Neuroscience ICU: A Statewide. Critical Care Resource. Ansgar M Brambrink,
MD, PhD. Director, Neuroscience Intensive Care Unit. Oregon Health & Science ...
Neuroscience ICU: A Statewide Critical Care Resource Ansgar M Brambrink, MD, PhD Director, Neuroscience Intensive Care Unit Oregon Health & Science University Portland, OR AMB, June 2010
Neurocritical care in the US First dedicated units: • late 1960s: ‐ University of Colorado, Denver • early 1970s: ‐ Massachuchetts General Hospital, Boston • In the 1980s: ‐ Columbia University, New York ‐ Johns Hopkins University, Baltimore ‐ University of Virginia, Charlottesville Today: • Dedicated Neurocritical Care Units staffed by board certified; ‐ eligible neurointensivists in 93 institutions (as of May 2010) across the US
AMB, June 2010
AMB, June 2010
Neurocritical care in the US First dedicated units: • late 1960s: ‐ University of Colorado, Denver • early 1970s: ‐ Massachuchetts General Hospital, Boston • In the 1980s: ‐ Columbia University, New York ‐ Johns Hopkins University, Baltimore ‐ University of Virginia, Charlottesville Today: • Dedicated Neurocritical Care Units staffed by board certified; ‐ eligible neurointensivists in 93 institutions (May 2010) • Currently 30 UCNS‐accredited training programs (Neurocritical Care Fellowship) • NSICU at OHSU the only one in the State of Oregon AMB, June 2010
Our Neighbors
UW Seattle, Harborview: Neuro‐ICU, 15+ beds. Neurosurgery, neurology, and Neuro‐trauma patients. ICU managed by Anesthesiology with Neurosurgery and Neurology consulting teams.
UCSF & SF General Hospital: ‐ UCNS accredited Fellowship. ‐ Neuro ICU with 20 beds, Neurology patients only. ‐ Additional 13 bed step‐down unit. ‐ Intensivists with background in Pulmo CCM, Anesthesiology and Neurology; ‐ Neuro CC Team also sees also neurosurgery patients on campus AMB, June 2010
Neurocritical Care at OHSU • Until 2005: Neurosurgery patients: Neurosurgical ICU (part of 7A) Neurology patients: Medical ICU (now on 12K) • Jan 2006: Inauguration of dedicated Neurocritical Care Service; consults on neurosurgical patients (7‐12 pat.; 7A Unit) • Oct 2006: Dedicated space = Neuroscience Intensive Care Unit; 7NSICU); admission of neurosurgical and neurology patients; Team expansion (residents, fellows, PAs); 24/7 in‐house coverage AMB, June 2010
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Neuroscience ICU
WHY A SPECIALIZED ICU SERVICE?
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• The availability of dedicated intensivist teams improves patient outcomes and medical training, and reduces expenses • Neurointensivists require all skills expected of general intensivists + special skills as a clinical neuroscientist; + management of multi‐professional team, resources, infectious control, budget oversight and regulation, etc. )
• => Comprehensive, yet specialized critical care AMB, June 2010
Evidence Specially trained Neurointensivists indeed are important for patients suffering from nervous system disorders and who are critically ill: • Mirski M et al: Outcome + cost after ICH improved after introduction of NeuroICU (JNA 13:83‐92, 2001)
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AMB, June 2010
Evidence Specially trained Neurointensivists indeed are important for patients suffering from nervous system disorders and who are critically ill: • Mirski M et al: Outcome + cost after ICH improved after introduction of Neuro‐ICU (JNA 13:83‐92, 2001) • Diringer MN et al: Lower mortality after ICH in Neuro‐ICU (Crit Care Med 29:635‐40, 2001) AMB, June 2010
AMB, June 2010
Evidence Specially trained Neurointensivists indeed are important for patients suffering from nervous system disorders and who are critically ill: • Mirski M et al: Outcome + cost after ICH improved after introduction of Neuro‐ICU (JNA 13:83‐92, 2001) • Diringer MN et al: Lower mortality after ICH in Neuro‐ICU (Crit Care Med 29:635‐40, 2001) • Varelas PN et al: Outcome in all neuro‐ICU patients before/after neurointensivist (Crit Care Med 32:2191‐98, 2004) • Varelas PN et al: Outcome after TBI before/after neurointensivist (J Neurosurg 104:713‐19, 2006) • Varelas PN et al: Outcome of patients after stroke before/after neurointensivist (Neurocrit Care 9:293‐99, 2008) AMB, June 2010
Critical Assets: • Specialized Neurocritical Care Nurses • Dedicated anxillary services, eg. specialized physiotherapists, occupational therapists, speech therapists • Professional Society: “Neurocritical Care Society” Professional Meetings: “Neurocritical Care” Scientific Journal: “Neurocritical Care”
AMB, June 2010
AMB, June 2010
Critical Assets: • Specialized Neurocritical Care Nurses • Dedicated anxillary services, eg. specialized physiotherapists, occupational therapists, speech therapists • Professional Society: “Neurocritical Care Society” Professional Meetings: “Neurocritical Care” Scientific Journal: “Neurocritical Care” • Training Program for future leaders in the field: “Neurocritical Care Fellowship” (accredited, 2 yrs) AMB, June 2010
