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