delivering neuro-critical care in a public hospital: a general intensivist experience
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Generations + Northern Manhattan Health Network Lincoln Medical and Mental Health Center. Delivering Neuro-Critical Care in a Public Hospital: A General Intensivist Experience. Raghu S. Loganathan, MD, FCCP Director, Medical ICU & Stroke Center. Today’s Talk. - PowerPoint PPT PresentationTRANSCRIPT
Delivering Neuro-Critical Care in a Public Hospital:
A General Intensivist Experience
Raghu S. Loganathan, MD, FCCPDirector, Medical ICU & Stroke Center
Generations + Northern Manhattan Health NetworkGenerations + Northern Manhattan Health NetworkLincoln Medical and Mental Health CenterLincoln Medical and Mental Health Center
Today’s Talk You are NOT going hear ground breaking
stuff
Background of neurocritical care
Describe an incremental implementation of NC at a public hospital University affiliated teaching hospital Level-1 Trauma center ~37 critical care beds (MICU and & SICU) 24/ 7 intensivist coverage ~ 1500 discharges per month
BackgroundEvidence For Neurointensivist Care
Intracerebral hemorrhage (higher mortality in general medical-surgical ICU compared to a neuroscience unit (OR 3.4, 95% CI 1.65–7.6)
Economic benefitDiringer etc al. Crit Care Med 2001; 29:635–640
Mirski MA, Chang CW. J Neurosurg Anesthesiol 2001; 13:83–92
Traumatic brain injuryPatel HC Intensive Care Med 2002; 28:547–553
Varelas PN J Neurosurg 2006; 104:713–719
Positive impact with Ischemic strokesBershad EM Neurocrit Care
Varelas PN. Neurocritical Care
Subarachnoid hemorrhage (decreased LOS and mortality)Jose Suarez. Crit Care Med 2004; 32:2311–2317
BackgroundCurrent Neurocritical Care Work Force
Evolution of Neuro critical fellowships Accredited by UCNS First Board exam in 2007 195 diplomates graduated so far
Neurocritical Care Society 127 members
~ 50 dedicated Neurointensive units in US
Trend towards regionalization of care
Critical care work force shortageIs evolution of Neurointensive Care Making It
Worse?
Huge gap between supply and demand
Growing shortage of general intensivists
Drawing CC physicians into a specialized areas
Fragmentation of critical care training: Surgical critical care Neurointensive care Cardiothoracic care
Reality: > 80% of critically ill patients are cared for in multidisciplinary units by
general intensivists
Neurointensivists: Part of the problem or part of the solution? Chang & Krell. Crit Care Med 2008 Vol. 36, No. 10
Krell K: Critical care workforce. Crit Care Med 2008; 36:1350–1353
Delivering Neurointensive CareAlternate Solutions
Retraining various specialties:
Neurologists Neuro-surgeons Anesthesiologists ED Physicians General intensivists
Neuro-hospitalists
Teleneurology
Delivering Neurointensive CareGeneral Intensivists : Natural Choice
Strengths
Invasive and non-invasive hemodynamic monitoring
Managing mechanical ventilation
Managing infections
Management of hypertensive emergencies
Managing electrolyte imbalances
Areas to Learn
Reading of CT angios, MRIs
Learn standardized protocols to deliver thrombolytics therapy
Learn neuro-diagnostic monitoring Trans-cranial doppler Cerebral blood flow
studies Bed side EEGs
Typical Neurocritical Care Functions
Manage ischemic and hemorrhage strokes
Non-traumatic SAH
Traumatic Brain Injury Bleeds SAH
Hypothermia for Cardiac arrest patients
Evolution Of Neurocritical Care at Lincoln Directed by General Intensivists
NYSDOH mandate
Stroke centerestablished
EndovascularRx for ischemic
strokes
Hypothemia Center
established
November
2004
January 2005
January2009
August 2009 2010
SAH Mx
DEVELOPING A STROKE CENTER AT LINCOLN MEDICAL CENTER
Reluctance to institute thrombolytic therapy Shortage of vascular neurologists ED physicians reluctant to institute thrombolytic
therapy
~ 30 to 40% of admitted strokes will require ICU level of care
DEVELOPING A STROKE CENTER AT LINCOLN MEDICAL CENTER
Mandate to establish NYSDOH Primary Stroke Centers in 2005
Unique model of care Utilized intensive care physicians who were
present 24/ 7 at Lincoln Intensivist to lead stroke team
Protocols and policies developed Training with NIHSS Instituting thrombolytic therapy Obtaining stroke CMEs every year
Stroke Team ActivationFor patients presenting within 7 hours of symptom onset
ER ARRIVAL:Rapid triage, Stroke team activation
CT head , Labs
Not a candidate for lysis
Triage based on severity
Indication for Lysis or
