A step-down unit transfer protocol for low-risk aneurysmal subarachnoid hemorrhage

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1 NEUROSURGICAL FOCUS Neurosurg Focus 43 (5):E15, 2017 A ste-down unit transfer rotocol for low-risk aneurysmal subarachnoid hemorrhage Alexander G. Chartrain, BS, 1 Ahmed J. Awad, MD, 1 Christoher A. Sarkiss, MD, 1 Rui Feng, MSc, 1 Yangbo Liu, MS, 1 J Mocco, MD, MS, 1 Joshua B. Bederson, MD, 1 Stehan A. Mayer, MD, 2 Neha S. Dangayach, MD, 1,3 and Errol Gordon, MD 1,3 Deartments of 1 Neurosurgery and 3 Neurology, Icahn School of Medicine at Mount Sinai, New York, New York; and 2 Deartment of Neurology, Henry Ford Health System, Detroit, Michigan OBJECTIVE Patients who have exerienced subarachnoid hemorrhage (SAH) often receive care in the setting of the ICU. However, SAH atients may not all require extended ICU admission. The authors established a rotocol on January 1, 2015, to transfer select, low-risk atients to a ste-down unit (SDU) to streamline care for SAH atients. This study describes the results of the imlemented rotocol. METHODS In this retrosective chart review, atients resenting with SAH between January 2011 and Setember 2016 were reviewed for inclusion. The control grou consisted of atients admitted rior to establishment of the SDU transfer rotocol, while the intervention grou consisted of atients admitted afterward. RESULTS Of the atients in the intervention grou, 79.2% (57/72) were transferred to the SDU during their admission. Of these transferred atients, 29.8% (17/57) required return to the neurosurgical ICU (NSICU). There were no instances of morbidity or mortality directly related to care in the SDU. Patients in the intervention grou had a mean reduced NSICU length of stay, by 1.95 days, which trended toward significance, and a longer average hositalization, by 2.7 days, which also trended toward significance. In-hosital mortality and 90-day readmission rate were not statistically different between the grous. In addition, early transfer timing rior to 7 days was associated with neither a higher return rate to the NSICU nor higher 90-day readmission rate. CONCLUSIONS In this retrosective study, the authors demonstrated that the transfer rotocol was safe, feasible, and effective in reducing the ICU length of stay and was indeendent of transfer timing. Confirmation of these results is needed in a large, multicenter study. htts://thejns.org/doi/abs/ / focus17448 KEY WORDS aneurysmal subarachnoid hemorrhage; ste-down unit; intensive care unit; transfer rotocol; high-volume center The benefit of interhosital transfer of atients with aneurysmal subarachnoid hemorrhage (SAH) has been well suorted in the literature, and many now advocate for the regionalization of care to imrove atient outcomes. 11,14 As SAH atients are routed and transferred to high-volume centers with secialized infrastructure and ersonnel, sace has become increasingly limited, articularly in the ICU. However, many have suggested that ICU care should only be indicated if it imroves outcomes. 9,15,17 To this end, atients who have exerienced SAH, articularly those with low-grade clinical severity (Hunt and Hess Grades I III), may not require extended ICU stays. Rather, for select low-risk atients, care in a ste-down unit (SDU), defined as an intermediate ward conceived to treat atients no longer requiring full intensive care but needing closer monitoring than those in the general wards, may be aroriate. 12 Across all fields of medicine, research has aimed to reduce the costs of care delivery while maintaining high standards for outcomes and atient safety. ICU care is a limited and costly resource, as ICU beds account for less than 10% of the nation s inatient beds but account for greater than 25% of hosital costs. 2,5,17 By selecting SAH atients who can be safely and aroriately managed in the SDU, hositals can reduce acute care costs without affecting safety or outcomes. 2 ABBREVIATIONS GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial ressure; LOS = length of stay; NSICU = neurosurgical intensive care unit; SAH = subarachnoid hemorrhage; SDU = ste-down unit; TBI = traumatic brain injury; TCD = transcranial Doler. ACCOMPANYING EDITORIAL DOI: / FOCUS SUBMITTED July 1, ACCEPTED August 15, INCLUDE WHEN CITING DOI: / FOCUS AANS, 2017 Neurosurg Focus Volume 43 November

