J Korean Med Sci.  2017 Jun;32(6):1024-1030. 10.3346/jkms.2017.32.6.1024.

Impact of Neurointensivist Co-management on the Clinical Outcomes of Patients Admitted to a Neurosurgical Intensive Care Unit

• Ryu JA
• Yang JH
• Chung CR
• Suh GY
• Hong SC

• KMID: 2377734
• DOI: http://doi.org/10.3346/jkms.2017.32.6.1024

Abstract

Limited data are available on improved outcomes after initiation of neurointensivist co-management in neurosurgical intensive care units (NSICUs) in Korea. We evaluated the impact of a newly appointed neurointensivist on the outcomes of neurosurgical patients admitted to an intensive care unit (ICU). This retrospective observational study involved neurosurgical patients admitted to the NSICU at Samsung Medical Center between March 2013 and May 2016. Neurointensivist co-management was initiated in October 1 2014. We compared the outcomes of neurosurgical patients before and after neurointensivist co-management. The primary outcome was ICU mortality. A total of 571 patients were admitted to the NSICU during the study period, 291 prior to the initiation of neurointensivist co-management and 280 thereafter. Intracranial hemorrhage (29.6%) and traumatic brain injury (TBI) (26.6%) were the most frequent reasons for ICU admission. TBI was the most common cause of death (39.0%). There were no significant differences in mortality rates and length of ICU stay before and after co-management. However, the rates of ICU and 30-day mortality among the TBI patients were significantly lower after compared to before initiation of neurointensivist co-management (8.5% vs. 22.9%; P = 0.014 and 11.0% vs. 27.1%; P = 0.010, respectively). Although overall outcomes were not different after neurointensivist co-management, initiation of a strategy of routine involvement of a neurointensivist significantly reduced the ICU and 30-day mortality rates of TBI patients.

Keyword

Neurosurgery; Intensive Care Unit; Critical Care Outcomes

MeSH Terms

Brain Injuries
Cause of Death
Critical Care Outcomes
Critical Care*
Humans
Intensive Care Units*
Intracranial Hemorrhages
Korea
Mortality
Neurosurgery
Observational Study
Retrospective Studies

Figure

• 

  Fig. 1 Kaplan-Meier 30-day survival analyses before and after neurointensivist co-management in all ICU patients (A) and TBI patients (B). Black solid line, before neurointensivist co-management; red solid line, after neurointensivist co-management; P = 0.373 and P = 0.011, respectively, based on log-rank tests. ICU = intensive care unit, TBI = traumatic brain injury.

Reference

1. Park CM, Chun HK, Lee DS, Jeon K, Suh GY, Jeong JC. Impact of a surgical intensivist on the clinical outcomes of patients admitted to a surgical intensive care unit. Ann Surg Treat Res. 2014; 86:319–324.

2. Josephson SA, Douglas VC, Lawton MT, English JD, Smith WS, Ko NU. Improvement in intensive care unit outcomes in patients with subarachnoid hemorrhage after initiation of neurointensivist co-management. J Neurosurg. 2010; 112:626–630.

3. Varelas PN, Eastwood D, Yun HJ, Spanaki MV, Hacein Bey L, Kessaris C, Gennarelli TA. Impact of a neurointensivist on outcomes in patients with head trauma treated in a neurosciences intensive care unit. J Neurosurg. 2006; 104:713–719.

4. Suarez JI, Zaidat OO, Suri MF, Feen ES, Lynch G, Hickman J, Georgiadis A, Selman WR. Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med. 2004; 32:2311–2317.

5. Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, et al. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation. 2012; 126:1408–1428.

6. Jarquin-Valdivia AA, Bonovich DC, Hemphill JC 3rd. The role of the neurointensivist. Semin Neurosurg. 2003; 14:131–138.

7. Suarez JI. Outcome in neurocritical care: advances in monitoring and treatment and effect of a specialized neurocritical care team. Crit Care Med. 2006; 34:S232–S238.

8. Bithal PK. Neurointensive care unit and neurointensivist: do we need them? J Neuroanaesth Crit Care. 2016; 3:1–2.

9. Knopf L, Staff I, Gomes J, McCullough L. Impact of a neurointensivist on outcomes in critically ill stroke patients. Neurocrit Care. 2012; 16:63–71.

10. Varelas PN, Conti MM, Spanaki MV, Potts E, Bradford D, Sunstrom C, Fedder W, Hacein Bey L, Jaradeh S, Gennarelli TA. The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit. Crit Care Med. 2004; 32:2191–2198.

11. Mirski MA, Chang CW, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol. 2001; 13:83–92.

12. Bershad EM, Feen ES, Hernandez OH, Suri MF, Suarez JI. Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care. 2008; 9:287–292.

13. Kümpers P, Hafer C, Lukasz A, Lichtinghagen R, Brand K, Fliser D, Faulhaber-Walter R, Kielstein JT. Serum neutrophil gelatinase-associated lipocalin at inception of renal replacement therapy predicts survival in critically ill patients with acute kidney injury. Crit Care. 2010; 14:R9.

14. Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, Murray GD, Marmarou A, Roberts I, Habbema JD, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008; 5:e165.

15. Raj R, Siironen J, Kivisaari R, Hernesniemi J, Skrifvars MB. Predicting outcome after traumatic brain injury: development of prognostic scores based on the IMPACT and the APACHE II. J Neurotrauma. 2014; 31:1721–1732.

16. Deepika A, Prabhuraj AR, Saikia A, Shukla D. Comparison of predictability of Marshall and Rotterdam CT scan scoring system in determining early mortality after traumatic brain injury. Acta Neurochir (Wien). 2015; 157:2033–2038.

17. Song HK, Lee BI, Lee JH, Lee KS, Whang SH. Status of neurocritical care in Korea: a nationwide questionnaire survey. J Neurocrit Care. 2013; 6:82–86.

18. Lim CM, Kwak SH, Suh GY, Koh Y. Critical care in Korea: present and future. J Korean Med Sci. 2015; 30:1540–1544.

19. Kwak SH, Jeong CW, Lee SH, Lee HJ, Koh Y. Current status of intensive care units registered as critical care subspecialty training hospitals in Korea. J Korean Med Sci. 2014; 29:431–437.

20. Wijayatilake DS, Shepherd SJ, Sherren PB. Updates in the management of intracranial pressure in traumatic brain injury. Curr Opin Anaesthesiol. 2012; 25:540–547.

21. Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: intensive care management. Br J Anaesth. 2007; 99:32–42.

22. Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med. 2012; 20:12.