Is Neurointensive Care Really Optional for Comprehensive Stroke Care?
To the Editor:
Expertise matters. The recent recommendations for Comprehensive Stroke Centers (CSC) put forth by the Brain Attack Coalition (BAC) make this argument convincingly using consensus and medical evidence when available.1 This document represents a landmark in advancing the care of stroke patients and will likely have important policy implications for hospitals, administrators, and regulatory agencies in planning for identification, certification, and management of CSCs. Certainly, this has been the case for the certification of Primary Stroke Centers recently implemented by the Joint Commission on Accreditation of Healthcare Organizations.
Given the important implications of the CSC recommendations, it is unfortunate that the BAC has actually created recommendations that encourage less than comprehensive care for critically ill stroke patients, placing them at risk for less favorable outcomes. Specifically, the BAC has designated neuroscience intensive care units (NICU) and neurointensivists as optional components of a Comprehensive Stroke Center. Moreover, with no supporting evidence referenced, they have indicated that hiring a neurointensivist (and presumably developing an NICU) is likely associated with significant institutional cost. Some hospital administrators would likely see this as a BAC-sanctioned opportunity to reduce the availability of neurointensivists and NICUs (including specially trained neurocritical care nurses) because they will be perceived as costly and optional for certification. Thus, the BAC has created recommendations that may well have a real and potentially dangerous impact on stroke patients.
Why is this a bad idea? Several studies have shown that, in fact, neurointensivists and NICUs save lives and improve the outcome of stroke patients.2–5 Additionally, this usually comes with reduced length of stay and cost of care.3–5 Throughout the CSC recommendations, the BAC acknowledges the desirability of neurointensive care expertise and neuroscience critical care. Although left out of the CSC document, the medical literature supporting the favorable impact of neurocritical care (compared with general critical care) is more substantial than the literature supporting the favorable impact of a vascular neurologist (compared with a general neurologist). Yet even without strong supporting evidence, the presence of a vascular neurologist seems a reasonable requirement for a CSC. All the more so, given the available data, the presence of a neurointensivist and neuroscience critical care is also a reasonable requirement.
Ideally, every hospital that receives acute stroke patients will create the infrastructure to be certified as a Primary Stroke Center. Many fewer hospitals that are equipped to deal with the most complex cases will deserve CSC designation. We are sensitive to the concern that there may not currently be adequate numbers of neurointensivists to meet the CSC need. However, we feel that the bar should be set high for CSCs, and institutions pursuing this designation should not have the ability to sacrifice care for a mistaken expectation of cost savings. Recognizing that neurointensivists may include neurologists, neurosurgeons, anesthesiologists, internists, and pediatricians with special training in neurocritical care, there are more of us than you realize. The Neurocritical Care Society has over 500 members from 43 states and 24 countries and is growing rapidly.
We challenge the BAC to revise their recommendations to include neurointensive care expertise as mandatory for Comprehensive Stroke Centers. Failing to do so will likely undermine the goal of providing comprehensive care for the sickest and most complex stroke patients. Expertise matters. Our patients deserve it; so do yours.
Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, Koroshetz W, Marler JR, Booss J, Zorowitz RD, Croft JB, Magnis E, Mulligan D, Jagoda A, O’Connor R, Cawley CM, Connors JJ, Rose-Derenzy JA, Emr M, Warren M, Walker MD. Recommendations for Comprehensive Stroke Centers. A consensus statement from the Brain Attack Coalition. Stroke. 2005.