Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care

How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU?

BACKGROUND

Neurological patients have lower mortality and better outcomes when cared for in specialized neurointensive care units than in general ICUs. However, little is known about how the process of care differs between these types of units.

METHODS

The Greater New York Hospital Association conducted a city-wide 24-h ICU prevalence survey on March 15th, 2007. Data was collected on all patients admitted to 143 ICUs in 69 different hospitals.

RESULTS

Of 1,906 ICU patients surveyed, 231 had a primary neurological diagnosis. Of these, 52 (22%) were admitted to one of 9 neuro-ICU's in NY and 179 (78%) to a medical or surgical ICU. Neurological patients in neuro-ICUs were more likely to have been transferred from an outside hospital (37% vs. 11%, P < 0.0001). Hemorrhagic stroke was more frequent in neuro-ICUs (46% vs. 16%, P < 0.0001), whereas traumatic brain injury (2% vs. 24%, P < 0.0001) and ischemic stroke (0% vs. 19%, P = 0.001) were less common. Despite a lower rate of mechanical ventilation (39% vs. 50%, P = 0.15), ICU length of stay was longer in neuro-ICU patients (≥10 days, 40% vs. 17%, P < 0.0001). More neuro-ICU patients had undergone tracheostomy (35% vs. 15%, P = 0.04), invasive hemodynamic monitoring (40% vs. 20%, P = 0.002), and invasive intracranial pressure monitoring (29% vs. 9%, P < 0.001) than patients cared for in general ICUs. Intravenous sedation was less prevalent in neuro-ICUs (12% vs. 30%, P = 0.009) and more patients were receiving nutritional support compared to general ICUs (67% vs. 39%, P < 0.001).

CONCLUSIONS

Neurological patients cared for in specialty neuro-ICUs underwent more invasive intracranial and hemodynamic monitoring, tracheostomy, and nutritional support, and received less IV sedation than patients in general ICUs. These differences in care may explain previously observed disparities in outcome between neurocritical care and general ICUs.

Intracerebral hemorrhage: clinical overview and pathophysiologic concepts

Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.

The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists

BACKGROUND

Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences.

METHODS

An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training.

RESULTS

The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care.

CONCLUSION

Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.

The critical care research networks experience

Neurocritical care is a subspecialty of critical care medicine, dedicated to the care and the advancement of care of critically ill patients with neurosurgical or neurological diseases. Neurocritical care patients are heterogeneous, in both their disease process and the therapies they receive, however, several studies demonstrate that care of these patients in dedicated NeuroIntensive Care Units (neuroICUs) by neurointensivists, who coordinate their care is associated with reduced mortality and resource utilization. NeuroICUs foster innovation, and yet despite all the recent advances, much research needs to be undertaken in neurocritical care to better understand the disease pathophysiology and to demonstrate improved outcome with the use of goal-directed therapy based on evolving techniques and therapies.

Geographic access to US Neurocritical Care Units registered with the Neurocritical Care Society

BACKGROUND

Neurocritical care provides multidisciplinary, specialized care to critically ill neurological patients, yet an understanding of the proportion of the population able to rapidly access specialized Neurocritical Care Units (NCUs) in the United States is currently unknown. We sought to quantify geographic access to NCUs by state, division, region, and for the US as a whole. In addition, we examined how mode of transportation (ground or air ambulance), and prehospital transport times affected population access to NCUs.

METHODS

Data were obtained from the Neurocritical Care Society (NCS), US Census Bureau and the Atlas and Database of Air Medical Services. Empirically derived prehospital time intervals and validated models estimating prehospital ground and air travel times were used to calculate total prehospital times. A discrete total prehospital time interval was calculated for each small unit of geographic analysis (block group) and block group populations were summed to determine the proportion of Americans able to reach a NCU within discrete time intervals (45, 60, 75, and 90 min). Results are presented for different geographies and for different modes of prehospital transport (ground or air ambulance).

