Neuroscience ICU: A Statewide Critical Care Resource

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1 Neuroscience ICU: A Statewide Critical Care Resource Ansgar M Brambrink, MD, PhD Director, Neuroscience Intensive Care Unit Oregon Health & Science University Portland, OR

2 Neurocritical care in the US First dedicated units: late 1960s: University of Colorado, Denver early 1970s: Massachuchetts General Hospital, Boston In the 1980s: Columbia University, New York Johns Hopkins University, Baltimore University of Virginia, Charlottesville Today: Dedicated Neurocritical Care Units staffed by board certified; eligible neurointensivists in 93 institutions (as of May 2010) across the US

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4 Neurocritical care in the US First dedicated units: late 1960s: University of Colorado, Denver early 1970s: Massachuchetts General Hospital, Boston In the 1980s: Columbia University, New York Johns Hopkins University, Baltimore University of Virginia, Charlottesville Today: Dedicated Neurocritical Care Units staffed by board certified; eligible neurointensivists in 93 institutions (May 2010) Currently 30 UCNS accredited training programs (Neurocritical Care Fellowship) NSICU at OHSU the only one in the State of Oregon

5 Our Neighbors UW Seattle, Harborview: Neuro ICU, 15+ beds. Neurosurgery, neurology, and Neuro trauma patients. ICU managed by Anesthesiology with Neurosurgery and Neurology consulting teams. UCSF & SF General Hospital: UCNS accredited Fellowship. Neuro ICU with 20 beds, Neurology patients only. Additional 13 bed step down unit. Intensivists with background in Pulmo CCM, Anesthesiology and Neurology; Neuro CC Team also sees also neurosurgery patients on campus

6 Neurocritical Care at OHSU Until 2005: Neurosurgery patients: Neurosurgical ICU (part of 7A) Neurology patients: Medical ICU (now on 12K) Jan 2006: Inauguration of dedicated Neurocritical Care Service; consults on neurosurgical patients (7 12 pat.; 7A Unit) Oct 2006: Dedicated space = Neuroscience Intensive Care Unit; 7NSICU); admission of neurosurgical and neurology patients; Team expansion (residents, fellows, PAs); 24/7 in house coverage

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8 Neuroscience ICU WHY A SPECIALIZED ICU SERVICE?

9 The availability of dedicated intensivist teams improves patient outcomes and medical training, and reduces expenses Neurointensivists require all skills expected of general intensivists + special skills as a clinical neuroscientist; + management of multi professional team, resources, infectious control, budget oversight and regulation, etc. ) => Comprehensive, yet specialized critical care

10 Evidence Specially trained Neurointensivists indeed are important for patients suffering from nervous system disorders and who are critically ill: Mirski M et al: Outcome + cost after ICH improved after introduction of NeuroICU (JNA 13:83 92, 2001)

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12 Evidence Specially trained Neurointensivists indeed are important for patients suffering from nervous system disorders and who are critically ill: Mirski M et al: Outcome + cost after ICH improved after introduction of Neuro ICU (JNA 13:83 92, 2001) Diringer MN et al: Lower mortality after ICH in Neuro ICU (Crit Care Med 29:635 40, 2001)

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14 Evidence Specially trained Neurointensivists indeed are important for patients suffering from nervous system disorders and who are critically ill: Mirski M et al: Outcome + cost after ICH improved after introduction of Neuro ICU (JNA 13:83 92, 2001) Diringer MN et al: Lower mortality after ICH in Neuro ICU (Crit Care Med 29:635 40, 2001) Varelas PN et al: Outcome in all neuro ICU patients before/after neurointensivist (Crit Care Med 32: , 2004) Varelas PN et al: Outcome after TBI before/after neurointensivist (J Neurosurg104:713 19, 2006) Varelas PN et al: Outcome of patients after stroke before/after neurointensivist (Neurocrit Care 9:293 99, 2008)

15 Critical Assets: Specialized Neurocritical Care Nurses Dedicated anxillary services, eg. specialized physiotherapists, occupational therapists, speech therapists Professional Society: Neurocritical Care Society Professional Meetings: Neurocritical Care Scientific Journal: Neurocritical Care

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17 Critical Assets: Specialized Neurocritical Care Nurses Dedicated anxillary services, eg. specialized physiotherapists, occupational therapists, speech therapists Professional Society: Neurocritical Care Society Professional Meetings: Neurocritical Care Scientific Journal: Neurocritical Care Training Program for future leaders in the field: Neurocritical Care Fellowship (accredited, 2 yrs)

