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
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
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
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.”