A Novel Neuroscience Intermediate-Level Care Unit Model: Retrospective Analysis of Impact on Patient Flow and Safety

Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges

BACKGROUND

Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC.

OBJECTIVE

To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa.

METHODS

We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included.

RESULTS

Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources.

CONCLUSION

Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.

Developing a Trauma Intermediate Care Unit

BACKGROUND

Trauma-specific nursing units are integral to providing quality trauma care. Yet, little has been published on intermediate care units for the trauma population.

OBJECTIVE

This article aims to describe one trauma center's journey to develop and implement a trauma intermediate care unit.

METHODS

The need for a trauma intermediate care unit was identified during the review of patient care at a Level II trauma center. An interdisciplinary team was created and met weekly for 6 months to plan the implementation of a trauma intermediate care unit. Education plans, training, equipment procurement, and staffing were evaluated throughout the process.

RESULTS

Positive results were noted from the implementation of the intermediate care unit through the first year following implementation. The average length of stay for patients in the surgical trauma intensive care unit was reduced, resulting in cost savings for the organization. In addition, this collaborative work positively impacted patient safety, staff engagement, and finances.

CONCLUSION

With leadership support, the proper key stakeholders, clear deliverables, and a well-defined development plan, the implementation of this intermediate care unit was successful.

Admitting Low-Risk Patients With Intracerebral Hemorrhage to a Neurological Step-Down Unit Is Safe, Results in Shorter Length of Stay, and Reduces Intensive Care Utilization: A Retrospective Controlled Cohort Study

Background and Purpose

Patients suffering intracerebral hemorrhage (ICH) are at risk for early neurologic deterioration and are often admitted to intensive care units (ICU) for observation. There is limited data on the safety of admitting low-risk patients with ICH to a non-ICU setting. We hypothesized that admitting such patients to a neurologic step-down unit (SDU) is safe and less resource-intensive.

Methods

We performed a retrospective analysis of patients with primary ICH admitted to our SDU. We compared this cohort to a control group of ICH patients admitted to a neurologic-ICU (NICU) at a partner institution. We analyzed patients with supratentorial ICH ≤15 cc, Glasgow Coma Scale ≥ 13, National Institutes of Health Stroke Scale ≤ 10, and no to minimal intraventricular hemorrhage. Primary end points were (re-)admission to an NICU and rates of hematoma expansion (HE). We also compared total NICU days and hospital length of stay (LOS).

Results

Eighty patients with ICH were admitted to the SDU. Only 2 required transfer to the NICU for complications related to ICH, including 1 for HE. Seventy-four SDU patients met inclusion criteria and were compared to 58 patients admitted to an NICU. There was no difference in rates of NICU (re-)admission (7 vs 2, P = .17) or rates of HE (3 vs 5, P = .28). Median NICU days were 0 versus 1 (P < .001). Step-down unit admission was associated with shorter LOS (3 vs 4 days, P = .05).

Conclusions

Select patients with ICH can be safely admitted to an SDU. This may reduce LOS and ICU utilization. We also propose criteria for admitting patients with ICH to an SDU.

Access to the Intensive Care Unit by Severe Head Injury Patients

Background The management of severe traumatic brain injury is directed at avoidance of secondary brain injuries. The intensive care unit (ICU) provides the ideal environment to achieving improved survival and functional outcome. The study sets out to identify the factors that determine the access of patients with severe head injury presenting at our hospital, to the ICU and their impact on outcome.

Materials and Methods his was a longitudinal study at the University College Hospital, Ibadan. Data of all consecutive severe head injury patients over a 9-month period, presenting to the accident and emergency department, was collected and analyzed using descriptive statistics and chi-squared test. The level of significance was p < 0.05.

Result There were 36 males (80.0%) in our study, with road crashes (25; 79.5%) as the most common mechanism of injury. Most patients (33; 73.3%) were transferred to our center after initial care in another hospital. Though 31(68.9%) patients had access to the ICU, they were all delayed, with the most common reason for the delay being lack of ICU space. More patients who got admitted into ICU (14; 45.2%) were alive at 28 days into admission ( p = 0.04). The females (6; 13.3%) significantly survived till 28 days on admission compared with males ( p = 0.03), but there was no difference in the survival rates between children and adults.

Conclusion Our study underscores the need for ICU admission in these patients to optimize outcome and identify the nonavailability of beds, as the most important cause of delayed access, as well as the need for increased manpower capacity and organized resource utilization.

Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System

Objectives:

To determine whether Telemedicine intervention can affect hospital mortality, length of stay, and direct costs for progressive care unit patients.

Design:

Retrospective observational.

Setting:

Large healthcare system in Florida.

Patients:

Adult patients admitted to progressive care unit (PCU) as their primary admission between December 2011 and August 2016 (n = 16,091).

Interventions:

Progressive care unit patients with telemedicine intervention (telemedicine PCU [TPCU]; n = 8091) and without telemedicine control (nontelemedicine PCU [NTPCU]; n = 8000) were compared concurrently during study period.

