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Are the skills of neurological assessment in need of resuscitation?

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The aim of this paper is to outline the background to several recent papers which highlight deficiencies in acute neurological care- all of which highlight (to differing degrees) issues in relation to neurological assessment with some proposed solutions. Given that 10% of acute emergency admissions are for neurological conditions (up to 20% if stroke included), this should be of concern to all acute medical physicians.
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Acute Medicine 2014; 13(4): 178-180178
Viewpoint
© 2014 Rila Publications Ltd.
D J Nicholl
Background
The neurological examination is a fundamental
part of undergraduate and postgraduate medical
examinations, yet a number of threads of evidence
suggest a level of assessment in acute neurological
emergencies that would be insufficient to pass an
undergraduate medical examination.
Acute neurological emergencies
Epilepsy
Seizures account for 2–3% of emergency department
attendances in the UK, yet the NASH (National
Audit of Seizures in Hospital) showed that only a
minority had a reasonable neurological examination
(only 36% of patients had plantar reflexes examined).
Only 70% of ‘first seizure’ patients had an ECG,
despite clear guidance from the National Institute
for Health and Clinical Excellence. Following the
emergency attendance or admission, care was poorly
coordinated, with only half of patients referred on to
‘first seizure’ or epilepsy services.1
Subarachnoid haemorrhage
The UK national confidential enquiry into patient
outcome and death (NCEPOD) in subarachnoid
haemorrhage, in 18% of cases, when initially
assessed, no neurological examination was either
performed or documented.2
• 32% of secondary care hospitals had no
protocol or policy to investigate and treat
acute onset headache.
• 43% (32 of 75) of patients in primary care had
their diagnosis of aneurysmal subarachnoid
haemorrhage overlooked, a delay that may
have affected the outcome in 72% (23/32).
• 13% (49 of 383) of patients in secondary care
did not have a timely diagnosis of aneurysmal
subarachnoid haemorrhage; in 10 (20%) of
these, the outcome was adversely affected.
• 13% (51 of 383) patients in secondary care
experienced a delay related to their CT scan; 7
deteriorated as a result.3
Other admissions on the acute medical take
A recent study identified that 33% of patients
admitted on the medical take as neurological
emergencies could not recollect being examined
with a tendon hammer, while 48% said they had not
been examined with an ophthalmoscope.4 In the US,
the figure was even worse- only 14% of those with
symptoms which would necessitate examination
with an ophthalmoscope (mainly headache) were
actually examined with one.6
These findings are disturbing as neurological
disorders carry such a high risk of mortality and
morbidity if poorly managed (table 15- lists those
disorders I have personally seen in ‘table top reviews’
(our local process for case review where a concern
of patient harm has been raised)over 12 years- in all
instances there have been issues in relation to the
quality of the neurological assessment.
Why do failings in neurological
assessment occur?
The reasons are complex and are reviewed elsewhere,
but neurophobia- a fear of neurology may have a role,
combined with difficulties in access to equipment,5
such as an ophthalmoscope.6 Some groups have, in
effect, dropped direct ophthalmoscopy altogether
and opted for other modalities. The use of non-
mydriatic ocular fundus photography (comparable to
a diabetic eye camera) is one (expensive) solution7,8
- a camera costs in the region of $25,000. Others
are developing Smartphone applications for retinal
photography ($500/adaptor) which are being trialled
in developing nations. The latter could be very
promising more generally.9
It is possible there is an over-reliance on imaging-
a false reassurance could occur with many of the
disorders listed in table 1 if a CT scan was ‘normal’.
Conversely, there is the risk of VOMIT- victim of
modern imaging technology- causing harm from
inappropriate imaging.5 This is why the neurological
assessment is crucial prior to requesting any imaging
or investigation. Decades before the existence of
MRI, the late Bryan Matthews’ made the somewhat
David J Nicholl
Dept of Neurology,
City Hospital, Birmingham,
Correspondence:
David J Nicholl
Dept of Neurology,
City Hospital, Birmingham,
B18 7QH
Email:
David.nicholl@nhs.net
Abstract
The aim of this paper is to outline the background to several recent papers which highlight deficiencies in acute
neurological care- all of which highlight (to differing degrees) issues in relation to neurological assessment with some
proposed solutions. Given that 10% of acute emergency admissions are for neurological conditions (up to 20% if stroke
included), this should be of concern to all acute medical physicians.
