challenge where we may have an EEG, electroencephalography over on the left-hand side of the bed, and we have intracranial pressure monitor on the far right. We may have a brain tissue oxygenation monitor in the back corner. We may even have a core temperature at the foot of the bed, and nothing is time locked. And so depending on what time the nurses gathered the data, or what time we pull it into the EMR, if we do pull in an EMR , we are missing opportunities to intervene, and it prevents us from really understanding our therapeutic interventions, such as if we gave a medicine, what does that medicine do to the ICP? What does that medicine do to the, at the same time, the oxygenation monitor? We are missing that.

And as you can imagine with all these machines, you can just imagine walking in, and your head just going all over the place, trying to figure out what to do, what to make sense of it. And you may find out that there is some information overload. You can only interpret or input so much and be able to make sense of it. So having a multimodal monitoring program really is the first step in trying to make sense of all this data that we have in ICU.

Glen Stevens, DO, PhD: So, Chris, I know that with COVID, there was a lot of innovation in terms of how equipment is stored, trying to move it out of the room to the outside, so that there's less movement in and out of a patient's room. Is that taking place in the neuro intensive care unit as well? Has it changed maybe how you'll do things in the future?

Christopher Newey, DO: Oh, absolutely. So pre-COVID, we took care of our machines. We wiped them down. We did what we could do between patients, but with COVID all of a sudden there's a concern, "Well, what about having extra people in the room to place EEG leads? Or having another person in the room to place that monitor?" And so there are challenges with that. How do we clean the machines and how do we dispose of items? A lot of innovations come about with this. For example, some institutions have started this thing called rapid EEG, where you can place a headset on a patient, and this could be placed by a nurse, a respiratory therapist, someone who needs to be in the room. Based on that, we've decreased the exposure. We are in the process of acquiring these as well. It has changed the way we will probably work in the future.

One of the ways that we've instituted multimodal monitoring is that we've started this monthly multimodal monitoring review session. And what we do at this review session is that we review the current literature, as well as review any cases that the residents or fellows may have, or anybody else may have. And this is in conjunction with the weekly review sessions that we have with the epilepsy service. So our goal is to review the data, provide meaningful information about the data that's being obtained, and ultimately just try to individualize the care for the patients. But while doing so augment the education that we have for the residents and fellows.

Glen Stevens, DO, PhD: So I assume with all this data, real-time data acquisition is important. You've also emphasized the critical need of capturing, storing, and analyzing data. It sounds like a tremendous amount of data. Tell us how the team at the Cleveland Clinic is doing that.

Christopher Newey, DO: So right now we have a machine. And from there, the data is captured locally onto the machine. Once we are done recording, or periodically, the data is uploaded into the internal storage of the Cleveland Clinic. We are using some storage from another center. And from there our data is stored. And the nice thing about being stored in that center is that we can access that data remotely. For example, if I'm in Akron, or if I'm at my house, or I could even get it from my phone, that data is accessible. And so it is a lot of data that we are acquiring with each patient. And so data storage, data is a problem.

Now, the other question you asked was about data analytics and that's where it really gets fun is that as you can imagine, if you're collecting data, if you want to collect it every second you can, if you want to collect it every minute, hour, it provides a lot of data, and it also provides a lot of noise. So we have to figure out how to claim that data. And then from there we can interpret it. And luckily we've had some very interested residents, as well as other team members who have a special interest in this big data and data analytics. And so they were helping with some modeling with this.

Glen Stevens, DO, PhD: Yeah, I think that really dovetails into my next question that you sort of touched on in that is, does artificial intelligence and machine learning help in this regard? I would assume so.

Christopher Newey, DO: Oh, absolutely. And that's where it gets really fun is you can imagine all this data and the stories it tells. One of my interests is can you predict who may seize before even hooking him up on the EEG? We have I believe enough data to suggest who is at high risk and who should be monitored. Similar to like how can you identify septic patients before they're truly septic? And we are working on that. And so yeah, the data that it's providing is just fantastic. And it's so much fun to look into.

