Handbook of Neurocritical Care, Second Edition

Handbook of Neurocritical Care

Anish Bhardwaj, MD, FAHA, FCCM, FAAN Marek A. Mirski, MD, PhD Editors

Handbook of Neurocritical Care Second Edition

Editors Anish Bhardwaj Chairman Department of Neurology Tufts University School of Medicine Professor of Neurology Neurological Surgery, and Neuroscience Neurologist-in-Chief Tufts Medical Center Boston, MA, USA [email protected]

Marek A. Mirski Vice-Chair, Department of Anesthesiology and Critical Care Medicine Director, Neurosciences Critical Care Division Chief, Division of Neuro Anesthesiology Director, Anesthesia Perioperative Clinical Research Program Co-Director, Comprehensive Stroke Program Professor of Anesthesiology, Neurology, Neurosurgery Johns Hopkins Medical Institutions Baltimore, MD, USA [email protected]

ISBN 978-1-4419-6841-8 e-ISBN 978-1-4419-6842-5 DOI 10.1007/978-1-4419-6842-5 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010934376 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in ­connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Foreword

Neurocritical Care is a multi-specialty multi-disciplinary field dedicated to ­improving the care and outcomes of critically ill patients with neurological conditions. It has moved the central nervous system from being an innocent bystander in the management of critically ill patients to a major player. No longer is brain function all but ignored in managing critically ill patients, but rather critical care management is focused on optimizing brain function. This shift in focus has been driven as much by advances in medical knowledge and techniques as by the vision of its practitioners such as the editors and contributors to this second edition of Handbook of Neurocritical Care. Over the past 20 years I have watched the field grow in terms of perceived need, knowledge, and acceptance across a growing number of medical specialties and disciplines. This is clearly evident in this text with contributors from the specialties of neurology, vascular neurology, neurosurgery, interventional neuroradiology, anesthesiology, and medical critical care and the disciplines of nutrition and advanced practice nursing. By bringing together this breadth of expertise to update this concise focused handbook the editors have created a tool useful to practitioners from a wide range of specialties and disciplines who care for critically ill patients. The format of this handbook lends itself to being easy to use, concise, and to the point. While it is not meant to be comprehensive, it captures the most important key points that are necessary for thoughtful clinical decision making. The tables and figures provide easy to use tools that facilitate rapid evaluation and decision making both for trainees in neurocritical care as well as for experienced practitioners in related fields. This text provides concise practical review of the current state of this rapidly emerging field. Michael N. Diringer, MD, FCCM Professor, Neurology and Neurosurgery Section Chief, Neurological Critical Care Past President, Neurocritical Care Society Washington University School of Medicine.

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Preface

In the preface to the first edition of Handbook of Neurocritical Care, we commented that neurocritical care as a subspecialty has grown rapidly over the last two decades and has reached a level of maturity with the advent of newer monitoring, diagnostic, and therapeutic modalities in a variety of brain and spinal cord injury paradigms. This growth and maturation are clearly exhibited by the emerging fellowship training programs at various facilities, the recently instituted subspecialty certification examination by the United Council for Neurologic Subspecialties, and the increasing number of critical care units around the world. These major strides in the subspecialty that are commensurate with the goals of “decade of the brain,” coupled with the emerging data from clinical series and translational research, occasions another edition of this handbook. The overarching goal of the handbook remains the same. The operative tenet continues to be that “time is brain,” and rapid diagnosis and therapeutic interventions in these challenging patients cannot be overemphasized. The care provided to this subset of critically ill neurologic and neurosurgical patients continues to be interdisciplinary and includes care rendered by colleagues in emergency medical services and emergency medicine, neurologists, neurosurgeons, anesthesiologists, critical care physicians, critical care nurses, nurse practitioners, and physician assistants. The onus lies heavily on first-line physicians and other healthcare providers for early recognition, timely therapeutic interventions, and proper referrals in patients experiencing acute neurologic deterioration. This handbook is not meant to substitute for a full-length text, rather it is intended to serve as a quick-reference guide for those involved in the care of critically ill neurologic and neurosurgical patients. In response to feedback from the readership and colleagues regarding the previous edition, the first section of this edition, which covers general principles, logically progresses into a section regarding specific problems encountered in neurocritical care. We have focused further on management algorithms for making and confirming the clinical diagnosis with appropriate ancillary radiologic and laboratory tests and algorithms for managing acute neurologic diseases. Tables and illustrations provide quick and easy bedside reference. At the end of each chapter, key points and references highlight essential elements and should serve as quick summaries of salient features. We hope that this second edition of the handbook