Currently 30 UCNS‐accredited Neurocritical Care Fellowship programs in the US AMB, June 2010
Neuroscience Intensive Care Unit (NSICU) at OHSU
WHO WE ARE AND WHAT WE DO … AMB, June 2010
17 Beds
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Dedicated Nursing Staff
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Decidated Physicians
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Dedicated Anxillary Services AMB, June 2010
Team Communication
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OHSU NSICU Physician Coverage Attending (24 hrs/7 days/w x1‐2 [week days]): • Anesthesiology‐, Neurology‐based Neurointensivists
Midlevel (day‐shift x2‐3; night‐shift x1): • PAs: specialized in critical care environment • MDs: – Residents: Neurology, Neurosurgery, Anesthesiology – Fellows: Neurocritical Care, Anesthesiology, PCCM
Medical Students: from OHSU & other institutions AMB, June 2010
OHSU Neurocritical Care Service, Patient Volume / month 700
(n=9546 patient days / last 19 months)
600
continuous overflow into other units
500
400
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100
0 1 2 3 4 13 14 15 10 11 12 1 52 63 47 58 69 10 7 11 8 912 10 11 12 116 217 318 419
2008
2009 (n=5807)
2010 AMB, June 2010
Neuroscience Crit Care Census (7NSICU, + overflow into 7A, 12K)
January 2010 (average = 21.9 patients/day @ midnight) 35
30
25
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15
10
5
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0
Fri Sat Sun Mon Tues Wed Thur Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
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OHSU NSICU patient population Neurosurgery (~75%) • SAH (aneurismal, AVM) • ICH (IPH + IVH) • Tumor surgery • Hydrocephalus (+ infect) • SDH • Spine surgery • INR procedures
Neurology (~25%) • Ischemic stroke, TIA • Neuromuscular disease • Seizures • Encephalitis • Meningitis
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WHAT CAN WE OFFER ?
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Multidisciplinary Approach • • • • • • • • • • • •
Neurocritical Care Nurse Respirator Therapist Neurointensivist Neurosurgeon Neurologist Interventional Neuroradiologist Pharmacist Physiotherapist Occupational therapist Speech therapist Social worker Case manager
Truly comprehensive care of patients suffering from nervous system disorders and who are critically ill
• Consultant(s)
(eg. Cardiology, Infectious Disease, Anesthesiologist, Radiologist, Nephrology, Endocrinology, Palliative Care, etc.) AMB, June 2010
Special Monitoring • • • • • •
Ventricular drainage (+ eg. IVC‐tPA) Intracranial pressure monitoring Continuous invasive hemodynamics (eg. PiCCO, PA‐C) Ventilator treatment ECHO cardiography, Ultrasound Continuous video EEG
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Special Monitoring / Intervention • • • • • • • • • • •
Ventricular drainage (+ eg. IVC‐tPA) Intracranial pressure monitoring Continuous invasive hemodynamics (eg. PiCCO, PA‐C) Ventilator treatment ECHO cardiography, Ultrasound Continuous video EEG Transcranial Doppler (vasospasm; => CT‐P, Angio) Neuromuscular testing Hyperosmolar treatment (eg. 3%‐, 23.4% saline) Immediate cerebrovascular imaging / intervention Immediate neurosurgical intervention
• AND: 24/7 presence of specialist teams AMB, June 2010
Immediate Access To State‐of‐the Art ‐ Diagnostic Neuroradiology eg.: CT head/neck CT‐Angio CT‐Perfusion MRI / MRA AMB, June 2010
‐ Interventional Neuroradiology eg.: Cerebral angio, Angioplasty, Stents Thrombus retrieval Aneurysm treatment
Merci® Retriever
Microsuction
Coils AMB, June 2010
OHSU Healthcare Mission
Through innovation, education and clinical expertise, we provide the best possible healthcare experience for patients and their families.
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WHERE CAN WE IMPROVE, WHERE FOCUS FOR DEVELOPMENT ? AMB, June 2010
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Telemedicine: OHSU Network OHSU
Sacred Heart
Mid‐Columbia
Case discussion prior to inter‐hospital transport ‐ Plan for optimization ‐ Best transport logistic
Management advice in selected ICU cases
Mercy
Rogue Valley
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Community Outreach
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Summary • OHSU’s Neurocritical Care Service is the only specialized ICU Service in the State of Oregon for patients suffering from nervous system disorders and who are critically ill • The Service offers unique diagnostic and interventional opportunities for further evaluation and treatment • OHSU’s NCC Service features dedicated individuals with outstanding expertise and the ultimate ambition for Excellence in ICU Care • Telemedicine and educational outreach hold great prommiss for future development of, and excellence in Neurocritical Care in the State of Oregon AMB, June 2010
THANK YOU.
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