1
|
Viarasilpa T. Implementation of neurocritical care in Thailand. Front Neurol 2022; 13:990294. [PMID: 36330426 PMCID: PMC9622761 DOI: 10.3389/fneur.2022.990294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/29/2022] [Indexed: 11/23/2022] Open
Abstract
Dedicated neurointensive care units and neurointensivists are rarely available in Thailand, a developing country, despite the high burden of life-threatening neurologic illness, including strokes, post-cardiac arrest brain injury, status epilepticus, and cerebral edema from various etiologies. Therefore, the implementation of neurocritical care is essential to improve patient outcomes. With the resource-limited circumstances, the integration of neurocritical care service by collaboration between intensivists, neurologists, neurosurgeons, and other multidisciplinary care teams into the current institutional practice to take care of critically-ill neurologic patients is more suitable than building a new neurointensive care unit since this approach can promptly be made without reorganization of the hospital system. Providing neurocritical care knowledge to internal medicine and neurology residents and critical care fellows and developing a research system will lead to sustainable quality improvement in patient care. This review article will describe our current situation and strategies to implement neurocritical care in Thailand.
Collapse
|
2
|
The History of Neurocritical Care as a Subspecialty. Crit Care Clin 2022; 39:1-15. [DOI: 10.1016/j.ccc.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
3
|
Quality Improvement in Neurocritical Care: a Review of the Current Landscape and Best Practices. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00734-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose of Review
The field of neurocritical care (NCC) has grown such that there is now a substantial body of literature on quality improvement specific to NCC. This review will discuss the development of this literature over time and highlight current best practices with practical tips for providers.
Recent Findings
There is tremendous variability in patient care models for NCC patients, despite evidence showing that certain structural elements are associated with better outcomes. There now also exist evidence-based recommendations for neurocritical care unit (NCCU) structure and processes, as well as NCC-specific performance measure (PM) sets; however, awareness of these is variable among care providers. The evidence-based literature on NCC structure, staffing, training, standardized order sets and bundles, transitions of care including handoff, prevention of bounce backs, bed flow optimization, and inter-hospital transfers is growing and offers many examples of successful performance improvement initiatives in NCCUs.
Summary
NCC providers care for patients with life-threatening conditions like intracerebral and subarachnoid hemorrhages, ischemic stroke, and traumatic brain injury, which are associated with high morbidity, complexity of treatment, and cost. Quality improvement initiatives have been successful in improving many aspects of NCC patient care, and NCC providers should continue to update and standardize their practices with consideration of this data. More research is needed to continue to identify high-risk and high-cost NCCU structures and processes and strategies to optimize them, validate current NCC PMs, and encourage clinical adoption of those that prove to be associated with improved outcomes.
Collapse
|
4
|
Al Hashmi A, von Bandemer S, Shuaib A, Mansour OY, Wassy M, Ozdemir AO, Farhoudi M, Al Jehani H, Khan A, John S, Saqqur M. Lessons learned in stroke care during COVID-19 pandemic and preparing for future pandemics in the MENA+ region: A consensus statement from the MENA+-SINO. J Neurol Sci 2022; 432:120060. [PMID: 34864375 PMCID: PMC8626147 DOI: 10.1016/j.jns.2021.120060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 10/22/2021] [Accepted: 11/17/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND COVID-19 pandemic has negatively impacted stroke care services at multiple levels. There was a decline in acute stroke admissions. Fewer interventions have been performed. Increased "door-to-needle times and "door-to-groin puncture" during this pandemic. These factors combined have led to declining in the favoured outcomes of stroke patients' globally. Yet this pandemic permits an opportunity for higher preparedness for future pandemics. OBJECTIVES AND METHODS This paper aims to shed light on the main lessons learned in the field of stroke care during the first wave of COVID-19 pandemic. Here we are presenting proposals and initiatives for better preparedness in future similar emergencies. These proposals are based primarily on literature review of COVID-19 publications, as well as the first-hand experience gained during the first wave at the regional level. In addition to the consensus and collective ride of stroke experts in the Middle East North Africa Stroke and Interventional Neurotherapies Organization (MENA+-SINO) and interaction and collaboration with international stroke specialists from the Stroke World Organization (WSO), European Stroke Organization (ESO) and stroke and COVID-19 papers authors. CONCLUSION Stroke care is very complex, particularly in the initial hours after onset of symptoms. A successful outcome requires very close collaboration between clinical personnel from multiple specialties. Preparedness for future pandemics requires the improvement of care plans that allow for rapid assessment of stroke patients and ensuring that regular 'mock exercises' familiarize quintessential services that care for the stroke patients.
Collapse
Affiliation(s)
- Amal Al Hashmi
- Neuroscience Directorate, Khoula Hospital Ministry of Health of Oman, Muscat, Sultanate of Oman.
| | - Stephan von Bandemer
- Division of Health Service Research, Institute of Work and Technology, Gelsenkirchen, Germany.
| | - Ashfaq Shuaib
- Medicine and Neurology, Director Stroke Program, University of Alberta, Edmonton, AB, Canada.
| | - Ossama Yassin Mansour
- Alexandria Faculty of Medicine, Department of Neurology, Alexandria University, Egypt.
| | | | - Atilla Ozcan Ozdemir
- Interventional Neurology &Neurocritical Care Program, Eskisehir Osmangazi University, Turkey.
| | - Mehdi Farhoudi
- Neuroscience Research Center, Tabriz University, Islamic Republic of Iran.
| | - Hosam Al Jehani
- Department of Neurosurgery and Interventional Radiology, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Adnan Khan
- Department of Medicine, Research Division, Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Seby John
- Neurology and Neurointerventional Surgery, Neurological Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates.
| | - Maher Saqqur
- University of Alberta Edmonton, Canada; Trillium Hospital, University of Toronto at Mississauga, Mississauga, ON. Canada.
| |
Collapse
|
5
|
Mongolia health situation: based on the Global Burden of Disease Study 2019. BMC Public Health 2022; 22:5. [PMID: 34983445 PMCID: PMC8729000 DOI: 10.1186/s12889-021-12070-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Over the past few decades, economic, political, and social changes have directly and indirectly affected the health of the Mongolian population. To date, no comprehensive analysis has been conducted on the burden of diseases in this country. Thus, we aimed to describe the leading causes of death and disabling conditions and their trends between 1990 and 2019 in the Mongolian population. METHODS We used the data from the Global Burden of Disease (GBD) 2019 study. In the current study, we examined life expectancy at birth, healthy life expectancy, the 20 leading causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted-life-years (DALYs), and the contribution of major risk factors to DALYs in Mongolia. FINDINGS The life expectancy at birth in Mongolia has gradually increased since 1995 and reached 63.8 years for men and 72.7 for women in 2019. The highest increase in the age-standardised death rate between 1990 and 2019 occurred in alcohol use disorders (628.6%; 95% UI 10.0-1109.6) among men, and in liver cancer (129.1%; UI 65.3-222.4) among women. Ischaemic heart disease and stroke showed the highest rates of death, YLLs, and DALYs among both men and women. In 2019, the highest age-standardised rates of DALYs were attributable to high systolic blood pressure and dietary risks. INTERPRETATION Although Mongolia saw substantial improvements across many communicable diseases, maternal and neonatal disorders, and under-5 mortality between 1990 and 2019, non-communicable diseases remained leading causes of mortality. The mortality from the most preventable causes such as injury, alcohol use, and dietary risks remain substantially high, suggesting that individual and social efforts are needed to tackle these diseases. Our analyses will support the development of policy priorities and action plans in multiple sectors to improve the overall health of the Mongolian population. FUNDING Bill & Melinda Gates Foundation.
Collapse
|
6
|
Han HJ, Park KY, Kim J, Lee W, Lee YH, Jang CK, Cho KC, Park SK, Chung J, Kwon YS, Kim YB, Lee JW, Kim SY. Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era. Yonsei Med J 2021; 62:911-917. [PMID: 34558870 PMCID: PMC8470569 DOI: 10.3349/ymj.2021.62.10.911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. MATERIALS AND METHODS From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017-2019). RESULTS Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0-106.0), pre-COVID-19; 40.0 min (27.0-98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0-560.0), pre-COVID-19; 184.0 min (134.0-271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID19, 46.7% in pre-COVID-19, p=0.039). CONCLUSION During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.
