51
|
Freeman WD, Vatz KA, Griggs RC, Pedley T. The Workforce Task Force report: clinical implications for neurology. Neurology 2013; 81:479-86. [PMID: 23783750 DOI: 10.1212/wnl.0b013e31829d8783] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The American Academy of Neurology Workforce Task Force (WFTF) report predicts a future shortfall of neurologists in the United States. The WFTF data also suggest that for most states, the current demand for neurologist services already exceeds the supply, and by 2025 the demand for neurologists will be even higher. This future demand is fueled by the aging of the US population, the higher health care utilization rates of neurologic services, and by a greater number of patients gaining access to the health care system due to the Patient Protection and Affordable Care Act. Uncertainties in health care delivery and patient access exist due to looming concerns about further Medicare reimbursement cuts. This uncertainty is set against a backdrop of Congressional volatility on a variety of issues, including the repeal of the sustainable growth rate for physician reimbursement. The impact of these US health care changes on the neurology workforce, future increasing demands, reimbursement, and alternative health care delivery models including accountable care organizations, nonphysician providers such as nurse practitioners and physician assistants, and teleneurology for both stroke and general neurology are discussed. The data lead to the conclusion that neurologists will need to play an even larger role in caring for the aging US population by 2025. We propose solutions to increase the availability of neurologic services in the future and provide other ways of meeting the anticipated increased demand for neurologic care.
Collapse
|
52
|
da Silva IRF, Provencio JJ. Intracerebral hemorrhage in patients receiving oral anticoagulation therapy. J Intensive Care Med 2013; 30:63-78. [PMID: 23753250 DOI: 10.1177/0885066613488732] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracerebral hemorrhage (ICH) in patients with oral anticoagulation therapy is an increasingly prevalent problem in large part due to the aging population and the increased use of anticoagulants for patients at high risk of thrombosis. Warfarin has been virtually the only outpatient anticoagulant choice until fairly recently. The development of subcutaneously injected heparinoids, and more recently, of direct thrombin inhibitors, has made the treatment and prognostication of ICH in anticoagulated patients more difficult. In this review, we will review the current state of diagnosis, prognostication, and treatment for patients with this often-devastating type of bleeding. We will focus on warfarin therapy, because the preponderance of evidence comes from studies of warfarin treatment. Where there is evidence, we will contrast warfarin with some of the newer treatment modalities. We review the evidence of the 4 major reversal agents for warfarin, vitamin K, prothrombin complex concentrates, activated factor VII, and fresh frozen plasma as well as rational treatment choices. We offer possible treatments for the newer anticoagulants based on the limited evidence available. Finally, we review recommendations from the major societies and studies that support early and aggressive therapies in intensive care units with dedicated neurological specialists.
Collapse
Affiliation(s)
| | - J Javier Provencio
- Neurointensive Care Unit, Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA Neuroinflammation Research Center, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
55
|
O’Connor S, Ayres A, Cortellini L, Rosand J, Rosenthal E, Kimberly WT. Process improvement methods increase the efficiency, accuracy, and utility of a neurocritical care research repository. Neurocrit Care 2012; 17:90-6. [PMID: 22434546 PMCID: PMC3401358 DOI: 10.1007/s12028-012-9689-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Reliable and efficient data repositories are essential for the advancement of research in Neurocritical care. Various factors, such as the large volume of patients treated within the neuro ICU, their differing length and complexity of hospital stay, and the substantial amount of desired information can complicate the process of data collection. METHODS We adapted the tools of process improvement to the data collection and database design of a research repository for a Neuroscience intensive care unit. By the Shewhart-Deming method, we implemented an iterative approach to improve the process of data collection for each element. After an initial design phase, we re-evaluated all data fields that were challenging or time-consuming to collect. We then applied root-cause analysis to optimize the accuracy and ease of collection, and to determine the most efficient manner of collecting the maximal amount of data. RESULTS During a 6-month period, we iteratively analyzed the process of data collection for various data elements. For example, the pre-admission medications were found to contain numerous inaccuracies after comparison with a gold standard (sensitivity 71% and specificity 94%). Also, our first method of tracking patient admissions and discharges contained higher than expected errors (sensitivity 94% and specificity 93%). In addition to increasing accuracy, we focused on improving efficiency. Through repeated incremental improvements, we reduced the number of subject records that required daily monitoring from 40 to 6 per day, and decreased daily effort from 4.5 to 1.5 h/day. CONCLUSIONS By applying process improvement methods to the design of a Neuroscience ICU data repository, we achieved a threefold improvement in efficiency and increased accuracy. Although individual barriers to data collection will vary from institution to institution, a focus on process improvement is critical to overcoming these barriers.
