Neurocritical Care. Does it make a difference?
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1 Neurocritical Care Does it make a difference? Dr Hilary Madder Neurosciences Intensive Care Unit John Radcliffe Hospital, Oxford ANZCA Neuroanaesthesia SIG July 2013
2 Neurocritical Care Capacity 32 neurosurgical centres in UK 13 dedicated NCCUs 19 combined ICUs
3 Neurocritical Care Capacity - snapshot Snapshot audit 9 th Feb 2006 All adult ICUs England and Wales 84% response rate (24 of 27 neuro ICUs) Total 2161 critical care beds reported 1378 level 3, 783 level 2 Nov 2006: Neurocritical care capacity and demand. A report from the neurocritical care stakeholder group.
4 Neurocritical Care Capacity - snapshot 83% TBI patients were thought to be more appropriate in a neurosciences centre
5 Neurocritical Care Capacity - snapshot Neuroscience = 12.6% critical care workload 90% occupancy neurocritical care beds need rapid access
6 NICU Occupancy Trends
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8 Retrospective review pre NCCU post NCCU Total 285 patients TBI admitted within 24h injury GOS at 6 months or more
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11 309 patients pre, 239 patients post Single diagnostic category UHC risk adjustment model risk-adjusted NICU mortality (51%) hospital LOS 12% Discharge to home/rehab Improved documentation of prognostic indicators JNS 2006
12 More intensive monitoring Treatment protocols with flexibility Clinical director, resident medical team Education Establishment of MDT
13 Effect of volume on outcome following cerebral aneurysm treatment New York State (257 hospitals) asah admissions (3763) + unruptured aneurysms (2200) Endovascular + neurosurgical intervention Outcome measures In-hospital mortality Adverse outcome (death or discharge destination) Highest volume hospitals had resident neurosurgeon + dedicated NICU Stroke. 2003; 34:
14 Adverse outcome In-hospital death LOS Effect of embolisation on unruptured aneurysms
15 Top 10 high volume hospitals High volume hospitals had resident neurosurgeon + dedicated NICU Effect greatest with surgical interventions Potential effect of post-operative NICU
16 Designated Stroke Centre N = 30, designated stroke centres vs 140 nondesignated in State of NY Adjusted for pre-hospital selection bias (49.4%) admitted to DSC JAMA. 2011;305(4):
17 Designated Stroke Centre use thrombolytic therapy (2.2%)
18 RAIN: Risk Adjustment In Neurocritical Care DA Harrison et al. Health Technology Assessment, June 2013 Evaluation of optimum location + comparative costs of neurocritical care in TBI Completed at N = 2975 TBI admissions to critical care 13 (100%) dedicated NCCU, 14 (74%) combined neuro/general units GOSE, EQ-5D-3L at 6 months
19 RAIN: Cost-effectiveness of dedicated NCCU Case mix adjustment to give incremental effect Higher mean lifetime QALYs At ceiling ratio incremental net monetary benefit positive ( 1316) Conservative approach
20 Benefits for Training High volume of specific conditions and procedures
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22 Referral Region
23 Neuro ICU, Radcliffe Infirmary, January 13, 2007
24 Neuro ICU, West Wing, January 13, 2007
25 Purpose-built state of the art Co-location of neurologists, neurosurgeons, neuroradiologists Adjacent neurosurgery theatres Neuroradiology Angiography suite CT MRI fmri + angiography suite Neurophysiology Neuropsychology Neuropathology
26 NICU Admission Trends
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29 asah Traumatic Brain Injury NICU Stroke Organ Donation Neurology
30 Does neurocritical care make a difference? Evidence of benefits: Reduced mortality Reduced LOS Cost effectiveness Functional outcome measures Training
31 Does neurocritical care make a difference? Why? High volume across narrow range Organised, standardised care Protocols Familiarity + flexibility Co-location, concentration of resources The facilities The multidisciplinary team Development of expertise
32 Does neurocritical care make a difference? What is done differently? Focus on cerebral O 2 demand-supply balance Neuromonitoring Nursing expertise Assessment Combined Neuro MDT Quality Emphasis on benchmarking with general ICUs
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