18 Currently 30 UCNS accredited Neurocritical Care Fellowship programs in the US

19 Neuroscience Intensive Care Unit (NSICU) at OHSU WHO WE ARE AND WHAT WE DO

20 17 Beds

21 Dedicated Nursing Staff

22 Decidated Physicians

23 Dedicated Anxillary Services

24 Team Communication

25 OHSU NSICU Physician Coverage Attending (24 hrs/7 days/w x1 2 [week days]): Anesthesiology, Neurology based Neurointensivists Midlevel (day shift x2 3; night shift x1): PAs: specialized in critical care environment MDs: Residents: Neurology, Neurosurgery, Anesthesiology Fellows: Neurocritical Care, Anesthesiology, PCCM Medical Students: from OHSU & other institutions

26 OHSU Neurocritical Care Service, Patient Volume / month 700 (n=9546 patient days / last 19 months) continuous overflow into other units (n=5807) 2010

27 Neuroscience Crit Care Census (7NSICU, + overflow into 7A, 12K) January 2010 (average = 21.9 midnight) 0 1 Jan 2 Jan 3 Jan 4 Jan 5 Jan 6 Jan 7 Jan 8 Jan 9 Jan 10 Jan 11 Jan 12 Jan 13 Jan 14 Jan 15 Jan 16 Jan 17 Jan 18 Jan 19 Jan 20 Jan 21 Jan 22 Jan 23 Jan 24 Jan 25 Jan 26 Jan 27 Jan 28 Jan 29 Jan 30 Jan 31 Jan Fri Sat Sun Mon Tues Wed Thur Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun

28 OHSU NSICU patient population Neurosurgery (~75%) SAH (aneurismal, AVM) ICH (IPH + IVH) Tumor surgery Hydrocephalus (+ infect) SDH Spine surgery INR procedures Neurology (~25%) Ischemic stroke, TIA Neuromuscular disease Seizures Encephalitis Meningitis

29 WHAT CAN WE OFFER?

30 Multidisciplinary Approach Neurocritical Care Nurse Respirator Therapist Neurointensivist Neurosurgeon Neurologist Interventional Neuroradiologist Pharmacist Physiotherapist Occupational therapist Speech therapist Social worker Case manager Truly comprehensive care of patients suffering from nervous system disorders and who are critically ill Consultant(s) (eg. Cardiology, Infectious Disease, Anesthesiologist, Radiologist, Nephrology, Endocrinology, Palliative Care, etc.)

31 Special Monitoring Ventricular drainage (+ eg. IVC tpa) Intracranial pressure monitoring Continuous invasive hemodynamics (eg. PiCCO, PA C) Ventilator treatment ECHO cardiography, Ultrasound Continuous video EEG

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34 Special Monitoring / Intervention Ventricular drainage (+ eg. IVC tpa) Intracranial pressure monitoring Continuous invasive hemodynamics (eg. PiCCO, PA C) Ventilator treatment ECHO cardiography, Ultrasound Continuous video EEG Transcranial Doppler (vasospasm; => CT P, Angio) Neuromuscular testing Hyperosmolar treatment (eg. 3%, 23.4% saline) Immediate cerebrovascular imaging / intervention Immediate neurosurgical intervention AND: 24/7 presence of specialist teams

35 Immediate Access To State of the Art Diagnostic Neuroradiology eg.: CT head/neck CT Angio CT Perfusion MRI / MRA

36 Interventional Neuroradiology eg.: Cerebral angio, Angioplasty, Stents Thrombus retrieval Aneurysm treatment Merci Retriever Microsuction Coils

37 OHSU Healthcare Mission Through innovation, education and clinical expertise, we provide the best possible healthcare experience for patients and their families.

38 WHERE CAN WE IMPROVE, WHERE FOCUS FOR DEVELOPMENT?

39

40 Telemedicine: OHSU Network OHSU Mid Columbia Case discussion prior to inter hospital transport Plan for optimization Best transport logistic Sacred Heart Management advice in selected ICU cases Mercy Rogue Valley

41 Community Outreach

42 Summary OHSU s Neurocritical Care Service is the only specialized ICU Service in the State of Oregon for patients suffering from nervous system disorders and who are critically ill The Service offers unique diagnostic and interventional opportunities for further evaluation and treatment OHSU s NCC Service features dedicated individuals with outstanding expertise and the ultimate ambition for Excellence in ICU Care Telemedicine and educational outreach hold great prommiss for future development of, and excellence in Neurocritical Care in the State of Oregon

43 THANK YOU.

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