RESULTS

There are 73 NCUs in the US using ground transportation alone, 12.8, 20.5, 27.4, and 32.6% of the US population are within 45, 60, 75, and 90 min of an NCU, respectively. Use of air ambulances increases access to 36.8, 50.4, 60, and 67.3 within 45, 60, 75, and 90 min, respectively. The Northeast has the highest access rates in the US using ground ambulances and for 45, 60, and 75 min transport times with the addition of air ambulances. At 90 min, the West has the highest access rate. The Southern region has the lowest ground and air access to NCUs access rates for all transport times.

CONCLUSIONS

Using NCUs registered with the NCS, current geographic access to NCUs is limited in the US, and geographic disparities in access to care exist. While additional NCUs may exist beyond those identified by the NCS database, we identify geographies with limited access to NCUs and offer a population-based planning perspective on the further development of the US neurocritical care system.

Isoflurane preconditioning protects astrocytes from oxygen and glucose deprivation independent of innate cell sex

BACKGROUND

Isoflurane exposure can protect the mammalian brain from subsequent insults such as ischemic stroke. However, this protective preconditioning effect is sexually dimorphic, with isoflurane preconditioning decreasing male while exacerbating female brain damage in a mouse model of cerebral ischemia. Emerging evidence suggests that innate cell sex is an important factor in cell death, with brain cells having sex-specific sensitivities to different insults. We used an in vitro model of isoflurane preconditioning and ischemia to test the hypothesis that isoflurane preconditioning protects male astrocytes while having no effect or even a deleterious effect in female astrocytes after subsequent oxygen and glucose deprivation (OGD).

METHODS

Sex-segregated astrocyte cultures derived from postnatal day 0 to 1 mice were allowed to reach confluency before being exposed to either 0% (sham preconditioning) or 3% isoflurane preconditioning for 2 hours. Cultures were then returned to normal growth conditions for 22 hours before undergoing 10 hours of OGD. Twenty-four hours after OGD, cell viability was quantified using a lactate dehydrogenase assay.

RESULTS

Isoflurane preconditioning increased cell survival after OGD compared with sham preconditioning independent of innate cell sex.

CONCLUSION

More studies are needed to determine how cell type and cell sex may impact on anesthetic preconditioning and subsequent ischemic outcomes in the brain.

Impact of a dedicated neurocritical care team in treating patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Intensivist staffing of intensive care units (ICUs) has been associated with a reduction in in-hospital mortality. These improvements in patient outcomes have been extended to neurointensivist staffing of neuroscience ICUs for patients with intracranial hemorrhage and traumatic brain injury.

OBJECTIVE

The primary objective of this study is to determine if hospital outcomes (measured by discharge status) for patients admitted with aneurysmal subarachnoid hemorrhage changed after the introduction of a neurointensivist-led multidisciplinary neurocritical care team.

METHODS

The authors retrospectively identified 703 patients admitted to the neuroscience ICU with a diagnosis of aneurysmal subarachnoid hemorrhage at a single academic tertiary care hospital between January 1, 1995 and December 31, 2002. It was compared with discharge outcomes for those patients treated prior to and following the development of a multidisciplinary neurocritical care team.

RESULTS

Patients treated after the introduction of a neurocritical care team were significantly more likely to be discharged to home (25.2% vs. 36.5%) and less likely to be discharged to a rehab facility (25.2% vs. 36.5%). Patients treated after introduction of a neurocritical care team were also more likely to receive definitive aneurysm treatment (10.9% vs. 18%).

CONCLUSION

The implementation of a neurointensivist-led neurocritical care team is associated with improved hospital discharge disposition for patients with aneurysmal subarachnoid hemorrhage.

The impact of a "low-intensity" versus "high-intensity" medical intensive care unit on patient outcomes in critically ill veterans

OBJECTIVE

To determine whether a low-intensity versus high-intensity medical intensive care unit (MICU) format in a Veterans Affairs (VA) hospital setting improves patient outcomes, as measured by duration of mechanical ventilation (MV), ventilator-free days (VFDs), and hospital mortality.

DESIGN

Retrospective cohort study.

SETTING

Medical intensive care unit at the San Francisco Veterans Affairs Medical Center (SFVAMC).

