Improvement in intensive care unit outcomes in patients with subarachnoid hemorrhage after initiation of neurointensivist co-management

Clinical article

S. Andrew Josephson M.D.1, Vanja C. Douglas M.D.1, Michael T. Lawton M.D.2, Joey D. English M.D., Ph.D.1, Wade S. Smith M.D., Ph.D.1, and Nerissa U. Ko M.D.1
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  • 1 Departments of Neurology and
  • | 2 Neurological Surgery, University of California, San Francisco, California
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Object

Neurointensivists are specialists trained to manage all aspects of the intensive care unit (ICU) stay of neurologically ill patients. No study to date has examined the role of neurointensivists specifically in subarachnoid hemorrhage (SAH) management. This study examined the use of a team-based neurointensivist co-management approach.

Methods

The authors reviewed all cases involving patients with SAH admitted to the neurosurgical service during a period of more than 4 years. A comparison was made between those patients admitted before and those admitted after the initiation of a mandatory neurointensivist co-management strategy. The primary outcome examined was length of ICU stay. Secondary outcomes included in-hospital mortality, ventriculoperitoneal shunt placement, and other complications such as fever, antibiotic use, pressor utilization, and ventilator-associated pneumonia.

Results

A total of 512 patients were included, 216 prior to and 296 after the initiation of neurointensivist comanagement. Length of ICU stay was significantly decreased after the initiation of neurointensivist co-management (mean 12.4 vs 10.9 days, p = 0.02), even after adjusting for demographic characteristics and admission Hunt and Hess grade. The percentage of patients requiring a ventriculoperitoneal shunt significantly decreased after initiation of the co-management approach (23.0 vs 11.5%, p = 0.001), but in-house mortality was unaffected.

Conclusions

Initiation of a strategy of routine involvement of a neurointensivist, charged with managing all aspects of the patients' care, resulted in a significantly reduced length of ICU stay for neurosurgical SAH patients. This team-based approach, using neurointensivists to manage neurosurgical SAH patients, merits further study as a successful model of care.

Abbreviations used in this paper:

EVD = external ventricular drain; ICD-9 = International Classification of Diseases, Ninth Revision; ICU = intensive care unit; RR = relative risk; SAH = subarachnoid hemorrhage; UCSF = University of California, San Francisco; VAP = ventilator-associated pneumonia.

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  • 1

    Berenholtz SM, , Dorman T, , Ngo K, & Pronovost PJ: Qualitative review of intensive care unit quality indicators. J Crit Care 17:112, 2002

  • 2

    Berman MF, , Solomon RA, , Mayer SA, , Johnston SC, & Yung PP: Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke 34:22002207, 2003

    • Search Google Scholar
    • Export Citation
  • 3

    Diringer MN, & Edwards DF: Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 29:635640, 2001

    • Search Google Scholar
    • Export Citation
  • 4

    Gore DC, & Prough DS: Impact of intensivists on outcome of critically ill neurologic and neurosurgical patients. Crit Care Med 32:23632364, 2004

    • Search Google Scholar
    • Export Citation
  • 5

    Josephson SA, , Engstrom JW, & Wachter RM: Neurohospitalists: an emerging model for inpatient neurological care. Ann Neurol 63:135140, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Ko NU, , Rajendran P, , Kim H, , Rutkowski M, , Pawlikowska L, & Kwok PY, et al.: Endothelial nitric oxide synthase polymorphism (–786T→C) and increased risk of angiographic vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 39:11031108, 2008

    • Search Google Scholar
    • Export Citation
  • 7

    Komotar RJ, , Hahn DK, , Kim GH, , Starke RM, , Garrett MC, & Merkow MB, et al.: Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review. J Neurosurg 111:147154, 2009

    • Search Google Scholar
    • Export Citation
  • 8

    Komotar RJ, , Olivi A, , Rigamonti D, & Tamargo RJ: Microsurgical fenestration of the lamina terminalis reduces the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 51:14031413, 2002

    • Search Google Scholar
    • Export Citation
  • 9

    Naidech AM, , Bendok BR, , Tamul P, , Bassin SL, , Watts CM, & Batjer HH, et al.: Medical complications drive length of stay after brain hemorrhage: a cohort study. Neurocrit Care 10:1119, 2009

    • Search Google Scholar
    • Export Citation
  • 10

    Nathens AB, , Rivara FP, , MacKenzie EJ, , Maier RV, , Wang J, & Egleston B, et al.: The impact of an intensivist-model ICU on trauma-related mortality. Ann Surg 244:545554, 2006

    • Search Google Scholar
    • Export Citation
  • 11

    Pronovost PJ, , Angus DC, , Dorman T, , Robinson KA, , Dremsizov TT, & Young TL: Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 288:21512162, 2002

    • Search Google Scholar
    • Export Citation
  • 12

    Smith M: Intensive care management of patients with subarachnoid haemorrhage. Curr Opin Anaesthesiol 20:400407, 2007

  • 13

    Suarez JI: Outcome in neurocritical care: advances in monitoring and treatment and effect of a specialized neurocritical care team. Crit Care Med 34:S232S238, 2006

    • Search Google Scholar
    • Export Citation
  • 14

    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 32:23112317, 2004

    • Search Google Scholar
    • Export Citation
  • 15

    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 32:21912198, 2004

    • Search Google Scholar
    • Export Citation

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