Collapse
Affiliation(s)
- Sydney O’Connor
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Alison Ayres
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Lynelle Cortellini
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Eric Rosenthal
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
56
|
Lindekleiv H, Sandvei MS, Romundstad PR, Wilsgaard T, Njølstad I, Ingebrigtsen T, Vik A, Mathiesen EB. Joint Effect of Modifiable Risk Factors on the Risk of Aneurysmal Subarachnoid Hemorrhage. Stroke 2012; 43:1885-9. [DOI: 10.1161/strokeaha.112.651315] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Haakon Lindekleiv
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| | - Marie S. Sandvei
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| | - Pål R. Romundstad
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| | - Tom Wilsgaard
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| | - Inger Njølstad
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| | - Tor Ingebrigtsen
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| | - Anne Vik
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| | - Ellisiv B. Mathiesen
- From the Departments of Clinical and Community Medicine (H.L., T.W., I.N., T.I., and E.B.M.), Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; Divisions of Neurosurgery and Neurology (H.L., T.I, E.B.M.), University Hospital of North Norway, Tromsø, Norway; Departments of Public Health and Community Medicine (P.R.R.) and Neuroscience (M.S.S., A.V.), Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurosurgery (A.V.), St Olavs University Hospital,
| |
Collapse
|
57
|
Naval NS, Chang T, Caserta F, Kowalski RG, Carhuapoma JR, Tamargo RJ. Impact of pattern of admission on outcomes after aneurysmal subarachnoid hemorrhage. J Crit Care 2012; 27:532.e1-7. [PMID: 22520493 DOI: 10.1016/j.jcrc.2012.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 03/09/2012] [Accepted: 03/11/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Patients with aneurysmal subarachnoid hemorrhage (aSAH) require management in centers with neurosurgical expertise necessitating emergent interhospital transfer (IHT). Our objective was to compare outcomes in aSAH IHTs to our institution with aSAH admissions from our institutional emergency department (ED). METHODS Data for consecutive patients with aSAH admitted to Johns Hopkins Medical Institutions between 1991 and 2009 were analyzed from a prospectively obtained database. We compared in-hospital mortality and functional outcomes at first clinical appointment post-aSAH (30-120 days) using dichotomized Glasgow Outcome Scale (good outcome: Glasgow Outcome Scale 4-5) in ED admissions with IHTs. RESULTS A total of 1134 consecutive patients with aSAH were included in analysis (ED 40.1%, IHT 59.9%). Direct ED admissions had a higher incidence of poor Hunt and Hess grade (4/5) and major medical comorbidities, with no significant differences between the 2 groups in age, intraventricular hemorrhage, and hydrocephalus. In-hospital mortality for ED admissions (14.9%) was significantly lower than that for IHTs (20.5%), with 1.8 times greater adjusted odds of survival after multivariate analysis (P = .001). Emergency department admissions had nearly 2-fold greater odds of good outcomes (odds ratio, 1.89; P < .001) after multivariate analysis. CONCLUSIONS Our institutional ED SAH admissions had significantly better outcomes than did IHTs, suggesting that delays in optimizing care before transfer could deleteriously impact outcomes.