Measurements and Main Results:

Primary outcome was progressive care unit and hospital mortality. Secondary outcomes were hospital length of stay, progressive care unit length of stay, and mean direct costs. The mean age NTPCU and TPCU patients were 63.4 years (95% CI, 62.9–63.8 yr) and 71.1 years (95% CI, 70.7–71.4 yr), respectively. All Patient Refined-Diagnosis Related Group Disease Severity (p < 0.0001) and All Patient Refined-Diagnosis Related Group patient Risk of Mortality (p < 0.0001) scores were significantly higher among TPCU versus NTPCU. After adjusting for age, sex, race, disease severity, risk of mortality, hospital entity, and organ systems, TPCU survival benefit was 20%. Mean progressive care unit length of stay was lower among TPCU compared with NTPCU (2.6 vs 3.2 d; p < 0.0001). Postprogressive care unit hospital length of stay was longer for TPCU patients, compared with NTPCU (7.3 vs 6.8 d; p < 0.0001). The overall mean direct cost was higher for TPCU ($13,180), compared with NTPCU ($12,301; p < 0.0001).

Conclusions:

Although there are many studies about the effects of telemedicine in ICU, currently there are no studies on the effects of telemedicine in progressive care unit settings. Our study showed that TPCU intervention significantly decreased mortality in progressive care unit and hospital and progressive care unit length of stay despite the fact patients in TPCU were older and had higher disease severity, and risk of mortality. Increased postprogressive care unit hospital length of stay and total mean direct costs inclusive of telemedicine costs coincided with improved survival rates. Telemedicine intervention decreased overall mortality and length of stay within progressive care units without substantial cost incurrences.

Challenging the myth of outpatient craniotomy for brain tumor in a Sub-Saharan African setting: A case series of two patients in Ibadan, Nigeria

BACKGROUND

The concept of modern neuro-oncology hinges on strategic innovation and refinement of procedures with the intention to enhance safety, optimize extent of tumor resection, and improve not only survival but also the quality of life as well. One of such refinements includes same-day hospital admission, as well as early discharge following brain tumor surgeries. The latter has been further stretched to same-day discharge in particular settings to reduce the risk of nosocomial infections, cut brain tumor surgery costs, and improve patients' satisfaction. We highlight the challenges and possible benefits of outpatient craniotomy in a sub-Saharan African setting portrayed by the presence of lean resources and a predominant "out of pocket" health-care financing.

CASE DESCRIPTION

Outpatient craniotomy was performed in two selected patients harboring intra-axial tumors: a right temporal low-grade glioma and a left frontal metastasis. The clinical outcome proved successful at short- and long-term in both patients; complications related to surgery and same-day discharge were not reported.

CONCLUSION

Outpatient craniotomy is practicable and safe in resource-challenged environments and can further make brain tumor surgery cost effective and acceptable in carefully selected patients. Further prospective studies in similar settings but involving larger groups of patients are warranted.

Criteria for Intensive Care admission and monitoring after elective craniotomy

PURPOSE OF REVIEW

The current article revises the recent evidence on ICU admission criteria and postoperative neuromonitoring for patients undergoing elective craniotomy.

RECENT FINDINGS

Only a small proportion of elective postoperative neurosurgical patients require specific medical interventions and invasive monitoring. Among these, patients undergoing elective craniotomy are frequently admitted to neuro-ICU, specialist postanaesthesia care units or intermediate-level care unit in the postoperative period.Craniotomy patients have a high risk of neurological complications in the immediate postoperative period and might require advanced neuromonitoring, especially if sedation is continued in the ICU.Furthermore, the concept of enhanced recovery after surgery with the goal of improving functional capacity after surgery and decreasing morbidity has expanded to encompass neurosurgery.Postoperative clinical examination and neurological scores, bispectral index and simplified electroencephalography, and morning discharge huddles are the most used strategies in this context.

SUMMARY

After elective craniotomy, ICU admission should be warranted to patients who show new neurological deficits, especially when these include reduced consciousness or deficits of the lower cranial nerves, or have surgical indication for delayed extubation. Currently, evidence does not allow defining standardized protocol to guide ICU admission and postoperative neuromonitoring.

Safety and Costs of Stroke Unit Admission for Select Acute Intracerebral Hemorrhage Patients

Background and Purpose

There are limited data to guide intensive care unit (ICU) versus dedicated stroke unit (SU) admission for intracerebral hemorrhage (ICH) patients. We hypothesized select patients can be safely cared for in SU versus ICU at lower costs.

Methods

We conducted a retrospective cohort study of consecutive patients with predefined minor ICH (≤20 cm³, supratentorial, no coagulopathy) receiving care in either an ICU or an SU. Multiple linear regression and inverse probability weighting were used to adjust for differences in patient characteristics and nonrandom ICU versus SU assignment. The primary outcome was poor functional status at discharge (modified Rankin score [mRS] ≥3). Secondary outcomes included complications, discharge disposition, hospital length of stay, and direct inpatient costs.

Results

The study population included 104 patients (41 admitted to the ICU and 63 admitted to the SU). After controlling for differences in baseline characteristics, there were no differences in poor functional outcome at discharge (93% vs 85%, P = .26) or in mean mRS (2.9 vs 3.0, P = .73). Similarly, there were no differences in the rates of complications (6% vs 10%, P = .44), discharged dead or to a skilled nursing facility (8% vs 13%, P = .59), or direct patient costs (US$7100 vs US$6200, P = .33). Median length of stay was significantly longer in the ICU group (5 vs 4 days, P = .01).

Conclusions

This study revealed a shorter length of stay but no large differences in functional outcome, safety, or cost among patients with minor ICH admitted to a dedicated SU compared to an ICU.