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HONOLULU -- The establishment of a critical care unit for neurological and neurosurgical patients, with a dedicated team of specialists, reduces mortality and length of stay while providing better clinical outcomes in a tertiary care teaching center, according to a group of Emory University researchers. Owen Samuels, MD, assistant professor of neurology and neurosurgery, Emory University School of Medicine, and director of the Division of Neurointensive Care at Emory oresented outcome data on the topic at the American Academy of Neurology (AAN) 55th Annual Meeting in Honolulu, Hawaii on April 3.
"The medical literature supports the effectiveness of intensive care specialists at reducing mortality, improving clinical outcome and decreasing resource utilization (use of health care resources and services) in general medical and surgical critical care patients," says Dr. Samuels, a neurointensivist. "However, despite the growth of neurointensive care specialists and the establishment of dedicated neurointensive care units, there is limited data that these efforts actually improve patient outcome, reduce mortality or reduce intensive care resource utilization. With the shrinking health care costs and pay outs, these data really need to be examined."
Emory researchers collected retrospective outcome data on consecutive neurological and neurosurgical patients admitted in the neurointensive care unit (NICU) at Emory University Hospital for three 6-month periods over three years (April-September 1998, 1999 and 2000), following the establishment of a neurointensive care service. Patients admitted to the unit suffered from one of the three most common neurological diagnoses: subarachnoid hemorrhage (bleeding between the brain and the membranes that cover it), intracranial hemorrhage (bleeding in the brain caused by a ruptured blood vessel) and ischemic stroke (cutting off the blood supply to a part of the brain).
The researchers found that the mean length of stay in the NICU for patients with subarachnoid hemorrhage dropped from 16.0 days (1998) to 11.2 days (1999) to 10.5 days (2000) with a relative reduction of 34 percent. The mean length of stay in the NICU for patients with intracranial hemorrhage dropped by two days from 6.4 days (1998) to 4.3 days (1999) and then a slight increase to 4.4 days in 2000, with a relative reduction of 30 percent. For patients with ischemic stroke, the mean length of stay dropped from 4.4 days (1998) to 4.3 days (1999) to 3.1 days (2000), with a relative reduction of 30 percent.
Use of the ventilator was also measured in these patients. Before a NICU service was established at Emory, patients remained on a ventilator an average of 17 days in 1997-1998. Once the NICU service was established, the mean patient-ventilator days dropped from 12 days (1999-2000) to 11 days (2001) and remained steady at 11 days (2002). Ventilator associated mortality dropped from 20 percent (1998) to 11 percent (1999) to 8.5 percent (2000), with a relative reduction of 76 percent. The researchers also looked at the severity-adjusted data, which compares expected length of stay to observed length of stay. The difference between the days is called opportunity days. Following establishment of the NICU at Emory, doctors saw an increase in opportunity days because patients were discharged in a shorter amount of time than expected. The University Hospital Consortium considers this severity-adjusted data a benchmark of quality of care.
During the time of review, the NICU was staffed with a fellowship-trained neurointensive care physician (Dr. Samuels), two nurse practitioners, a pharmacist, a respiratory therapist, a nutritionist and post-graduate neurology and neurosurgery residents. Mustapha Ezzeddine, MD, assistant professor of neurology and neurosurgery at Emory has recently joined the team, as the demand for this specialty in critical care continues to increase. Emory University Hospital is the only hospital in the state of Georgia with such a neurocritical care unit and two fellowship-trained neurointensivists on board.
After receiving his MD, Dr. Samuels completed his internship and residency training at the University of Rochester Medical Center. He then completed a cerebrovascular disease fellowship at Emory University and a second fellowship in neurointensive care medicine at the University of Pennsylvania. Dr. Ezzeddine did his internship and residency at Duke University Medical Center after receiving his MD. In addition, Dr. Ezzeddine completed a fellowship in neurointensive care and stroke at Massachusetts General Hospital in Boston.
"While data show that intensive care specialists can help reduce mortality, improve clinical outcome and save hospitals millions of dollars while saving the lives of critical care patients, this type of care is not the standard across the U.S.," says Dr. Samuels. "The Leapfrog Group, a consortium of more than 130 Fortune 500 companies and other large private and public health care purchasers, is setting the standard by encouraging more stringent patient safety measures, one of which is staffing intensive care units (ICU) with physicians who have credentials in critical care medicine. The Leapfrog Group reports this method has been shown to reduce the risk of patients dying in the ICU by nearly 30 percent," Dr. Samuels explains.
The Leapfrog Group also recommends that patients in need of certain medical procedures should go to hospitals that perform high volumes of the procedure each year. "For instance, Emory has nearly doubled the cases of subarachnoid hemorrhages since the development of the neurointensive care unit," Dr. Samuels says. "Last year, we saw approximately 145 subarachnoid hemorrhage cases alone." Emory has also doubled the number of beds in the unit to treat these patients, as well.
The results from this AAN presentation support the effectiveness of a neurointensivist team approach in caring for critically-ill neurological and neurosurgical patients. "We feel these findings are consistent with the larger, more established practice using the intensivist model in general medical and surgical ICUs," says Dr. Samuels.