Glen Stevens, DO, PhD: Any particular challenges that you've faced as you've implemented these new technologies?

Christopher Newey, DO: Yeah, absolutely. One of the biggest challenges is that because it's not as well known to everybody as it is to say a few of us, reminding people to consider the multimodal monitoring approach to patient care, it's been a challenge, and something that we are working on and we've actually made a lot of progress in that. Our residents and our fellows have been great supporters. So getting them to really help out has been great.

But the other thing is we created this field at the same time COVID was happening. And there are some financial challenges right now that everybody's struggling with. And so because of that, the devices, we are not able to expand as fast as we would like, but we are in the process of expanding.

Glen Stevens, DO, PhD: So Chris, I often will have to see consults in the cardiac intensive care or the medical intensive care unit. And I just wonder if you can help me with your experience in the neurologic intensive care unit with sick patients. We see patients that have altered mental status. What's the likelihood those patients may be having subclinical seizures? What's your data show you on that?

Christopher Newey, DO: So the patient who's walking, talking awake, their risk for seizures is a lot less than that patient who's in a comatose state. And we know that patients who are comatose with certain etiologies, such as the intra cerebral hemorrhage, the cardic arrest, even some of these subcortical and cortical tumors, are at higher risk for seizing than some of these other etiologies. And so we do have ability to identify or think about which patients we should monitor, and go into like other units, for example, a medical ICU. Our data is showing that maybe up to 14% of patients monitored on EEG who are just septic, purely admitted for sepsis, could be seizing.

And so the risk is high. In general, overall, we're seeing about 14 to 19% of patients that we monitor have non-convulsive seizures. And that is the majority of the seizures that we do see.

Glen Stevens, DO, PhD: Chris, can you talk just very briefly about transcranial Doppler and its role in noninvasive monitoring?

Christopher Newey, DO: Yeah, absolutely. I'm glad you brought that up. We recently acquired a transcranial Doppler for the neural ICU. It's a robotic transcranial Doppler. And what we can do with this is apply it and we can monitor for extended amount of time. It's a robotic meaning that it automatically will move to maintain the main flow of velocity. So it provides some really good data. One of the interests that our group has is can we use these minimally invasive to non-invasive monitors to monitor or predict intercranial pressure? And I think as we gather all this big data through different algorithms and whatnot, we may get to that point.

I'm not sure what device or what combination devices will lead to us to that pathway. A lot of people are looking into it, but the transcranial Doppler is something that is going to be playing a big role in the neuro ICU as we move forward.

Glen Stevens, DO, PhD: Yeah, it sounds like you're at a really exciting time in neuro intensive care management. As the medical director of the neuro intensive care unit at the Cleveland Clinic Akron General and a leader in the field, can you share what you believe the future state of multimodal monitoring will become in the neuro intensive care unit now, and as we move forward?

Christopher Newey, DO: Oh, yeah. Great question. It is just now starting. We've been talking about it for years and now it's just becoming where it's more feasible. The technology is catching up to the ideas. We've got better software and hardware. And so a lot of people are becoming very interested in this field, to the point of I'm part of a national group, looking at creating standards and guidelines for what exactly constitutes multimodal monitoring? What do you have to monitor? How much do you have to monitor? And then ultimately the goal would be is can we create some CPT codes or lobby for them so that people who do this can get reimbursed for the work that they're providing.

So it's an exciting time. We are in its infancy right now, and it's just fun watching it grow over the last few years.

Glen Stevens, DO, PhD: Well, listen, Chris, I really appreciate your sharing your time with us today and thank you much for joining us and we look forward to seeing how your work continues to change the way that we care for patients in the intensive care unit. Thank you very much.

Christopher Newey, DO: Yeah. Thank you. Thank you for having me.

Outro: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word and thank you for listening.