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continues to provide a succinct and practical approach to the management of the critically ill patient population that we serve. We are indebted to the authors for their valuable contributions and thank Tzipora Sofare, MA, for lending her exceptional editorial skills. We would also like to particularly express our thanks to the Johns Hopkins Clinician Scientist Program, the American Heart Association, the National Stroke Association, and the National Institutes of Health extramural programs; their support has helped to advance our investigative work, aided in the establishment of fellowship training programs in neurosciences critical care, and augmented the much needed advancement of this field. Anish Bhardwaj, MD, FAHA, FCCM, FAAN Marek A. Mirski, MD, PhD

Special Introduction

This second edition of the Handbook of Neurocritical Care is a major revision of the first edition that appeared in 2004. As pointed out by the editors, since that time this field has grown and matured to include many more training fellowships as well as recent sub-specialty certification by the United Council for Neurologic Subspecialties. This handbook has also progressed forward: an expanded yet handy and easy to use reference manual for the management of patients with life threatening neurologic and neurosurgical illnesses. As in the first edition, all of the chapters are made up of bulleted teaching points followed by a list of Key Points and important references allowing for the rapid access to vital information critical for rapid and timely decision making. A major addition to the volume is the first section which covers a myriad of important general principles such as electrolyte derangements, fever and infection, cerebral blood flow, cerebral edema, brain and cardiovascular monitoring, ventilatory management, and sedation and analgesia to mention only a few. The second section covers the major diagnostic categories of neurocritical care with several new topics including neuroleptic malignant syndrome and malignant hyperthermia, meningitis and encephalitis, and intraventricular hemorrhage. Useful algorithms, tables, and illustrations throughout the book assist the decision making process. Whereas most of the contributors to the first edition were colleagues of the editors at the Johns Hopkins Hospitals, an impressive array of new authors has been added from all over the country reflecting the broad scope of this subspecialty. This handbook covers the current state of the art concisely and completely and should find itself into critical care units everywhere. It serves as a useful complement to other monographs in the Humana Press Current Clinical Neurology series such as Critical Care Neurology and Neurosurgery by Jose Suarez, Seizures in Critical Care by Panayiotis Varelas, and Status Epilepticus by Frank Drislane. This second edition is published by Springer, the new parent company of Humana Press. All books in the series can be found at www.springer.com. Daniel Tarsy, MD Professor Neurology Harvard Medical School Vice Chair, Department of Neurology Beth Israel Deaconess Medical Center ix

Contents

Part I  General Principles of Neurocritical Care   1 Establishing and Organizing a Neuroscience Critical Care Unit........ Marek A. Mirski

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  2 Electrolyte and Metabolic Derangements.............................................. Nikki Jaworski and Ansgar Brambrink

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  3 Fever and Infections................................................................................. Neeraj Badjatia

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  4 Cerebral Blood Flow and Metabolism: Physiology and Monitoring........................................................................................ Jeremy Fields and Anish Bhardwaj

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  5 Multimodality Monitoring in Acute Brain Injury................................ Kristine H. O’Phelan, Halinder S. Mangat, Stephen E. Olvey, and M. Ross Bullock

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  6 Cerebral Edema and Intracranial Hypertension.................................. Matthew A. Koenig

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  7 Cardiac Dysfunction, Monitoring, and Management........................... Andrew Naidech

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  8 Airway Management and Mechanical Ventilation in the NCCCU.......................................................................................... Paul Nyquist

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  9 Blood Pressure Management.................................................................. 115 Ameer E. Hassan, Haralabos Zacharatos, and Adnan I. Qureshi 10 Nutrition in Neurocritical Care.............................................................. 123 Tara Nealon xi

