SPECIALIZED UNITS: DO THEY SAVE LIVES? NEUROCRITICAL CARE David Zygun MD MSc FRCPC Zone Clinical Department Head Critical Care Medicine, Edmonton Zone Professor and Director Division of Critical Care Medicine University of Alberta
Care of the Neurologically Injured Closed ICU Care is primarily provided general intensivists, who rely heavily on consultative support from neurosurgeons and neurologists Common in Canada, Australia, New Zealand, and some European countries Admissions and discharges are largely the responsibility of the attending intensivist Daily multidisciplinary rounds with a single team of clinicians Open ICU Care is primarily delivered by neurosurgeons or neurologists, depending greatly on consultative input from various subspecialists. At any given time, there may be multiple attending physicians with patients admitted under their care, each of which, in turn, has numerous consultants involved This approach has, historically, been the most common in the United States.
Care of the Neurologically Injured General ICU ICU bedside nurses and ancillary health professionals (e.g., respiratory therapists, pharmacists, social workers are usually welltrained in the provision of physiologic support, especially to patients with multi-organ failure However, specific nuances that are important to subspecialties such as neurocritical care patients may sometimes be underrecognized. Specialty ICU Nurses and ancillary health profesionals are specifically trained to detect and treat neurologic deterioration in a timely fashion However, there may be less experience in the management of systemic complications.
41 general ICUs and 1 neuro ICU from Project Impact dataset Merged with data from one nonparticipating neuro ICU that prospectively collects similar data by using the QuIC data system nontraumatic ICH Severity adjusted in two ways: APACHE II and GCS (radiographic features unavailable)
1038 patients 266 neuro ICU 772 general ICU
Retrospective cohort study using the Acute Physiology and Chronic Health Evaluation (APACHE) IV database (Cerner Corporation, Kansas City, MO) 3 categories of exposure: general ICU, ideal specialty ICU, and nonideal specialty ICU
Acknowledgement Andreas Kramer MD FRCPC
Objectives To summarize evidence with respect to the effects of specialty neurocritical care models on outcomes in critically ill adults with life threatening neurologic injury Methods OVID interface to search MEDLINE, EMBASE and Cochrane Databases from their inception until the third week of February, 2011. The keyword search terms we used included neurocritical care ; neurointensive care or neuro-intensive care ; neurointensivist or neuro-intensivist ; neuro$ ICU or neuro$ intensive care unit Study Selection We included retrospective or prospective cohort studies comparing two or more models of care, one of which involved specialized care, for critically ill patients with neurologic disorders. We excluded studies which involved subsets of previously published data Outcomes neurologic outcome, mortality
Results
Results 12 studies involving 24,520 patients
Results - Mortality
Results Neurological Outcome
Heterogeneity Mortality I 2 = 80%, Q = 53.7, P < 0.0001 Neurological Outcome I 2 = 74%, Q = 35.0, P < 0.0001 When analyis restricted to studies with an neurointensivist: Mortality: OR 0.85, 95% CI 0.74 0.98, P = 0.03 Favorable outcome: OR 1.38, 95% CI 1.15 1.66, P = 0.0005 Heterogeneity in results was less (I 2 9 and 51%, respectively)
Neurointensivists Additional Benefits reductions in length of stay (not consistent) cost savings less need for ventriculoperitoneal shunts in SAH patients improved documentation increased organ and tissue donation rates
Limitations Conflict of Interest Publication Bias Historically controlled studies, especially within a single ICU, are susceptible to a Hawthorne effect Other positive changes may have been introduced at individual centers over time, apart from implementation of a neurocritical care service (ex. clip to coil) It is likely that the technical skills and judgment of other clinicians, such as neurosurgeons or neuro-interventionalists, have matured over time. Some of the benefits may largely reflect the introduction of an intensivist-led, systematic, organized approach to critically ill patients, rather than only to specific content expertise in neurocritical care Published studies do not clarify which specific interventions or modifications in practice were responsible for the observed positive effects
Explanations Provider Volume-Outcome association it is virtually impossible to find a surgical procedure or medical condition that has been evaluated in more than one study that does not have a volume-outcome association. Practice makes perfect Selective referral David R. Urbach HCQ 2004
Explanations Coherence What is one plus one?... Four... principle of coherence, the magnifying effect of one factor upon another... Each piece of the system reinforces the other parts of the system to form a integrated whole that is much more powerful than the sum of the parts. It is only through consistency over time, through multiple generations, that you get maximum results. Jim Collins, Good to Great, Harper Collins, 2001
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Conclusions Existing studies have notable limitations, and there is a considerable degree of heterogeneity in the published results. However, the cumulative experience, involving almost 25,000 patients, suggests that specialized neurocritical care units are associated with decreased mortality and improved neurological outcome. Unfortunately, published studies do not clarify which specific interventions or modifications in practice were responsible for the observed positive effects. Future research should aim to determine which factors are of particular benefit.