Difficulties in establishing Neurocritical Care Units

Dr.Omar AyoubConsultant & Assistant Professor of Neurology

Stroke, Neurocritical CareRTP Neurology at KAUH

Evolution of ICUs

• ICUs started as “specialized care units” or “respiratory care units.”

• In the 1950s, in Denmark, Bendixen and Pontoppidan “experts in poliomyelitis” created a respiratory care unit in Boston’s MGH

• Historically, neurosurgeon Dandy opened the 1st

neurosurgical ICU at Johns Hopkins in 1932.

• In London, the Batten Respiratory Unit at the Institute of Neurology and National Hospital for Nervous Diseases opened in 1954 • Treat acute neuromuscular disease• Stroke• Spinal cord disorders

The need for NICU

• Neurologists got interested in acute conditions

• Neurologists judge the severity of injury and prognosticate

• Fred Plum, Raymond Adams, and C. Miller Fisher, the first to describe causes of coma and other acute conditions (i.e., brain death, locked-in syndrome, anoxic- ischemic encephalopathy)

• In 1980s, neurologists were stationed in these units

• Neurologists became more knowledgeable in

• Acute neuromuscular respiratory failure

• Treatment of ICP

• Systemic complications specific for acute neurologic disease

• In 2004, a Society was founded and a journal was established

• Accreditation was sought through the American Academy of Neurology

• Care of the critically ill neurologic patient requires training in:

– Clinical physiology of ICP

– CBF and metabolism

– Brain and neuromuscular electrophysiology

– Postoperative care

– Systemic complications of nervous system diseases.

The evidence

• In retrospective studies, outcome can be improved with neurointensivist

• Prospective randomization of patients with life-threatening neurologic disease into medical or surgical ICU Vs NICU has ethical issues

Why do we need it?

• Studies looking at the effect of NICU showed:

– Improved outcomes

– Decreased hospital mortality rates

– Reduced hospital length of stay

– Reduced number of significant medical complications

• Mirski et al. reported on the effect of a NICU on patients with ICH in the same institution.

• Admission to NICU has reduced mortality and hospital length of stay.

• Diringer and Edwards prospectively collected patients in 3 yrs from 42 ICUs.

• Compared outcomes of ICH in general ICUs Vs. NICU.

• Not being admitted to NICU increased hospital mortality.

Training of residents

• The survey sent to all US neurology PD on February 23, 2011

• A response rate of 74.2% (98 of 132)

• The median beds was 16 (5–42)

• 75% have at least one UCNS board eligible/certified neurology-trained neurointensivist.

• Specialties involved in teaching and clinical care:– Neurology (68%)

– Anesthesiology (40%)

– Internal medicine (22%)

– Neurosurgery (15%)

– Emergency medicine (10%)

– Surgery (7%)

• Factors to increase participation in NICU rotation – Dedicated neuro-ICU (87% vs 13%, p < 0.001), – Neurology-trained intensivists (87% vs 13%, p <

0.001), – Presence of a neuro-ICU fellowship (56% vs 44%, p

< 0.001), – Higher number of neurology residents (mean 19

vs 13, p < 0.001) in the program.

• 2005 to 2010, 150% growth in programs that send at least one resident into a neurocritical fellowship.

• Almost half of graduating residents have little/no access to a dedicated neuro-ICU.

Recommendation

• Formal neurocritical care training.

• Put a working group of neurology educators and PDs, along with practicing neurointensivists. – Guidance for neurocritical care training

– Requirements for skills and concepts for procedures.

Difficulties in our system

• The system

• The hospital

• The unit

• The physicians

• The patients

• The budget

The System

• Fragmented sectorial services

• No ambulance system

• No clear referral between hospitals

• There is no coordination in resource organization between sectors/hospitals

• There is no clear national data yet

The hospital

• Administration don’t appreciate it

• No available space

• No available nurses to cover

• No enough consultants

• No residents/registrars

The unit

• The need for large space

• The need for physicians

• The need for special equipment

• The unique approach

• The lack of knowledge of its existence

The physicians

• Handful number of NICU doctors across Saudi

• Other physicians

• Needs special training

• No funds for them

• Training programs do not mandate it

Recent survey

• Neurocritical Care Education During Residency: Opinions (NEURON) Study– 95 individuals from 32 programs – Most train with NICU attendings, fellows and

advanced practitioners and have exposure during residency

– 54 % cite improvement in education in their training– Those that raised concern had no difference in time in

NICU (9.4 weeks vs 8.8 weeks), exposure to trained neurointensivists, fellows or advanced providers

The patients

• Patient flow

• Referral from other hospitals

• Late presentation

The funds

• No funds available to accommodate the need

• Ministry of health interest

The future

• The number of NICU physicians are increasing

• The number of units are slowly growing

• The interest from administrative point of view is not there

• Budget is an issue in some hospitals

Whats done so far

• Establishment of the Neurocritical Care Chapter in 2010

• Variable backgrounds (Neurology, Neurosurgery, Internal medicine and ICU background, anesthesia)

• Participated as part of the chapter in multiple conferences and courses over the years

Saudi Neurocritical Care

Chapter• 2010 Establishment under the Saudi Critical

Care Society “ SCCS “

• SCCS 2012 Dammam– 1st Saudi Neurocritical Care Meeting.

• SCCS 2013 Riyadh – 2nd Saudi Neurocritical Care Meeting.

• SCCS 2014 Riyadh– 3rd Saudi Neurocritical Care Meeting

• 2015, 2016, and there will be Neuro track in the upcoming 2017 meeting

THANK YOU