PATIENTS

On July 1, 2004, the SFVAMC transitioned from a low-intensity MICU to a high-intensity MICU. All patients admitted to the MICU who required MV for 18 months before (n = 96) and 18 months after (n = 131) the transition were included in the analysis.

MEASUREMENTS

We prospectively defined the primary outcome measure as the difference in the median duration of MV between groups. Secondary outcomes included VFDs and hospital mortality. Continuous variables were compared using the Wilcoxon rank sum test; dichotomous variables were compared using Fisher exact test.

MAIN RESULTS

The low-intensity and high-intensity MICU groups were similar in age, gender, weight, and admitting diagnosis (P > .27 in all cases). Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 22.0 in the low-intensity era and 20.0 in the high-intensity era (P = .048). Median duration of MV was significantly lower in the high-intensity MICU format compared to the low-intensity MICU format (102 vs 61 hours, P for log-rank test = .0052). After controlling for covariates, there were 4.2 more VFDs in the high-intensity era (95% CI 1.9 to 6.6 days). The high-intensity era was associated with a reduced hospital mortality rate (27% vs 40%) and an adjusted odds ratio of 0.34 (95% CI 0.15 to 0.74).

CONCLUSIONS

For critically ill veterans admitted to an MICU requiring MV, a high-intensity ICU structure is associated with more favorable mechanical ventilatory outcomes and lower mortality.

A new neurological focus in neonatal intensive care

Advances in the care of high-risk newborn babies have contributed to reduced mortality rates for premature and term births, but the surviving neonates often have increased neurological morbidity. Therapies aimed at reducing the neurological sequelae of birth asphyxia at term have brought hypothermia treatment into the realm of standard care. However, this therapy does not provide complete protection from neurological complications and a need to develop adjunctive therapies for improved neurological outcomes remains. In addition, the care of neurologically impaired neonates, regardless of their gestational age, clearly requires a focused approach to avoid further injury to the brain and to optimize the neurodevelopmental status of the newborn baby at discharge from hospital. This focused approach includes, but is not limited to, monitoring of the patient's brain with amplitude-integrated and continuous video EEG, prevention of infection, developmentally appropriate care, and family support. Provision of dedicated neurocritical care to newborn babies requires a collaborative effort between neonatologists and neurologists, training in neonatal neurology for nurses and future generations of care providers, and the recognition that common neonatal medical problems and intensive care have an effect on the developing brain.

Are trauma patients better off in a trauma ICU?

There is very little data on the value of specialized intensive care unit (ICU) care in the literature. To determine if specialize ICU care for the trauma patient improved outcomes in this patient population. Level I Trauma Center Compared outcomes of trauma patients treated in a surgical trauma ICU (STICU) to those treated in non- trauma ICUs (non-STICU). Retrospective review of trauma registry data.

STATISTICAL ANALYSIS

Wilcoxon Rank Test, Fischer's Exact test, logistic regression. There were 1146 STICU patients compared to 1475 non-STICU. In all ISS groups there were more penetrating trauma patients in the STICU (32.54% STICU vs. 18.15% non-STICU, P<0.0001 (ISS< 15)), (21.03% STICU vs. 12.98% non-STICU, P=0.0074 (ISS between 15-25)), and (19.42% STICU vs. 11.35% non-STICU, P=0.0026 (ISS> 25)). All groups had similar lengths of stay. The blunt trauma patients were sicker in the STICU (20.8 ISS +/- 12.2 STICU vs. 19.7 ISS +/- 11.9 non-STICU, P=0.03) yet had similar outcomes to the non-STICU group. Logistic regression identified penetrating trauma and not ICU location as a predictor of mortality. Sicker STICU patients do as well as less injured non-STICU patients. Severely injured patients should be preferentially treated in a STICU where they are better equipped to care for the complex multi-trauma patient. All patients, regardless of location, do well when their management is guided by a surgical critical care team.

Care models and associated outcomes in congenital heart surgery

OBJECTIVE

Recently, there has been a shift toward care of children undergoing heart surgery in dedicated pediatric cardiac intensive care units (CICU). The impact of this trend on patient outcomes is unclear. We evaluated postoperative outcomes associated with a CICU versus other ICU models.

