A Dedicated Neurological Intensive Care Unit Offers Improved Outcomes for Patients With Brain and Spine Injuries

Clinical Characteristics and Outcomes of Neurosurgical Patients at a Level III Intensive Care Unit in Pakistan: A Retrospective Cohort Study

Objective Neurosurgical patients account for the majority of cases across all surgical specialties that are admitted to the surgical intensive care unit (ICU) at our institution. The goal of this study was to analyze factors leading to ICU admission, type of neurosurgical intervention, length of ICU/hospital stays, and outcomes in terms of complications and ICU and in-hospital mortality. Methods This retrospective study conducted at the surgical ICU, Aga Khan University Hospital, investigated clinical data of neurosurgical patients admitted between January 2020 and June 2022. Quantitative data were collected regarding patients' characteristics, such as age, gender, comorbidities, type of surgical intervention, mode of surgery, source of admission to ICU, and type of osmotherapy. The primary and secondary outcomes were in terms of ICU and hospital mortality and complications. Results Among 321 patients admitted to the SICU, 197 were included according to inclusion/exclusion criteria. A total of 168 patients (85.3%) required surgical intervention, of whom 101 (60%) underwent elective surgery and 67 (40%) required emergency surgery. Thirteen patients died during the ICU or hospital stay, representing a mortality rate of 6.6%. The average length of stay in the ICU had a median IQR of 4 (4,6) days while the average hospital stay median IQR was 11 (12,18) days. Tracheostomy was performed in 77 patients (39%), and the median IQR day for tracheostomy was 4 (3,5) days. APACHE-II (Acute Physiology and Chronic Health Evaluation) score, length of ICU, and length of hospital stay were significantly higher in the deceased patients with a p-value of 0.042, 0.019, and 0.043, respectively. Conclusion In conclusion, this study on neurosurgical patients from the surgical intensive care unit of a low-middle-income country provided valuable insights about factors and their influence on outcomes. The study implies that a high APACHE-II score is linked to poorer outcomes for neurosurgical patients in this particular setting. Undertaking a large multicenter prospective study is vital for tailoring interventions and improving patient care in regions with limited resources where healthcare challenges may be distinct.

Cognitive Biases and Shared Decision Making in Acute Brain Injury

Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.

Intracranial Hypotension Syndrome: The Importance of Neurointensive Care

Surgical procedures involving the spine can result in various complications, including vascular, nerve root and dura mater injury, surgical wound infection, and hematoma formation. Unintentional durotomy is a frequent complication of these procedures (up to 17%). Two clinical cases are reported in which the occurrence of epileptiform activity in the form of generalized tonic-clonic seizures after instrumentation of the dorsal and lumbar spine raised suspicion of cerebrospinal fluid (CSF) fistula. In both cases, the diagnostic suspicion and early approach allowed for the adoption of a timely medical and surgical plan, with the aim of reducing the volume of lost CSF as well as the potential neurological dysfunction resulting from this surgical complication.

Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury: A Systematic Review and Meta-analysis

Importance

Neurocritical care (NCC) aims to improve the outcomes of critically ill patients with brain injury, although the benefits of such subspecialized care are yet to be determined.

Objective

To evaluate the association of NCC with patient-centered outcomes in adults with acute brain injury who were admitted to intensive care units (ICUs). The protocol was preregistered on PROSPERO (CRD42020177190).

Data Sources

Three electronic databases were searched (Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials) from inception through December 15, 2021, and by citation chaining.

Study Selection

Studies were included for interventions of neurocritical care units (NCCUs), neurointensivists, or NCC consulting services compared with general care in populations of neurologically ill adults or adults with acute brain injury in ICUs.

Data Extraction and Synthesis

Data extraction was performed in keeping with PRISMA guidelines and risk of bias assessed through the ROBINS-I Cochrane tool by 2 independent reviewers. Data were pooled using a random-effects model.

Main Outcomes and Measures

The primary outcome was all-cause mortality at longest follow-up until 6 months. Secondary outcomes were ICU length of stay (LOS), hospital LOS, and functional outcomes. Data were measured as risk ratio (RR) if dichotomous or standardized mean difference if continuous. Subgroup analyses were performed for disease and models of NCC delivery.

