J. Claude Hemphill III, M.D. - Neurocritical Care Society

Is Neurointensive Care
Really Optional for
Comprehensive Stroke
Centers?
J. Claude Hemphill III, M.D.
Disclosures
Research Support: Novo Nordisk
Consulting: Astra Zeneca, Innercool Therapies
Stock options: Cardium Therapeutics (Innercool Therapies)
UC SF
NEUROCRITICAL
CARE PROGRAM

Comprehensive Stroke Centers

Optional
Personnel with expertise in:
Neuroscience intensive care
Infrastructure:
Neuroscience ICU

CSC Recs
• What is going on here?
• What are these recommendations based on?
• Who made them?
• Is neurointensive care really optional?
– Why?
– Why not?

Stroke Center Recommendations
• Brain Attack Coalition
– Multidisciplinary group of representatives from major
professional organizations involved with delivering stroke care
– AAN, AANS, AANN, ACEP, AHA, ASNR, NINDS, NSA, SBC,
ASITN, CNS, , CDC, NAEMSP, PMR, VA
• Primary Stroke Centers – JAMA 2000
– Led to JCAHO Primary Stroke Center certification
• Comprehensive Stroke Centers – Stroke 2005
• These are generally good and important documents
– Limited evidence as to what works
– Provide framework for regulatory agencies and hospitals

CSC – Neurointensive Care Units
• ICU
– “A dedicated neurosciences ICU, although
desirable, is not required.”
• ICU Nurses
– “It is preferred (but not required) that nurses
caring for neuroscience patients in the ICU
be board certified in neuroscience nursing.”

CSC - Neurointensivists
• ICU Director
– “Formal training as a neurointensivist,
although preferred, is not a requirement.”
• Costs
– “The hiring of additional personnel (ie(
ie,
endovascular interventionists and
neurointensivists) ) and having staff members
on call would also increase the costs,
perhaps by $200,000 to $300,000 or more
each year. Some of these costs could be
offset by hospital billing…”

CSC – Neurointensive Care
• Hm…let’s see, so you’re telling me that for our CSC
• Neurointensive care is optional
• Neurointensive care increases costs
• Likely hospital administrator response
– “BAC-sanctioned opportunity to reduce the availability of
neurointensivists and NICUs (including specially trained
neuroscience nurses)…”
• Is Neurointensive Care Really Optional for
Comprehensive Stroke Care?
(letter on behalf of NCS to Stroke 2005)

Why is this a bad idea?
• Expertise Matters
– Paradoxical effect of providing less than
“comprehensive care”
• What’s the evidence?
• Neurointensivists and neurocritical care
improve outcomes
• Neurointensivists often decrease costs

Neurocritical Care Improves Outcomes
• Diringer MN, Edwards DF. Admission to a
neurologic/neurosurgical intensive care unit is associated with
reduced mortality rate after intracerebral hemorrhage. Crit Care
Med. Mar 2001;29(3):635-640.
640.
• Mirski MA, Chang CW, Cowan R. Impact of a neuroscience
intensive care unit on neurosurgical patient outcomes and cost of o
care: evidence-based support for an intensivist-directed specialty
ICU model of care. J Neurosurg Anesthesiol. Apr 2001;13(2):83-92.
• Suarez JI, Zaidat OO, Suri MF, et al. Length of stay and mortality in
neurocritically ill patients: impact of a specialized neurocritical
care team. Crit Care Med. Nov 2004;32(11):2311-2317.
2317.
• Varelas PN, Conti MM, Spanaki MV, et al. The impact of a
neurointensivist-led team on a semiclosed neurosciences
intensive care unit. Crit Care Med. Nov 2004;32(11):2191-2198.
2198.
• Varelas P, Eastwood D, Yun H, et al. Impact of a neurointensivist
on outcomes in patients with head trauma treated in a
neurosciences intensive care unit. J Neurosurg. 2006;104:713-719.
719.

As Well as Decreases LOS and costs
• 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. Apr 2001;13(2):83-92.
• Suarez JI, Zaidat OO, Suri MF, et al. Length of stay and
mortality in neurocritically ill patients: impact of a
specialized neurocritical care team. Crit Care Med. Nov
2004;32(11):2311-2317.
2317.
• Varelas PN, Conti MM, Spanaki MV, et al. The impact of
a neurointensivist-led team on a semiclosed
neurosciences intensive care unit. Crit Care Med. Nov
2004;32(11):2191-2198.
2198.
• Varelas P, Eastwood D, Yun H, et al. Impact of a
neurointensivist on outcomes in patients with head
trauma treated in a neurosciences intensive care unit. J
Neurosurg. 2006;104:713-719.
719.

So Who Disagrees with Me Now?
• Regarding the importance of
neurointensive care for CSCs?
• No one
(at least in public in the U.S.)
• So what’s the issue?
• Supply and demand
• Vascular neurology leaders agree and are
asking us for the answer
– (Tony Furlan, , Mark Alberts, , Richard Hughes)
• Can’t require something that isn’t available

Role of CSCs

How Many CSCs are needed?
• US Trauma Centers
– 190 Level I
– 255 Level II
– 258 Level III
1.5 per million
2.4 per million
• How many CSCs are needed?
– Don’t forget Primary Stroke Centers
– ~200 CSCs in continental U.S.?
– Driven by
» Equitable distribution across population?
» Program building for institutions?
» $$$$$

Supply of Neurointensivists
• Neurocritical Care Society
– 531 members
» 43 states
» 26 countries (65 int’l members)
– 342 MD, non-junior, members
• 19 “registered” fellowship training programs
– 31 annual training spots
• “there is currently a limited supply and
unequal distribution of neurointensivists.”

Challenge
• Congratulations, good job!
– We have created a demand for neurocritical care and
neurointensivists
– Not just stroke (trauma, status – cEEG, , NM disease)
• If we do not deliver neurocritical care,
someone else will care for these patients
(and think it’s neurocritical care)
• This is the major threat to our continued success
– And biggest opportunity
– Including neurointensivists from all parent specialties
(neuroanesthesia,, neurology, neurosurgery, internal
medicine, pediatrics)

Neurocritical Care – the next phase
• Go forth and multiply
– Every practicing neurointensivist should consider having
a fellowship training program
– Populate new institutions (academic and private)
– UCNS individual certification and fellowship training program
accreditation coming soon
• Enhance and develop a variety of models of neurointensivist-led
delivery of neurocritical care
– Exclusive group of neurointensivists
– Neurointensivist member/leader of multi-disciplinary ICU group
– Neurointensivist coordinator of vascular neurology and/or
neurosurgery trauma group
– Neurointensivist as “neuro“
neuro-hospitalist,”
esp in priv. . practice
– Neurointensivist-led education efforts for non-neurointensivists
neurointensivists?

Acknowledgements
The
Neurocritical
Care Society