The introduction of neurointensivists into a hospital can lead to uncertainty on the part of other specialists, and in particular other neurologists and neurosurgeons, regarding “turf” and authority. To establish a successful program, several concepts should be kept in mind.
First, avoid placing complete responsibility for decision making on one individual (i.e. the intensivist or surgeon). The neurointensivist should work to build consensus and to facilitate team consensus decision making for all important decisions. No one person is in charge. The team is in charge.
Second, it is undesirable to have competing or duplicative “services” within different departments at the same medical center. For instance, two competing services (i.e. neurology and neurosurgery) that that can admit and provide care to an intracerebral hemorrhage patient in the same can lead to conflict and tension on a daily basis. Neurointensivists function best when they can work with everyone, and when everyone works together.
Finally, critical care is not a 9-to-5 job: intensive care must be provided 365 days a year, 7 days a week, 24 hours a day. It has been said that until you are part of a team delivering around the clock care, your are not truly an intensivist. This creates a special challenge for solo neurointensivists who are starting their own program at a hospital, without adequate coverage to create a constant standard of care. Often when starting out this is unavoidable, but the goal should eventually be to create at the very least a team of caregivers who can deliver a consistent level of care.
Apart from these principles, here is a to-do list of key things that can help make your neurocritical care program highly successful.
1. Identify a Neuro-ICU directors from neurology, neurosurgery, anesthesiology, or another discipline, who is interested in a commitment to working together, sharing responsibility, andy leading a multidisciplinary team. Specific administrative responsibilities should include final responsibility for patient transfers, bed flow, nursing and resident education, QA, and protocol development. Key point: the old-school model of a neurosurgeon who rules with an iron fist, and is physically absent most of the time, no longer cuts it.
2. Emphasize the multidisciplinary nature of the ICU, use a “global” descriptive term for the unit such as “neurological,” “neuroscience,” or “neurocritical” rather than "neurological" or “neurosurgical” alone. These terms can be used to divide rather than unify, and reinforce old concepts of what a neurologist or neurosurgeon does or doesn’t do.
3. A minimum of 2 neurointensivists are required at any medical center to start a neuro-ICU program, to avoid physician burn-out. If this is not possible covering medical or surgical intensivists should be identified, but it will hard to really get rolling without the critical mass that results from two like-minded individuals. Approximately 25% to 60% of a neurointensivist’s time should be devoted to patient care.
4. Specialized neurocritical care nurses are possibly the single most important aspect of care in the neuro-ICU. The hospital should identify a nurse manager for the ICU with expertise in neuro-ICU care nursing, and make this individual responsible for nursing education, care standards, patient flow, and protocol development, working in conjunction with the unit directors.
5. A common pathway (i.e. central phone number and coverage system) and mechanism for triaging and arranging interhospital transfers should be developed. A corollary of this that an efficient protocol for identifying and expediting transfers out of the ICU should be developed. This function absolutely cannot be delegated to team members who are not absolutely committed to bringing in every transfer possible, with extreme prejudice.
6. Bullet rounds should be held every morning with neurosurgery, and the ICU team. The doctors who are authorized to make the decisions must be involved. Wasting time later in the day to “get an okay” or “run things by” attending physicians is murder in terms of efficiency. The focus is on establishing an agreed-upon action plan for each patient when it comes to interventions of mutual interest (i.e. angiography, pulling an EVD, CT scans, ICP monitor, establishing threshold criteria for a hemicraniectomy), and on patient flow into and out of the ICU. Decision-making should be made by consensus.
7. Things can change quickly. A clearly delineated protocol should be established for communicating clinical events throughout the day. For instance, in a teaching hospital, the nurse should communicate changes to the primary ICU resident; and the resident calls the fellow (or neurointensivist attending), and is also responsible for directly calling the neurosurgery resident on-call for any “red flag” event. If the nurses constantly run directly to the ICU director with every problem, everyone else might as well go home.
8. The ultimate goal for every patient, with the exception of end-of-life cases, is to stabilize the patient and get them into a recovery environment as quickly as possible. If you direct every action to getting the patient out of the ICU and discharged as quickly as possible, it simply follows that you have to make them better or help them have their peace, and you will always be making the right decision. A multidisciplinary team should meet daily to create athe plan for post-ICU and post-hospital care. This should include doctors, nurses, social work, care coordinators, and most importantly the providers of post-ICU floor or step-down unit care.
9. A commitment should be made by the hospital to provide adequate technological resources and support staff for advanced neuromonitoring (i.e. continuous EEG monitoring, ICP and brain tissue oxygen monitors, hypothermia devices, multimodality data management systems, transcranial Doppler). This is what makes the neuro-ICU special.
10. Finally, it has long been said that “hospitals are essentially turning into big ICUs.” This may never actually be the case, but it is true that well-integrated care delivery teams on the hospital floor can promote patient stability after transfer from the ICU, lead to the more widespread adoption of best medical practices, and facilitate discharge planning for rehabilitation. Neurontensivists can improve outcomes for patients discharged from the ICU and supplement their practice by creating or covering a “neurohospitalist” service which covers floor and step-down patients, runs interdisciplinary rounds on the floor, provides hospital consultations, and covers the emergency room.
Okay, that’s it, says me. Am I missing anything important?