Results

After 5659 nonduplicated published records were screened, 26 nonrandomized observational studies fulfilled eligibility criteria. A meta-analysis of mortality outcomes for 55 792 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.75-0.92; P = .001) in those receiving subspecialized care (n = 27 061) compared with general care (n = 27 694). Subgroup analyses did not identify subgroup differences. Eight studies including 4667 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.70-0.97; P = .03) for an unfavorable functional outcome with subspecialized care compared with general care. There were no differences in LOS outcomes. Heterogeneity was substantial in all analyses.

Conclusions and Relevance

Subspecialized NCC is associated with improved survival and functional outcomes for critically ill adults with brain injury. However, confidence in the evidence is limited by substantial heterogeneity. Further investigations are necessary to determine the specific aspects of NCC that contribute to these improved outcomes and its cost-effectiveness.

"Peas in a Pod": Clustering minorly injured trauma patients together during their hospitalization results in decreased hospital costs and fewer inpatient complications

BACKGROUND

Trauma patient care is complex. Clustering these patients within the hospital seems intuitive. This study's purpose was to explore the benefits of trauma patient clustering, hypothesizing these patients will have decreased costs and better outcomes.

METHODS

This was an analysis of all adult (18-99 years) trauma patients admitted from 1/2017-1/2019 without an intensive care unit stay. Patients were grouped into those admitted to the trauma unit (TU) versus non-trauma units (NTU). Outcomes evaluated between groups were baseline demographics, direct costs, complication rates (using our TQIP registry), and discharge location. T-test, median test, and chi squared test were used. Linear regression was performed. Significance was set at p < 0.05.

RESULTS

1481 patients (684 TU and 797 NTU) were analyzed. TU patients were younger. Injury Severity Score, mortality, and hospital length of stay were similar between groups. Direct hospital costs were decreased for TU patients ($4941(±$4740) versus $5639(±$4897), p = 0.006). Fewer TU patients experienced inpatient complications (7.8% versus 13.5%, p < 0.001). More TU patients were discharged to home (78.9% versus 73.8%, p = 0.02). Linear regression analysis demonstrated admission to NTUs predicted a direct cost increase of $766.35 (p < 0.001).

CONCLUSIONS

Clustering minorly injured trauma patients on a dedicated unit resulted in reduced costs, decreased complications, and higher likelihood for discharge to home.

A Perspective from the Neurocritical Care Society and the Society of Critical Care Medicine: Team-Based Care for Neurological Critical Illness

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.

A Randomized Trial of Complications of Peripherally and Centrally Inserted Central Lines in the Neuro-Intensive Care Unit: Results of the NSPVC Trial

OBJECTIVE

The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous catheters (CVC) in the neuroscience intensive care unit (NSICU).

METHODS

This study was carried out in a 32-bed NSICU in a large academic hospital in the USA from July 2015 until January 2017. Patients admitted requiring central venous access were randomly assigned to have a PICC or CVC inserted. Complications were recorded and compared. The primary outcome was all complications as well as combined numbers of large vein thrombosis, central-line-associated blood stream infections, and insertional trauma. Outcomes were compared using the Fisher's exact test, logistic regression, or unpaired T tests, as appropriate.

RESULTS

One hundred and fifty-two patients were enrolled; 72 were randomized to the PICC arm and 80 to the CVC arm. There were no crossovers, withdrawals, nor losses to follow-up. The study was stopped at the second pre-planned interim analysis for futility. The combined number of large vein thrombosis, central-line-associated blood stream infection, and insertional trauma was 4/72 in the PICC arm and 1/80 in the CVC group (OR 4.6 (95% CI 0.5-42.6) p = 0.14). The number of all complications in the PICC arm was 14/72 compared to 10/80 in the CVC arm (OR 1.7 (95% CI 0.7-4.1) p = 0.24).

CONCLUSIONS

PICCs and CVCs have similar numbers of complications when placed in patients admitted to the NSICU.

Reserved Bed Program Reduces Neurosciences Intensive Care Unit Capacity Strain: An Implementation Study

BACKGROUND

Neurosciences intensive care units (NICUs) provide institutional centers for specialized care. Despite a demonstrable reduction in morbidity and mortality, NICUs may experience significant capacity strain with resulting supraoptimal utilization and diseconomies of scale. We present an implementation study in the recognition and management of capacity strain within a large NICU in the United States. Excessive resource demand in an NICU creates significant operational issues.

OBJECTIVE

To evaluate the efficacy of a Reserved Bed Pilot Program (RBPP), implemented to maximize economies of scale, to reduce transfer declines due to lack of capacity, and to increase transfer volume for the neurosciences service-line.