Are the skills of neurological
assessment in need of resuscitation?
178
Viewpoint
Acute Medicine 2014; 13(4): 178-180
Are the skills of neurological assessment in need of resuscitation?
© 2014 Rila Publications Ltd.
179
prescient comment ‘if [investigations] can be carried
out by the signing of a form requesting someone else
to do them there is a temptation to obtain as much
information as possible by this simple method’.10
In my own Trust there has been an 18% increase
in MRI requests just in the last year, the USA now
spends over $1billion dollars per annum just on MRI
imaging for headache.5 Given the risk of finding
incidental findings on MRI,11 there should be a wider
debate on appropriate use of investigations. In the
US, there has been a big emphasis on the “Choosing
Wisely” campaign to try and prevent inappropriate
investigations in a wide range of conditions.12 Finally,
MRI is not an infinite resource- a source of helium is
essential as a coolant for MRI scanners, yet there is a
global shortage of Helium.13
A neurological assessment
for the 21st century
For all of the above reasons, I argue that we need to
ensure that a proper neurological assessment does
need to occur in any acute medical patient. This does
not need to be lengthy and time-consuming (a rapid
neurological assessment can be performed in less
than 3 minutes)5 but it does need to occur. Moore
et al identified 22 core items in the neurological
examination that are key (in a patient where the
history suggests that there are unlikely to be abnormal
findings on neurological examination):14
• fundoscopy,
• light reflex,
• visual fields,
• pursuit extraocular movements,
• facial muscles,
• tongue,
• gait,
• tandem gait,
• pronator drift,
• rapid alternating movements of arms,
• finger-nose,
• tone in arms and legs,
• power in arms and legs,
• reflexes (biceps, brachioradialis, triceps, patellar,
Achilles, plantar)
• light touch.
If we can ensure that these core items are
performed and all acute physicians are knowledgeable
in the initial assessment and management of the
conditions listed in table 1, we will likely see a
major step forward in the care of patients with acute
neurological conditions.
Clearly clinical skills are relevant to all acute
medical specialties, not just neurology, and it is quite
correct to challenge physical signs of uncertain value
(eg Tinel’s sign in suspected carpal tunnel syndrome,
the clinical assessment of suspected community
acquired pneumonia- see Simel & Rennie15 for
many excellent examples). Studies such as the TOS
audit provide one method, via patient recall, to audit
completeness of examination for clinically relevant
physical signs.4 TOS assumed that all doctors have
access to a stethoscope as a surrogate control for
the questions regarding recollection of examination
with a tendon hammer and ophthalmoscope. This
may not always be the case in the future- as some
have suggested dropping the stethoscope for a
handheld ultrasound scanner.16 If this is to happen, it
is essential that such new technology, as with PEEK,9
are properly evaluated. Other forms of patient recall
audit in other medical domains could include- rectal
examination in suspected melaena, or HallPike
manoeuvres in episodic vertigo.
If there is one lesson I have learned from
performing the TOS audit it is this: if I read
“Neurology NAD” in the patient’s notes, this should
never mean ‘not actually done’. That truly is the
path to self-fulfilling neurophobia for the clinician
concerned.
Table 1. Acute neurological emergencies which are
common causes of missed diagnosis or error (adapted from
Nicholl and Appleton (2014))
Diagnosis Risks of missing the diagnosis
IschaemicStroke
(especiallyposterior
circulationstroke)
PlainlmCTscancanbenormalin
initialstages,posteriorcirculation
strokesaredifculttovisualiseonCT.
