Do you need certification for the Modified NIHSS?

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Hi all! My employer recently rolled out the modified NIH stroke scale (mNIHSS) and said it can be completed by float nurses who are not NIHSS certified - hence the 'modification'. Does anyone know if this is true? I can't find anything online or in our internal policy manual regarding this.

MunoRN, RN

8,058 Posts

Specializes in Critical Care. Has 10 years experience.

I think first it helps to put the clinical usefulness of the NIHSS into context in order to consider the importance of ensuring clinicians are doing it correctly.

The NIHSS was designed solely for research, to help compare different stroke interventions.  As a way of guiding clinical care of stroke patients, it has little to no usefulness.

Someone 'officially certified' in the NIHSS needs to perform one NIHSS assessment in the first 12 hours of admission as a requirement of a JC accredited Stroke Center, but it doesn't serve much actual purpose and additional NIHSS assessments during their stay aren't useful, yet for some reason hospitals have gone a little overboard with the use of the NIHSS.

The modified NIHSS is intended to have less interrater variability, which is the main reason for the extensive training to be certified for the full NIHSS, so should be more "accurate" when used by those with no specific mNIHSS training.

MelEpiRN

181 Posts

It's going to pose more of a problem with a re-certification if y'all aren't assessing the deficits. If your mNIHSS is only assessing LOC and extremities but the deficits are sensory or speech, what good is it going to do? How do you catch a patient in neuro decline?

JBMmom, MSN, NP

4 Articles; 2,353 Posts

Specializes in New Critical care NP, Critical care, Med-surg, LTC. Has 11 years experience.

I hate the NIHSS scoring. There's too much interscorer variability and people don't often understand how to score. For example, if a patient is unable to perform the movement they shouldn't score a positive for ataxia, but they often do. When shifts change a patient's score with often fluctuate by 2-5 points when another nurse takes over. Whenever I get a patient from another floor, I make sure we do one score together so I can see how the previous nurse scored the patient. That way whatever number I get the next time, I can say with certainty whether it's a change in condition.

I think that the certification itself has more to do with the hospital accreditation then it does the ability to do the scoring itself. 

MunoRN, RN

8,058 Posts

Specializes in Critical Care. Has 10 years experience.
12 hours ago, MelEpiRN said:

It's going to pose more of a problem with a re-certification if y'all aren't assessing the deficits. If your mNIHSS is only assessing LOC and extremities but the deficits are sensory or speech, what good is it going to do? How do you catch a patient in neuro decline?

You would catch a patient in neuro decline by conducting assessments with clinical relevance, NIH assessments don't provide this nor were they ever intended to.

JBMmom, MSN, NP

4 Articles; 2,353 Posts

Specializes in New Critical care NP, Critical care, Med-surg, LTC. Has 11 years experience.
On 5/17/2022 at 12:09 AM, MunoRN said:

You would catch a patient in neuro decline by conducting assessments with clinical relevance, NIH assessments don't provide this nor were they ever intended to.

And with the way my hospital has us do the assessments (every 15 minutes for 2 hours, every 30 minutes for six hours and then every hour for 16 hours) are they have actual cognitive changes due to a new hemorrhagic stroke, or are they just delirious from being sleep deprived? It's ridiculous- and it just makes many people angry. I've been in my unit for four years, we've probably had nearly a hundred people post tPA, I've NEVER had a patient have a new hemorrhagic stroke post tPA. I've only had one patient that had worsening of neurologic status and it was not related to a new bleed, it also wasn't detected by the NIHSS activities and questions. 

MunoRN, RN

8,058 Posts

Specializes in Critical Care. Has 10 years experience.
9 hours ago, JBMmom said:

And with the way my hospital has us do the assessments (every 15 minutes for 2 hours, every 30 minutes for six hours and then every hour for 16 hours) are they have actual cognitive changes due to a new hemorrhagic stroke, or are they just delirious from being sleep deprived? It's ridiculous- and it just makes many people angry. I've been in my unit for four years, we've probably had nearly a hundred people post tPA, I've NEVER had a patient have a new hemorrhagic stroke post tPA. I've only had one patient that had worsening of neurologic status and it was not related to a new bleed, it also wasn't detected by the NIHSS activities and questions. 

I have a term, that I actually include in my charting, for the inevitable delirium that results from q 1hr neuro checks through the night, or multiple nights, on an elderly hospitalized patient; "iatrogenic observer effect".

My favorite is when a provider decides we need to extend the q 1hr neuro checks because there have been cognitive changes in the patient (ignoring that the cognitive changes are likely a result of the q 1hr neuro checks day and night). 

Aside from the fact that cognitive changes and neurological changes are two very different things, the problem with frequent NIH based neuro checks (mNIHSS or "brief neuro" checks) is that they provide no clinically relevant information, and just distract from the assessments that actually might guide our treatment.

An NIH that changes from 19 to 22 means absolutely nothing in terms of how we are going to treat the patient.