Collapse
Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woosung Lee
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Ho Lee
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chang Ki Jang
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Kwang-Chun Cho
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University, Inchoen, Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Sub Kwon
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - So Yeon Kim
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University, Inchoen, Korea.
| |
Collapse
|
7
|
Neurocritical Care Resource Utilization in Pandemics: A Statement by the Neurocritical Care Society. Neurocrit Care 2021; 33:13-19. [PMID: 32468327 PMCID: PMC7255702 DOI: 10.1007/s12028-020-01001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
8
|
Aneurysmal Subarachnoid Hemorrhage: Review of the Pathophysiology and Management Strategies. Curr Neurol Neurosci Rep 2021; 21:50. [PMID: 34308493 DOI: 10.1007/s11910-021-01136-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Aneurysmal subarachnoid hemorrhage remains a devastating disease process despite medical advances made over the past 3 decades. Much of the focus was on prevention and treatment of vasospasm to reduce delayed cerebral ischemia and improve outcome. In recent years, there has been a shift of focus onto early brain injury as the precursor to delayed cerebral ischemia. This review will focus on the most recent data surrounding the pathophysiology of aneurysmal subarachnoid hemorrhage and current management strategies. RECENT FINDINGS There is a paucity of successful trials in the management of subarachnoid hemorrhage likely related to the targeting of vasospasm. Pathophysiological changes occurring at the time of aneurysmal rupture lead to early brain injury including cerebral edema, inflammation, and spreading depolarization. These events result in microvascular collapse, vasospasm, and ultimately delayed cerebral ischemia. Management of aneurysmal subarachnoid hemorrhage has remained the same over the past few decades. No recent trials have resulted in new treatments. However, our understanding of the pathophysiology is rapidly expanding and will advise future therapeutic targets.
Collapse
|
9
|
Neurological Critical Care: The Evolution of Cerebrovascular Critical Care. Crit Care Med 2021; 49:881-900. [PMID: 33653976 DOI: 10.1097/ccm.0000000000004933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Kaplan L, Moheet AM, Livesay SL, Provencio JJ, Suarez JI, Bader MK, Bailey H, Chang CWJ. A Perspective from the Neurocritical Care Society and the Society of Critical Care Medicine: Team-Based Care for Neurological Critical Illness. Neurocrit Care 2021; 32:369-372. [PMID: 32043264 DOI: 10.1007/s12028-020-00927-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The Neurocritical Care Society and the Society of Critical Care Medicine have worked together to create a perspective regarding the Standards of Neurologic Critical Care Units (Moheet et al. in Neurocrit Care 29:145-160, 2018). The most neurologically ill or injured patients warrant the highest standard of care available; this supports the need for defining and establishing specialized neurological critical care units. Rather than interpreting the Standards as being exclusionary, it is most appropriate to embrace them in the setting of team-based care. Since there are many more patients than there are highly specialized beds, collaborative care and appropriate transfer agreements are essential in promoting excellent patient outcomes. This viewpoint addresses areas of clarification and emphasizes the need for collegiality and partnership in delivering the best specialty critical care to our patients.
Collapse
Affiliation(s)
- Lewis Kaplan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Asma M Moheet
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | | | | | | | | | | | - Cherylee W J Chang
- Neuroscience Institute/Neurocritical Care, The Queen's Medical Center Neuroscience Institute, Honolulu, HI, 96813, USA.
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA.
| |
Collapse
|
11
|
Adamczak S, Fritz R, Patel D, Geh N, Laurent D, Polifka A, Hoh BL, Fox WC. Trends in Hospital-to-Hospital Transfers for Aneurysmal Subarachnoid Hemorrhage: A Single-Institution Experience from 2006 to 2017. World Neurosurg 2020; 148:e17-e26. [PMID: 33359879 DOI: 10.1016/j.wneu.2020.11.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite evidence to support that aneurysmal subarachnoid hemorrhage (aSAH) is best treated at high-volume centers, it is unknown whether clinical practice reflects these findings. METHODS We analyzed patients transferred to our high-volume center for aSAH between 2006 and 2017. Data collection included number of transfers, demographic data, Hunt and Hess score, Fisher score, comorbid conditions, length of stay (LOS), discharge disposition, in-hospital mortality rates, insurance status, and hospital charges. Comparisons were made across 3 time periods (2006-2009, 2010-2013, and 2014-2017) and included subgroup analyses by treatment modality (endovascular vs. microsurgical). RESULTS aSAH transfers declined from 213 in 2006-2009 to 160 in 2014-2017. While there was no change in presenting Hunt and Hess scores, the percentage of modified Fisher scores of 4 increased from 2006-2009 to 2014-2017. Transferred patients had a greater comorbidity index and decreased predicted 10-year survival. Despite this, the average LOS decreased. In-hospital mortality decreased from 2006-2009 to 2014-2017, especially in the endovascular cohort. The proportions of patients who were either self-pay or Medicaid did not change. Overall inflation-adjusted hospital charges decreased from $76,975 in 2006-2009 to $59,870 in 2014-2017. CONCLUSIONS Between 2006 and 2017, transfers to our center for aSAH declined. However, transferred patients had greater levels of complexity, more comorbidities, and were at greater risk for vasospasm based on their presenting Fisher score. Nonetheless, average LOS, in-hospital mortality, and cost declined. These changing referral patterns have implications for outcome data, quality reporting, resident education, and developing systems of care to optimize outcomes.
Collapse
Affiliation(s)
- Stephanie Adamczak
- Department of Neurosurgery and College of Medicine, University of Florida, Gainesville, Florida, USA.
| | - Rachel Fritz
- Department of Neurosurgery and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Devan Patel
- Department of Neurosurgery and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ndi Geh
- Department of Neurosurgery and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Dimitri Laurent
- Department of Neurosurgery and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Adam Polifka
- Department of Neurosurgery and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Brian Lim Hoh
- Department of Neurosurgery and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - W Christopher Fox
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| |
Collapse
|
12
|
Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
Collapse
|
13
|
Jo KW, Kim H, Yoo DS, Hyun DK, Cheong JH, Park HK, Park BJ, Cho BM, Kim YW, Kim TH, Han I, Lee SW, Kwon TH. Current Status of Neurosurgical and Neurointensive Care Units in Korea : A Brief Report on Nationwide Survey Results. J Korean Neurosurg Soc 2020; 63:519-531. [PMID: 32664714 PMCID: PMC7365282 DOI: 10.3340/jkns.2020.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/23/2020] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study is identify the operation status of the neurosurgical care units (NCUs) in neurosurgical residency training hospitals nationwide and determine needed changes by comparing findings with those obtained from the Korean Neurosurgical Society (KNS) and Korean Society of Neurointensive Care Medicine (KNIC) survey of 2010.
Method This survey was conducted over 1 year in 86 neurosurgical residency training hospitals and two neurosurgery specialist hospitals and focused on the following areas : 1) the current status of the infrastructure and operating systems of NCUs in Korea, 2) barriers to installing neurointensivist team systems, 3) future roles of the KNS and KNIC, and 4) a handbook for physicians and practitioners in NCUs. We compared and analyzed the results of this survey with those from a KNIC survey of 2010.
Results Seventy seven hospitals (87.5%) participated in the survey. Nineteen hospitals (24.7%) employed a neurointensivist or faculty member; Thirty seven hospitals (48.1%) reported high demand for neurointensivists, and 62 hospitals (80.5%) stated that the mandatory deployment of a neurointensivist improved the quality of patient care. Forty four hospitals (57.1%) believed that hiring neurointensivist would increase hospital costs, and in response to a question on potential earnings declines. In terms of potential solutions to these problems, 70 respondents (90.9%) maintained that additional fees were necessary for neurointensivists’ work, and 64 (83.1%) answered that direct support was needed of the personnel expenses for neurointensivists.
Conclusion We hope the results of this survey will guide successful implementation of neurointensivist systems across Korea.
Collapse
Affiliation(s)
- Kwang Wook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hoon Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Keun Hyun
- Department of Neurosurgery, Inha Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bong Jin Park
- Department of Neurosurgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Byung Moon Cho
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Young Woo Kim
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Hee Kim
- Department of Anesthology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Insoo Han
- Department of Anesthology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Taek Hyun Kwon
- Department of Neurosurgery, Korea Universuty Guro Hospital, Seoul, Korea
| |
Collapse
|
14
|
Kim TJ, Lee JS, Yoon JS, Oh MS, Kim JW, Jung KH, Yu KH, Lee BC, Ko SB, Yoon BW. Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea. J Korean Med Sci 2020; 35:e135. [PMID: 32476299 PMCID: PMC7261699 DOI: 10.3346/jkms.2020.35.e135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/22/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Neurocritical care by dedicated neurointensivists may improve outcomes of critically ill patients with severe brain injury. In this study, we aimed to validate whether neurointensive care could improve the outcome in patients with critically ill acute ischemic stroke using the linked big dataset on stroke in Korea. METHODS We included 1,405 acute ischemic stroke patients with mechanical ventilator support in the intensive care unit after an index stroke. Patients were retrieved from linking the Clinical Research Center for Stroke Registry and the Health Insurance Review and Assessment Service data from the period between January 2007 and December 2014. The outcomes were mortality at discharge and at 3 months after an index stroke. The main outcomes were compared between the centers with and without dedicated neurointensivists. RESULTS Among the included patients, 303 (21.6%) were admitted to the centers with dedicated neurointensivists. The patients treated by dedicated neurointensivists had significantly lower in-hospital mortality (18.3% vs. 26.8%, P = 0.002) as well as lower mortality at 3-month (38.0% vs. 49.1%, P < 0.001) than those who were treated without neurointensivists. After adjusting for confounders, a treatment without neurointensivists was independently associated with higher in-hospital mortality (odds ratio [OR], 1.59; 95% confidence intervals [CIs], 1.13-2.25; P = 0.008) and 3-month mortality (OR, 1.48; 95% CIs, 1.12-1.95; P = 0.005). CONCLUSION Treatment by dedicated neurointensivists is associated with lower in-hospital and 3-month mortality using the linked big datasets for stroke in Korea. This finding stresses the importance of neurointensivists in treating patients with severe ischemic stroke.
Collapse
Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji Sung Lee
- Department of Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sun Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Woo Kim
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Keun Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kyung Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Byung Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sang Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Byung Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.
| | | |
Collapse
|
15
|
Focused Subspecialty Critical Care Training Is Superior for Trainees and Patients. Crit Care Med 2020; 47:1645-1647. [PMID: 31393322 DOI: 10.1097/ccm.0000000000003962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Busl KM, Bleck TP, Varelas PN. Neurocritical Care Outcomes, Research, and Technology: A Review. JAMA Neurol 2020; 76:612-618. [PMID: 30667464 DOI: 10.1001/jamaneurol.2018.4407] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology. Observations Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress. Conclusions and Relevance Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.
Collapse
Affiliation(s)
- Katharina Maria Busl
- NeuroIntensive Care Unit, University of Florida Health Shands Hospital, Gainesville.,Department of Neurology, Division of Neurocritical Care, College of Medicine, University of Florida, Gainesville
| | - Thomas P Bleck
- Rush University Medical Center, Rush Medical College, Chicago, Illinois
| | - Panayiotis N Varelas
- Neurosciences Critical Care Services, Neuro-Intensive Care Unit, Henry Ford Hospital, Wayne State University, Detroit, Michigan
| |
Collapse
|
17
|
Roychoudhury S, Esser MJ, Buchhalter J, Bello-Espinosa L, Zein H, Howlett A, Thomas S, Murthy P, Appendino JP, Scott JN, Metcalfe C, Lind J, Oliver N, Kozlik S, Mohammad K. Implementation of Neonatal Neurocritical Care Program Improved Short-Term Outcomes in Neonates With Moderate-to-Severe Hypoxic Ischemic Encephalopathy. Pediatr Neurol 2019; 101:64-70. [PMID: 31047757 DOI: 10.1016/j.pediatrneurol.2019.02.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite the introduction of therapeutic hypothermia, infants with moderate-to-severe hypoxic-ischemic encephalopathy remain at risk of mortality and morbidity. A dedicated service with standardized management protocols and improved communication may help improve care. We aimed to evaluate the impact of a dedicated neonatal neurocritical care service on short-term outcomes in infants with hypoxic-ischemic encephalopathy. METHODS We performed a retrospective cohort study (July 2008 to December 2017) on term and near-term infants admitted to two tertiary neonatal intensive care units with moderate-to-severe hypoxic-ischemic encephalopathy, before and after neonatal neurocritical care service implementation. The primary outcome was brain magnetic resonance imaging findings consistent with those of hypoxic-ischemic encephalopathy. Secondary outcomes included the cooling initiation rate, hospital stay duration, antiseizure medication use, and inotrope use. Regression analysis and interrupted time series analysis were performed after adjusting for confounding factors. RESULTS In total, 216 infants with moderate-to-severe hypoxic-ischemic encephalopathy were analyzed-109 before and 107 after neonatal neurocritical care implementation. After adjusting for confounding factors, there was a significant reduction in primary outcomes (adjusted odds ratio: 0.3, confidence interval: 0.15 to 0.57, P < 0.001) after neonatal neurocritical care implementation. Average hospital stay duration reduced by 5.2 days per infant (P = 0.03), identification of eligible infants for cooling improved (P < 0.001), antiseizure medication use reduced (P = 0.001), and early inotropes use reduced (P = 0.04). CONCLUSION Implementation of a neonatal neurocritical care service associated with decreased brain injury shortened the hospital stay duration and improved the care of infants with moderate-to-severe hypoxic-ischemic encephalopathy.
Collapse
Affiliation(s)
- Smita Roychoudhury
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Esser
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey Buchhalter
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Luis Bello-Espinosa
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Howlett
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Juan Pablo Appendino
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - James N Scott
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Metcalfe
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jan Lind
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Norma Oliver
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Silvia Kozlik
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
18
|
Suarez JI. Neurocritical Care Has Matured and it is Time to Raise the Bar…Yet Again. Neurocrit Care 2019; 29:143-144. [PMID: 30298334 DOI: 10.1007/s12028-018-0621-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Sheikh Zayed Building, 3014C, Baltimore, MD, 21287, USA.
| |
Collapse
|
19
|
Building a Case for a Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
20
|
Neurointensive (NCCU) Care Business Planning. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
21
|
Hemodynamic Management of Patients During Endovascular Treatment of Acute Ischemic Stroke Under Conscious Sedation: A Retrospective Cohort Study. J Neurosurg Anesthesiol 2019; 31:299-305. [DOI: 10.1097/ana.0000000000000514] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Patel MD, Honvoh G, Fernandez AR, Cadena R, Kelly ER, McDaniel P, Brice JH. Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina. South Med J 2019; 112:331-337. [PMID: 31158888 DOI: 10.14423/smj.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability. METHODS This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural). RESULTS Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends. CONCLUSIONS In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.
Collapse
Affiliation(s)
- Mehul D Patel
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Gilson Honvoh
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Antonio R Fernandez
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Rhonda Cadena
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Emma R Kelly
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Philip McDaniel
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Jane H Brice
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| |
Collapse
|
23
|
|
24
|
Inoue S, Saito M, Kotani J. Immunosenescence in neurocritical care. J Intensive Care 2018; 6:65. [PMID: 30349725 PMCID: PMC6186132 DOI: 10.1186/s40560-018-0333-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 09/20/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Several advanced and developing countries are now entering a superaged society, in which the percentage of elderly people exceeds 20% of the total population. In such an aging society, the number of age-related diseases such as malignant tumors, diabetes, and severe infections including sepsis is increasing, and patients with such disorders often find themselves in the ICU. MAIN BODY Age-related diseases are closely related to age-induced immune dysfunction, by which reductions in the efficiency and specificity of the immune system are collectively termed "immunosenescence." The most noticeable is a decline in the antigen-specific acquired immune response. The exhaustion of T cells in elderly sepsis is related to an increase in nosocomial infections after septicemia, and even death over subacute periods. Another characteristic is that senescent cells that accumulate in body tissues over time cause chronic inflammation through the secretion of proinflammatory cytokines, termed senescence-associated secretory phenotype. Chronic inflammation associated with aging has been called "inflammaging," and similar age-related diseases are becoming an urgent social problem. CONCLUSION In neuro ICUs, several neuro-related diseases including stroke and sepsis-associated encephalopathy are related to immunosenescence and neuroinflammation in the elderly. Several advanced countries with superaged societies face the new challenge of improving the long-term prognosis of neurocritical patients.
Collapse
Affiliation(s)
- Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ward, Kobe, 650-0017 Japan
| | - Masafumi Saito
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ward, Kobe, 650-0017 Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ward, Kobe, 650-0017 Japan
| |
Collapse
|
25
|
McCarthy JJ, Carr B, Sasson C, Bobrow BJ, Callaway CW, Neumar RW, Ferrer JME, Garvey JL, Ornato JP, Gonzales L, Granger CB, Kleinman ME, Bjerke C, Nichol G. Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e645-e660. [DOI: 10.1161/cir.0000000000000557] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a national process to develop and implement evidence-based guidelines for cardiac resuscitation systems of care. Significant experience has been gained with implementing these systems, and new evidence has accumulated. This update describes recent advances in the science of cardiac resuscitation systems and evidence of their effectiveness, as well as recent progress in dissemination and implementation throughout the United States. Emphasis is placed on evidence published since the original recommendations (ie, including and since 2010).
Collapse
|
26
|
Yu W, Kavi T, Majic T, Alva K, Moheet A, Lyden P, Schievink W, Lekovic G, Alexander M. Treatment Modality and Quality Benchmarks of Aneurysmal Subarachnoid Hemorrhage at a Comprehensive Stroke Center. Front Neurol 2018; 9:152. [PMID: 29599745 PMCID: PMC5862861 DOI: 10.3389/fneur.2018.00152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/01/2018] [Indexed: 01/23/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is the most severe type of stroke. In 2012, the Joint Commission, in collaboration with the American Heart Association/American Stroke Association (AHA/ASA), launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification was designed to promote higher standard of care for patients with complex stroke. Objective The goal of this study was to examine the treatment modality and quality benchmarks of aSAH at one of the first five certified CSCs in the United States. Methods Consecutive patients with aSAH at Cedars-Sinai Medical Center between April 1, 2012 and May 30, 2014 were included for this retrospective study. The ruptured aneurysm was treated with coiling or clipping within 24 h. All patients were managed per AHA guidelines. Discharge outcomes were assessed using modified Rankin Scale (mRS). The rate of aneurysm treatment, door-to-treatment time, rate of posttreatment rebleed, hospital length of stay (LOS), discharge outcome, and mortality rates were evaluated as quality indicators. Results The median age (interquartile range) of the 118 patients with aSAH was 55 (19). Among them, 84 (71.2%) were females, 94 (79.7%) were transfers from outside hospitals, and 74 (62.7%) had Hunt and Hess grades 1-3. Sixty patients (50.8%) were treated with coiling, 52 (44.1%) with clipping, and 6 (5.1%) untreated due to ictal cardiac arrest or severe comorbidities. The rate of aneurysm treatment was 95% (112/118) with median door-to-treatment time at 12.5 (8.5) h and 0.9% (1/112) posttreatment rebleed. The median ICU and hospital LOS were 12.5 (7) and 17.0 (14.5) days, respectively. Coiling was associated with significantly shorter LOS than clipping. There were 59 patients (50%) with favorable outcome and 19 deaths (16.1%) at hospital discharge. There was no significant difference in discharge outcome between coiling and clipping. Conclusion Care of aSAH at one of the early CSCs in the United States was associated with high rate of aneurysm treatment, fast door-to-treatment time, low posttreatment rebleed, excellent outcome, and low mortality rate. Coiling was associated with significant shorter LOS than clipping. There was no significant difference in discharge outcomes between treatment modalities.
Collapse
Affiliation(s)
- Wengui Yu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurology, University of California Irvine Medical Center, Orange, CA, United States
| | - Tapan Kavi
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurology and Neurosurgery, Cooper University Hospital, Camden, NJ, United States
| | - Tamara Majic
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Kimberly Alva
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Asma Moheet
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Wouter Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Gregory Lekovic
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Neurosurgery, House Clinic, Los Angeles, CA, United States
| | - Michael Alexander
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| |
Collapse
|
27
|
Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization. J Crit Care Med (Targu Mures) 2018. [DOI: 10.2478/jccm-2018-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI.
Methods: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05.
Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).
Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.
The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients.
Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.
Collapse
|
28
|
Shah SO, Au YK, Rincon F, Vibbert M. Neurological Critical Care Services' Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization. J Crit Care Med (Targu Mures) 2018; 4:5-11. [PMID: 29967894 PMCID: PMC5953264 DOI: 10.1515/jccm-2018-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 12/12/2017] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. METHODS Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. RESULTS Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. CONCLUSION The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.
Collapse
Affiliation(s)
- Syed Omar Shah
- Department of Neurology, Thomas Jefferson University, Philadelphia, PAUSA
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PAUSA
- Divisions of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PAUSA
- Department of Cerebrovascular Diseases, Thomas Jefferson University, Philadelphia, PAUSA
| | - Yu Kan Au
- Department of Neurology, Thomas Jefferson University, Philadelphia, PAUSA
| | - Fred Rincon
- Department of Neurology, Thomas Jefferson University, Philadelphia, PAUSA
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PAUSA
- Divisions of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PAUSA
- Department of Cerebrovascular Diseases, Thomas Jefferson University, Philadelphia, PAUSA
| | - Matthew Vibbert
- Department of Neurology, Thomas Jefferson University, Philadelphia, PAUSA
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PAUSA
- Divisions of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PAUSA
- Department of Cerebrovascular Diseases, Thomas Jefferson University, Philadelphia, PAUSA
| |
Collapse
|
29
|
Improvement in Quality Metrics Outcomes and Patient and Family Satisfaction in a Neurosciences Intensive Care Unit after Creation of a Dedicated Neurocritical Care Team. Crit Care Res Pract 2017; 2017:6394105. [PMID: 29119023 PMCID: PMC5651093 DOI: 10.1155/2017/6394105] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/19/2017] [Accepted: 09/05/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Dedicated neurointensivists have been shown to improve outcome measurements in the neurosciences intensive care unit (NSICU). Quality outcome data in relation to patient and family satisfaction is lacking. This study evaluated the impact of newly appointed neurointensivists and creation of a neurocritical care team on quality outcome measures including patient satisfaction in a NSICU. Methods This is a retrospective study of data over 36 months from a 14-bed NSICU evaluating quality outcome measures and anonymous patient satisfaction questionnaires before and after neurointensivists appointment. Results After appointment of neurointensivists, patient acuity of the NSICU increased by 33.4% while LOS decreased by 3.5%. There was a decrease in neurosciences mortality (35.8%), catheter-associated urinary tract infection (50%), central line associated bloodstream infection (100%), and ventilator-associated pneumonia (50%). During the same time, patient satisfaction increased by 28.3% on physicians/nurses consistency (p = 0.025), by 69.5% in confidence/trust in physicians (p < 0.0001), by 78.3% on physicians treated me with courtesy/respect (p < 0.0001), and by 46.4% on physicians' attentiveness (p < 0.0001). Ultimately, patients recommending the hospital to others increased by 67.5% (p < 0.0001). Conclusion Dedicated neurointensivists and the subsequent development of a neurocritical care team positively impacted quality outcome metrics, particularly significantly improving patient satisfaction.
Collapse
|
30
|
Kyeremanteng K, Hendin A, Bhardwaj K, Thavorn K, Neilipovitz D, Kubelik D, D'Egidio G, Stotts G, Rosenberg E. Neuroscience Intermediate-Level Care Units Staffed by Intensivists: Clinical Outcomes and Cost Analysis. J Intensive Care Med 2017; 34:109-114. [PMID: 28443389 DOI: 10.1177/0885066617706651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION: With an aging population and increasing numbers of intensive care unit admissions, novel ways of providing quality care at reduced cost are required. Closed neurointensive care units improve outcomes for patients with critical neurological conditions, including decreased mortality and length of stay (LOS). Small studies have demonstrated the safety of intermediate-level units for selected patient populations. However, few studies analyze both cost and safety outcomes of these units. This retrospective study assessed clinical and cost-related outcomes in an intermediate-level neurosciences acute care unit (NACU) before and after the addition of an intensivist to the unit's care team. METHODS: Starting in October 2011, an intensivist-led model was adopted in a 16-bed NACU unit, including daytime coverage by a dedicated intensivist. Data were obtained from all patients admitted 1 year prior to and 2 years after this intervention. Primary outcomes were LOS and hospital costs. Safety outcomes included mortality and readmissions. Descriptive and analytic statistics were calculated. Individual and total patient costs were calculated based on per-day NACU and ward cost estimates and significance measured using bootstrapping. RESULTS: A total of 2931 patients were included over the study period. Patients were on average 59.5 years and 53% male. The most common reasons for admission were central nervous system (CNS) tumor (27.6%), ischemic stroke (27%), and subarachnoid hemorrhage (11%). Following the introduction of an intensivist, there was a significant reduction in NACU and hospital LOS, by 1 day and 3 days, respectively. There were no differences in readmissions or mortality. Adding an intensivist produced an individual cost savings of US$963 in NACU and US$2687 per patient total hospital stay. CONCLUSION: An intensivist-led model of intermediate-level neurointensive care staffed by intensivists is safe, decreases LOS, and produces cost savings in a system increasingly strained to provide quality neurocritical care.
Collapse
Affiliation(s)
- Kwadwo Kyeremanteng
- 1 Division of Critical Care and Palliative Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kalpana Bhardwaj
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- 3 Department of Epidemiology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dave Neilipovitz
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dalibour Kubelik
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gianni D'Egidio
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Grant Stotts
- 4 Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
31
|
Implementation of Neurocritical Care Is Associated With Improved Outcomes in Traumatic Brain Injury. Can J Neurol Sci 2017; 44:350-357. [PMID: 28343456 DOI: 10.1017/cjn.2017.25] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Traditionally, the delivery of dedicated neurocritical care (NCC) occurs in distinct NCC units and is associated with improved outcomes. Institution-specific logistical challenges pose barriers to the development of distinct NCC units; therefore, we developed a consultancy NCC service coupled with the implementation of invasive multimodal neuromonitoring, within a medical-surgical intensive care unit. Our objective was to evaluate the effect of a consultancy NCC program on neurologic outcomes in severe traumatic brain injury patients. METHODS We conducted a single-center quasi-experimental uncontrolled pre- and post-NCC study in severe traumatic brain injury patients (Glasgow Coma Scale ≤8). The NCC program includes consultation with a neurointensivist and neurosurgeon and multimodal neuromonitoring. Demographic, injury severity metrics, neurophysiologic data, and therapeutic interventions were collected. Glasgow Outcome Scale (GOS) at 6 months was the primary outcome. Multivariable ordinal logistic regression was used to model the association between NCC implementation and GOS at 6 months. RESULTS A total of 113 patients were identified: 76 pre-NCC and 37 post-NCC. Mean age was 39 years (standard deviation [SD], 2) and 87 of 113 (77%) patients were male. Median admission motor score was 3 (interquartile ratio, 1-4). Daily mean arterial pressure was higher (95 mmHg [SD, 10]) versus (88 mmHg [SD, 10], p<0.001) and daily mean core body temperature was lower (36.6°C [SD, 0.90]) versus (37.2°C [SD, 1.0], p=0.001) post-NCC compared with pre-NCC, respectively. Multivariable regression modelling revealed the NCC program was associated with a 2.5 increased odds (odds ratios, 2.5; 95% confidence interval, 1.1-5.3; p=0.022) of improved 6-month GOS. CONCLUSIONS Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.
Collapse
|
32
|
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a neurological emergency with high risk of neurological decline and death. Although the presentation of a thunderclap headache or the worst headache of a patient's life easily triggers the evaluation for SAH, subtle presentations are still missed. The gold standard for diagnostic evaluation of SAH remains noncontrast head computed tomography (CT) followed by lumbar puncture if the CT is negative for SAH. Management of patients with SAH follows standard resuscitation of critically ill patients with the emphasis on reducing risks of rebleeding and avoiding secondary brain injuries.
Collapse
Affiliation(s)
- Michael K Abraham
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| | - Wan-Tsu Wendy Chang
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| |
Collapse
|
33
|
McDermott M, Jacobs T, Morgenstern L. Critical care in acute ischemic stroke. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:153-176. [PMID: 28187798 DOI: 10.1016/b978-0-444-63600-3.00010-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Most ischemic strokes are managed on the ward or on designated stroke units. A significant proportion of patients with ischemic stroke require more specialized care. Several studies have shown improved outcomes for patients with acute ischemic stroke when neurocritical care services are available. Features of acute ischemic stroke patients requiring intensive care unit-level care include airway or respiratory compromise; large cerebral or cerebellar hemisphere infarction with swelling; infarction with symptomatic hemorrhagic transformation; infarction complicated by seizures; and a large proportion of patients require close management of blood pressure after thrombolytics. In this chapter, we discuss aspects of acute ischemic stroke care that are of particular relevance to a neurointensivist, covering neuropathology, neurodiagnostics and imaging, blood pressure management, glycemic control, temperature management, and the selection and timing of antithrombotics. We also focus on the care of patients who have received intravenous thrombolysis or mechanical thrombectomy. Complex clinical decision making in decompressive hemicraniectomy for hemispheric infarction and urgent management of basilar artery thrombosis are specifically addressed.
Collapse
Affiliation(s)
- M McDermott
- Stroke Program, University of Michigan, Ann Arbor, MI, USA.
| | - T Jacobs
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - L Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
34
|
Alberts MJ, Range J, Spencer W, Cantwell V, Hampel MJ. Availability of endovascular therapies for cerebrovascular disease at primary stroke centers. Interv Neuroradiol 2016; 23:64-68. [PMID: 27895242 DOI: 10.1177/1591019916678199] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Endovascular therapies (EVTs) are useful for treating cerebrovascular disease. There are few data about the availability of such services at primary stroke centers (PSCs). Our hypothesis was that some of these services may be available at some PSCs. Methods We conducted an internet-based survey of hospitals certified as PSCs by the Joint Commission. The survey inquired about EVTs such as intra-arterial (IA) lytics, IA mechanical clot removal, coiling of aneurysms, and cervical arterial stenting, physician training, coverage models, hospital type, and outcomes. Chi-square analyses were used to detect differences between academic and community PSCs. Results Data were available from 352 PSCs, of which 75% were community hospitals, 23% academic medical centers, and 80% were non-profit; almost half (48%) see 300 or more patients annually with ischemic stroke. A majority (60%) provided some or all EVTs on site, while 29% had none on site and no plans to add them. Among the respondents offering EVTs, 95% offered stenting of neck vessels, 86% IA lytics, 80% IA mechanical, and 74% aneurysm coiling. The majority (>55%) that did offer such services provided them 24/7/365. Most endovascular coverage was provided by interventional neuroradiologists (60%), fellowship trained endovascular neurosurgeons (42%), and interventional radiologists (41%). The majority of hospitals (81%) did not participate in an audited national registry. Conclusions A variety of EVT services are offered at many PSCs by interventionalists with diverse types of training. The availability of such services is clinically relevant now with the proven efficacy of mechanical thrombectomy for ischemic stroke.
Collapse
Affiliation(s)
- Mark J Alberts
- 1 UT Southwestern Medical Center, Department of Neurology and Neurotherapeutics, USA
| | | | | | | | | |
Collapse
|
35
|
Quimby AE, Shamy MCF, Rothwell DM, Liu EY, Dowlatshahi D, Stotts G. A Novel Neuroscience Intermediate-Level Care Unit Model: Retrospective Analysis of Impact on Patient Flow and Safety. Neurohospitalist 2016; 7:83-90. [PMID: 28400902 DOI: 10.1177/1941874416672558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Neurointensive care units have been shown to improve patient outcomes across a variety of neurological and neurosurgical conditions. However, the efficacy of less resource-intensive intermediate-level care units to deliver similar care has not been well studied. The purpose of this study is to evaluate the impact of neurocritical specialist comanagement on patient flow and safety in a neuroscience intermediate-level care unit. METHODS Our intervention consisted of the addition of a physician with critical care experience as well as training in neurology, anesthesiology, or intensive care to a neuroscience intermediate-level care unit to comanage patients alongside neurology and neurosurgery staff during weekday daytime hours. A retrospective analysis was performed on prospectively collected data pertaining to all patients admitted to the unit over a 3-year period, 1 year before our intervention and 2 years after. Patient statistics including wait times to admission, length of stay (LOS), and mortality were reviewed. RESULTS Following the intervention, there were significant reductions in wait times to unit admission from both the emergency department and postanesthetic care unit, as well as reductions in the average LOS. No significant safety concerns were identified. CONCLUSION This study has demonstrated that the optimization of a neuroscience intermediate-level care unit involving comanagement of patients by a neurocritical specialist can reduce wait times to admission and lengths of stay, with preserved safety outcomes.
Collapse
Affiliation(s)
- Alexandra E Quimby
- Department of Otolaryngology-Head & Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel C F Shamy
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Deanna M Rothwell
- The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Erin Y Liu
- The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grant Stotts
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada
| |
Collapse
|
36
|
Rush B, Romano K, Ashkanani M, McDermid RC, Celi LA. Impact of hospital case-volume on subarachnoid hemorrhage outcomes: A nationwide analysis adjusting for hemorrhage severity. J Crit Care 2016; 37:240-243. [PMID: 27663296 DOI: 10.1016/j.jcrc.2016.09.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/19/2016] [Accepted: 09/09/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There have been suggestions that patients with subarachnoid hemorrhage (SAH) have a better outcome when treated in high-volume centers. Much of the published literature on the subject is limited by an inability to control for severity of SAH. METHODS This is a nationwide retrospective cohort analysis using the Nationwide Inpatient Sample (NIS). The NIS Subarachnoid Severity Scale was used to adjust for severity of SAH in multivariate logistic regression modeling. RESULTS The records of 47 911 414 hospital admissions from the 2006-2011 NIS samples were examined. There were 11 607 patients who met inclusion criteria for the study. Of these, 7787 (67.0%) were treated at a high-volume center compared with 3820 (32.9%) treated at a low-volume center. Patients treated at high-volume centers compared with low-volume centers were more likely to receive endovascular aneurysm control (58.5% vs 51.2%, P=.04), be transferred from another hospital (35.4% vs 19.7%, P<.01), be treated in a teaching facility (97.3% vs 72.9%, P<.01), and have a longer length of stay (14.9 days [interquartile range 10.3-21.7] vs 13.9 days [interquartile range, 8.9-20.1], P<.01). After adjustment for all baseline covariates, including severity of SAH, treatment in a high-volume center was associated with an odds ratio for death of 0.82 (95% confidence interval, 0.72-0.95; P<.01) and a higher odds of a good functional outcome (odds ratio, 1.16; 95% confidence interval, 1.04-1.28; P<.01). CONCLUSION After adjustment for severity of SAH, treatment in a high-volume center was associated with a lower risk of in-hospital mortality and a higher odds of a good functional outcome.
Collapse
Affiliation(s)
- Barret Rush
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 W 12th Ave, Vancouver, British Columbia, Canada V5Z 1M9; Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Ave, Boston, MA 02115.
| | - Kali Romano
- Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Mohammad Ashkanani
- Division of Epilepsy, Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Robert C McDermid
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 W 12th Ave, Vancouver, British Columbia, Canada V5Z 1M9; Department of Critical Care Medicine, Surrey Memorial Hospital, Surrey, BC, Canada.
| | | |
Collapse
|
37
|
Abstract
This update comprises six important topics under neurocritical care that require reevaluation. For post-cardiac arrest brain injury, the evaluation of the injury and its corresponding therapy, including temperature modulation, is required. Analgosedation for target temperature management is an essential strategy to prevent shivering and minimizes endogenous stress induced by catecholamine surges. For severe traumatic brain injury, the diverse effects of therapeutic hypothermia depend on the complicated pathophysiology of the condition. Continuous electroencephalogram monitoring is an essential tool for detecting nonconvulsive status epilepticus in the intensive care unit (ICU). Neurocritical care, including advanced hemodynamic monitoring, is a fundamental approach for delayed cerebral ischemia following subarachnoid hemorrhage. We must be mindful of the high percentage of ICU patients who may develop sepsis-associated brain dysfunction.
Collapse
Affiliation(s)
- Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki, Kita, Kagawa Japan 761-0793
| |
Collapse
|
38
|
Pandey AS, Gemmete JJ, Wilson TJ, Chaudhary N, Thompson BG, Morgenstern LB, Burke JF. High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes. Neurosurgery 2016; 77:462-70; discussion 470. [PMID: 26110818 DOI: 10.1227/neu.0000000000000850] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High-volume centers have better outcomes than low-volume centers when managing complex conditions including subarachnoid hemorrhage (SAH). OBJECTIVE To quantify SAH volume-outcome association and determine the extent to which this association is influenced by aggressiveness of care. METHODS A serial cross-sectional retrospective study using the Nationwide Inpatient Sample for 2002 to 2010 was performed. Included were all adult (older than 18 years of age) discharged patients with a primary diagnosis of SAH admitted from the emergency department or transferred to a discharging hospital; cases of trauma or arteriovenous malformation were excluded. Survey-weighted descriptive statistics estimated temporal trends. Multilevel logistic regression estimated volume-outcome associations for inpatient mortality and discharge home. Models were adjusted for demographic characteristics, year, transfer status, insurance status, all individual Charlson comorbidities, intubation, and all patient-refined, diagnosis-related group mortality. Analyses were repeated, excluding cases in which aggressive care was not pursued. RESULTS A total of 32,336 discharges were included; 13,398 patients underwent clipping (59.1%) or coiling (40.9%). The inpatient mortality rate decreased from 32.2% in 2002 to 22.2% in 2010; discharge home increased from 28.5% to 40.8% during the same period. As SAH volume decreased from 100/year, the mortality rate increased from 18.7% to 19.8% at 80/year, 21.7% at 60/year, 24.5% at 40/year, and 28.4% at 20/year. As SAH patient volume decreased, the probability of discharge home decreased from 40.3% at 100/year to 38.7% at 60/year, and 35.3% at 20/year. Better outcomes persisted in patients receiving aggressive care and in those not receiving aggressive care. CONCLUSION Short-term SAH outcomes have improved. High-volume hospitals have more favorable outcomes than low-volume hospitals. This effect is substantial, even for hospitals conventionally classified as high volume.
Collapse
Affiliation(s)
- Aditya S Pandey
- Departments of *Neurosurgery, ‡Radiology, and §Neurology, University of Michigan, Ann Arbor, Michigan
| | | | | | | | | | | | | |
Collapse
|
39
|
Ecker RD. The Rheology of Subarachnoid Hemorrhage. World Neurosurg 2016; 87:494-7. [DOI: 10.1016/j.wneu.2015.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 11/27/2022]
|
40
|
Makarenko S, Griesdale DE, Gooderham P, Sekhon MS. Multimodal neuromonitoring for traumatic brain injury: A shift towards individualized therapy. J Clin Neurosci 2016; 26:8-13. [PMID: 26755455 DOI: 10.1016/j.jocn.2015.05.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/30/2015] [Indexed: 01/08/2023]
Abstract
Multimodal neuromonitoring in the management of traumatic brain injury (TBI) enables clinicians to make individualized management decisions to prevent secondary ischemic brain injury. Traditionally, neuromonitoring in TBI patients has consisted of a combination of clinical examination, neuroimaging and intracranial pressure monitoring. Unfortunately, each of these modalities has its limitations and although pragmatic, this simplistic approach has failed to demonstrate improved outcomes, likely owing to an inability to consider the underlying heterogeneity of various injury patterns. As neurocritical care has evolved, so has our understanding of underlying disease pathophysiology and patient specific considerations. Recent additions to the multimodal neuromonitoring platform include measures of cerebrovascular autoregulation, brain tissue oxygenation, microdialysis and continuous electroencephalography. The implementation of neurocritical care teams to manage patients with advanced brain injury has led to improved outcomes. Herein, we present a narrative review of the recent advances in multimodal neuromonitoring and highlight the utility of dedicated neurocritical care.
Collapse
Affiliation(s)
- Serge Makarenko
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Peter Gooderham
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
| |
Collapse
|
41
|
Schaller SJ, Stäuble CG, Suemasa M, Heim M, Duarte IM, Mensch O, Bogdanski R, Lewald H, Eikermann M, Blobner M. The German Validation Study of the Surgical Intensive Care Unit Optimal Mobility Score. J Crit Care 2015; 32:201-6. [PMID: 26857328 DOI: 10.1016/j.jcrc.2015.12.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/03/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Immobilization of critically ill patients leads to muscle weakness, which translates to increased costs of care and long-term functional disability. We tested the validity of a German Surgical Intensive Care Unit (ICU) Optimal Mobilization Score (SOMS) in 2 different cohorts (neurocritical and nonneurocritical care patients). MATERIALS AND METHODS Physical therapists estimated the patients' mobilization capacity by using the German version of the SOMS the morning after admission. We tested the prognostic value of the prediction for ICU and hospital length of stay (LOS) as well as for mortality, and built a model to account for other known predictors of these outcomes in the 2 cohorts. RESULTS A total of 128 patients were included in the analysis, 48 of these were neurocritical care patients. The SOMS predicted mortality and ICU and hospital LOS. Neurocritical care patients stayed significantly longer in the ICU (median 12 vs 4 days, P < .001) and in the hospital (25 vs 17 days, P = .02). The SOMS predicted ICU and hospital LOS. It predicted mortality only in nonneurocritical patients. CONCLUSIONS The German SOMS assessed by physical therapists on the day after ICU admission predicts ICU and hospital LOS, and mortality. Our data suggest that the association between early mobilization and mortality is more complex in neurocritical care patients.
Collapse
Affiliation(s)
- Stefan J Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Christiane G Stäuble
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Mika Suemasa
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Markus Heim
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ingrid Moreno Duarte
- Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Oliver Mensch
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ralph Bogdanski
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heidrun Lewald
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Manfred Blobner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| |
Collapse
|
42
|
Egawa S, Hifumi T, Kawakita K, Okauchi M, Shindo A, Kawanishi M, Tamiya T, Kuroda Y. Impact of neurointensivist-managed intensive care unit implementation on patient outcomes after aneurysmal subarachnoid hemorrhage. J Crit Care 2015; 32:52-5. [PMID: 26703419 DOI: 10.1016/j.jcrc.2015.11.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/06/2015] [Accepted: 11/14/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of the study is to evaluate the impact of neurointensivist-managed intensive care unit (NIM-ICU) implementation for patients admitted with aneurysmal subarachnoid hemorrhage (SAH). METHODS This study retrospectively evaluated 234 patients (mean age, 61.7 years; male, 67) admitted with SAH between January 1, 2001, and March 31, 2014. Neurologic outcomes between patients admitted from January 2001 to December 2006 (intensivist-managed intensive care unit group) and January 2007 to March 2014 (NIM-ICU group) were compared. The primary outcome was the incidence of a good neurologic outcome at discharge (GO; the modified Ranking Scale score: GO, 0-2; poor neurological outcome, 3-6) at discharge. RESULTS Neurointensivist-managed intensive care unit was initiated for 151 (64.5%) of 234 patients. Univariate analysis demonstrated significantly better outcomes for NIM-ICU group vs intensivist-managed intensive care unit group (GOs, 58.3% vs 41.0%, respectively, P = .01). Multivariate logistic regression was used to evaluate NIM-ICU efficacy for SAH patients, but NIM-ICU was not significantly associated with GOs (P = .054). Subgroup analysis of patient grading by Hunt and Kosnik grades I to II showed that NIM-ICU implementation was an independent predictor of GOs (odds ratio, 4.54; 95% confidence interval, 1.08-22.17; P = .04). CONCLUSION Neurointensivist-managed intensive care unit may improve neurologic outcomes in SAH patients with Hunt and Kosnik grades I to II.
Collapse
Affiliation(s)
- Satoshi Egawa
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Masanobu Okauchi
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Atsushi Shindo
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Masahiko Kawanishi
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Takashi Tamiya
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
| |
Collapse
|
43
|
International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care. Neurocrit Care 2015; 21 Suppl 2:S215-28. [PMID: 25208666 DOI: 10.1007/s12028-014-0020-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.
Collapse
|
44
|
Prabhakaran S, Fonarow GC, Smith EE, Liang L, Xian Y, Neely M, Peterson ED, Schwamm LH. Hospital case volume is associated with mortality in patients hospitalized with subarachnoid hemorrhage. Neurosurgery 2015; 75:500-8. [PMID: 24979097 DOI: 10.1227/neu.0000000000000475] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prior studies have suggested that hospital case volume may be associated with improved outcomes after subarachnoid hemorrhage (SAH), but contemporary national data are limited. OBJECTIVE To assess the association between hospital case volume for SAH and in-hospital mortality. METHODS Using the Get With The Guidelines-Stroke registry, we analyzed patients with a discharge diagnosis of SAH between April 2003 and March 2012. We assessed the association of annual SAH case volume with in-hospital mortality by using multivariable logistic regression adjusting for relevant patient, hospital, and geographic characteristics. RESULTS Among 31,973 patients with SAH from 685 hospitals, the median annual case volume per hospital was 8.5 (25th-75th percentile, 6.7-12.9) patients. Mean in-hospital mortality was 25.7%, but was lower with increasing annual SAH volume: 29.5% in quartile 1 (range, 4-6.6), 27.0% in quartile 2 (range, 6.7-8.5), 24.1% in quartile 3 (range, 8.5-12.7), and 22.1% in quartile 4 (range, 12.9-94.5). Adjusting for patient and hospital characteristics, hospital SAH volume was independently associated with in-hospital mortality (adjusted odds ratio 0.79 for quartile 4 vs 1, 95% confidence interval, 0.67-0.92). The quartile of SAH volume also was associated with length of stay but not with discharge home or independent ambulatory status. CONCLUSION In a large nationwide registry, we observed that patients treated at hospitals with higher volumes of SAH patients have lower in-hospital mortality, independent of patient and hospital characteristics. Our data suggest that experienced centers may provide more optimized care for SAH patients.
Collapse
Affiliation(s)
- Shyam Prabhakaran
- *Department of Neurology, Northwestern University, Chicago, Illinois; ‡Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, California; §Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; ¶Duke Clinical Research Institute, Durham, North Carolina; and ‖Division of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Rabinstein AA. Critical care of aneurysmal subarachnoid hemorrhage: state of the art. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:239-42. [PMID: 25366630 DOI: 10.1007/978-3-319-04981-6_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Subarachnoid hemorrhage (SAH) from a ruptured aneurysm is a very complex disease. The brain can be injured from the immediate effects of the acute bleeding, but can also be threatened by secondary insults hours and days later. Early and delayed systemic complications are common and can be very serious. This brief paper summarizes key practical concepts regarding the neurocritical care of patients with aneurysmal SAH (aSAH). It proposes as a framework the division of the time course of the disease into a first phase (from aneurysm rupture to aneurysm treatment) of resuscitation and stabilization and a second phase (from aneurysm treatment to the end of the acute hospitalization) of prevention and treatment of secondary insults. The main mechanisms of cerebral injury and the principal systemic complications are discussed and diagnostic and therapeutic advice is provided based on a combination of available evidence and clinical experience.
Collapse
Affiliation(s)
- Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, 200 First Street SW, Mayo W8B, Rochester, MN, 55905, USA,
| |
Collapse
|
46
|
Botting MJ, Phan N, Rubenfeld GD, Speke AK, Chapman MG. Using barriers analysis to refine a novel model of neurocritical care. Neurocrit Care 2015; 20:5-14. [PMID: 24101105 DOI: 10.1007/s12028-013-9905-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In order to deliver specialized neurocritical care (NCC) without a dedicated neurological intensive care unit (ICU), we established a virtual NCC unit within an existing mixed level III ICU. This initiative required changes to patient allocation, physician staffing, and care protocols. In advance of its implementation, we gaged readiness, assessed barriers, and solicited feedback from staff. METHODS Clinicians at our academic hospital and trauma centre in Toronto, Ontario were the subjects of this concurrent mixed methods study. Eighteen stakeholders were individually interviewed. 116 of 217 eligible ICU staff participated in the survey and 36 staff attended the focus group sessions. RESULTS From the survey, the most significant barriers to this reorganization were staff anxiety about coping (28 %) and a concern that patients would not receive better care (24 %). Noteworthy obstacles about the use of protocols were their lack of flexibility (19 %) and that implementation was seen as impractical (16 %). Seventeen barriers were proposed through an open-ended survey question. Content analysis revealed general resistance, educational challenges, workflow adjustment to a diagnosis-based rounding pattern and coordination conflicts to be the central barriers. These findings were confirmed in focus group discussions, with a lack of resources as an additional important challenge. CONCLUSIONS A new workable model for NCC has been developed, facilitated by this analysis. Steps to overcome barriers demonstrated in this study include additional educational measures, changes to the rounding protocols, and patient allocation algorithms.
Collapse
Affiliation(s)
- Marianne J Botting
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Room D108, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | | | | | | | | |
Collapse
|
47
|
Chang TR, Kowalski RG, Carhuapoma JR, Tamargo RJ, Naval NS. Impact of case volume on aneurysmal subarachnoid hemorrhage outcomes. J Crit Care 2015; 30:469-72. [PMID: 25648904 DOI: 10.1016/j.jcrc.2015.01.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/03/2014] [Accepted: 01/07/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE To compare aneurysmal subarachnoid hemorrhage (aSAH) outcomes between high- and low-volume referral centers with dedicated neurosciences critical care units (NCCUs) and shared neurosurgical, endovascular, and neurocritical care practitioners. MATERIALS AND METHODS Prospectively collected data of aSAH patients admitted to 2 institutional NCCUs were reviewed. NCCU A is a 22-bed unit staffed 24/7 with overnight in-house NCCU fellow and resident coverage. NCCU B is a 14-bed unit with home call by NCCU attending/fellow and in-house residents. RESULTS A total of 161 aSAH patients (27%) were admitted to NCCU B compared with 447 at NCCU A (73%). Among factors that independently impacted hospital mortality, there were no differences in baseline characteristics: mean age (A: 53.5 ± 14.1 years, B: 53.1 ± 13.6 years), poor grade Hunt and Hess (A: 28.2%, B: 26.7%), presence of multiple medical comorbidities (A: 28%, B: 31.1%), and associated cocaine use (A: 11.6%, B: 14.3%). There was no significant difference in hospital mortality (A: 17.9%, B: 18%), poor functional outcome (A: 30%, B: 25.4%), aneurysm rerupture (A: 2.8%, B: 2.4%), or delayed cerebral ischemia (A: 14.1%, B: 16.1%). CONCLUSIONS The noninferior outcomes at the lower SAH volume center suggests that provider expertise, not patient volume, is critical to providing high-quality specialized care.
Collapse
Affiliation(s)
- Tiffany R Chang
- Departments of Neurosurgery and Neurology, University of Texas Medical School, Houston, TX.
| | - Robert G Kowalski
- Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - J Ricardo Carhuapoma
- Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Rafael J Tamargo
- Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Neeraj S Naval
- Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| |
Collapse
|
48
|
Talke PO, Sharma D, Heyer EJ, Bergese SD, Blackham KA, Stevens RD. Republished: Society for Neuroscience in Anesthesiology and Critical Care expert consensus statement: Anesthetic management of endovascular treatment for acute ischemic stroke. Stroke 2014; 45:e138-50. [PMID: 25070964 DOI: 10.1161/strokeaha.113.003412] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Literature on the anesthetic management of endovascular treatment of acute ischemic stroke (AIS) is limited. Anesthetic management during these procedures is still mostly dependent on individual or institutional preferences. Thus, the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) created a task force to provide expert consensus recommendations on anesthetic management of endovascular treatment of AIS. The task force conducted a systematic literature review (up to August 2012). Because of the limited number of research articles relating to this subject, the task force solicited opinions from experts in this area. The task force created a draft consensus statement based on the available data. Classes of recommendations and levels of evidence were assigned to articles specifically addressing anesthetic management during endovascular treatment of stroke using the standard American Heart Association evidence rating scheme. The draft consensus statement was reviewed by the Task Force, SNACC Executive Committee and representatives of Society of NeuroInterventional Surgery (SNIS) and Neurocritical Care Society (NCS) reaching consensus on the final document. For this consensus statement the anesthetic management of endovascular treatment of AIS was subdivided into 12 topics. Each topic includes a summary of available data followed by recommendations. This consensus statement is intended for use by individuals involved in the care of patients with acute ischemic stroke, such as anesthesiologists, interventional neuroradiologists, neurologists, neurointensivists and neurosurgeons.
Collapse
Affiliation(s)
- Pekka O Talke
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.
| | - Deepak Sharma
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Eric J Heyer
- Departments of Anesthesiology and Neurology, Columbia University, New York, NY
| | - Sergio D Bergese
- Departments of Anesthesiology and Neurological Surgery, The Ohio State University, Columbus (on behalf of Society for Neuroscience in Anesthesiology and Critical Care [SNACC])
| | - Kristine A Blackham
- Department of Radiology, Case Western Reserve University, Cleveland, OH (representing the Society of NeuroInterventional Surgery [SNIS])
| | - Robert D Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery and Radiology, Hopkins University School of Medicine, Baltimore, MD (representing the Neurocritical Care Society [NCS])
| |
Collapse
|
49
|
Ghaly RF. Do neurosurgeons need Neuroanesthesiologists? Should every neurosurgical case be done by a Neuroanesthesiologist? Surg Neurol Int 2014; 5:76. [PMID: 24949219 PMCID: PMC4061581 DOI: 10.4103/2152-7806.133106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/19/2014] [Indexed: 11/30/2022] Open
Abstract
Neuroscience is exponentially growing and accompanied with everyday innovations and intriguing developments. There are new branches of science that are being developed within neuroscience. For instance, the fields of computer interface nanotechnology, molecular biology, ultra cellular, and gene therapy. The neuroscience programs have been established nationwide and worldwide. There is strong belief that better patient care is obtained through high volume and specialty physicians and hospitals. In fact, there are new subspecialties that already developed from within the specialty itself. Neuroanesthesia is one of the specialties that has contributed tremendously over the years to neuroscience yet it remained non-accredited and supported. In fact, there is a discouraging trend to pursue advocating the necessity of neurosurgery cases to be done by neuroanesthesiologists. It is one of the specialties that is lagging behind compared with other specialties and subspecialties in neuroscience. There is an ongoing debate within the neuroanesthesia society about the role of neuroanesthesiologists in neurosurgery. The author, being a neurosurgeon, neuroanesthesiologist, and neurointensivist, is presenting the topic, the views and expressing his opinion.
Collapse
Affiliation(s)
- Ramsis F. Ghaly
- Professor of Neurological Surgery and Anesthesiology University of Illinois at Chicago, Ghaly Neurosurgical Associates, Aurora, Illinois, Advocate Illinois Masonic medical center and JSH of Cook County hospital, Chicago, Illinois, USA
| |
Collapse
|
50
|
Society for Neuroscience in Anesthesiology and Critical Care Expert Consensus Statement. J Neurosurg Anesthesiol 2014; 26:95-108. [DOI: 10.1097/ana.0000000000000042] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|