Abstract
Background
Introduction of neurocritical care services to dedicated neuro-ICUs is associated with improved quality of care. The impact of a neurocritical care service without a dedicated neuro-ICU has not been studied.
Methods
We retrospectively identified all patients admitted to our institution with intracerebral hemorrhage (ICH) in two 12-month periods: immediately before the arrival of the first neurointensivist (“before”) and after the neurocritical care service was established (“after”). There was no nursing team, ICU housestaff/physician extender team, or physical unit dedicated to the care of patients with critical neurologic illness during either period. Using an uncontrolled before-after design, we compared clinical outcomes and performance on quality metrics between groups.
Results
We included 74 patients with primary supratentorial ICH. Mortality, length of stay (LOS), proportion of patients with modified Rankin Score 0–3, and destination on discharge did not differ between groups when adjusted for confounders. Time to first two consecutive systolic blood pressure (SBP) measurements <180 mmHg was shorter in the “after” cohort (mean 4.5 vs. 3.2 h, p = 0.001). Area under the curve measurement for change in SBP from baseline over the first 24 h after ED arrival demonstrated greater, sustained SBP reduction in the “after” cohort (mean −187.9 vs. −720.9, p = 0.04). A higher proportion of patients were fed without passing a dysphagia screen in the “before” group (45 vs. 0 %, p < 0.001).
Conclusions
Introduction of a neurocritical service without a neuro-ICU at our institution was associated with a trend toward longer ICU LOS and improvement in some key metrics of quality of care for patients with ICH.
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs12028-013-9818-1/MediaObjects/12028_2013_9818_Fig1_HTML.gif)
Similar content being viewed by others
References
Ropper AH. Neurological intensive care. Ann Neurol. 1992;32:564–9.
Kramer AH, Zygun DA. Do neurocritical care units save lives? Measuring the impact of specialized ICUs. Neurocrit Care. 2011;14:329–33.
Mirski MA, Chang CW, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol. 2001;13:83–92.
Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med. 2001;29:635–40.
Knopf L, Staff I, Gomes J, McCullough L. Impact of a neurointensivist on outcomes in critically ill patients. Neurocrit Care. 2012;16:63–71.
Varelas PN, Schultz L, Conti M, Spanaki M, Genarrelli T, Hacein-Bey L. The impact of a neuro-intensivist on patients with stroke admitted to a neurosciences intensive care unit. Neurocrit Care. 2008;9:293–9.
Bershad EM, Feen ES, Hernandez OH, Suri MF, Suarez JI. Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care. 2008;9:287–92.
Varelas PN, Conti MM, Spanaki MV, Potts E, Bradford D, Sunstrom C, et al. The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit. Crit Care Med. 2004;32:2191–8.
Varelas PN, Eastwood D, Yun HJ, Spanaki MV, Hacein Bey L, Kessaris C, Gennarelli TA. Impact of a neurointensivist on outcomes in patients with head trauma treated in a neurosciences intensive care unit. J Neurosurg. 2006;104:713–9.
Suarez JI, Zaidat OO, Suri MF, Feen ES, Lynch G, Hickman J, et al. Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med. 2004;32:2311–7.
Josephson SA, Douglas VC, Lawton MT, English JD, Smith WS, Ko NU. Improvement in intensive care unit outcomes in patients with subarachnoid hemorrhage after initiation of neurointensivist co-management. J Neurosurg. 2010;112:626–30.
Lerch C, Yonekawa Y, Muroi C, Bjeljac M, Keller E. Specialized neurocritical care, severity grade, and outcome of patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2006;5:85–92.
Samuels O, Webb A, Culler S, Martin K, Barrow D. Impact of a dedicated neurocritical care team in treating patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2011;14:334–40.
Qureshi AI. Intracerebral hemorrhage specific intensity of care quality metrics. Neurocrit Care. 2011;14:291–317.
Hemphill JC III, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7.
Qureshi AI, Majidi S, Chaudhry SA, Qureshi MH, Suri MF. Validation of intracerebral hemorrhage-specific intensity of care quality metrics. J Stroke Cerebrovasc Dis. 2012. doi:10.1016/j.jstrokecerebrovasdis.2012.03.015.
Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996;27:1304–5.
Morganstern LB, Hemphill JC III, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108–29.
Qureshi AI, Palesch YY, Martin R, Novitzke J, Cruz-Flores S, Ehtisham A, et al. Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study. Arch Neurol. 2010;67:570–6.
Tabachnick BG, Fidell LS, editors. Using multivariate statistics. 3rd ed. New York: Harper and Collins; 1996.
Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7:391–9.
Arima H, Anderson CS, Wang JG, Huang Y, Heeley E, Neal B, et al. Lower treatment blood pressure is associated with greatest reduction in hematoma growth after acute intracerebral hemorrhage. Hypertension. 2010;56:852–8.
Arima H, Huang Y, Wang JG, Heeley E, Delcourt C, Parsons M, et al. Earlier blood pressure-lowering and greater attenuation of hematoma growth in acute intracerebral hemorrhage: INTERACT pilot phase. Stroke. 2012;43:2236–8.
Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36:1972–6.
Burns JD, Manno EM. Primary intracerebral hemorrhage: update on epidemiology, pathophysiology, and treatment strategies. Compr Ther. 2008;34:183–95.
Kurtz P, Fitts V, Sumer Z, Jalon H, Cooke J, Kvetan V, Mayer SA. How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU? Neurocrit Care. 2011;15:477–80.
Fan E, Laupacis A, Pronovost PJ, Guyatt GH, Neehdam DM. How to use an article about quality improvement. JAMA. 2010;304:2279–87.
Conflicts of interest
The authors report no conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Burns, J.D., Green, D.M., Lau, H. et al. The Effect of a Neurocritical Care Service without a Dedicated Neuro-ICU on Quality of Care in Intracerebral Hemorrhage. Neurocrit Care 18, 305–312 (2013). https://doi.org/10.1007/s12028-013-9818-1
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12028-013-9818-1