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11 Sedation, Analgesia, and Neuromuscular Paralysis............................. 145 Marek A. Mirski 12 Postoperative Care................................................................................... 173 W. Andrew Kofke and Robert J. Brown 13 Care Following Neurointerventional Procedures.................................. 217 Yahia M. Lodi, Julius Gene Latorre, Jesse Corry, and Mohammed Rehman 14 Ethical Issues and Withdrawal of Life-Sustaining Therapies............. 247 Wendy L. Wright 15 Collaborative Nursing Practice in the Neurosciences Critical Care Unit.................................................................................... 265 Filissa M. Caserta Part II  Specific Problems in Neurocritical Care 16 Coma and Disorders of Consciousness.................................................. 277 Edward M. Manno 17 Acute Encephalopathy............................................................................. 287 Robert D. Stevens, Aliaksei Pustavoitau, and Tarek Sharshar 18 Traumatic Brain Injury........................................................................... 307 Geoffrey S.F. Ling and Scott A. Marshall 19 Acute Myelopathy.................................................................................... 323 Angela Hays and Julio A. Chalela 20 Ischemic Stroke........................................................................................ 341 Neeraj S. Naval and Anish Bhardwaj 21 Intracerebral Hemorrhage...................................................................... 353 Neeraj S. Naval and J. Ricardo Carhuapoma 22 Intraventricular Hemorrhage................................................................. 365 Kristi Tucker and J. Ricardo Carhuapoma 23 Subarachnoid Hemorrhage..................................................................... 371 Eric M. Bershad and Jose I. Suarez 24 Brain Injury Following Cardiac Arrest................................................. 389 Romergryko G. Geocadin

Contents

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25 Meningitis and Encephalitis.................................................................... 409 Barnett R. Nathan 26 Cerebral Venous Sinus Thrombosis....................................................... 421 Agnieszka A. Ardelt 27 Neuroleptic Malignant Syndrome, Malignant Hyperthermia, and Serotonin Syndrome......................................................................... 435 Panayiotis N. Varelas and Tamer Abdelhak 28 Brain Tumors .......................................................................................... 445 Sherry Hsiang-Yi Chou 29 Hydrocephalus.......................................................................................... 469 Michel T. Torbey 30 Neuromuscular Disorders....................................................................... 475 Jeremy D. Fields and Anish Bhardwaj 31 Status Epilepticus..................................................................................... 489 Marek A. Mirski 32 Deep Venous Thrombosis and Pulmonary Embolism.......................... 505 Wendy C. Ziai 33 Neurocritical Illness During Pregnancy and Puerperium.................... 523 Chere Monique Chase and Cindy Sullivan 34 Brain Death and Organ Donation.......................................................... 533 Alexander Y. Zubkov and Eelco F.M. Wijdicks Index.................................................................................................................. 541

Contributors

Tamer Abdelhak  Departments of Neurology and Neurosurgery, Henry Ford Hospital, Detroit, MI, USA Agnieszka A. Ardelt University of Chicago, Departments of Neurology and Surgery (Neurosurgery), Division of Neurocritical Care, 5841 South Maryland Ave MC2030, Chicago, IL 60637, USA Neeraj Badjatia Departments of Neurology and Neurosurgery, Columbia University, New York, NY 10032, USA Eric M. Bershad Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA Anish Bhardwaj Department of Neurology, Tufts University School of Medicine, Tufts Medical Center, Box 314, 800 Washington Street, Boston, MA 02111, USA Ansgar Brambrink Department of Anesthesiolgy, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA Robert J. Brown Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA M. Ross Bullock Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA

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J. Ricardo Carhuapoma Neurosciences Critical Care Division, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 8-140, Baltimore, MD 21287, USA Filissa M. Caserta Neurosciences Critical Care Unit, Johns Hopkins University School of Medicine, 600 N. Wolfe Street - Meyer 8-140, Baltimore, MD 21287-7840, USA Julio A. Chalela Medical University of South Carolina, PO BOX 250606, Charleston, SC 29425, USA Chere Monique Chase Forsyth Comprehensive Neurology, 2025 Frontis Plaza Boulevard, Greystone Professional Center, Suite 102, Winston-Salem, NC 27103, USA Sherry Hsiang-Yi Chou Division of Critical Care Neurology and Cerebrovascular Diseases, Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA Jesse Corry Upstate Medical University, Syracuse, NY, USA Jeremy D. Fields Department of Neurology, Oregon Health and Science University, Portland, OR, USA Romergryko G. Geocadin Division of Neuroscience Critical Care, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 8-140, Baltimore, MD 21287, USA Ameer E. Hassan Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, MN Angela Hays Medical University of South Carolina, Charleston, SC, USA Nikki Jaworski Department of Anesthesia and Peri-operative Medicine, Oregon Health and Science University, Portland OR Matthew A. Koenig Associate Medical Director of Neurocritical Care, The Queen’s Medical Center, Neuroscience Institute–QET5, 1301 Punchbowl Street, Honolulu, HI 96813, USA

Contributors

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W. Andrew Kofke Departments of Anesthesiology and Critical Care, Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street - 7 Dulles, Philadelphia, PA 19104, USA Julius Gene Latorre Neurosciences Critical Care Unit and Neurocritical Care Fellowship Program, Upstate Medical University, Syracuse, NY, USA Geoffrey S.F. Ling Critical Care Medicine for Anesthesiology and Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd. Bethesda, MD 20814, USA Yahia M. Lodi Division of Cerebrovascular Program and Services, Vascular/Neurological Critical Care Neurology and Envovascular Surgical Neuroradiology, Upstate Medical University and University Hospital, SUNY, NY and Department of Neurology, 813 Jacobsen Hall, 750 East Adams Street, Syracuse, NY 13210, USA Halinder S. Mangat Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA Edward M. Manno Mayo Clinic School of Medicine, 200 First St. SW, Rochester, MN 55905, USA Scott A. Marshall Uniformed Services University of the Health Science, Bethesda, MD, USA Marek A. Mirski Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 8-140, Baltimore, MD 21287, USA Andrew Naidech Department of Neurology, Northwestern University, Feinberg School of Medicine, Neuro/Spine ICU, Northwestern Memorial Hospital, Chicago, IL 60611-3078, USA Barnett R. Nathan Department of Neurology and Internal Medicine, University of Virginia School of Medicine, PO Box 800394, Charlottesville, VA 22908, USA Neeraj S. Naval Neurosciences Critical Care Fellowship Program, Oregon Health and Science University, Portland, OR, USA

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Contributors

Tara Nealon Johns Hopkins University School of Medicine, Baltimore, MD, USA Paul Nyquist Department of Neurology, Anesthesiology and Neurological Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street – Phipps 126, Baltimore, MD 21287, USA Stephen E. Olvey Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA Kristine H. O’Phelan Assistant Professor Director of Neurocritical Care Department of Neurology, University of Miami Miller School of Medicine, Miami, FL Tarek Sharshar Hospital Raymond Poincare, University of Versailles, Versailles, France Robert D. Stevens Neurosciences Critical Care Division, Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Division of Neurosciences Critical Care, 600 North Wolfe Street - Meyer 8-140, Baltimore, MD 21287, USA Jose I. Suarez Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA Kristine H. O’Phelan Department of Neurology, University of Miller School of Medicine, Miami, FL, USA Kristi Tucker Departments of Neurology and Anesthesiology/Critical Care, Wake Forest University Health Sciences, Winston-Salem, NC, USA Panayiotis N. Varelas Departments of Neurology and Neurosurgery, Henry Ford Hospital, Detroit, MI, USA Aliaksei Pustavoitau Johns Hopkins University School of Medicine, Baltimore, MD, USA