Poorlymanaged
epilepsy
Riskofdeathorharmfromdelayedor
inappropriatetreatment
Neuromuscular
disorders
Initialpresentationofbothmyasthenia
gravisandGuillain-Barrésyndrome
may(inearlyphases)bemisdiagnosed
asabrainstemstrokeorpossiblecord
compression(mortalityrateof8.7%
and7.7%respectivelyinthosepatients
requiringintensivecare.)
Subarachnoid
haemorrhage(SAH)
Althoughonly~2%ofSAHpatients
haveanormalCTheadscaninitially,
thereareriskswithamisseddiagnosis:
casefatalityrate~50%&mean
medicolegalcostofaclaimfordamages
inSAHintheUKstands~£211,000.
Missedcord
compression
Riskisfromdelayeddiagnosiswith
signicantmorbidityanddisabilityasa
consequence
Idiopathic
intracranial
hypertension
Imagingnormalbutpotentialfor
irreversiblesightlossifnotmanaged
appropriately
Functional
disorders
Riskisfromdelayeddiagnosis,over-
investigationandiatrogenicharm.
Acute Medicine 2014; 13(4): 178-180
Are the skills of neurological assessment in need of resuscitation?
© 2014 Rila Publications Ltd.
180
1. Marson T. UK epilepsy audit shows major deficiencies in care: who
should respond and how? Pract Neurol 2013;13:2-3 doi:10.1136/
practneurol-2012-000488
2. Subarachnoid Haemorrhage: Managing the Flow (2013) Accessed
18th May, 2014 http://www.ncepod.org.uk/2013sah.htm
3. Nicholl D, Weatherby S. Subarachnoid haemorrhage: the canary
in the mine, or the elephant in the room? Pract Neurol. 2014
Aug;14(4):204-5. doi: 10.1136/practneurol-2014-000816. Epub
2014 Mar 5.
4. Nicholl DJ, Yap CP, Cahill V, et al. The TOS study: can we use
our patients to help improve clinical assessment? J R Coll Physicians
Edinb 2012;42:306–10.
5. Nicholl DJ, Appleton JP. Clinical neurology: why this still matters
in the 21st century. J Neurol Neurosurg Psychiatry. 2014 May 29. pii:
jnnp-2013-306881. doi: 10.1136/jnnp-2013-306881. [Epub ahead
of print] Review.
6. Wong SH. A bright idea- solving the chronic lack of neurological
examination equipment on the wards with the Walton Neurostand.
Pract Neurol 2008;8:318-321 doi:10.1136/jnnp.2008.156851
7. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic Ocular
Fundus Photography in the Emergency Department. NEJM
2011;364:387–89.
8. Pérez MA, Bruce BB, Newman NJ, Biousse V. The use of
retinal photography in non-ophthalmic settings and its potential
for neurology Neurologist. 2012 November ; 18(6): 350–355.
doi:10.1097/NRL.0b013e318272f7d7
9. Portable Eye Examination Kit http://www.peekvision.org/
Accessed 18th October, 2014
10. Matthews B. Practical neurology. Oxford: Blackwell Scientific
Publications, 1963;1–256 (page 2).
11. Morris Z, Whiteley WN, Longstreth WT Jr, Weber F, Lee YC,
Tsushima Y, Alphs H, Ladd SC, Warlow C, Wardlaw JM, Al-
Shahi Salman R. Incidental findings on brain magnetic resonance
imaging: systematic review and meta-analysis. BMJ. 2009 Aug
17; 339:b3016.
12. Choosing Wisely http://www.choosingwisely.org/ Accessed
October 18th, 2014
13. BBC News Is it right to waste helium on party balloons? http://
www.bbc.co.uk/news/magazine-24903034 Dated18 November
2013. Accessed October 18th, 2014
14. Moore FG, Chalk C. The essential neurologic examination: what
should medical students be taught? Neurology 2009; 72: 2020-2023.
15. JAMA Evidence: The rational clinical examination- evidence-
based clinical diagnosis. Edited by Simel DL & Rennie D.