PATIENTS AND METHODS

Society of Thoracic Surgeons Congenital Heart Surgery Database participants (2007-2009) who completed an ICU survey were included. In multivariable analysis, we evaluated outcomes associated with a CICU versus other ICUs, adjusting for center volume, patient factors, and Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery surgical risk category.

RESULTS

A total of 20 922 patients (47 centers; 25 with a CICU) were included. Overall unadjusted mortality was 3.8%, median length of stay was 6 days (interquartile range: 4-13), and 21% had 1 or more complications. In multivariable analysis, there was no difference in mortality comparing CICUs versus other ICUs (odds ratio: 0.88 [95% confidence interval: 0.65-1.19]). In stratified analysis, CICUs were associated with lower mortality only among those in Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category 3 (odds ratio: 0.47 [95% confidence interval: 0.25-0.86]), primarily related to atrioventricular canal repair and arterial switch operation. There was no difference in length of stay or complications overall or in stratified analysis.

CONCLUSIONS

We were not able to detect a difference in postoperative morbidity or mortality associated with the presence of a dedicated CICU for children undergoing heart surgery. There may be a survival benefit in certain subgroups .

Neurosurgical intensive care unit--essential for good outcomes in neurosurgery?

INTRODUCTION

Neurosurgical intensive care units were increasingly agglomerated in large centralized interdisciplinary intensive care units in the last two decades. In the majority, these centralized interdisciplinary intensive care units were directed and managed by intensivists coming from anaesthesiology. We sought to review the evidence supporting neurosurgical intensive care as a highly specialized discipline resulting in benefits for the treated patients.

CONCLUSIONS

In general, neurosurgical and neurocritical intensive care has been associated with improved outcomes and reduced mortality rates, reduced length of intensive care stay, improved resource utilisation, decreased in-hospital mortality, and fiscal benefits.

The appointment of neurointensivists is financially beneficial to the employer

BACKGROUND

Although the impact of a neurointensivist (NI) on patient outcomes has been examined in the past, the financial impact has not been estimated before.

METHODS

We extracted the financial data from the Neuro-Intensive Care Unit (NICU) at Henry Ford Hospital during two 3-year periods, one before and one after the appointment of a NI. Net revenue (NR), total direct expenses (TDE), and contribution margin (CM) were compared between these two periods both for Henry Ford Hospital and the Henry Ford Medical Group.

RESULTS

The average number of admissions increased by 24% during the period when the NI was present, the number of patient-days by 25% and the average length of stay by 2%. In the second period, when the NI was billing for critical care time spent in the NICU, as well as for procedures he performed, the mean yearly NR was $402,000, the TDE $317,000 and the NR/TDE 1.24 (>1.0 represents profitability). The combined mean NR (Henry Ford Hospital + Medical Group) increased by 54.6%, the combined TDE by 42.2% and the combined CM by 91.2% in the period when the NI was present. This is reflected in the combined mean CM per admission, which also increased by 56.4% in the after period.

CONCLUSION

This study shows a significant financial benefit for the Henry Ford Health System during the period when a NI was present in the NICU.

Brain tumor resection in children: neurointensive care unit course and resource utilization

OBJECTIVE

To describe the pediatric intensive care unit (PICU) course and resource utilization for children with brain tumor resection and to identify factors predicting prolonged (>1 day) PICU length of stay. After craniotomy for brain tumor resection, children recover in the PICU. A few require critical care interventions and a >24-hr length of stay.

DESIGN

We reviewed all brain tumor resection patients admitted to the PICU over 2 yrs. Preoperative, intraoperative, and postoperative variables and tumor characteristics were examined. The extracted variables were compared between two groups with a length of stay in the PICU of >1 or <1 day.

SETTING

Pediatric intensive care unit in a tertiary academic children's medical center.

PATIENTS

A total of 105 patients post brain tumor resection were admitted to the PICU over the study period and analyzed.

INTERVENTIONS

Record review.

MEASUREMENTS AND MAIN RESULTS

Thirty-two (31%) of 105 patients remained in the PICU for >1 day. The mean age of patients in the >1 day group was 5.0 ± 0.81 yrs and 8.78 ± 0.65 yrs in the <1 day group (p < .05). The estimated blood loss was 20 ± 2.37 mL/kg in the >1 day and 9 ± 0.92 mL/kg in the <1 day group (p < .05). Fifteen (14.3%) patients were mechanically ventilated on arrival in the PICU; these patients more often had a length of stay of >1 day (p < .05). The number of unexpected intensive care unit interventions were 0.7 per patient, were more common in the >1 day group, and included treatment of sodium abnormalities, new neurologic deficits, paresis, or seizures (p < .05). In a logistic regression model, estimated blood loss and intubation on arrival predicted longer lengths of stay in the PICU (odds ratio, 1.1; 95% confidence interval, 1.05-1.18; and odds ratio, 33; 95% confidence interval, 2.57-333, respectively), with a receiver operating characteristic curve of 0.86 and 95% confidence interval, 0.78-0.94.

CONCLUSIONS

Large intraoperative estimated blood loss and intubation on arrival may be predictive of PICU lengths of stay of >1 day for children who have had a craniotomy for brain tumor resection. Intensive care unit interventions are more common in these children.

The impact of postoperative intensive care on outcomes in elective neurosurgical patients in good physical condition: a single centre propensity case-matched study

PURPOSE

In the last three years, all elective neurosurgical cases were performed by a single surgeon at Nara Medical University. For the last year and a half, all patients were transferred to a newly created neurosurgical intensive care unit. The purpose of this study was to evaluate the impact of admission to an intensive care unit after elective neurosurgery.

METHODS

This study was conducted as a retrospective clinical chart review. Institutional ethics approval was waived, and we reviewed the charts of 296 neurosurgical patients who were American Society of Anesthesiologists' physical status I-II. To avoid channelling bias, propensity score analysis was used to generate a set of matched cases (patients transferred to the intensive care unit [ICU]) and controls (patients transferred to the neurosurgical ward). This process resulted in 104 matched pairs of elective surgical patients who did or did not have an ICU admission after surgery. Glasgow outcome scale (GOS) at discharge or at three months after the operation was compared as the primary outcome measure. As secondary outcome measures, we also compared rates of severe early complications and patient satisfaction regarding perioperative patient care.

RESULTS

With an unmatched population, poor GOS tended to occur more often in the non-ICU group than in the ICU group (6.5% vs 2.3%, respectively). Mortality rates and severe early complication rates also tended to be higher in the non-ICU group than in the ICU group (2.4% and 5.3%, respectively, non-ICU group vs 0.8% and 2.3%, respectively, ICU group). However, after propensity score matching, there was no difference regarding the GOS between groups. Both groups showed very high good outcome percentages (98.1% ICU vs 97.1% non-ICU). With regard to mortality rates and severe early complications, both groups showed low mortality (0.96% vs 0.96%) and complication rates (2.89% ICU vs 3.85% non-ICU). Patient care in the ICU failed to increase patient satisfaction regarding the overall hospital care.

CONCLUSION

The results of this analysis suggest that admission to an ICU after elective neurosurgery has little impact on outcomes.

Braun's flexor tendons transfer in disabled hands by central nervous system lesions

INTRODUCTION

Since Braun's article, the nonfunctional hand of brain-injured patients has not been the subject of many publications. The objective of surgical treatment is to open the hand for hygiene and cosmetic reasons. The technique consists in lengthening the extrinsic flexor tendons group.

HYPOTHESIS

The purpose of this work is to assess eventual functional benefits from superficialis-to-profundus tendon transfer according to Braun.

MATERIAL AND METHODS

Our series comprised 15 patients aged a mean 55 years, operated using the Braun procedure for a nonfunctional hand (19 hands). Additional procedures were performed as required by the local condition (neurotomy of the deep branch of the ulnar nerve, wrist fusion, tenotomy of the flexors of the wrist and flexor pollicis longus, tenodesis of the extensors of the wrist). The results were assessed by the analysis of finger opening ability and by a specific scoring system (Mini Hand Score; MHS) rated from 6 (no discomfort) at 20 (major discomfort).