2 A. G. Chartrain et al. Our institution oerates a 16-bed NSICU with a team of critical care hysicians, critical care fellows, and nurse ractitioners and a 1:2 nursing-to-atient ratio. Our SDU is a 4-bed unit with a 1:4 nursing-to-atient ratio. Because of the trend toward the regionalization of SAH care and changing referral atterns in our hosital network, there has been a dramatic increase in the number of SAH atients transferred to our center in recent months. In resonse to this, an SDU transfer rotocol was introduced to streamline atient care for atients meeting low-risk criteria beginning on January 1, For this retrosective study, we hyothesized that our SDU transfer rotocol for select, low-risk SAH atients is safe and feasible, and it reduces ICU utilization. Methods Study Poulation The retrosective study rotocol and a waiver of consent were aroved by our institutional review board. All atients admitted to the NSICU with a diagnosis of SAH (ICD code 430) between January 2011 and Setember 2016 were screened for this retrosective study. January 2011 was chosen as the start date of the study, as this is when the electronic medical record system was initiated at our institution (Mount Sinai Hosital). Patients with SAH of nonaneurysmal etiology were excluded from the study, as were atients who died within 72 hours of admission. Patients were divided into 2 grous based on the date of the transfer rotocol imlementation (January 1, 2015). Those who were admitted rior to this date were categorized as the control grou. Those admitted afterward were categorized as the intervention grou. Age, sex, comorbid medical conditions, Glasgow Coma Scale (GCS) score, Hunt and Hess grade, and modified Fisher grade were recorded at the time of admission. 3,4 Aneurysm characteristics and treatment were collected. Dates identifying transfers to and from the NSICU, SDU, and ward were gathered from the medical record, as were the dates of discharge and the location of discharge. Hosital course comlications were also obtained from the medical record. Transfer Procedure Patients in the control grou (i.e., rior to the intervention) followed the reviously established ractice of remaining in the NSICU for the duration of the vasosasm eriod (i.e., through Day 14 of admission). Once atients were deemed to be beyond the vasosasm eriod, a high level of medical stability needed to be reached for transfer to a general ward. For the intervention grou, criteria for transfer to the SDU were assessed daily and included the following: 1) Hunt and Hess Grade III or better, 2) comleted diagnostic angiograhy since admission, 3) aneurysm secured or rotected if found, 4) stable neurological examination for longer than 24 hours, 5) no concern for imending symtomatic vasosasm (i.e., elevated or u-trending transcranial Doler [TCD] ultrasound velocities), and 6) no elevation in intracranial ressure (ICP) for > 24 hours. If each of these criteria were met, atients were deemed eligible for transfer to the SDU. The need for an external ventricular drain did not reclude transfer to the SDU. Management in the SDU included daily TCD measurements and hourly neurological examinations. The NSICU hysicians continued to serve as the rimary roviders for atients in the SDU. If a atient s medical or neurological status worsened or became comlicated, the atient was evaluated and, if deemed necessary, transferred back to the NSICU for higher level care. Criteria for transfer back to the NSICU included any of the following: 1) evidence of symtomatic vasosasm, 2) raidly increasing TCD ultrasound velocities, 3) uncontrolled elevated ICP, 4) neurological deterioration, or 5) general medical deterioration