title: Declining mortality in neurocritical care patients: a cohort study in Southern Alberta over eleven years.
abstract: OBJECTIVE
  Few interventions have been proven to improve outcomes in neurocritical care patients. It is unknown whether outcomes in Canada have changed over time. We performed a cohort study in Southern Alberta to determine whether survival and discharge disposition have improved.
  
  
  METHODS
  Using prospectively collected data, we identified patients admitted to regional intensive care units (ICUs) over a more than 11-year period with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage, anoxic encephalopathy, central nervous system infection, or status epilepticus. Four sequential time periods of 2.8 years were compared, as were periods before and after various practice modifications were introduced. Logistic regression was used to adjust for patient age, Glasgow Coma Scale score, and case mix.
  
  
  RESULTS
  A total of 4,097 patients were assessed. The odds of death were lowest in the most recent time quartile (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.56 to 0.88, P < 0.01). The odds of being discharged home without the need for support services increased over time (OR 1.45, 95% CI 1.38 to 1.85, P = 0.003). Improvements were not the same for all diagnostic subgroups. They were statistically significant for patients with TBI and SAH. Neurocritical care consultative services, evidence-based protocols, and clustering of patients within a multidisciplinary ICU were associated with improved outcomes. Length of stay in an ICU increased among hospital survivors (4.6 vs 3.8 days, P < 0.01).
  
  
  CONCLUSIONS
  Mortality and discharge disposition of neurocritical care patients in Southern Alberta have improved over time. Practice modifications in the region were associated with positive outcome trends. Longer ICU length of stay may imply that intensivists are increasingly delaying decisions about withdrawing life-sustaining interventions.
authors.affiliation: Departments of Critical Care Medicine & Clinical Neurosciences, Foothills Medical Centre, Hotchkiss Brain Institute, University of Calgary, 3134 Hospital Dr NW, Calgary, AB, T2N 2T9, Canada, Andreas.Kramer@AlbertaHealthServices.ca.
authors.forename: Andreas H
authors.initials: AH
authors.lastname: Kramer
authors.forename: David A
authors.initials: DA
authors.lastname: Zygun
mesh_terms: D000328:Adult; D000368:Aged; D000416:Alberta; D002493:Central Nervous System Diseases / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy; D015331:Cohort Studies; D016638:Critical Illness; D019317:Evidence-Based Medicine; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay; D016015:Logistic Models; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome