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Halpern NA, Tan KS, Bothwell LA, Boyce L, Dulu AO. Defining Intensivists: A Retrospective Analysis of the Published Studies in the United States, 2010-2020. Crit Care Med 2024; 52:223-236. [PMID: 38240506 PMCID: PMC11256975 DOI: 10.1097/ccm.0000000000005984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES The Society of Critical Care Medicine last published an intensivist definition in 1992. Subsequently, there have been many publications relating to intensivists. Our purpose is to assess how contemporary studies define intensivist physicians. DESIGN Systematic search of PubMed, Embase, and Web of Science (2010-2020) for publication titles with the terms intensivist, and critical care or intensive care physician, specialist, or consultant. We included studies focusing on adult U.S. intensivists and excluded non-data-driven reports, non-U.S. publications, and pediatric or neonatal ICU reports. We aggregated the study title intensivist nomenclatures and parsed Introduction and Method sections to discern the text used to define intensivists. Fourteen parameters were found and grouped into five definitional categories: A) No definition, B) Background training and certification, C) Works in ICU, D) Staffing, and E) Database related. Each study was re-evaluated against these parameters and grouped into three definitional classes (single, multiple, or no definition). The prevalence of each parameter is compared between groups using Fisher exact test. SETTING U.S. adult ICUs and databases. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 657 studies, 105 (16%) met inclusion criteria. Within the study titles, 17 phrases were used to describe an intensivist; these were categorized as intensivist in 61 titles (58%), specialty intensivist in 30 titles (29%), and ICU/critical care physician in 14 titles (13%). Thirty-one studies (30%) used a single parameter (B-E) as their definition, 63 studies (60%) used more than one parameter (B-E) as their definition, and 11 studies (10%) had no definition (A). The most common parameter "Works in ICU" (C) in 52 studies (50%) was more likely to be used in conjunction with other parameters rather than as a standalone parameter (multiple parameters vs single-parameter studies; 73% vs 17%; p < 0.0001). CONCLUSIONS There was no consistency of intensivist nomenclature or definitions in contemporary adult intensivist studies in the United States.
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Affiliation(s)
- Neil A Halpern
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lilly A Bothwell
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lindsay Boyce
- MSK Library, Technology Division, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alina O Dulu
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
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2
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Su Y, Teng J, Pan S, Jiang W, Wang F, Tian F, Jing J, Huang H, Cao J, Hu H, Liu L, Li W, Liang C, Ma L, Meng X, Tian L, Wang C, Wang L, Wang Y, Wang Z, Wang Z, Xie Z, You M, Yuan J, Zeng C, Zeng L, Zhang L, Zhang L, Zhang X, Zhang Y, Zhao B, Zhou S, Zhou Z. The development of the neurocritical care specialty in China based on the analysis of neurocritical care unit volume and quality. Brain Circ 2024; 10:67-76. [PMID: 38655441 PMCID: PMC11034439 DOI: 10.4103/bc.bc_71_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 04/26/2024] Open
Abstract
PURPOSE Through three neurocritical care unit (NCCU) surveys in China, we tried to understand the development status of neurocritical care and clarify its future development. METHODS Using a cross-sectional survey method and self-report questionnaires, the number and quality of NCCUs were investigated through three steps: administering the questionnaire, sorting the survey data, and analyzing the survey data. RESULTS At the second and third surveys, the number of NCCUs (76/112/206) increased by 47% and 84%, respectively. The NCCUs were located in tertiary grade A hospitals or teaching hospitals (65/100/181) in most provinces (24/28/29). The numbers of full-time doctors (359/668/1337) and full-time nurses (904/1623/207) in the NCCUs increased, but the doctor-bed ratio and nurse-bed ratio were still insufficient (0.4:1 and 1.3:1). CONCLUSION In the past 20 years, the growth rate of NCCUs in China has accelerated, while the allocation of medical staff has been insufficient. Although most NCCU hospital bed facilities and instruments and equipment tend to be adequate, there are obvious defects in some aspects of NCCUs.