METHODS

Key performance indicators (KPIs) were created to evaluate RBPP efficacy with respect to primary (strategic) objectives. Operational KPIs were established to evaluate changes in operational throughput for the neurosciences and other service-lines. For each KPI, pilot-period data were compared to the previous fiscal year.

RESULTS

RBPP implementation resulted in a significant increase in accepted transfer volume to the neurosciences service-line (P = .02). Transfer declines due to capacity decreased significantly (P = .01). Unit utilization significantly improved across service-line units relative to theoretical optima (P < .03). Care regionalization was achieved through a significant reduction in “off-service” patient placement (P = .01). Negative externalities were minimized, with no significant negative impact in the operational KPIs of other evaluated service-lines (P = .11).

CONCLUSION

Capacity strain is a significant issue for hospital units. Reducing capacity strain can increase unit efficiency, improve resource utilization, and augment service-line throughput. RBPP implementation resulted in a significant improvement in service-line operations, regional access to care, and resource efficiency, with minimal externalities at the institutional level.

A Bibliometric Analysis of the Most Cited Articles in Neurocritical Care Research

Bibliometric analyses may indicate the most active journals, authors, countries, institutions and specialties by evaluating the most cited articles in a given research field. To the authors' knowledge, there is no bibliometric analysis regarding neurocritical care research. Thus, the aim of this study is to analyze and to provide a scope of the current scientific production in this area. The 100 most cited articles in the neurocritical care research were retrieved from the research "(neurocritical) AND (care)" in the Scopus database. The variables collected and included in this analysis were: number of citations, article title, first author's name, year and journal of publication and its impact factor (IF), specialty, affiliation and country of the corresponding author at the time of publication, and category of the article. Also, these variables were assessed for primary research only. The articles were published in 34 different journals from 1995 to 2017, with a mean citation number of 109.36, ranging from 44 to 540. Neurocritical Care (23 articles in top 100 and 2190 citations, IF = 3.163) and Critical Care Medicine (20 articles and 2896 citations in top 100, IF = 6.630) were the journals with the greatest number of articles and citations, respectively. Neurocritical Care also had the highest number of primary research papers (15 articles, accounting for 850 citations). Excepting one article from Asia (Singapore) and one from Oceania (Australia), all the other 98 papers were from North America (67) or Europe (31). United States was the country with most articles (60, 35 primary research) and citations (6115) among the top 100. Columbia University (11 articles, being 7 primary research, and 915 citations) was the institution with the highest number of articles and primary research articles in top 100, whereas University of Heidelberg (6 articles and 1220 citations) was the most cited institution. Neurology was the specialty with the greatest number of publications in top 100 and the most cited one (57 articles and 5983 citations). The first author with the greatest number of publications as well as primary research articles was A. I. Qureshi (5 articles, being 4 primary research, and 660 citations), while the most cited was K. H. Polderman (2 articles and 749 citations). Fifty-nine publications were primary and 41 secondary research. Among primary research, treatment/management was the most frequent and most cited topics (33 articles and 4172 citations). To the authors' knowledge, this is the first bibliometric analysis regarding neurocritical care research. Our findings suggest that the neurocritical care research field is more prominent in North America and Europe, more frequently published in specific critical care journals and after 1994. The most discussed topic was related to treatment and/or management within neurocritical care.

Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea

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.

Impact of Neurointensivist Co-Management in a Semiclosed Neurocritical-Care Unit

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.

Can trauma surgeons keep up? A prospective cohort study comparing outcomes between patients with traumatic brain injury cared for in a trauma versus neuroscience intensive care unit

Background

Although many patients with traumatic brain injury (TBI) are admitted to trauma intensive care units (ICUs), some question whether outcomes would improve if their care was provided in neurocritical care units. We sought to compare characteristics and outcomes of patients with TBI admitted to and cared for in a trauma versus neuroscience ICU.

Methods

We conducted a prospective cohort study of adult (≥18 years of age) blunt trauma patients with TBI admitted to a trauma versus neuroscience ICU between May 2015 and December 2016. We used multivariable logistic regression to estimate an adjusted odds ratio (OR) comparing 30-day mortality between cohorts.

