Neuroscience Intermediate-Level Care Units Staffed by Intensivists: Clinical Outcomes and Cost Analysis
CCCF ePoster library. Hendin A. Nov 2, 2016; 150993; 112
Dr. Ariel Hendin
Dr. Ariel Hendin
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Topic: Retrospective or Prospective Cohort Study

Neuroscience Intermediate-Level Care Units Staffed by Intensivists: Clinical Outcomes and Cost Analysis

Hendin, Ariel1; Rosenberg, Erin1; Neilipovitz, David1; Kubelik, Dalibor1; Thavorn, Kednapa2; D'Egidio, Gianni1; Stotts, Grant1; Kyeremanteng, Kwadwo1

1 Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
2 Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada


Acute neurological conditions including ischemic and hemorrhagic stroke are the third leading cause of mortality in Canada, and the incidence of these conditions is increasing as the population ages1. Guidelines recommend admission of patients with stroke to dedicated Stroke Units; neurointensive care units are recognized to improve outcomes including decreased mortality and length of hospital stay (LOS) for patients with critical neurological conditions2–7 . In particular, closed units staffed by neurohospitalists or neurointensivists who work closely with Neurology and Neurosurgery have been shown to improve outcomes8,9.

Intensive care unit admissions have increased 12% over the past 6 years, and novel ways to provide high-quality neurocritical care but reduce costs are required10. Small studies have demonstrated the safety of admitting patients with intracranial hemorrhage or after neurosurgical procedures to step-down units, but few studies have analyzed both cost and safety outcomes of intermediate-level units11,12

This health records review assessed clinical and cost-related outcomes in an intermediate-level Neurosciences Acute Care Unit (NACU) before and after the addition of a neurointensivist to the unit’s multidisciplinary team.
This was a retrospective study of prospectively collected data from a 16-bed NACU of a Canadian hospital. Starting in October 2011, a closed model of NACU care was adopted including full-time day coverage by a neurointensivist. Data were obtained for all patients admitted to the NACU between October 2010 and September 2013, or one year prior to and two years after the intervention. Outcomes assessed included demographic information, time to admission, and length of stay in the NACU and hospital. Safety outcomes included mortality and readmission rates. Descriptive and analytic statistics were calculated, and the Kruskal-Wallis one-way analysis of variance test was used to detect differences in the LOS between groups; for all other outcomes, a chi-square test was used. For both pre- and post-groups, individual and total patient costs were calculated from NACU and hospital LOS, based on per-day cost estimates (NACU = $1262/day, ward bed = $1128/day). Statistical significance for costs was measured using bootstrapping technique for 95% confidence intervals. A sensitivity analysis was performed to demonstrate cost savings by increasing or decreasing NACU LOS by one day.
A total 2931 patients were discharged from NACU over the study period (822 prior to the addition of a neurointensivist and 2109 post). Patient demographics were similar, as displayed in Table 1. The mean age of patients admitted was 59.5 years +/- 18; 53% of patients were male. The most common reasons for admission were CNS tumor (27.6%), ischemic stroke (27%), and subarachnoid hemorrhage (11%). Following the introduction of a neurointensivist, there was a significant reduction in LOS both in NACU and on the ward (Table 2). There were no significant differences in rates of readmission or mortality. The addition of a neurointensivist produced an average individual cost savings of $1262 in NACU and $3518 for each patient’s total hospital stay (Table 3).

A closed-unit model of intermediate-level neurointensive care staffed by neurointensivists is safe, decreases patient LOS, and produces cost savings in a system that will be increasingly strained to provide quality neurocritical care.


1.        Statistics Canada. Leading Causes of Death in Canada. 1–3 (2009).
2.        Suarez, J. I. et al. Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit. Care Med. 32, 2311–2317 (2004).
3.        Diringer, M. N. & Edwards, D. F. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit. Care Med. 29, 635–640 (2001).
4.        Burns, J. D. et al. The effect of a neurocritical care service without a dedicated neuro-ICU on quality of care in intracerebral hemorrhage. Neurocrit. Care 18, 305–312 (2013).
5.        Casaubon, L. K. et al. Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015. Int. J. Stroke 11, 239–252 (2016).
6.        Varelas, P. N. et al. The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit. Crit. Care Med. 32, 2191–2198 (2004).
7.        Elf, K., Nilsson, P. & Enblad, P. Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit. Care Med. 30, 2129–34 (2002).
8.        Knopf, L., Staff, I., Gomes, J. & McCullough, L. Impact of a neurointensivist on outcomes in critically Ill stroke patients. Neurocrit. Care 16, 63–71 (2012).
9.        Freeman, W. D. et al. Neurohospitalists reduce length of stay for patients with ischemic stroke. The Neurohospitalist 1, 67–70 (2011).
10.      Canadian Institute for Health Information. Care in Canadian ICUs. (2016).
11.      Richards, B., Fleming, B., Shannon, C., Walters, B. & Harrigan, M. Safety and Cost Effectiveness Of Step-Down Unit Admission Following Elective Neurointerventional Procedures. J Neurointervent Surg 4, 390–392 (2012).
12.      Hafeez, S. & Behrouz, R. The Safety and Feasibility of Admitting Patients With Intracerebral Hemorrhage to the Step-Down Unit. J. Intensive Care Med. 31, 1–3 (2015).

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