requiring ICU care. Outcome Measures There were two rimary outcomes for the study. The first rimary outcome was safety and feasibility of the SDU transfer rotocol, measured by mortality and morbidity of atients transferred to the SDU. The second rimary outcome was ICU utilization, measured by NSICU length of stay (LOS). These were chosen as the rimary outcome measures to assess whether the transfer rotocol clinical criteria were effective in identifying eligible atients for transfer and reducing ICU bed utilization. The secondary outcomes included the following: hosital LOS, mortality rate, 90-day readmission rate, and Glasgow Outcome Scale (GOS) score at discharge. GOS score at discharge was graded based on discharge location: home (Score 5), acute (Score 4), subacute (Score 3), long-term nursing facility (Score 2), and death (Score 1). Statistical Methods The marginal comarison of covariates and outcomes between the control and intervention grous was comleted using a 2-samle t-test for continuous outcomes and chi-square test for categorical outcomes. For multivariate analysis, linear regression was alied when continuous variables were used as outcomes, including NSICU LOS, hosital LOS, and average discharge GOS score. Logistic regression was alied when categorical variables were used as outcomes, including hosital mortality rate and readmission rate. Patient inclusion in either the control or intervention grou was used as the rimary covariate. Age, sex, modified Fisher grade, Hunt and Hess grade, and GCS score, and the resence of medical comorbidities, including coronary artery disease, hyertension, and diabetes mellitus, were also included in the regression models, for adjustment. The values of the marginal comarisons were calculated to show the crude difference of each variable between the 2 grous. Those variables with a value < 0.05 were considered to have a significant difference between control and intervention grous. The value for the rimary covariate in each model was generated to indicate the relationshi between each outcome and the rimary covariate after adjusting by age, sex, modified Fisher grade, Hunt and Hess grade, GCS, and the resence of medical comorbidities, including coronary artery disease, hyertension, and diabetes mellitus. A value of < 0.05 indicated a significant as- 2 Neurosurg Focus Volume 43 November 2017

3 SDU transfer rotocol for aneurysmal SAH TABLE 1. Demograhics and admission characteristics No. of atients NA Mean age in yrs 53.9 (13.2) 53.3 (12.2) Male sex 25 (38.5) 21 (29.2) Total no. of aneurysms treated NA Aneurysm location* Anterior/osterior Anterior 61 (85.9) 54 (72.0) Posterior 10 (14.1) 21 (28.0) Laterality Left 24 (33.8) 23 (30.7) Right 24 (33.8) 32 (42.7) Midline 23 (32.4) 20 (26.7) Artery A 1 3 (4.2) 3 (4.0) ACoA 21 (29.6) 16 (21.3) AICA 1 (1.4) 1 (1.3) Basilar ti 2 (2.8) 3 (4.0) ICA terminus 2 (2.8) 2 (2.7) ICA-AChA 1 (1.4) 3 (4.0) ICA-ohthalmic 2 (2.8) 0 (0.0) ICA-araclinoid 2 (2.8) 3 (4.0) ICA-PCoA 21 (29.6) 14 (18.7) ICA-suerior hyohyseal 0 (0.0) 2 (2.7) M 1 2 (2.8) 0 (0.0) M 2 1 (1.4) 1 (1.3) MCA bifurcation 4 (5.6) 7 (9.3) Mid-basilar 0 (0.0) 1 (1.3) PCA 0 (0.0) 1 (1.3) Pericallosal 2 (2.8) 3 (4.0) PICA 4 (5.6) 11 (14.7) Pontine erforator 1 (1.4) 0 (0.0) SCA 1 (1.4) 2 (2.7) Vertebral 1 (1.4) 2 (2.7) Aneurysm treatment* Endovascular embolization 43 (60.6) 63 (84.0) Craniotomy & cliing 20 (28.2) 10 (13.3) Exectant management 8 (11.3) 2 (2.7) CAD 2 (3.1) 4 (5.6) HTN 27 (41.5) 31 (43.1) DM 3 (4.6) 3 (4.2) Admission GCS score (16.9) 13 (18.1) (18.5) 16 (22.2) (64.6) 43 (59.7) Admission H&H grade I III 52 (80) 51 (70.8) IV or V 13 (20) 21 (29.2) CONTINUED IN NEXT COLUMN»» CONTINUED FROM PREVIOUS COLUMN TABLE 1. Demograhics and admission characteristics Admission MF grade (35.4) 16 (22.2) (64.6) 56 (77.8) SDU transfer NA 57 (79.2) NA Returned to NSICU NA 17 (29.8) NA AChA = anterior choroidal artery; ACoA = anterior communicating artery; AICA = anterior inferior cerebellar artery; CAD = coronary artery disease; DM = diabetes mellitus; H&H = Hunt and Hess; HTN = hyertension; ICA = internal carotid artery; MCA = middle cerebral artery; MF = modified Fisher; NA = not alicable; PCA = osterior cerebral artery; PCoA = osterior communicating artery; PICA = osterior inferior cerebellar artery; SCA = suerior cerebellar artery. s are resented as the number of atients (%) unless stated otherwise. Boldface tye indicates statistical significance. * s are the number of aneurysms (%). The denominator is the number of atients who were transferred to the SDU (n = 57). sociation after adjustments. An estimation of the arameters in each model was generated and used to exlain the direction of change. Subgrou Analysis Patients in the intervention grou were slit into 3 subgrous: 1) those who were not transferred to the SDU, 2) those who were transferred to the SDU within 7 days of admission, and 3) those transferred to the SDU after 7 days of admission. These grous were analyzed to assess for any differences in 90-day readmission rate. In addition, for those who were transferred to the SDU, early transfer (within 7 days) versus later transfer was assessed for any association with the need to return to the NSICU. Results A total of 215 atients were admitted to the Mount Sinai Hosital NSICU with a diagnosis of SAH between January 2011 and Setember Patients were excluded because of nonaneurysmal etiology (n = 70) or death within 72 hours of admission (n = 8, 4 atients from each grou). After alying exclusion criteria, a total of 137 atients were included, 65 atients before the intervention was imlemented (control grou) and 72 atients after the transfer rotocol was in lace (intervention grou). Baseline atient characteristics, including modified Fisher grade, Hunt and Hess grade, age, sex, comorbid conditions, and aneurysm characteristics were not significantly different between the 2 grous, with some excetions (Table 1). A greater roortion of atients in the intervention grou resented with aneurysms of the osterior circulation. The intervention grou was also more likely to have an aneurysm treated by endovascular means than was the control grou, which follows the national trend favoring first-line endovascular embolization of rutured aneurysms. In the intervention grou, 79.2% (57/72) of atients were transferred to the SDU during their admission. The Neurosurg Focus Volume 43 November

4 A. G. Chartrain et al. TABLE 2. Hosital comlications No. of atients NA Vasosasm requiring IA theray 12 (18.5) 17 (23.6) Hydrocehalus EVD required 35 (53.8) 44 (61.1) VPS required 8 (12.3) 15 (20.8) Acute resiratory failure 33 (50.8) 37 (51.4) Tracheostomy required 9 (13.8) 9 (12.5) Pulmonary edema 3 (4.6) 5 (6.9) Pulmonary embolism 0 (0.0) 1 (1.4) DVT 4 (6.2) 8 (11.1) Pneumonia 9 (13.8) 8 (11.1) SICM 3 (4.6) 4 (5.6) Ventriculitis 5 (7.7) 6 (8.3) DVT = dee venous thrombosis; EVD = external ventricular drain; IA = intraarterial; SICM = stress-induced cardiomyoathy; VPS = ventriculoeritoneal shunt. s are resented as the number of atients (%). average day of transfer to the SDU was Day 9.5 (SD 7.7) of admission. Of the atients transferred to the SDU, 29.8% (17/57) returned to the NSICU during their admission. Of these, 9 atients returned because of susected symtomatic vasosasm, 5 returned for routine ostoerative monitoring following a subsequent rocedure (2 for a ventriculoeritoneal shunt and 3 for diagnostic angiograhy), and 2 returned because of culture-ositive CSF infection. There were no emergency or unscheduled returns to the oerating room. Additional days sent in the NSICU after return from the SDU were included in the calculated NSICU LOS. Hosital course comlications are resented in Table 2 and were not significantly different between the grous. Unadjusted outcome measures comaring the 2 grous are described in Table 3. Hosital LOS was significantly longer in the intervention grou rior to adjustments for atient demograhics, SAH severity measures, and medical comorbidities. Multivariate analysis of outcome measures