Results

In total, 548 patients were included in the study, including 207 (38%) who were admitted to the trauma ICU and 341 (62%) to the neuroscience ICU. When compared with neuroscience ICU admissions, patients admitted to the trauma ICU were more likely to have sustained their injuries from a high-speed mechanism (71% vs. 34%) and had a higher Injury Severity Score (ISS) (median 25 vs. 16) despite a similar head Abbreviated Injury Scale score (3 vs. 3, p=0.47) (all p<0.05). Trauma ICU patients also had a lower initial Glasgow Coma Scale score (5 vs. 15) and systolic blood pressure (128 mm Hg vs. 136 mm Hg) and were more likely to have fixed or unequal pupils at admission (13% vs. 8%) (all p<0.05). After adjusting for age, ISS, a high-speed mechanism of injury, fixed or unequal pupils at admission, and field intubation, the odds of 30-day mortality was 70% lower among patients admitted to the trauma versus neuroscience ICU (adjusted OR=0.30, 95% CI 0.11 to 0.82).

Conclusions

Despite a higher injury burden and worse neurological examination and hemodynamics at presentation, patients admitted to the trauma ICU had a lower adjusted 30-day mortality. This finding may relate to improved care of associated injuries in trauma versus neuroscience ICUs.

Level of evidence

Prospective comparative study, level II.

Effects of Appointing a Full-Time Neurointensivist to Run a Closed-Type Neurological Intensive Care Unit

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.

Neurointensive care of patients with cerebral venous sinus thrombosis and intracerebral haemorrhage

The aim was to review the neurointensive care (NIC) of cerebral venous sinus thrombosis patients with haemorrhage during a 15-year period. This is a severe condition with substantial mortality caused by increased intracranial pressure (ICP) and studies are lacking describing the complex picture of the NIC, which offers a large treatment arsenal for intracranial hypertension. Patients treated 2000-2015 were investigated. Data regarding patient characteristics, symptoms, imaging, ICP-treatment, NIC-treatment intensity, and outcome were collected and analysed. Twenty-four patients (13 women) were studied, mean age 46 (range 16-75). Twenty patients were in Glasgow coma scale motor score 6 (obeys), 2 in score 5 (localizes) and 2 in score 2 (extension) on admission. Mean haemorrhage volume was 17 ml (range 1-70). Twenty patients (83%) received unfractionated heparin and 3 (13%) low molecular weight heparin. Haemorrhagic progression occurred in 10 patients (42%). In 9 patients (38%), 4-6 of the treatment options mechanical ventilation, hyperventilation, ICP-monitoring, cerebrospinal fluid-drainage, osmotherapy, barbiturates or surgery were used. In 3 patients mechanical ventilation only was used (hyperventilation in 1). Twelve patients were not managed with any of those treatment options. At follow up, 15/24 patients (62%) had favourable outcome (4 missing). The study shows that many patients needed multiple actions to treat intracranial preassure but more than 60% achieved favourable clinical outcome. Preferably, patients with cerebral venous sinus thrombosis and haemorrhage who are awake should have fast access to NIC because it appears difficult to predict who will deteriorate and promptly need NIC treatment.

Improved Outcomes following the Establishment of a Neurocritical Care Unit in Saudi Arabia

Background

Dedicated neurocritical care units have dramatically improved the management and outcome following brain injury worldwide.

Aim

This is the first study in the Middle East to evaluate the clinical impact of a neurocritical care unit (NCCU) launched within the diverse clinical setting of a polyvalent intensive care unit (ICU).

Design and Methods

A retrospective before and after cohort study comparing the outcomes of neurologically injured patients. Group one met criteria for NCCU admission but were admitted to the general ICU as the NCCU was not yet operational (group 1). Group two were subsequently admitted thereafter to the NCCU once it had opened (group 2). The primary outcome was all-cause ICU and hospital mortality. Secondary outcomes were ICU length of stay (LOS), predictors of ICU and hospital discharge, ICU discharge Glasgow Coma Scale (GCS), frequency of tracheostomies, ICP monitoring, and operative interventions.

Results

Admission to NCCU was a significant predictor of increased hospital discharge with an odds ratio of 2.3 (95% CI: 1.3–4.1; p=0.005). Group 2 (n = 208 patients) compared to Group 1 (n = 364 patients) had a significantly lower ICU LOS (15 versus 21.4 days). Group 2 also had lower ICU and hospital mortality rates (5.3% versus 10.2% and 9.1% versus 19.5%, respectively; all p < 0.05). Group 2 patients had higher discharge GCS and underwent fewer tracheostomies but more interventional procedures (all p < 0.05).

Conclusion

Admission to NCCU, within a polyvalent Middle Eastern ICU, was associated with significantly decreased mortality and increased hospital discharge.