RESULTS

The mean follow-up was 6 months. We observed imperfect results: thumb opening incapacity, spasticity of the intrinsic flexors, and hyperextension of the wrist. The preoperative MHS was a mean 13.87 out of 20 and the postoperative MHS was 9.67 out of 20, with a very substantial difference.

DISCUSSION

Our easy-to-use system for evaluating the nonfunctional hand (MHS) was shown to be very effective in demonstrating the improvement of the postoperative result. The originality of our series was to show that Braun's original operation goals were only exceptionally and remotely achieved and that an additional technical procedure must be nearly systematically considered. All the patients in our series were followed up in multidisciplinary team visits where the patient's family and caretakers were encouraged to give their point of view. Level of evidence Level IV. Retrospective study.

Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

CONCLUSIONS

Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Predictors for good functional outcome after neurocritical care

Introduction

There are only limited data on the long-term outcome of patients receiving specialized neurocritical care. In this study we analyzed survival, long-term mortality and functional outcome after neurocritical care and determined predictors for good functional outcome.

Methods

We retrospectively investigated 796 consecutive patients admitted to a non-surgical neurologic intensive care unit over a period of two years (2006 and 2007). Demographic and clinical parameters were analyzed. Depending on the diagnosis, we grouped patients according to their diseases (cerebral ischemia, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), meningitis/encephalitis, epilepsy, Guillain-Barré syndrome (GBS) and myasthenia gravis (MG), neurodegenerative diseases and encephalopathy, cerebral neoplasm and intoxication). Clinical parameters, mortality and functional outcome of all treated patients were analyzed. Functional outcome (using the modified Rankin Scale, mRS) one year after discharge was assessed by a mailed questionnaire or telephone interview. Outcome was dichotomized into good (mRS ≤ 2) and poor (mRS ≥ 3). Logistic regression analyses were calculated to determine independent predictors for good functional outcome.

Results

Overall in-hospital mortality amounted to 22.5% of all patients, and a good long-term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of ICH, GBS/MG, and inoperable cerebral neoplasm as well as Therapeutic Intervention Scoring System (TISS)-28 on Day 1 were independently associated with functional outcome after one year.

Conclusions

This investigation revealed that age, LOV and TISS-28 on Day 1 were strongly predictive for the outcome. The diagnoses of hemorrhagic stroke and cerebral neoplasm leading to neurocritical care predispose for functional dependence or death, whereas patients with GBS and MG are more likely to recover after neurocritical care.

The future of neurology

For the past 200 years, neurology has been deeply rooted in the history and neurologic examination, but 21st century advances in neurosurgery, endovascular techniques, and neuropathology, and an explosion in basic neuroscience research and neuroimaging have added exciting new dimensions to the field. Neurology residency training programs face intense governmental regulatory changes and economic pressures, making it difficult to predict the number of neurology residents being trained for the future. The future job outlook for neurologists in the United States, based on recent survey and trends, suggests an increased demand because of the prevalence of neurologic diseases within the aging population, particularly in underserved urban and rural areas. Telemedicine and "teleconsultation" offer a potential solution to bringing virtual subspecialists to underserved areas. The future for neurology and neuroscience research in the United States remains a high priority according to the National Institute of Neurologic Diseases and Stroke, but this may be affected in the long run by budgetary constraints and a growing deficit.

Centralized triage for multiple intensive care units: the central intensivist physician

Subspecialization of critical care units and overall increasing demand for critical care services has led to inefficiencies in allocation of critical care resources with potential impacts on hospital economics and patient outcomes. Centralized management of critical care resource allocation within an institution may improve use while simultaneously ensuring quality of patient care. The authors' institution has implemented a Central Intensivist Physician (CIP) program to oversee resource allocation within the adult surgical intensive care units (ICUs). The result has been an improvement in patient flow throughout the surgical ICUs manifested by steady case cancellation rates despite increasing acuity and length of stay. Additionally, triage duties have been shifted from the individual unit physician to the CIP, resulting in improved provider satisfaction from improved continuity of rounds. The authors conclude that the CIP program may improve overall critical care resource use while maintaining unit specialization within a large tertiary care hospital setting.