Collapse
Affiliation(s)
- Neeraj S Naval
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | | | | | | | | | | |
Collapse
|
58
|
Knopf L, Staff I, Gomes J, McCullough L. Impact of a neurointensivist on outcomes in critically ill stroke patients. Neurocrit Care 2012; 16:63-71. [PMID: 21847702 DOI: 10.1007/s12028-011-9620-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Current guidelines for management of critically ill stroke patients suggest that treatment in a neurocritical care unit (NCCU) and/or by a neurointensivist (NI) may be beneficial, but the contribution of each to outcome is unknown. The relative impact of a NCCU versus NI on short- and long-term outcomes in patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (SAH) was assessed. METHODS 2,096 stroke patients admitted to a NCCU or nonneuro ICU at a tertiary stroke center were analyzed before the appointment of a NI, during the NI's tenure, and after the NI departed and was not replaced. Data included admission ICU type, availability of a NI, age, NIHSS, ICH score, and 3 and 12 month outcome. RESULTS For AIS, compared to the time interval with a NI, departure of the NI predicted a worse rate of return to pre-stroke function at 3 months. For ICH, NCCU treatment predicted shorter ICU and hospital LOS but had no effect on short- or long-term outcomes. No effect of a NI was seen. For SAH, availability of an NI (but not an NCCU) predicted improved outcomes but longer ICU LOS. Disposition and in-hospital mortality improved when a NI was present, but continued improvement did not occur after the NI's departure. CONCLUSION Presence of an NI was associated with improved clinical outcomes. This effect was more evident in patients with SAH. Patients with ICH tend to have poor outcomes regardless of the presence of a NCCU or a NI.
Collapse
Affiliation(s)
- Lisa Knopf
- The University of Connecticut School of Medicine, Farmington, CT, USA
| | | | | | | |
Collapse
|
62
|
Cobelens PM, Tiebosch IACW, Dijkhuizen RM, van der Meide PH, Zwartbol R, Heijnen CJ, Kesecioglu J, van den Bergh WM. Interferon-β attenuates lung inflammation following experimental subarachnoid hemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R157. [PMID: 20731855 PMCID: PMC2945141 DOI: 10.1186/cc9232] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 06/02/2010] [Accepted: 08/23/2010] [Indexed: 01/11/2023]
Abstract
Introduction Aneurysmal subarachnoid hemorrhage (SAH) affects relatively young people and carries a poor prognosis with a case fatality rate of 35%. One of the major systemic complications associated with SAH is acute lung injury (ALI) which occurs in up to one-third of the patients and is associated with poor outcome. ALI in SAH may be predisposed by neurogenic pulmonary edema (NPE) and inflammatory mediators. The objective of this study was to assess the immunomodulatory effects of interferon-β (IFN-β) on inflammatory mediators in the lung after experimental SAH. Methods Male Wistar rats were subjected to the induction of SAH by means of the endovascular filament method. Sham-animals underwent sham-surgery. Rats received IFN-β for four consecutive days starting at two hours after SAH induction. After seven days, lungs were analyzed for the expression of inflammatory markers. Results SAH induced the influx of neutrophils into the lung, and enhanced expression of the pulmonary adhesion molecules E-selectin, inter-cellular adhesion molecule (ICAM)-1, and vascular cell adhesion molecule (VCAM)-1 compared to sham-animals. In addition, SAH increased the expression of the chemokines macrophage inflammatory protein (MIP)-1α, MIP-2, and cytokine-induced neutrophil chemoattractant (CINC)-1 in the lung. Finally, tumor necrosis factor-α (TNF-α) was significantly increased in lungs from SAH-animals compared to sham-animals. IFN-β effectively abolished the SAH-induced expression of all pro-inflammatory mediators in the lung. Conclusions IFN-β strongly reduces lung inflammation after experimental SAH and may therefore be an effective drug to prevent SAH-mediated lung injury.
Collapse
Affiliation(s)
- Pieter M Cobelens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|