Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality after intracranial haemorrhage

Neurology/Neurosurgery Intensive Care Unit, Department of Neurology and Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA.
Critical Care Medicine (Impact Factor: 6.31). 04/2001; 29(3):635-40. DOI: 10.1097/00003246-200103000-00031
Source: PubMed


To determine whether mortality rate after intracerebral hemorrhage (ICH) is lower in patients admitted to a neurologic or neurosurgical (neuro) intensive care unit (ICU) compared to those admitted to general ICUs.
The utility of specialty ICUs is debated. From a cost perspective, having fewer larger ICUs is preferred. Alternatively, the impact of specialty ICUs on patient outcome is unknown. Patients with ICH are admitted routinely to both general and neuro ICUs and provide an opportunity to address this question.
Forty-two neuro, medical, surgical, and medical-surgical ICUs.
The study was an analysis of data prospectively collected by Project Impact over 3 yrs from 42 participating ICUs (including one neuro ICU) across the country. The records of 36,986 patients were merged with records of 3,298 patients from a second neuro ICU that collected the same data over the same period. The impact of clinical (age, race, gender, Glasgow Coma Scale score, reason for admission, insurance), ICU (size, number of ICH patients, full-time intensivist, clinical service, American College for Graduate Medical Education or Critical Care Medicine fellowship), and institutional (size, location, medical school affiliation) characteristics on hospital mortality rate of ICH patients was assessed by using a forward-enter multivariate analysis. Data from 1,038 patients were included. The 13 ICUs that admitted >20 patients accounted for 83% of the admissions with a mortality rate that ranged from 25% to 64%. Multivariate analysis adjusted for patient demographics, severity of ICH, and ICU and institutional characteristics indicated that not being in a neuro ICU was associated with an increase in hospital mortality rate (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.65-7.6). Other factors associated with higher mortality rate were greater age (OR, 1.03/year; 95% CI, 1.01-1.04), lower Glasgow Coma Scale score (OR, 0.6/point; 95% CI, 0.58-0.65), fewer ICH patients (OR, 1.01/patient; 95% CI, 1.00-1.01), and smaller ICU (OR, 1.1/bed; 95% CI, 1.02-1.13). Having a full time intensivist was associated with lower mortality rate (OR, 0.388; 95% CI, 0.22-0.67).
For patients with acute ICH, admission to a neuro vs. general ICU is associated with reduced mortality rate.

