Admitting Low-Risk Patients With Intracerebral Hemorrhage to a Neurological Step-Down Unit Is Safe,Results in Shorter Length of Stay,and Reduces Intensive Care Utilization: A Retrospective Controlled Cohort Study

Abstract

Background and Purpose:

Patients suffering intracerebral hemorrhage (ICH) are at risk for early neurologic deterioration and are often admitted to intensive care units (ICU) for observation. There is limited data on the safety of admitting low-risk patients with ICH to a non-ICU setting. We hypothesized that admitting such patients to a neurologic step-down unit (SDU) is safe and less resource-intensive.

Methods:

We performed a retrospective analysis of patients with primary ICH admitted to our SDU. We compared this cohort to a control group of ICH patients admitted to a neurologic-ICU (NICU) at a partner institution. We analyzed patients with supratentorial ICH ≤15 cc, Glasgow Coma Scale ≥ 13, National Institutes of Health Stroke Scale ≤ 10, and no to minimal intraventricular hemorrhage. Primary end points were (re-)admission to an NICU and rates of hematoma expansion (HE). We also compared total NICU days and hospital length of stay (LOS).

Results:

Eighty patients with ICH were admitted to the SDU. Only 2 required transfer to the NICU for complications related to ICH, including 1 for HE. Seventy-four SDU patients met inclusion criteria and were compared to 58 patients admitted to an NICU. There was no difference in rates of NICU (re-)admission (7 vs 2, P = .17) or rates of HE (3 vs 5, P = .28). Median NICU days were 0 versus 1 (P < .001). Step-down unit admission was associated with shorter LOS (3 vs 4 days, P = .05).

Conclusions:

Select patients with ICH can be safely admitted to an SDU. This may reduce LOS and ICU utilization. We also propose criteria for admitting patients with ICH to an SDU.

Keywords

intracerebral hemorrhage step-down unit transitional care unit neurologic intensive care unit intensive care unit utilization

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References

van Asch

Luitse

Rinkel

van der Tweel

Algra

Klijn

. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol. 2010;9(2):167–176.

Sahni

Weinberger

. Management of intracerebral hemorrhage. Vasc Health Risk Manag. 2007;3(5):701–709.

Hill

Muir

. INTERACT-2: Should blood pressure be aggressively lowered acutely after intracerebral hemorrhage? Stroke. 2013;44(10):2951–2952.

Wartenberg

Wang

Muñoz-Venturelli

. et al. Intensive care unit admission for patients in the INTERACT2 ICH blood pressure treatment trial: characteristics, predictors, and outcomes. Neurocrit Care. 2017;26(3):371–378.

Diringer

Edwards

. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med. 2001;29(3):635–640.

Hemphill

Greenberg

Anderson

. et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–2060.

Quimby

Shamy

MCF

Rothwell

Liu

Dowlatshahi

Stotts

. A novel neuroscience intermediate-level care unit model: retrospective analysis of impact on patient flow and safety. Neurohospitalist. 2017;7(2):83–90.

Kyeremanteng

Hendin

Bhardwaj

. et al. Neuroscience intermediate-level care units staffed by intensivists: clinical outcomes and cost analysis. J Intensive Care Med. 2019;34(2):109–114.

Alexandrov

Coleman

Palazzo

Shahripour

Alexandrov

. Direct stroke unit admission of intravenous tissue plasminogen activator: safety, clinical outcome, and hospital cost savings. Ther Adv Neurol Disord. 2016;9(4):304–309.

10.

Gershengorn

Chan

. et al. The impact of opening a medical step-down unit on medically critically ill patient outcomes and throughput: a difference-in-differences analysis [published online January 1, 2018]. J Intensive Care Med. 2018;35(5):425–437.

11.

Yang

Shen

. et al. Benign intracerebral hemorrhage: a population at low risk for hematoma growth and poor outcome. J Am Heart Assoc. 2019;8(8):e011892.

12.

Hafeez

Behrouz

. The safety and feasibility of admitting patients with intracerebral hemorrhage to the step-down unit. J Intensive Care Med. 2016;31(6):409–411.

13.

Klaas

Braksick

Mandrekar

. et al. Factors associated with the need for intensive care unit admission following supratentorial intracerebral hemorrhage: the triage ICH model. Neurocrit Care. 2017;27(1):75–81.

14.

Alkhachroum

Bentho

Chari

Kulhari

Xiong

. Neuroscience step-down unit admission criteria for patients with intracerebral hemorrhage. Clin Neurol Neurosurg. 2017;162:12–15.

15.

Fehnel

Glerum

Wendell

. et al. Safety and costs of stroke unit admission for select acute intracerebral hemorrhage patients. Neurohospitalist. 2018;8(1):12–17.

16.

Cereda

George

Pelloni

. et al. Beneficial effects of a semi-intensive stroke unit are beyond the monitor. Cerebrovasc Dis. 2015;39(2):102–109.

17.

Hemphill

Bonovich

Besmertis

Manley

Johnston

. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–896.

18.

Graeb

Robertson

Lapointe

Nugent

Harrison

. Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis. Radiology. 1982;143(1):91–96.

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