was alied to adjust for age, sex, modified Fisher grade, Hunt and Hess grade, and Glasgow Coma Scale score, and the resence of medical comorbidities, including coronary artery disease, hyertension, and diabetes mellitus (Table 4). The rimary outcome measure, NSICU LOS, was shorter in the intervention grou by 1.95 days (95% CI to 0.33 days), after adjusting for these covariates, and trended toward significance ( = 0.092). Paradoxically, hosital LOS was longer in the intervention grou by 2.7 days (95% CI to 5.71), and also trended toward significance after multivariate adjustment ( = 0.080). The mortality rate was lower in the intervention grou (5.6% vs 12.3%), although after adjustment the estimated odds of in-hosital death for atients in the intervention grou were 0.49 (95% CI ) times the odds for control grou atients and therefore were not significantly different between the grous. The estimated odds of 90-day readmission for intervention grou atients were 1.96 (95% TABLE 3. Unadjusted transfer rotocol outcomes Mean NSICU LOS in days 13.0 (6.4) 12.0 (8.3) Mean hosital LOS in days 16.6 (7.6) 19.9 (10.2) Discharge GOS score (53.8) 31 (43.1) (46.2) 41 (56.9) 90-day readmission (%) 4 (6.2) 8 (11.1) s are resented as the number of atients (%) unless stated otherwise. Boldface tye indicates statistical significance. CI ) times the odds for control grou atients, after adjustment. The subgrou analysis of the intervention grou revealed no statistically significant differences between the 3 grous (Table 5). There was no areciable difference in 90-day readmission rate for those who were not transferred, those transferred within 7 days of admission, and those transferred after more than 7 days of admission. In addition, there was no statistically significant difference in the rate of return to the NSICU between those transferred within 7 days and those transferred after 7 days of admission. Discussion To the best of our knowledge, this is the first study investigating the intrahosital transfer of low-risk atients with nontraumatic SAH to an SDU. Comared with a control oulation, institution of a transfer rotocol to the SDU for low-risk atients with SAH resulted in a reduction in the average NSICU LOS by aroximately 2 days. This amounts to an areciably imroved NSICU bed availability, which is of utmost imortance, as the care of SAH becomes centralized at high-volume centers. The total hosital LOS, however, was, on average, 2.7 days longer after the institution of the rotocol. This dramatic increase may be artially exlained by the fact that our medical center saw an increase in the number of atients with SAH transferred to our institution from aroximately 30 cases er year rior to January 2015 to about 100 cases er year afterward, which may have contributed to a loss of efficiency. TABLE 4. Adjusted transfer rotocol outcomes Parameter Estimation OR 95% CI (lower, uer bounds) Adjusted Mean NSICU LOS in , days Mean hosital LOS in days , Death (GOS Score 1) , day readmission , Adjusted by age, sex, modified Fisher grade, and Hunt and Hess grade. 4 Neurosurg Focus Volume 43 November 2017

5 SDU transfer rotocol for aneurysmal SAH TABLE 5. subgrou analysis: transfer rotocol outcomes by timing Not Transferred SDU Transfer From Admission 7 Days >7 Days No. of atients 15 (20.8) 28 (38.9) 29 (40.3) NA Returned to NSICU NA 11 (19.3) 6 (10.5) day readmission 3 (20.0) 3 (10.7) 2 (6.9) 0.610* s are resented as the number of atients (%). * Significance of chi-square statistic roduced by the cross-tabulation of transfer within 7 days and transfer after 7 days. Patients who were not transferred were excluded from this calculation. Of the atients transferred to the SDU, 17 (29.8%) required return to the NSICU. However, 5 of these atients returned for routine monitoring following lanned rocedures and not due to a neurological decline. Among the atients who returned to the NSICU, there were no deaths or morbidity due to care in the SDU. This suggests that desite some atients needing to return to