clot removal
Start tPA and follow clinical pathway
Evaluation within 15 minutes by ICU MD(Stroke Team Leader)
MEASURES and OUTCOMES
2005 to 2009
Stroke Team Activations
0
50
100
150
200
250
300
350
2005 222 180 26
2006 261 209 54
2007 294 237 75
2008 320 249 87
2009 310 219 142
Total strokes IschemicStroke Team activations
Median Door to Stroke Team In Minutes
26
8
54
7
75
7
87
10
142
9
0
20
40
60
80
100
120
140
160
Stroke team activations 26 54 75 87 142
Door to stroke team (target15 minutes)
8 7 7 10 9
2005 2006 2007 2008 2009
Door to CT performed, CT read and Lab turnaround times (minutes) for patients presenting within
therapeutic window (3 - 4.5 hours)
Performance of NIH Stroke Scale(Target 100%)
92.3 100 100 100 100
0
10
20
30
40
50
60
70
80
90
100
LINCOLN 92.3 100 100 100 100
NY Hospitals 46.2 40.9 37.6 43.1 64.5
US Hospitals 36.7 40.6 40.6 47.5 52.4
2005 2006 2007 2008 2009
Thrombolytic Therapy Administered100% of all eligible patients received t-PA
0
2
4
6
8
10
12
14
2005 4
2006 8
2007 11
2008 10
2009 14
tPA administered
Median Door to Needle time (Target < 60 minutes)
0
10
20
30
40
50
60
70
80
90
100
LINCOLN 70 62.5 52.5 53.5 62.5
All NY Hospitals 80 82.5 80 75 74
All US Hospitals 81.5 82 82.5 79 82
2005 2006 2007 2008 2009
2005
2006 2007 2008 2009 Total observed
Data from
studies
t-PA given 4 8 11 10 14 33
Protocol Violations
2 # 0 0 1# 1# 10% 35 to 50%
Complications 0 0 1 0 1 2.1% 6%
Mortality 1 0 2 1 2 11.8% 17 to 32%
Analysis of thrombolytic therapy among
patients presenting within 4.5 hours
(# minor)
Impact of the Stroke Initiative
Implemented an effective stroke system of care without need for additional resources
100% of all eligible patients received thrombolytic therapy compared to ~ 25 to 35% nationwide when
presenting within window
Evolution Of Neurocritical Care at Lincoln Directed by General intensivists
NYSDOH mandate
Stroke centerestablished
EndovascularRx for ischemic
strokes
Hypothemia Center
established
November
2004
January 2005
January2009
August 2009 2010
SAH Mx
FDNY initiative
Traditionally cardiologists who performs
Started in Jan 2009
Cooled > 25 patients thus far Outpatients and Inpatients
Hypothermia Center
EXPANSION OF THE STROKE PROGRAM Endovascular therapy for ischemic strokes:
Expansion of time window for definitive therapy up to 8 hours
Mechanical clot removal
Large-vessel acute strokes: Derive less benefit from IV t-PA (compared
to lacunar or distal embolic strokes) Have less than a 30% recanalization NIHSS > 10 and MCA, PCA infarcts
associated with poor outcomes
2 Neuro-Interventionalists
Neuro-interventional Therapies
Pharmacologic Thrombolysis (t-PA, Urokinase) Intra-arterial IV and Intra-arterial (Bridging)
Mechanical Thrombolysis Clot angioplasty Clot retrieval
MERCI corkscrew device (FDA approved) Penumbra Aspiration device (FDA approved)
Combination Therapy
LINCOLNEXPANDED
ISCHEMIC STROKE PROTOCOL
CATEGORY 1
> 7 HOURS AND WITHIN 12 HOURS OF
SYMPTOM ONSET
CATEGORY 2
Within 7 hour window from symptom onset
ANDIf NIHSS < 8/ No Aphasia
CATEGORY 3Within 7 hours from symptom onset ANDIf NIHSS > 8 or Aphasia
NIHSS < 15 MINUTESSTAT Non contrast CTStroke labs
Non contrast CT/Stroke labsPage Stroke Team # 28890
Systemic thrombolytic therapy up to 4.5 hours
< 15 MinutesCall (718) 251 7777Page Stroke Team # 28890
ENDOVASCULAR THERAPY
Evolution Of Neurocritical Care at Lincoln Directed by General intensivists
NYSDOH mandate
Stroke centerestablished
EndovascularRx for ischemic
strokes
Hypothemia Center
established
November
2004
January 2005
January2009
August 2009 2010
SAH Mx
Majority are coiled
Neuro-interventionalists with neurosurgeons
TCD training: Intensivists and Neurologist Visiting fellowship at UCLA
Managing Non-Traumatic SAH
“Implementation of a Primary Stroke Center directed by Intensivists at a University- Affiliated Inner City Hospital”
Oral presentation at the Annual Meeting of the American College of Chest Physicians in 2007
“Medical Intensivist Directed Primary Stroke Center: A Unique Model To Improve Stroke Care”
Poster presentation at the National Patient Safety Foundation, Washington DC, 2009
Sharing Our Experience
FUTURE DIRECTIONS Extending Therapeutic Hypothermia to other
indications: MCA infarcts Intracranial HTN
EEG and cerebral blood flow studies
Regionalization/ Comprehensive Stroke Center Drip and Ship
NIH trials with Columbia-Presbyterian Endovascular cooling (K-99) grant
The future isn’t what it used to be! Yogi Berra