Management of acute intracranial and intraventricular hemorrhage

OBJECTIVE

Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage.

DATA SOURCES

PubMed search and review of the relevant medical literature.

SUMMARY

The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery.

CONCLUSIONS

Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.

Intracerebral hemorrhage: getting ready for effective treatments

PURPOSE OF REVIEW

Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke and a leading cause of disability and mortality in the United States and the rest of the world. The purpose of this article is to review recent advances in the management of spontaneous intracerebral hemorrhage.

RECENT FINDINGS

Although no interventions have consistently shown an improvement of mortality or functional outcomes after ICH, results from multicenter prospective randomized controlled trials have shown that early hemostasis to prevent hematoma growth, removal of clot by surgical or minimally invasive interventions, clearance of intraventricular hemorrhage, and adequate blood pressure control for the optimization of cerebral perfusion pressure may constitute the most important therapeutic goals to ameliorate secondary neurological damage, decrease mortality, and improve functional outcomes after ICH.

CONCLUSION

Several promising methods may be ready for routine clinical use in a few years to decrease disability and mortality from ICH.

Nurses' perceptions of subspecialization in pediatric cardiac intensive care unit: quality and patient safety implications

This study assessed the perceptions of nurses about the creation and staffing of a dedicated cardiac intensive care unit. Nurses perceived a clinical benefit to cohorting cardiac surgery patients; however, they reported more knowledge deficits in cardiac patient care than other intensive care unit disease categories. More than 25% of nurses reported a patient assignment in which they identified suboptimal skills to provide safe patient care. Years of clinical experience did not reduce concerns for quality of care or safe practice.

Withdrawal of life support in critically ill neurosurgical patients and in-hospital death after discharge from the neurosurgical intensive care unit. Clinical article

OBJECT

The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI).

METHODS

Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI.

RESULTS

One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03-1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04-1.07), transfer from another hospital (OR 3.7, 95% CI 1.6-8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4-12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2-17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4-20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9-16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92-0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1-1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83-47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate.

CONCLUSIONS

The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI-including patient age and the severity and type of neurological injury-play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.

Critical illness outcomes in specialty versus general intensive care units

RATIONALE

General intensive care units (ICUs) provide care across a wide range of diagnoses, whereas specialty ICUs provide diagnosis-specific care. Risk-adjusted outcome differences across such units are unknown.

OBJECTIVES

To determine the association between specialty ICU care and the outcome of critical illness.

METHODS

We conducted a retrospective cohort study design analyzing patients admitted to 124 ICUs participating in the Acute Physiology and Chronic Health Evaluation IV from January 2002 to December 2005. We examined 84,182 patients admitted to specialty and general ICUs with an admitting diagnosis or procedure of acute coronary syndrome, ischemic stroke, intracranial hemorrhage, pneumonia, abdominal surgery, or coronary-artery bypass graft surgery. ICU type was determined by a local data coordinator at each site. Patients were classified by admission to a general ICU, a diagnosis-appropriate ("ideal") specialty ICU, or a diagnosis-inappropriate ("non-ideal") specialty ICU. The primary outcomes were in-hospital mortality and ICU length of stay.

MEASUREMENTS AND MAIN RESULTS

After adjusting for important confounders, there were no significant differences in risk-adjusted mortality between general versus ideal specialty ICUs for all conditions other than pneumonia. Risk-adjusted mortality was significantly greater for patients admitted to non-ideal specialty ICUs. There was no consistent effect of specialization on length of stay for all patients or for ICU survivors.

CONCLUSIONS

Ideal specialty ICU care appears to offer no survival benefit over general ICU care for select common diagnoses. Non-ideal specialty ICU care (i.e., "boarding") is associated with increased risk-adjusted mortality.

Clinical review: Critical care management of spontaneous intracerebral hemorrhage

Intracerebral hemorrhage is by far the most destructive form of stroke. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging. Ventilatory support, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, treatment of hyerglycemia, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Dexamethasone and other glucocorticoids should be avoided. Ventricular drainage should be performed urgently in all stuporous or comatose patients with intraventricular blood and acute hydrocephalus. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage.