the NSICU, the monitoring in the SDU was aroriate and safe for all atients. Moreover, this suggests that the clinical eligibility criteria that we alied were rigorous and conservative enough to cature only the low-risk atients. The mortality rate was lower in the intervention grou, although the difference was not statistically significant. Nonetheless, this demonstrates that the transfer rotocol does not increase the mortality risk. The dichotomized GOS score at discharge was similar between the grous, indicating that the transfer rotocol did not areciably affect clinical outcome. Finally, the 90-day readmission rate was higher in the intervention grou (11.1% vs 6.2%), but the difference was not statistically significant, suggesting that it did not areciably affect long-term comlication rates in this atient oulation. Subgrou analysis assessing the timing of transfer either before or after 7 days did not reveal any statistically significant difference in need to return to the NSICU or in 90-day readmission rate. This suggests that both early and late transfers to an SDU are equally safe and that, once a atient meets the clinical criteria for transfer eligibility, the rocess can roceed. Similar studies evaluating the effectiveness of admitting select low-risk atients to SDUs rather than to ICUs exist rimarily in the traumatic brain injury (TBI) literature. Nishijima and colleagues investigated whether traumatic intracranial hemorrhage, including traumatic SAH, could be cared for in non-icu settings for low-risk atients. 9 The authors categorized atients into high-risk and low-risk grous based on their need for critical care intervention rior to formal admission. Of the 58.4% of atients who were deemed to be low risk, only 3.2% were incorrectly categorized but were safely treated with transfer back to ICU-level care. The authors concluded that low-risk atients could be safely admitted to a non-icu setting for observation using their selection criteria. Subsequent studies by the same grou confirmed these same results in a larger, multicenter retrosective cohort and outlined a clinical decision rule for this atient oulation. 7,8,10 A study by Levy and colleagues built on these results by showing that isolated traumatic SAH in the setting of mild TBI is not associated with oor outcomes and may not require ICU admission. 6 Bardes and colleagues erformed a similar study in which atients with mild TBI who met low-risk criteria were cared for in the SDU without reeat imaging rather than in an intensive care setting with serial CT scans. 2 The authors identified alternative criteria that included GCS score, age, and anticoagulant medication use and arrived at the conclusion that select low-risk atients could be safely treated in the SDU setting, echoing revious investigations. 8,16 Similar findings of safe and cost-effective care in a non-icu setting have also been reorted in low-risk traumatic subdural hemorrhage and after elective neurointerventional rocedures. 1,13 Our study has several limitations. It was conducted retrosectively and is, therefore, subject to the limitations of electronic medical record review. In addition, it was comleted at a single center, which limits its alicability, although our medical center serves a large, diverse oulation and receives transfers from a wide catchment area. Finally, the time eriods for the control and intervention grous are, by nature of the study, not matched. It is ossible that additional changes to care rotocols and ersonnel may have influenced the results of the study. Conclusions This retrosective study demonstrates that a transfer rotocol for select low-risk SAH atients from the NSICU to the SDU is feasible, safe, and effective. Further investigation with a large randomized trial is needed to confirm our results. Future research is also needed to identify SDU-transferred atients with a high likelihood of needing to be returned to the NSICU. References 1. Albertine P, Borofsky S, Brown D, Patel S, Lee W, Cauty A, et al: Small subdural hemorrhages: is routine intensive care unit admission necessary? Am J Emerg Med 34: , Bardes JM, Turner J, Bonasso P, Hobbs G, Wilson A: Delineation of criteria for admission to ste down in the mild traumatic brain injury atient. Am Surg 82:36 40, Claassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Coeland D, et al: Effect of cisternal and ventricular blood on risk of cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke 32: , Frontera JA, Claassen J, Schmidt JM, Wartenberg KE, Temes R, Sander Connolly E, et al: Prediction of symtomatic vasosasm after subarachnoid hemorrhage: the modified Fisher scale. Neurosurgery 59:21 27, Groeger JS, Guntualli KK, Strosberg M, Halern N, Rahaely RC, Cerra F, et al: Descritive analysis of critical care units in the United States: atient characteristics and intensive care unit utilization. Crit Care Med 21: , Levy AS, Orlando A, Hawkes AP, Salottolo K, Mains CW, Bar-Or D: Should the management of isolated traumatic subarachnoid hemorrhage differ from concussion in the setting of mild traumatic brain injury? J Trauma 71: , Nishijima DK, Haukoos JS, Newgard CD, Staudenmayer K, White N, Slattery D, et al: Variability of ICU use in adult Neurosurg Focus Volume 43 November

6 A. G. Chartrain et al. atients with minor traumatic intracranial hemorrhage. Ann Emerg Med 61: , 517.e1 517.e4, Nishijima DK, Sena M, Galante JM, Shahlaie K, London J, Melnikow J, et al: Derivation of a clinical decision instrument to identify adult atients with mild traumatic intracranial hemorrhage at low risk for requiring ICU admission. Ann Emerg Med 63: , 456.e1 456.e2, Nishijima DK, Sena MJ, Holmes JF: Identification of lowrisk atients with traumatic brain injury and intracranial hemorrhage who do not need intensive care unit admission. J Trauma 70:E101 E107, Nishijima DK, Shahlaie K, Echeverri A, Holmes JF: A clinical decision rule to redict adult atients with traumatic intracranial haemorrhage who do not require intensive care unit admission. Injury 43: , Nuño M, Patil CG, Lyden P, Drazin D: The effect of transfer and hosital volume in subarachnoid hemorrhage atients. Neurocrit Care 17: , Prin M, Wunsch H: The role of stedown beds in hosital care. Am J Resir Crit Care Med 190: , Richards BF, Fleming JB, Shannon CN, Walters BC, Harrigan MR: Safety and cost effectiveness of ste-down unit admission following elective neurointerventional rocedures. J Neurointerv Surg 4: , Rosner J, Nuno M, Miller C, Palestrant D, Schievink WI, Alexander MJ, et al: Subarachnoid hemorrhage atients: to transfer or not to transfer? Neurosurgery 60 (Sul 1):98 101, Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM: Rationing critical care beds: a systematic review. Crit Care Med 32: , Washington CW, Grubb RL Jr: Are routine reeat imaging and intensive care unit admission necessary in mild traumatic brain injury? J Neurosurg 116: , Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EA, et al: Variation in critical care services across North America and Western Euroe. Crit Care Med 36: , e1 e9, 2008 Disclosures The authors reort the following. Dr. Mocco: consultant for Rebound Medical, Endostream, Synchron, Cerebrotech; ownershi in Aama, The Stroke Project, Endostream, Synchron, Cerebrotech, NeurVana, and NeuroTechnology Investors. Dr. Mayer: consultant for Idorsia Pharmaceuticals and Edge Pharmaceuticals. Author Contributions Concetion and design: Gordon, Chartrain, Awad, Sarkiss, Bederson, Mayer, Dangayach. Acquisition of data: Feng. Analysis and interretation of data: Chartrain. Drafting the article: Chartrain. Critically revising the article: Gordon, Chartrain, Awad, Sarkiss, Feng, Mocco, Dangayach. Reviewed submitted version of manuscrit: all authors. Statistical analysis: Chartrain, Liu. Study suervision: Gordon, Mocco, Bederson, Mayer, Dangayach. Corresondence Errol Gordon, Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave., Annenberg Bldg., 8th Fl., NSICU, New York, NY errol.gordon@ mountsinai.org. 6 Neurosurg Focus Volume 43 November 2017