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Affiliation(s)
- Yingying Su
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Junfang Teng
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Suyue Pan
- Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Wen Jiang
- Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Furong Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Tian
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huijin Huang
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Cao
- The First Hospital of Jilin University, Changchun, China
| | - Huaiqiang Hu
- The 960(th) Hospital of Joint Logistics Support, PLA, Jinan, China
| | - Liping Liu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Daping Hospital, The Army Military Medical University, Chongqing, China
| | - Cheng Liang
- The Second Hospital of Lanzhou University, Lanzhou, China
| | - Liansheng Ma
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xuegang Meng
- The Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Linyu Tian
- West China Hospital, Sichuan University, Chengdu, China
| | - Changqing Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lihua Wang
- The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yan Wang
- Tangshan People's Hospital of Hebei Province, Tangshan, China
| | - Zhenhai Wang
- Neurology Center, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhiqiang Wang
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zunchun Xie
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Mingyao You
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jun Yuan
- Inner Mongolia People's Hospital, Hohhot, China
| | - Chaosheng Zeng
- The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Li Zeng
- The Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Le Zhang
- Xiangya Hospital, Central South University, Changsha, China
| | - Lei Zhang
- The First People's Hospital of Yunnan Province, Kunming, China
| | - Xin Zhang
- Nanjing Drum Tower Hospital, Nanjing, China
| | - Yongwei Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bin Zhao
- Tianjin Medical University General Hospital, Tianjin, China
| | - Saijun Zhou
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhonghe Zhou
- General Hospital of Northern Theater Command, Shenyang, China
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3
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Mark DG, Huang J, Sonne DC, Rauchwerger AS, Reed ME. Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated "Hub-and-Spoke" Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation? Neurocrit Care 2023; 38:761-770. [PMID: 36600074 DOI: 10.1007/s12028-022-01667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization. METHODS This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a "hub-and-spoke" model of neuroscience care in which two centers service as neuroscience "hubs" and the remaining 19 centers service as referral "spokes." Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less]. RESULTS A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44). CONCLUSIONS Within an integrated "hub-and-spoke" neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a "hub-and-spoke" care model for patients with nontraumatic ICH, although additional investigations are warranted.
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Affiliation(s)
- Dustin G Mark
- Departments of Emergency Medicine and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - D Chris Sonne
- Division of Neuroradiology, Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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4
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Shapshak AH, Shutter L. Neurocritical Care Education in the United States. Crit Care Clin 2023; 39:29-46. [DOI: 10.1016/j.ccc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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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]
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6
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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]
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7
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Critical Care Ultrasound Should Not Be a Priority First-Line Assessment Tool in the Management of Neurocritically Ill Patients. Crit Care Med 2020; 47:837-839. [PMID: 30889021 DOI: 10.1097/ccm.0000000000003736] [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]
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8
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Kim SH, Yum KS, Jeong JH, Choi JH, Park HS, Song YJ, Kim DH, Cha JK, Han MK. Impact of Neurointensivist Co-Management in a Semiclosed Neurocritical-Care Unit. J Clin Neurol 2020; 16:681-687. [PMID: 33029976 PMCID: PMC7541986 DOI: 10.3988/jcn.2020.16.4.681] [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: 05/07/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose The importance of the specialized management of neurocritical patients is being increasingly recognized. We evaluated the impact of neurointensivist comanagement on the clinical outcomes (particularly the mortality rate) of neurocritical patients admitted to a semiclosed neurocritical-care unit (NCU). Methods We retrospectively included neurocritical patients admitted to the NCU between March 2015 and February 2018. We analyzed the clinical data and compared the outcomes between patients admitted before and after the initiation of neurointensivist co-management in March 2016. Results There were 1,785 patients admitted to the NCU during the study period. Patients younger than 18 years (n=28) or discharged within 48 hours (n=200) were excluded. The 1,557 remaining patients comprised 590 and 967 who were admitted to the NCU before and after the initiation of co-management, respectively. Patients admitted under neurointensivist co-management were older and had higher Acute Physiologic Assessment and Chronic Health Evaluation II scores. The 30-day mortality rate was significantly lower after neurointensivist co-management (p=0.042). A multivariate logistic regression analysis demonstrated that neurointensivist co-management significantly reduced mortality rates in the NCU and in the hospital overall [odds ratio=0.590 (p=0.002) and 0.585 (p=0.001), respectively]. Conclusions Despite the higher severity of the condition during neurointensivist co-management, co-management significantly improved clinical outcomes (including the mortality rate) in neurocritical patients.
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Affiliation(s)
- Sang Hwa Kim
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Jin Heon Jeong
- Department of Intensive Care Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea.
| | - Jae Hyung Choi
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Hyun Seok Park
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Young Jin Song
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Dae Hyun Kim
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Moon Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
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9
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Halstead MR, Geocadin RG. The Medical Management of Cerebral Edema: Past, Present, and Future Therapies. Neurotherapeutics 2019; 16:1133-1148. [PMID: 31512062 PMCID: PMC6985348 DOI: 10.1007/s13311-019-00779-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Cerebral edema is commonly associated with cerebral pathology, and the clinical manifestation is largely related to the underlying lesioned tissue. Brain edema usually amplifies the dysfunction of the lesioned tissue and the burden of cerebral edema correlates with increased morbidity and mortality across diseases. Our modern-day approach to the medical management of cerebral edema has largely revolved around, an increasingly artificial distinction between cytotoxic and vasogenic cerebral edema. These nontargeted interventions such as hyperosmolar agents and sedation have been the mainstay in clinical practice and offer noneloquent solutions to a dire problem. Our current understanding of the underlying molecular mechanisms driving cerebral edema is becoming much more advanced, with differences being identified across diseases and populations. As our understanding of the underlying molecular mechanisms in neuronal injury continues to expand, so too is the list of targeted therapies in the pipeline. Here we present a brief review of the molecular mechanisms driving cerebral edema and a current overview of our understanding of the molecular targets being investigated.
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Affiliation(s)
- Michael R Halstead
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA.
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA
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10
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Geller BJ, Fleitman J, Sinha SS. Critical Care Cardiology: Implementing a Training Paradigm. J Am Coll Cardiol 2019; 72:1171-1175. [PMID: 30165989 DOI: 10.1016/j.jacc.2018.07.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Bram J Geller
- Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jessica Fleitman
- Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shashank S Sinha
- Samuel and Jean Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan. https://twitter.com/ShashankSinhaMD
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Builes-Aguilar A, Diaz-Gomez JL, Bilotta F. Education in neuroanesthesia and neurocritical care: trends, challenges and advancements. Curr Opin Anaesthesiol 2019; 31:520-525. [PMID: 29994944 DOI: 10.1097/aco.0000000000000628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW We summarize the latest evidence in neuroanesthesia and neurocritical care (NCC) training. In addition, we describe the newer advancements that clinical educators face in these subspecialties. Lastly, we highlight educational approaches that may lead to an enhanced learning experience and development of necessary skills for neurosciences trainees. RECENT FINDINGS Current neuroanesthesia and NCC training requires acquisition of specific skills for increasing complex surgical cases, specialized neurosurgical practice and new perioperative technologies. Furthermore, there is increasing international interest for standardization and accreditation of neuroanesthesia fellowship programs. Recent evidence has demonstrated that well structured training using high-fidelity simulation improves cognitive and technical skills in acute neurological crises. SUMMARY High-fidelity simulation in perioperative care of neurosurgical patients can be part of formal neuroanesthesia and NCC curricula, and potentially impact trainees' proficiency. A research agenda is needed to validate the assessment of most effective educational interventions in neurosciences trainees with diverse medical backgrounds. Creative combinations of cost-effective interventions including traditional teaching, specific technical skills workshops, low and high-fidelity simulation deserve to be assessed in future studies.
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Affiliation(s)
- Angela Builes-Aguilar
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine.,Department of Anesthesiology.,Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy
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Ko MA, Lee JH, Kim JG, Jeong S, Kang DW, Lim CM, Lee SA, Kim KK, Jeon SB. Effects of Appointing a Full-Time Neurointensivist to Run a Closed-Type Neurological Intensive Care Unit. J Clin Neurol 2019; 15:360-368. [PMID: 31286709 PMCID: PMC6620450 DOI: 10.3988/jcn.2019.15.3.360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 01/08/2023] Open
Abstract
Background and Purpose To investigate whether appointing a full-time neurointensivist to manage a closed-type neurological intensive care unit (NRICU) improves the quality of critical care and patient outcomes. Methods This study included patients admitted to the NRICU at a university hospital in Seoul, Korea. Two time periods were defined according to the presence of a neurointensivist in the preexisting open-type NRICU: the before and after periods. Hospital medical records were queried and compared between these two time periods, as were the biannual satisfaction survey results for the families of patients. Results Of the 15,210 patients in the neurology department, 2,199 were admitted to the NRICU (n=995 and 1,204 during the before and after periods, respectively; p<0.001). The length of stay was shorter during the after than during the before period in both the NRICU (3 vs. 4 days; p<0.001) and the hospital overall (12.5 vs. 14.0 days; p<0.001). Neurological consultations (2,070 vs. 3,097; p<0.001) and intrahospital transfers from general intensive care units to the NRICU (21 vs. 40; p=0.111) increased from the before to after the period. The mean satisfaction scores of the families of the patients also increased, from 78.3 to 89.7. In a Cox proportional hazards model, appointing a neurointensivist did not result in a statistically significant change in 6-month mortality (hazard ratio, 0.82; 95% confidence interval, 0.652–1.031; p=0.089). Conclusions Appointing a full-time neurointensivist to manage a closed-type NRICU had beneficial effects on quality indicators and patient outcomes.
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Affiliation(s)
- Myung Ah Ko
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hwa Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong Goo Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Neurology, Jeju National University Hospital, Jeju, Korea
| | - Suyeon Jeong
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwang Kuk Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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