Delivering Neuro-Critical Care in a Public Hospital: A General Intensivist Experience

1. 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

2. 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

3. 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 benefit Diringer etc al. Crit Care Med 2001; 29:635–640 Mirski MA, Chang CW. J Neurosurg Anesthesiol 2001; 13:83–92 • Traumatic brain injury Patel HC Intensive Care Med 2002; 28:547–553 Varelas PN J Neurosurg 2006; 104:713–719 • Positive impact with Ischemic strokes Bershad EM Neurocrit Care Varelas PN. Neurocritical Care • Subarachnoid hemorrhage (decreased LOS and mortality) Jose Suarez. Crit Care Med 2004; 32:2311–2317

4. 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

5. 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

6. Delivering Neurointensive CareAlternate Solutions • Retraining various specialties: • Neurologists • Neuro-surgeons • Anesthesiologists • ED Physicians • General intensivists • Neuro-hospitalists • Teleneurology

7. 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

8. Typical Neurocritical Care Functions • Manage ischemic and hemorrhage strokes • Non-traumatic SAH • Traumatic Brain Injury • Bleeds • SAH • Hypothermia for Cardiac arrest patients

9. Evolution Of Neurocritical Care at Lincoln Directed by General Intensivists November 2004 January 2005 January 2009 August 2009 2010 NYSDOH mandate Stroke center established Endovascular Rx for ischemic strokes SAH Mx Hypothemia Center established

10. 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

11. 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

12. Stroke Team ActivationFor patients presenting within 7 hours of symptom onset ER ARRIVAL: Rapid triage, Stroke team activation CT head , Labs Evaluation within 15 minutes by ICU MD (Stroke Team Leader) Not a candidate for lysis Indication for Lysis or clot removal Start tPA and follow clinical pathway Triage based on severity

13. MEASURES and OUTCOMES 2005 to 2009

14. Stroke Team Activations

15. Median Door to Stroke Team In Minutes

16. Door to CT performed, CT read and Lab turnaround times (minutes) for patients presenting within therapeutic window (3 - 4.5 hours)

17. Performance of NIH Stroke Scale(Target 100%)

18. Thrombolytic Therapy Administered100% of all eligible patients received t-PA

19. Median Door to Needle time (Target < 60 minutes)

20. Analysis of thrombolytic therapy among patients presenting within 4.5 hours (# minor)

21. 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

22. Evolution Of Neurocritical Care at Lincoln Directed by General intensivists November 2004 January 2005 January 2009 August 2009 2010 NYSDOH mandate Stroke center established Endovascular Rx for ischemic strokes SAH Mx Hypothemia Center established

23. Hypothermia Center • FDNY initiative • Traditionally cardiologists who performs • Started in Jan 2009 • Cooled > 25 patients thus far • Outpatients and Inpatients

24. 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

25. 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

27. Evolution Of Neurocritical Care at Lincoln Directed by General intensivists November 2004 January 2005 January 2009 August 2009 2010 NYSDOH mandate Stroke center established Endovascular Rx for ischemic strokes SAH Mx Hypothemia Center established

28. Managing Non-Traumatic SAH • Majority are coiled • Neuro-interventionalists with neurosurgeons • TCD training: • Intensivists and Neurologist • Visiting fellowship at UCLA

29. Sharing Our Experience • “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

30. 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

31. The future isn’t what it used to be! Yogi Berra