McGraw-Hill, New York 2008.
16. BBC News website An electronic revolution in the doctor’s bag
28th Sept 2014. Accessed 18th October 2014 http://www.bbc.
co.uk/news/magazine-29376437
References
... Instead we agree with Yusuf et al 2 that despite advances in non-mydriatic fundus photography, basic skills in ophthalmic assessment are essential and advocate that there is no substitute for appropriate clinical examination. 4,5 It is unrealistic to expect undergraduates to be competent at direct ophthalmoscopy at the end of their short ophthalmology attachment. Instead, these skills should be taught early in the clinical curriculum so that they can be practised, reinforced, honed, and (most importantly) assessed during further attachments in neurology and general medicine. ...
Article
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Eye is the official journal of the Royal College of Ophthalmologists. It aims to provide the practising ophthalmologist with information on the latest clinical and laboratory-based research.
... Neurophobia stems from inadequate undergraduate and postgraduate exposure to neurology teaching and practical neurological situations, and is prevalent in medical students and junior doctors alike. [10,11] One misconception is that neurological examination is time-consuming, when in fact a rapid neurological Page 2 of 4 assessment can be completed within three minutes. ...
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We aimed to establish whether recall of elements of the neurological examination can be improved by use of a simple patient assessment score. In a previous study we demonstrated that in-patients referred to neurology at two United Kingdom (UK) hospitals were not fully examined prior to referral; we therefore designed a larger quality improvement report with 80% power to detect a 10% increase in tendon hammer or ophthalmoscope use following an educational intervention. In-patients referred to neurology over a four month period (in hospitals in the UK (10), Jordan (1), Sweden (2), and the United Arab Emirates (1)) were asked whether they recalled being examined with a tendon hammer (T), ophthalmoscope (O), and stethoscope (S) since admission. The results were disseminated to local medical teams using various techniques (including Grand Round presentations, email, posters, discounted equipment). Data were then collected for a further four month period post-intervention. Pre-intervention and post-intervention data were available for 11 centres with 407 & 391 patients in each arm respectively. Median age of patients was 51 (range 13-100) and 49 (range 16-95) years respectively, with 44.72% and 44.76% being male in each group. 264 patients (64.86%) recalled being examined with a tendon hammer in the pre-intervention arm, which significantly improved to 298 (76.21%) (p<0.001). Only 119 patients (29.24%) recollected examination with an ophthalmoscope pre-intervention, which significantly improved to 149 (38.11%)(p=0.009). The majority of patients (321 (78.87%)) pre-intervention recalled examination with a stethoscope, which significantly improved to 330 (84.4%) to a lesser extent (p=0.045). Results indicate that most patients are not fully examined prior to neurology referral yet a simple assessment score and educational intervention can improve recall of elements of the neurological examination and thus the likelihood of patients being examined neurologically. This is the largest and - to our knowledge - only study to assess this issue. This has implications for national neurological educators.
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To quantify the prevalence of incidental findings on magnetic resonance imaging (MRI) of the brain. Systematic review and meta-analysis of observational studies. Ovid Medline (1950 to May 2008), Embase (1980 to May 2008), and bibliographies of relevant articles. Review methods Two reviewers sought and assessed studies of people without neurological symptoms who underwent MRI of the brain with or without intravenous contrast for research purposes or for occupational, clinical, or commercial screening. Overall disease specific and age specific prevalence of incidental brain findings, calculated by meta-analysis of pooled proportions using DerSimonian-Laird weights in a random effects model. In 16 studies, 135 of 19 559 people had neoplastic incidental brain findings (prevalence 0.70%, 95% confidence interval 0.47% to 0.98%), and prevalence increased with age (chi(2) for linear trend, P=0.003). In 15 studies, 375 of 15 559 people had non-neoplastic incidental brain findings (prevalence 2.0%, 1.1% to 3.1%, excluding white matter hyperintensities, silent infarcts, and microbleeds). The number of asymptomatic people needed to scan to detect any incidental brain finding was 37. The prevalence of incidental brain findings was higher in studies using high resolution MRI sequences than in those using standard resolution sequences (4.3% v 1.7%, P<0.001). The prevalence of neoplastic incidental brain findings increased with age. Incidental findings on brain MRI are common, prevalence increases with age, and detection is more likely using high resolution MRI sequences than standard resolution sequences. These findings deserve to be mentioned when obtaining informed consent for brain MRI in research and clinical practice but are not sufficient to justify screening healthy asymptomatic people.