Contributors

Adnan I. Qureshi Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, MN Mohammed Rehman Department of Neurology, Upstate Medical University, Syracuse, NY, USA Cindy Sullivan Neurocritical Care Program, Novant Health Systems, Forsyth Medical Center, Winston-Salem, NC, USA M.T. Torbey Department of Neurological Surgery and Neurology, Medical College of Wisconsin, Department of Neurology, 9200 W.Wisconsin Avenue, Milwaukee, WI 53226, USA Eelco F.M. Wijdicks Department of Neurology and Neurological Surgery, Mayo Clinic School of Medicine, 200 First Street SW, Rochester, MN 55905, USA Elco A. Widjicks Professor of Neurology Chair, Division or Critical Care Neurology Mayo Clinic and Mayo College of Medicine, Rochester, MN Wendy L. Wright Emory University School of Medicine, 1365B Clifton Rd., NE, Ste. 6200, Atlanta, GA 30322, USA Haralabos Zacharatos Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, MN Wendy C. Ziai Department of Neurology and Neurological Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street – Meyer 8-140, Baltimore, MD 21287, USA Alexander Y. Zukbov Stroke Center, Fairview Southdale Hospital, Minneapolis Clinic of Neurology, Rochester, MN, USA

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Part I

General Principles of Neurocritical Care

Chapter 1

Establishing and Organizing a Neuroscience Critical Care Unit Marek A. Mirski

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Goals and benefits for subspecialty neuroscience critical care unit (NCCU) ♦ Focused specialty care for unique ICU population ♦ Special expertise required by professionals in NCCU – neuroscience ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

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background Greater case efficiency of neurosurgical and neurointerventional cases Efficient ICU management Hub of clinical neuroscience communication Academic clinical neuroscience concentration Hospital hub for stroke, acute brain, and spinal cord injury centers Neurocritical-trained nursing Cohesive and comprehensive rounds Neurologic monitoring – capable and savvy Sensitive neurologic evaluations Precisely match therapeutics to neurologic pathophysiology Shorter lengths of stay (LOS) for patient in both the ICU and hospital Improved patient outcomes Increased regional referral network Enhanced marketing strategy

NCCU requires consensus-driven support from medical center ♦ ♦ ♦ ♦ ♦

Medical center administration Neurology Neurosurgery Radiology Anesthesiology

M.A. Mirski, MD, PhD (*) Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 8-140, Baltimore, MD 21287, USA e-mail: [email protected] A. Bhardwaj and M.A. Mirski (eds.), Handbook of Neurocritical Care: Second Edition, DOI 10.1007/978-1-4419-6842-5_1, © Springer Science+Business Media, LLC 2011

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Probable conflicts must be defined and respected; strategies to overcome conflicts must be defined ♦ ♦ ♦ ♦ ♦ ♦

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Administrative and political goals of medical center Other ICU environments – patient selection processes Territorial issues within medical center Potential increase in cost of care per patient Sacrifice in overall ICU bed efficiency Dilution of ICU intensivist coverage pool; more resources are required by medical center

Physician argument for an NCCU ♦ Lines of evidence for improvement in patient outcomes

• Several published reports in neurologic and neurosurgical ICU patient populations • Neurology – for intracranial hemorrhage (ICH), data has been published that compared general ICU care versus NCCU; Cumulative survival enhanced in NCCU (Fig. 1.1) • Patients with ischemic stroke – data demonstrates reduced ICU and hospital LOS and improved the disposition of patients • Patients with ICH, improvement in outcome as defined by percent of mortality, percent to home, and rehabilitation versus nursing home, despite lower Glasgow Coma Scale score in comparative grouping in NCCU versus general ICU (Fig. 1.2)

Fig. 1.1  Cumulative survival curve demonstrating a benefit in lower mortality of patients suffering from acute intracerebral hemorrhage that are admitted to and cared for in a neuroscience speciality critical care unit. There is approximately an additional 10 percent survival benefit after a 10 day ICU length of stay. Data from Diringer 2001

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Fig. 1.2  Comparative hospital outcome data from patients with intracerebral hemorrhage (ICH) treated in general medical-surgery intensive care unit (ICU) versus a neuroscience subspecialty ICU (NSICU). GCS = Glasgow Coma Scale score; Rehab = rehabilitation; LOS = total hospital length of stay; SEM = standard error of the mean. Data from Mirski 2001

♦ Improvement in ICU efficiency of care and ICU LOS

• Shorter ICULOS leads to reduction in cost and increased case-load profitability • For neurology patients, reduction of LOS from 4.2 ± 4.0 to 3.7 ± 3.4 following development of an NCCU; another series reports a reduction in LOS to 2.0 ± 0.9 NCCU days compared to 3.0 ± 0.2 for comparable patients in MICU • For neurosurgery patients, LOS post-craniotomy for tumor and traumatic brain injury reduced post-implementation of specialty NCCU compared to general surgical ICU model of care: (DRG 001-craniotomy; DRG 002-; DRG 027-; DRG 028-) (Fig. 1.3) ■

Hospital argument for NCCU ♦ Improvement in ICU efficiency of care and cost of care

• Subspecialty intensivist can minimize cost of services due to recognition of patient condition and diagnoses based on precise and focused examination and interpretation of findings; e.g., reduction of imaging requisitions and lower cost of pharmaceuticals can be expected with expertise at bedside (Fig. 1.4) • Further subdivision among costs for imaging studies, pharmacy, and laboratory testing found reduction across all aspects of clinical management

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Fig. 1.3  National database [HBS International, Inc. (HBSI, Bellevue, WA)] comparative difference (%) in ICU length of stay from the benchmark standard (0 on axis) for neuroscience subspecialty ICU (NSICU) care and other hospital areas (Non-NSICU areas included acute care ward, telemetry unit, and general medical/surgical intensive care unit [ICU]) for principal neurosurgery severity adjusted Adjacent Patient Related Groups (A-DRGs). The cohort size ranged from 20 (A-DRG 028, NSICU) to 152 (A-DRG 001, NSICU). Each care area (ward, ICU, telemetry unit) is compared with its own national benchmark standard. A-DRGs 001 and 002 = craniotomy with or without intracerebral hemorrhage or coma; A-DRGs 027 and 028 = skull fracture with and without hemorrhage or coma; SEM = standard error of the mean. Data from Mirski, 2001

♦ Improvement in ICU efficiency of care and documentation

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• Data from a sampling of records with three diagnoses: traumatic brain injury, ICH, and subarachnoid hemorrhage – pre- and post-appointment of neurointensivist • Documentation improved from 32.5 to 57.5% [Odds Ratio 2.8; 95% Confidence Interval (CI), 1.9–4.2] in the after period; documentation using Glasgow Coma Scale, clot volume, Hunt & Hess scale, and Fisher grade also improved significantly in each of the diagnoses examined in the after period Nationally – Studies by Leapfrog Group support neurointensivists ♦ ICU data clearly demonstrate decreased mortality in intensivist-run ICU

model • Leapfrog group examined nine published studies on intensivist-driven ICU care and found that relative reductions in mortality rates associated with intensivist-model ICUs ranged from 15 to 60% • Leapfrog Group conclusion – using a conservative estimate of effectiveness (15% reduction), full implementation of intensivist-model ICUs would save ~53,850 lives each year in the US

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Fig.  1.4  National database [HBS International, Inc. (HBSI, Bellevue, WA)] comparative difference in cost per case in US dollars ($, fiscal year 1997) from the benchmark standard (0 on axis) for neuroscience subspecialty ICU (NSICU) care and non-NSICU hospital areas for principal neurosurgery severity adjusted Adjacent Patient Related Groups (A-DRGs). Each care area (ward, intensive care unit, telemetry unit) is compared with its own national benchmark standard. A-DRGs 001 and 002 = craniotomy with or without intracerebral hemorrhage or coma; A-DRGs 027 and 028 = skull fracture with and without hemorrhage or coma; SEM = standard error of the mean. Data from Mirski, 2001

♦ Further evidence

• A meta-analysis of 26 relevant observational studies of alternative staffing strategies revealed that high-intensity staffing was associated with a lower ICU mortality, with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50–0.75) • High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment ♦ Neurointensivists – Support of staffing models and Leapfrog key standards

(http://www.leapfroggroup.org/media/file/Leapfrog) • Intensivists are present in the ICU during daytime hours 7 days/week, with no other clinical duties during this time • Return >95% of pages within 5 min • Rely on a physician (e.g., fellow or resident) or nonphysician extender who is in the hospital and able to reach ICU patients in