April 21, 2003

Study: Neuro-ICUs improve patient outcomes

By Janet Christenbury

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 researchers. Owen Samuels, assistant professor of neurology and neurosurgery and director of neurointensive care, presented outcome data on the topic at the American Academy of Neurology’s (AAN) 55th annual meeting in Honolulu, April 3.

“The medical literature supports the effectiveness of intensive care specialists at reducing mortality, improving clinical outcomes and decreasing resource utilization in general medical and surgical critical-care patients,” said 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 outcomes, reduce mortality or reduce intensive care resource utilization. With shrinking health care payouts, these data really need to be examined.”

Researchers collected outcome data on neurological and neurosurgical patients admitted in the neurointensive care unit (NICU) at Emory Hospital for three six-month periods (April–September) over three years (1998, 1999 and 2000). Patients 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) or 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 NICU stay for patients with intracranial hemorrhage dropped by two full 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. And 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. In 1997–98, before a NICU service was established at Emory, patients remained on a ventilator an average of 17 days. Once the NICU was established, mean patient-ventilator days dropped from 12 days (1999–2000) to 11 days (2001) and remained steady at 11 days in 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 is called “opportunity days.” Following NICU establishment, 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 (Samuels), two nurse practitioners, a pharmacist, a respiratory therapist, a nutritionist and post-graduate neurology and neurosurgery residents. Mustapha Ezzeddine, assistant professor of neurology and neurosurgery, recently joined the team as the demand for this specialty in critical care continues to increase. Emory Hospital is the only hospital in Georgia with such a neurocritical care unit and two fellowship-trained neurointensivists on board.

“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 United States,” Samuels said. “We feel these findings are consistent with the larger, more established practice using the intensivist model in general medical and surgical ICUs.”