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Loggini A, Hornik J, Hornik A, Braksick SA, Klaas JP. Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis. Neurocrit Care 2024:10.1007/s12028-024-02044-9. [PMID: 38955932 DOI: 10.1007/s12028-024-02044-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. The authors conducted a systematic review and meta-analysis evaluating the safety and outcome of admission to a step-down level of care or stroke unit (SU) compared to intensive care in adult patients with low-risk spontaneous ICH. PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, was applied to calculate an overall effect estimate for each outcome by combining the specific risk ratio (RR) or standardized mean difference. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (CRD42023481915). The primary outcome examined was in-hospital mortality. Secondary outcomes were unfavorable short-term outcome, length of hospital stay, and (re)admission to the ICU. Five retrospective cohort studies involving 1347 patients were included in the qualitative analysis. Two of the studies had severity-matched groups. The definition of low-risk ICH was heterogeneous among the studies. Admission to an SU was associated with a similar rate of mortality compared to admission to an ICU (1.4% vs. 0.6%; RR 1.66; 95% confidence interval [CI] 0.24-11.41; P = 0.61), a similar rate of unfavorable short-term outcome (14.6% vs. 19.2%; RR 0.77; 95% CI 0.43-1.36; P = 0.36), and a significantly shorter mean length of stay (standardized mean difference - 0.87 days; 95% CI - 1.15 to - 0.60; P < 0.01). Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.
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Affiliation(s)
- Andrea Loggini
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA.
- Southern Illinois University School of Medicine, Carbondale, IL, USA.
| | - Jonatan Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- Southern Illinois University School of Medicine, Carbondale, IL, USA
| | - Alejandro Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- Southern Illinois University School of Medicine, Carbondale, IL, USA
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Developing a Trauma Intermediate Care Unit. J Trauma Nurs 2023; 30:55-58. [PMID: 36633347 DOI: 10.1097/jtn.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Trauma-specific nursing units are integral to providing quality trauma care. Yet, little has been published on intermediate care units for the trauma population. OBJECTIVE This article aims to describe one trauma center's journey to develop and implement a trauma intermediate care unit. METHODS The need for a trauma intermediate care unit was identified during the review of patient care at a Level II trauma center. An interdisciplinary team was created and met weekly for 6 months to plan the implementation of a trauma intermediate care unit. Education plans, training, equipment procurement, and staffing were evaluated throughout the process. RESULTS Positive results were noted from the implementation of the intermediate care unit through the first year following implementation. The average length of stay for patients in the surgical trauma intensive care unit was reduced, resulting in cost savings for the organization. In addition, this collaborative work positively impacted patient safety, staff engagement, and finances. CONCLUSION With leadership support, the proper key stakeholders, clear deliverables, and a well-defined development plan, the implementation of this intermediate care unit was successful.
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Thomas SM, Reindorp Y, Christophe BR, Connolly ES. Systematic Review of Resource Use and Costs in the Hospital Management of Intracerebral Hemorrhage. World Neurosurg 2022; 164:41-63. [PMID: 35489599 DOI: 10.1016/j.wneu.2022.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND While clinical guidelines provide a framework for hospital management of spontaneous intracerebral hemorrhage (ICH), variation in the resource use and costs of these services exists. We sought to perform a systematic literature review to assess the evidence on hospital resource use and costs associated with management of adult patients with ICH, as well as identify factors that impact variation in such hospital resource use and costs, regarding clinical characteristics and delivery of services. METHODS A systematic literature review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Ovid MEDLINE(R) 1946 to present. Articles were assessed against inclusion and exclusion criteria. Study design, ICH sample size, population, setting, objective, hospital characteristics, hospital resource use and cost data, and main study findings were abstracted. RESULTS In total, 43 studies met the inclusion criteria. Pertinent clinical characteristics that increased hospital resource use included presence of comorbidities and baseline ICH severity. Aspects of service delivery that greatly impacted hospital resource consumption included intensive care unit length of stay and performance of surgical procedures and intensive care procedures. CONCLUSIONS Hospital resource use and costs for patients with ICH were high and differed widely across studies. Making concrete conclusions on hospital resources and costs for ICH care was constrained, given methodologic and patient variation in the studies. Future research should evaluate the long-term cost-effectiveness of ICH treatment interventions and use specific economic evaluation guidelines and common data elements to mitigate study variation.
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Affiliation(s)
- Steven Mulackal Thomas
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA.
| | - Yarin Reindorp
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Brandon R Christophe
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Edward Sander Connolly
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Faigle R, Chen BJ, Krieger R, Marsh EB, Alkhachroum A, Xiong W, Urrutia VC, Gottesman RF. Novel Score for Stratifying Risk of Critical Care Needs in Patients With Intracerebral Hemorrhage. Neurology 2021; 96:e2458-e2468. [PMID: 33790039 PMCID: PMC8205477 DOI: 10.1212/wnl.0000000000011927] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To develop a risk prediction score identifying patients with intracerebral hemorrhage (ICH) at low risk for critical care. METHODS We retrospectively analyzed data of 451 patients with ICH between 2010 and 2018. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting independent predictors of intensive care unit (ICU) needs according to strength of association. The risk score was tested in the validation cohort and externally validated in a dataset from another institution. RESULTS The rate of ICU interventions was 80.3%. Systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, intraventricular hemorrhage (IVH), and ICH volume were independent predictors of critical care, resulting in the following point assignments for the Intensive Care Triaging in Spontaneous Intracerebral Hemorrhage (INTRINSIC) score: SBP 160 to 190 mm Hg (1 point), SBP >190 mm Hg (3 points); GCS 8 to 13 (1 point), GCS <8 (3 points); ICH volume 16 to 40 cm3 (1 point), ICH volume >40 cm3 (2 points); and presence of IVH (1 point), with values ranging between 0 and 9. Among patients with a score of 0 and no ICU needs during their emergency department stay, 93.6% remained without critical care needs. In an external validation cohort of patients with ICH, the INTRINSIC score achieved an area under the receiver operating characteristic curve of 0.823 (95% confidence interval 0.782-0.863). A score <2 predicted the absence of critical care needs with 48.5% sensitivity and 88.5% specificity, and a score <3 predicted the absence of critical care needs with 61.7% sensitivity and 83.0% specificity. CONCLUSION The INTRINSIC score identifies patients with ICH who are at low risk for critical care interventions. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that the INTRINSIC score identifies patients with ICH at low risk for critical care interventions.
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Affiliation(s)
- Roland Faigle
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH.
| | - Bridget J Chen
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Rachel Krieger
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Elisabeth B Marsh
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Ayham Alkhachroum
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Wei Xiong
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Victor C Urrutia
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Rebecca F Gottesman
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
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