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Prognostication of ICU Patients by Providers with and without Neurocritical Care Training

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Abstract

Background

Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training.

Methods

Consecutive patients who were intubated for  ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups’ PVs of a good (mRS score 0–3) and a poor (mRS score 4–6) outcome prediction.

Results

Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89–99%]) than that by MICU attendings (88% [95% CI 80–93%]), RES (82% [95% CI 74–88%]), and RN (85% [95% CI 77–91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75–97%] vs. MICU 73% [95% CI 59–84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52–76%], NCC 63% [95% CI 51–73%], RES 71% [95% CI 55–84%], and RN 64% [95% CI 50–76%]).

Conclusions

Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.

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Acknowledgements

The authors would like to acknowledge the following contributors and organizations: (1) Christine A. C. Wijman, MD, PhD (deceased 2013), who was involved in the study design and initial data analysis; (2) the Program in Organizing Neuroethics Education and Research (PIONEAR), Stanford University (2006-2007); (3) the Stanford critical care medicine team and nurses; and (4) our patients and their families.

Funding

Anna Finley Caulfield reports receiving past funding (2006–2007) from the Program in Organizing Neuroethics Education and Research (PIONEAR), Stanford University. Maarten G. Lansberg reports receiving past funding (2005–2006) from the Stanford Bio-X grant.

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Authors and Affiliations

  1. Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA

    Anna Finley Caulfield, Michael Mlynash, Irina Eyngorn, Maarten G. Lansberg, Anousheh Afjei, Chitra Venkatasubramanian, Marion S. Buckwalter & Karen G. Hirsch

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  1. Anna Finley Caulfield
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  2. Michael Mlynash
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  3. Irina Eyngorn
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  4. Maarten G. Lansberg
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Contributions

Anna Finley Caulfield design and the conceptualized study, analyzed the data, and drafted the manuscript for intellectual content. Michael Mlynash interpreted the data, analyzed the data, conducted the statistical analysis, and revised the manuscript for intellectual content. Irina Eyngorn contributed a major role in the acquisition of data. Maarten Lansberg designed and the conceptualized study, interpreted the data, and revised the manuscript for intellectual content. Anousheh Afjei contributed a major role in the acquisition of data. Chitra Venkatasubramanian interpreted the data and revised the manuscript for intellectual content. Marion Buckwalter interpreted the data and revised the manuscript for intellectual content. Karen Hirsch interpreted the data and revised the manuscript for intellectual content. The final manuscript was approved by all authors.

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Correspondence to Anna Finley Caulfield.

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This study was approved by the Stanford Institutional Review Boad.

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Finley Caulfield, A., Mlynash, M., Eyngorn, I. et al. Prognostication of ICU Patients by Providers with and without Neurocritical Care Training. Neurocrit Care 37, 190–199 (2022). https://doi.org/10.1007/s12028-022-01467-6

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  • DOI: https://doi.org/10.1007/s12028-022-01467-6

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