Management of warfarin-related intracerebral hemorrhage

Warfarin-related intracerebral hemorrhage (WICH) is a medical and neurosurgical emergency with a 1-month mortality of approximately 50%. Warfarin is commonly is used in patients with atrial fibrillation to prevent ischemic stroke and to prevent progression of deep vein thrombosis to pulmonary embolism. Owing to the ageing population, and increased incidence of atrial fibrillation with age and warfarin use, the incidence of WICH is expected to rise in the future. When WICH occurs, immediate discontinuation of warfarin with rapid warfarin reversal remains the first-line intervention, often with neurosurgical intervention. The optimal agent for rapid warfarin anticoagulation reversal remains to be defined owing to the lack of prospective randomized trials. We review current literature and prospects for future research for this devastating neurologic emergency.

Controversies in neurosciences critical care

Perhaps the greatest recent controversy in the medical management of complex neurologic and neurosurgical patients has been the defining of the optimal care arena. Despite some early skepticism and measured recognition by the ICU community, neurosciences critical care has grown into a well-recognized subspecialty. Within this environment, the diverse expertise of surgeons, neurologists, and anesthesiologists come together to define best therapeutic strategies. Two neurologic disease states that, in particular, continue to elicit expansive interdisciplinary debate are spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage.

Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients

BACKGROUND AND PURPOSE

Dedicated stroke units are associated with improved patient outcomes after acute ischemic stroke in general. However, it is unknown whether the population of critically ill ischemic stroke patients admitted to the neurocritical care unit (NCCU) benefit from primary management by a specialized neurocritical care team (NCT). This study is intended to investigate such benefit.

METHODS

A retrospective chart review in a large academic university hospital identified 400 patients with acute ischemic stroke admitted to the NCCU, from January 1997 to April 2000, aged 65 +/- 14 years. We examined the short- and long-term outcomes of these patients before and after institution of a specialized NCT. We used logistic regression models to determine independent association between outcome and availability of NCT.

RESULTS

The presence of a NCT was associated with a decreased length of NCCU stay (2.9 +/- 2.0 vs. 3.7 +/- 2.9 days, P < 0.01), decreased length of hospital stay (7.5 +/- 4.7 vs. 9.9 +/- 7.6, P < 0.001), and increased proportion of home discharges (47% vs. 36%, P < 0.05). The only independent predictor of in-hospital and long-term mortality was the underlying severity of disease as determined by the APACHE III score.

CONCLUSIONS

In critically ill acute ischemic stroke patients, institution of a dedicated NCT was associated with a reduction in resource utilization and improved patient outcomes at hospital discharge. Several factors including improved patient care protocols may explain this association.

When are new graduate nurses competent in the intensive care unit?

Transitioning from the graduate nurse level to that of competent practitioner may be characterized as 5 distinct stages instead of 3 as previously thought. Educational and performance goals and challenges may be described for each stage to track a nurse's progress through a critical care nursing development program without the traditional prerequisite period of general ward service.

Quand faut-il décider d'un transfert en milieu neurochirurgical spécialisé?

The annual incidence of severe head injury lies between 9 and 25/100000 inhabitants, depending on the criteria used for its definition. In most countries, the shortage in neurosurgical ICU beds makes it impossible to take in charge all patients with a severe brain injury. But the beneficial effect of a specialized neurosurgical ICU on outcome after brain injury has been demonstrated in several retrospective studies. Ideally, the best strategy is to admit the patients with a severe head injury directly in a neurosurgical centre. When this is not possible, the appropriate decision of a secondary transfer relies on the quality of the relationships between physicians in the community and the neurosurgical hospitals. Teleradiology is the best method to avoid unnecessary transportation or deleterious delays before transfer. In an era of decreasing medical budgets, technical improvements to enhance medical cooperation should be encouraged.

Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury

RATIONALE

Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients.

OBJECTIVES

To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA).

METHODS

Cohort study of patients with acute lung injury (ALI).

MEASUREMENTS AND MAIN RESULTS

ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition.

CONCLUSIONS

Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.