Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage

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: 6.15). 04/2001; 29(3):635-40. DOI: 10.1097/00003246-200103000-00031
Source: PubMed

ABSTRACT 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: 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.
    American Journal of Emergency Medicine 01/2015; 33(4). DOI:10.1016/j.ajem.2015.01.001 · 1.15 Impact Factor
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    • "Some have advocated that intensive monitoring should be a routine procedure in stroke unit design [3]. Patients with acute nontraumatic intracerebral hemorrhage (ICH) who were admitted to the neurologic/neurosurgical ICU had lower mortality rate than those treated in the general ICU [4]. Furthermore, a specialized neurocritical care team can significantly reduce inhospital mortality and length of hospital stay [5]. "
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    ABSTRACT: Multivariate models have not been widely used to predict the outcome of acute stroke patients admitted to the intensive care unit (ICU). The purpose of this study was to determine potential measures observed in the first 12 h post-stroke that predict early mortality and functional outcomes in ICU-admitted stroke patients. Eight hundred and fifty acute stroke patients (ischemic stroke, 508; intracerebral hemorrhage, 342) were included in this analysis between November 2002 and December 2006. Measures of interest were obtained in the first 12 h after onset of stroke were analyzed for three types of outcome: 3-month mortality, 3-month mortality or institutional care, and poor functional outcomes at discharge. Poor functional outcomes were defined as a Barthel index <80 or a Rankin scale >2. Multivariate regression models were used to determine the predictive value of the observed measures. After 3 months, 17% of patients had died; 21% were alive but being cared for in institutional settings; and 62% were alive and living at home. Functional status at discharge indicated 16% of patients had died, poor function in 50%, and good function in 34% of patients. Initial stroke severity, measured by National Institute of Health Stroke Scale, and dependence on a ventilator predicts 3-month mortality and poor outcome in all stroke patients. In addition, old age, previous stroke, and total anterior circulatory infarct were associated with poor outcome in ischemic stroke patients; old age, low body mass index and the presence of intraventricular hemorrhage were associated with poor outcomes in intracerebral hemorrhage patients. In conclusion, early stroke mortality and outcome at discharge can be predicted in the first few hours following an acute stroke for moderate to severe ICU-admitted stroke patients.
    Journal of the Neurological Sciences 08/2008; 270(1-2):60-6. DOI:10.1016/j.jns.2008.01.015 · 2.26 Impact Factor
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    • "Hier zeigte sich, dass abgesehen von € ublichen Risikofaktoren f€ ur ein schlechtes Outcome (h€ oheres Lebensalter, niedriger Glasgow Coma Scale, intraventrikul€ ares Blut, H€ amatomvolumen, Hydrozephalus ) die Betreuung an nicht-Neuro-ICUs mit einer h€ oheren Mortalit€ at (OR 3,4; 95 %CI, 1,65–7,6) verbunden war. Zus€ atzlich spielte die Erfahrenheit der ICU mit ICB-Patienten und die 24 Stunden Anwesenheit eines Intensivmediziners eine Rolle [21]. Andere Untersuchungen besch€ aftigten sich mit fr€ uher ,,do not resuscitate , , (DNR) Order oder der fr€ uhen Entscheidung lebensverl€ angernde Maßnahmen zu unterlassen. "
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    ABSTRACT: Few studies could show a beneficial effect of stroke units for the treatment of patients with intracerebral hemorrhages. A total of 1539 patients with intracerebral hemorrhages have been registered in the GOG-BIQG Austrian Stroke Unit Registry between January 2003 and February 2007. Their data were analysed with regard to clinical aspects and treatment characteristics. A first survey about the dealings of stroke units with ICH-Patients was drawn. For statistical analyses we used R 2.4.1 (The R Project). We registered a male predominance (52.89%), but women were older (76 vs. 67 yrs) and more seriously affected (NIHSS 9.0 vs. 8.0). The use of invasive measurements was dependent on the clinical severity on admission; the outcome was related to the NIHSS on admission. The 3-month mortality rate was 19.05% and constant for the whole observational period. Austrian stroke units are capable of dealing with the management of intracerebral hemorrhages.
    Wiener Medizinische Wochenschrift 02/2008; 158(15-16):435-45. DOI:10.1007/s10354-008-0567-2
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