title: Improvement in intensive care unit outcomes in patients with subarachnoid hemorrhage after initiation of neurointensivist co-management.
abstract: OBJECTIVE
  Neurointensivists are specialists trained to manage all aspects of the intensive care unit (ICU) stay of neurologically ill patients. No study to date has examined the role of neurointensivists specifically in subarachnoid hemorrhage (SAH) management. This study examined the use of a team-based neurointensivist co-management approach.
  
  
  METHODS
  The authors reviewed all cases involving patients with SAH admitted to the neurosurgical service during a period of more than 4 years. A comparison was made between those patients admitted before and those admitted after the initiation of a mandatory neurointensivist co-management strategy. The primary outcome examined was length of ICU stay. Secondary outcomes included in-hospital mortality, ventriculoperitoneal shunt placement, and other complications such as fever, antibiotic use, pressor utilization, and ventilator-associated pneumonia.
  
  
  RESULTS
  A total of 512 patients were included, 216 prior to and 296 after the initiation of neurointensivist comanagement. Length of ICU stay was significantly decreased after the initiation of neurointensivist co-management (mean 12.4 vs 10.9 days, p = 0.02), even after adjusting for demographic characteristics and admission Hunt and Hess grade. The percentage of patients requiring a ventriculoperitoneal shunt significantly decreased after initiation of the co-management approach (23.0 vs 11.5%, p = 0.001), but in-house mortality was unaffected.
  
  
  CONCLUSIONS
  Initiation of a strategy of routine involvement of a neurointensivist, charged with managing all aspects of the patients' care, resulted in a significantly reduced length of ICU stay for neurosurgical SAH patients. This team-based approach, using neurointensivists to manage neurosurgical SAH patients, merits further study as a successful model of care.
authors.affiliation: Department of Neurology, University of California, San Francisco, California 94143, USA. ajosephson@memory.ucsf.edu
authors.forename: S Andrew
authors.initials: SA
authors.lastname: Josephson
authors.forename: Vanja C
authors.initials: VC
authors.lastname: Douglas
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
authors.forename: Joey D
authors.initials: JD
authors.lastname: English
authors.forename: Wade S
authors.initials: WS
authors.lastname: Smith
authors.forename: Nerissa U
authors.initials: NU
authors.lastname: Ko
mesh_terms: D003422:Critical Care; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009462:Neurology; D009493:Neurosurgery / Q000379:methods; D010348:Patient Care Team; D012720:Severity of Illness Index; D013038:Specialization; D013345:Subarachnoid Hemorrhage / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D017287:Ventriculoperitoneal Shunt