Difficulties in establishing Neurocritical Care Units Dr.Omar Ayoub Consultant & Assistant Professor of Neurology Stroke, Neurocritical Care RTP

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1 Difficulties in establishing Neurocritical Care Units Dr.Omar Ayoub Consultant & Assistant Professor of Neurology Stroke, Neurocritical Care RTP Neurology at KAUH

2 Evolution of ICUs ICUs started as specialized care units or respiratory care units. In the 1950s, in Denmark, Bendixen and Pontoppidan experts in poliomyelitis created a respiratory care unit in Boston s MGH

3 Historically, neurosurgeon Dandy opened the 1 st neurosurgical ICU at Johns Hopkins in In London, the Batten Respiratory Unit at the Institute of Neurology and National Hospital for Nervous Diseases opened in 1954 Treat acute neuromuscular disease Stroke Spinal cord disorders

4 The need for NICU Neurologists got interested in acute conditions Neurologists judge the severity of injury and prognosticate Fred Plum, Raymond Adams, and C. Miller Fisher, the first to describe causes of coma and other acute conditions (i.e., brain death, locked-in syndrome, anoxic- ischemic encephalopathy)

5 In 1980s, neurologists were stationed in these units Neurologists became more knowledgeable in Acute neuromuscular respiratory failure Treatment of ICP Systemic complications specific for acute neurologic disease

6 In 2004, a Society was founded and a journal was established Accreditation was sought through the American Academy of Neurology

7 Care of the critically ill neurologic patient requires training in: Clinical physiology of ICP CBF and metabolism Brain and neuromuscular electrophysiology Postoperative care Systemic complications of nervous system diseases.

8 The evidence In retrospective studies, outcome can be improved with neurointensivist Prospective randomization of patients with life-threatening neurologic disease into medical or surgical ICU Vs NICU has ethical issues

9 Why do we need it? Studies looking at the effect of NICU showed: Improved outcomes Decreased hospital mortality rates Reduced hospital length of stay Reduced number of significant medical complications

10 Mirski et al. reported on the effect of a NICU on patients with ICH in the same institution. Admission to NICU has reduced mortality and hospital length of stay.

11 Diringer and Edwards prospectively collected patients in 3 yrs from 42 ICUs. Compared outcomes of ICH in general ICUs Vs. NICU. Not being admitted to NICU increased hospital mortality.

12

13

14

15 Training of residents

16 The survey sent to all US neurology PD on February 23, 2011 A response rate of 74.2% (98 of 132)

17

18 The median beds was 16 (5 42) 75% have at least one UCNS board eligible/certified neurology-trained neurointensivist. Specialties involved in teaching and clinical care: Neurology (68%) Anesthesiology (40%) Internal medicine (22%) Neurosurgery (15%) Emergency medicine (10%) Surgery (7%)

19

20 Factors to increase participation in NICU rotation Dedicated neuro-icu (87% vs 13%, p < 0.001), Neurology-trained intensivists (87% vs 13%, p < 0.001), Presence of a neuro-icu fellowship (56% vs 44%, p < 0.001), Higher number of neurology residents (mean 19 vs 13, p < 0.001) in the program.

21

22 2005 to 2010, 150% growth in programs that send at least one resident into a neurocritical fellowship. Almost half of graduating residents have little/no access to a dedicated neuro-icu.

23 Recommendation Formal neurocritical care training. Put a working group of neurology educators and PDs, along with practicing neurointensivists. Guidance for neurocritical care training Requirements for skills and concepts for procedures.

24 Difficulties in our system The system The hospital The unit The physicians The patients The budget

25 The System Fragmented sectorial services No ambulance system No clear referral between hospitals There is no coordination in resource organization between sectors/hospitals There is no clear national data yet

26 The hospital Administration don t appreciate it No available space No available nurses to cover No enough consultants No residents/registrars

27 The unit The need for large space The need for physicians The need for special equipment The unique approach The lack of knowledge of its existence

28 The physicians Handful number of NICU doctors across Saudi Other physicians Needs special training No funds for them Training programs do not mandate it

29 Recent survey Neurocritical Care Education During Residency: Opinions (NEURON) Study 95 individuals from 32 programs Most train with NICU attendings, fellows and advanced practitioners and have exposure during residency 54 % cite improvement in education in their training Those that raised concern had no difference in time in NICU (9.4 weeks vs 8.8 weeks), exposure to trained neurointensivists, fellows or advanced providers

30 The patients Patient flow Referral from other hospitals Late presentation

31 The funds No funds available to accommodate the need Ministry of health interest

32 The future The number of NICU physicians are increasing The number of units are slowly growing The interest from administrative point of view is not there Budget is an issue in some hospitals

33 Whats done so far Establishment of the Neurocritical Care Chapter in 2010 Variable backgrounds (Neurology, Neurosurgery, Internal medicine and ICU background, anesthesia) Participated as part of the chapter in multiple conferences and courses over the years

34 Saudi Neurocritical Care Chapter 2010 Establishment under the Saudi Critical Care Society SCCS SCCS 2012 Dammam 1 st Saudi Neurocritical Care Meeting. SCCS 2013 Riyadh 2 nd Saudi Neurocritical Care Meeting. SCCS 2014 Riyadh 3 rd Saudi Neurocritical Care Meeting 2015, 2016, and there will be Neuro track in the upcoming 2017 meeting

35 THANK YOU

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