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    • "The current guidelines recommend all ICH patients be managed initially in a facility with neuroscience expertise, preferably in a dedicated neuroscience intensive care unit (NSICU) with the capacity to perform subspecialized neurosurgical procedures (SNP) [4]. It has been suggested that the admission of ICH patients to a dedicated NSICU is associated with improved outcomes compared to admission to a general intensive care unit [5]. As a result, the majority of ICH patients seen in the emergency department (ED) are being transferred to a higher-level facility with NSICU and neurosurgical coverage in accordance with the Emergency Medical Treatment and Active Labor Act [6] [7]. "
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    ABSTRACT: Background: Currently, intracerebral hemorrhage (ICH) patients from neighbor islands are air transported to a higher-level facility on Oahu with neuroscience expertise. However, the majority of them do not receive subspecialized neurosurgical procedures (SNP) upon transfer. Hence, their transfer may potentially be considered as excess cost. Methods: Consecutive ICH patients hospitalized at a tertiary center on Oahu between 2006 and 2013 were studied. Subspecialized neurosurgical procedure was defined as any neurosurgical procedure or conventional cerebral angiogram. Total excess cost was estimated as the cost of interisland transfer multiplied by the number of interisland transfer patients who did not receive any SNP. Results: Among a total of 825 patients, 100 patients (12%) were transferred from the neighbor islands. Among the neighbor-island patients, 69 patients (69%) did not receive SNP, which translates to $1035000 of excess cost over an 8-year period (approximately $129375/y). Multivariable analyses showed age (odds ratio [OR], 0.95; 95% confidence interval [CI]: 0.94-0.96), lack of hypertension (OR, 1.62; 95% CI: 1.002-2.61), initial Glasgow Coma Scale (OR, 0.94; 95% CI: 0.89-0.98), lobar hemorrhage (OR, 2.74; 95% CI: 1.59-4.71), cerebellar hemorrhage (OR, 5.47; 95% CI: 2.78-10.76), primary intraventricular hemorrhage (OR, 4.40; 95% CI: 1.77-10.94), and any intraventricular hemorrhage (OR, 2.47l 95% CI: 1.53-3.97) to be independent predictors of receiving SNP. Conclusion: Approximately two-thirds of ICH patients who were air transferred did not receive SNP. Further study is needed to assess the cost-effectiveness of creating a triage algorithm to optimally select ICH patients who would benefit from air transport to a higher-level facility.
    American Journal of Emergency Medicine 01/2015; 33(4). DOI:10.1016/j.ajem.2015.01.001 · 1.27 Impact Factor
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    • "Approximately 15 to 20% of ischemic stroke patients will require care in an intensive care unit (ICU) [1]—this includes patients at considerable risk of hemorrhagic transformation or the development of malignant cerebral edema, patients who require intubation due to brainstem stroke or a decline in the level of alertness, and patients exhibiting hemodynamic instability ranging from atrial fibrillation with rapid ventricular rate to symptomatic hypotension with extension of infarction. And, as studies of other groups of critically ill neurologic patients have suggested [2], the care of unstable ischemic stroke patients in a neurosciences ICU staffed by trained neurointensivists results not only in greater efficiency of care, but also in improved patient outcomes. In one retrospective study by Bershad et al., critically ill ischemic stroke patients treated by a dedicated neurointensivist team not only had shorter stays in the ICU and in the hospital in general, but also a greater likelihood of being discharged to home [3]. "
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    ABSTRACT: Given recent advances in diagnostic modalities and revascularization capabilities, clinicians are not only able to rapidly and accurately identify acute ischemic stroke, but may also be able to aggressively intervene to minimize the extent of infarction. In those cases where revascularization cannot occur and/or the extent of infarction is large, there are multiple strategies to prevent secondary decompensation as the stroke evolves, for instance, if malignant cerebral edema should develop. In this paper, we will review the indications for specialized ICU care for an ischemic stroke patient, the treatment principles, and strategies employed by neurointensivists to minimize secondary neuronal injury, the literature in support of such strategies (and the questions to be addressed by future studies), all with the ultimate goal of increasing the likelihood of favorable neurologic outcomes in our ischemic stroke population.
    Stroke Research and Treatment 05/2013; 2013:510481. DOI:10.1155/2013/510481
    • "All its team members, be it the neurosurgeon, cosmetic surgeon, maxillofacial surgeon, intensivists or any other specialist, have worked in a non-tiring manner to bring the desired results with a lot of dedicated efforts. Betterment of the patients in polytrauma injuries invariably requires a lot of cohesiveness and understanding in improving the outcome among various specialties.[2021] "
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    ABSTRACT: Polytrauma is a leading cause of mortality in the developing countries and efforts from various quarters are required to deal with this increasing menace. An attempt has been made by the coordinated efforts of the intensive care and trauma team of a newly established tertiary care institute in designing and improving the trauma care services to realign its functions with national policies by analyzing the profile of polytrauma victims and successfully managing them. A retrospective analysis was carried out among the 531 polytrauma admissions in the emergency department. The information pertaining to age and gender distribution, locality, time to trauma and initial resuscitation, cause of injury, type of injury, influence of alcohol, drug addiction, presenting clinical picture, Glasgow Coma score on admission and few other variables were also recorded. The indications for various operative interventions and intensive care unit (ICU) admissions were analyzed thoroughly with a concomitant improvement of our trauma care services and thereby augmenting the national policies and programs. A statistical analysis was carried out with chi-square and analysis of variance ANOVA tests, using SPSS software version 10.0 for windows. The value of P<0.05 was considered significant and P<0.0001 as highly significant. Majority of the 531 polytrauma patients hailed from rural areas (63.65%), riding on the two wheelers (38.23%), and predominantly comprised young adult males. Fractures of long bones and head injury was the most common injury pattern (37.85%) and 51.41% of the patients presented with shock and hemorrhage. Airway management and intubation became necessary in 42.93% of the patients, whereas 52.16% of the patients were operated within the first 6 hours of admission for various indications. ICU admission was required for 45.76% of the patients because of their deteriorating clinical condition, and overall,ionotropic support was administered in 55.93% of the patients for successful resuscitation. There is an urgent need for proper implementation ofpre-hospital and advanced trauma life support measures at grass-root level. Analyzing the profile of polytrauma victims at a national level and simultaneously improving the trauma care services at every health center are very essential to decrease the mortality and morbidity. The improvement can be augmented further by strengthening the rural health infrastructure, strict traffic rules, increasing public awareness and participation and coordination among the various public and private agencies in dealing with polytrauma.
    Journal of Emergencies Trauma and Shock 03/2011; 4(4):494-500. DOI:10.4103/0974-2700.86642
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