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: Ocular fundus examination is an important element of the neurological examination. However, direct ophthalmoscopy is difficult to perform without pupillary dilation and requires extensive practice to accurately recognize optic nerve and retinal abnormalities. Recent studies have suggested that digital retinal photography can replace direct ophthalmoscopy in many settings. : Ocular fundus imaging is routinely used to document and monitor disease progression in ophthalmology. Advances in optical technology have made it easier to obtain high-quality retinal imaging, even without pupillary dilation. Retinal photography has a high sensitivity, specificity, and interexamination/intraexamination agreement compared with in-person ophthalmologist examination, suggesting that photographs can be used in lieu of ophthalmoscopy in many clinical situations. Nonmydriatic retinal photography has recently gained relevance as a helpful tool for diagnosing neuro-ophthalmologic disorders in the emergency department. In addition, several population-based studies have used retinal imaging to relate ophthalmic abnormalities to the risk of hypertension, renal dysfunction, cardiovascular mortality, subclinical and clinical stroke, and cognitive impairment. The possibility of telemedical consultation offered by digital retinal photography has already increased access to timely and accurate subspecialty care, particularly for underserved areas. : Retinal photography (even without pupillary dilation) has become increasingly available to medical fields outside of ophthalmology, allowing for faster and more accurate diagnosis of various ocular, neurological, and systemic disorders. The potential for telemedicine may provide the additional benefits of improving access to appropriate urgent consultation in both clinical and research settings.
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Graduating medical students often identify the neurologic examination (NE) as one of the clinical skills with which they are least comfortable. We hypothesized that this is because they are unsure about which elements of the NE are important, and conducted a study 1) to identify whether neurologists agree about the essential elements of the NE and 2) to determine whether the views of medical students about what is essential differ from those of neurologists. Using a Delphi process, we asked McGill University neurologists which elements of the NE they would perform at least 80% of the time in a common clinical scenario. We confirmed the results in a sample of Canadian neurologists, and then compared the results of the McGill neurologists to a sample of graduating McGill University medical students. The neurologists surveyed rated 22 items of the NE as essential, and there was a high degree of consensus about which items were essential. Medical student ratings of the importance of NE items were largely similar to those of the neurologists, although there were some noteworthy discrepancies. The anxiety felt by medical students regarding the neurologic examination (NE) seems unlikely to be solely due to uncertainty about which elements of the NE are important. Expert consensus about the essential elements of the NE and awareness of areas where neurologist and student views differ should be used to guide teaching of the NE.
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Do you often get frustrated by the lack of neurological examination equipment on the wards? Are your residents’ backs breaking from lugging around their neurological “case”, weighing in excess of 5 kg?1 Is your ward manager complaining of the never-ending cost of repurchasing lost ophthalmoscopes? If so, read on … this solution might work for your unit! The Walton Centre is a stand-alone Neurology and Neurosurgery Hospital, with four in-patient wards. An audit showed that over a period of three years, 18 ophthalmoscopes were purchased at a total cost of £2283, 50 tuning forks at £1000 and 30 tendon hammers at £40. Despite this, at the time of the audit, there were only two tendon hammers, two ophthalmoscopes (one locked away in the ward sister’s office) and one otoscope, shared between the four wards; furthermore, these were only found after at least 30 …
  • B Matthews
  • Practical
  • Oxford
Matthews B. Practical neurology. Oxford: Blackwell Scientific Publications, 1963;1-256 (page 2).