State-of-the-Art Neurointensive Care

by Nobl Barazangi, M.D., Ph.D.

Neurointensive care is a relatively new field that has developed as a subspecialty of critical care and neurology. The goal of neurointensive care, and the neurointensivist, is to treat and prevent primary and secondary brain (or other nervous system) injury. Inherent in this goal are the monitoring tools unique to the neurointensive care unit, including the most basic but perhaps the most important tool – the neurologic examination. The neurointensivist’s role is to help follow and treat the patient’s neurologic status while integrating his/her knowledge of other organ systems and expertise in critical care, to provide the most comprehensive care possible for the patient. Neurointensive care has many iterations and may be composed of health professionals with different expertise, including neurointensivists, stroke neurologists, neurosurgeons, pulmonary/critical care specialists, anesthesiologists, nurse practitioners, critical care registered nurses, and therapists all working together towards improved neurologic recovery. Regardless of how each institution chooses to develop their neurointensive care unit, data has shown that care provided by clinicians specializing in neurologic injury, and within dedicated neurointensive care units, improves patient functional outcome, and reduces hospital mortality, length of stay and resource utilization (1-4). In fact, in 2008 the Leapfrog Group, a consortium of corporations and public agencies dedicated to the improvement of health care services, deemed neurointensivists as a part of the critical care pool of physicians that are vital to providing safe and efficient health care to the critically ill patient.

At California Pacific Medical Center, we have recently opened a dedicated Neuroscience Intensive Care Unit (ICU) at the Davies Campus. California Pacific, which provides acute stroke care and critical care at both the Davies and Pacific campuses, is a Joint Commission Certified Primary Stroke Center, and a Get With The Guidelines Gold Award recipient (2008 and 2009). The Neuroscience ICU is an eight-bed unit with a twelve-bed stepdown unit that helps provide state-of-the-art neurointensive care for our neurocritically ill patients, including but not limited to, patients with ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and status epilepticus. In addition to the routine monitoring and high level of care available in all our ICUs, this unit provides the patient with 24/7 coverage by a neurointensivist – the Stroke/Neurocritical Care team is composed of Nobl Barazangi,M.D., Jack Rose, M.D. and David Tong, M.D. all of whom are triple-boarded in Neurology, Neurocritical Care, and Vascular Neurology, and Ann Bedenk, a Clinical Nurse Specialist with many years of experience in stroke. Furthermore, California Pacific has a UCNS (United Council of Neurologic Subspecialties) accredited Neurocritical Care Fellowship Program, and the first fellow has started training this year, enhancing the teaching and clinical expertise environment already present in the Neuroscience ICU. The ICU also has 24/7 coverage by a Pulmonary/Critical Care physician and a nurse practitioner trained in Stroke and Neurocritical Care. There is 24/7 Neurointerventional and Neurosurgical coverage, for any immediate or delayed emergencies requiring neurosurgical intervention. Jeffrey Thomas, M.D., is the Neurosurgical Director of the CPMC Comprehensive Stroke Care Center, and his expertise in neurointerventional and vascular neurosurgery techniques is essential to the care of our patients. The team functions seamlessly, with daily interdisciplinary rounds that includes the neurointensivist, critical care physician, internal medicine hospitalist, the palliative care service if needed, and therapists involved in patient care, to allow for easy transition to the floor unit or rehabilitation once the patient is ready to leave the ICU. In fact, the Davies campus houses one of the Bay Area’s most renowned rehabilitation facilities, allowing for rapid transition to the important process of rehabilitation for our patients.

In addition to the clinical expertise of the team, many new and state-of-the-art facilities and imaging techniques aide in the care of our patients, including a 64-slice CT scanner with CT perfusion technology used on a regularly for all stroke patients, 3-Tesla MRI also readily available for all patients, and a new Neurointerventional Surgery Suite which is a combined neurointerventional and microvascular operating environment and includes ultramodern digital imaging and 3D image guidance in real time. Continuous EEG monitoring, with 24/7 supervision by an attending epileptologist, is available to all our patients as well, and therapeutic hypothermia is used regularly for treatment of malignant cerebral edema and for post-cardiac arrest patients. The infrastructure of the California Pacific hospital system and the cooperation of the California Pacific transfer center, nursing, emergency department physicians, and in-hospital practitioners, allows for rapid and safe intra- and inter-campus transport of patients, and transfer of patients who require tertiary and specialized care from outside facilities. This process has been optimized to allow for any patient requiring acute stroke care immediate access to the Neurointerventional Suite and allowing for a guaranteed ICU bed for any patient requiring acute stroke/neurocritical care in Northern California and beyond. Finally, clinical research also plays an important role in helping us provide cutting-edge technologies and therapies to our patients; California Pacific participates in multi-center acute stroke and neurologic emergency trials, and there are also investigator-initiated studies for the treatment of severe vasospasm in subarachnoid hemorrhage patients, as well as in expanding the criteria for intravenous tissue plasminogen activator use.

Future goals of the Neuroscience ICU at Davies include adding advanced neuromonitoring, such as monitors for brain tissue oxygenation, cerebral blood flow, and cerebral microdialysis, to help guide management and individualize patient care. As the technology progresses, portable imaging devices may be added to expedite diagnostic testing. Finally, our Stroke Center is already at the forefront of telemedicine, and videoconferencing is already being used at our facility to allow for immediate and 24/7 physician coverage in the Neurosciences ICU and the Emergency Department, as well as the treatment of patients at outside facilities and the triaging of patients that may need to be transferred to our facility for further care.

In sum, neurointensive care at California Pacific has advanced to provide the most up-to-date facilities, leading-edge technology, and clinical expertise all dedicated to caring for the whole patient and ensuring the best neurologic recovery possible.

References:

1. Varelas PN, Schultz L, Conti M, Spanaki M, Genarrelli T, Hacein-Bey L. Neurocrit Care. 2008;9(3):293-9. The impact of a neuro-intensivist on patients with stroke admitted to a neurosciences intensive care unit.


2. Suarez JI. Crit Care Med. 2006 Sep;34(9 Suppl):S232-8. Outcome in neurocritical care: advances in monitoring and treatment and effect of a specialized neurocritical care team.


3. Rincon F, Mayer SA. Curr Opin Crit Care. 2007 Apr;13(2):115-21. Neurocritical care: a distinct discipline?


4. Varelas PN, Conti MM, Spanaki MV, Potts E, Bradford D, Sunstrom C, Fedder W, Hacein Bey L, Jaradeh S, Gennarelli TA. Crit Care Med. 2004 Nov;32(11):2191-8. The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit.