Objective Post-procedure monitoring in a neurointensive care unit (NICU) after neurointerventional procedures is conventional at most centers. However, NICU resources are scarce and costly. The purpose of this study was to determine whether an intermediate care step-down unit could be a safe and cost-effective alternative to the NICU for patients after uncomplicated neurointerventional procedures.
Methods A retrospective review was undertaken of 127 consecutive patients over a 3-year period undergoing elective neurointerventional procedures including treatment of intracranial aneurysms, tumors, arteriovenous malformations and dural arteriovenous fistulas. Seventy-one patients were admitted to a step-down unit and 56 patients were admitted to the NICU. Endpoints were post-procedural complications, hospital costs and length of stay. Patients admitted to the step-down unit were compared with patients admitted to the NICU.
Results Patients admitted to the step-down unit did not have more complications than patients admitted to the NICU. Two patients admitted to the step-down unit had neurological complications after the procedure which were immediately recognized by nursing staff and adequately managed. The mean (SD) total cost per patient was $19 299 ($6955) for patients admitted to the step-down unit and $22 716 ($8052) for patients admitted to the NICU, resulting in a statistically significant cost saving for patients admitted to the step-down unit of $3417 (p=0.012). The mean (SD) total cost less procedural costs per patient was $8442 ($4062) for patients in the step-down unit and $10 631 ($4727) for those admitted to the NICU, which was also statistically significant (p=0.005). Length of stay averaged 21.7 h for patients admitted to the step-down unit and 24.9 h for those admitted to the NICU (p=0.016).
Conclusions A step-down unit is a safe and cost-effective alternative to the NICU for patients undergoing elective neurointerventional procedures.
- arteriovenous malformation
Statistics from Altmetric.com
- arteriovenous malformation
At many centers all patients are placed in a neurointensive care unit (NICU) after elective neurointerventional procedures, even if the procedure is uneventful and the patient wakes without neurological or medical problems. The rationale for this practice is the belief that complications after procedures may be recognized more quickly and accurately and managed better because of the lower nurse-to-patient ratio and the availability of more elaborate monitoring techniques in a NICU. However, high-level intensive care unit resources are scarce and costly, and this practice has not been systematically evaluated.
The present investigation is a retrospective cohort study of patients from a single center which aimed to evaluate the safety of directly transferring patients undergoing an elective neurointerventional procedure (including aneurysm coil embolization, stent placement for atherosclerosis as well as arteriovenous malformation and tumor embolization) to a step-down unit. A cost analysis of this practice is provided.
A retrospective analysis of 138 consecutive patients who underwent elective endovascular procedures for the treatment of aneurysms, arteriovenous malformation, tumors and dural arteriovenous fistulas at the University of Alabama at Birmingham (UAB) Hospital from October 2006 to May 2010 was carried out. All patients who had uncomplicated procedures were eligible for inclusion in the analysis. Patients who had an intraoperative or immediate postoperative complication (ie, a thromboembolic complication, neurologic change or anesthesia-related complication) necessitating NICU admission were excluded. In addition, any patients who had an unrelated procedure during the hospitalization which would prolong the length of stay and increase costs were excluded from the analysis. Beginning in October 2008, patients were sent to the step-down unit or NICU based strictly on bed availability, with the first choice being the step-down unit. Seventy-one patients were admitted to the step-down unit and 56 patients were admitted to the NICU, allocated by access alone.
The step-down unit used at UAB Hospital is designated the Intermediate Cardio-Vascular Unit. This unit admits post-procedure cardiac, vascular and neurosurgical patients. The nurses are therefore familiar with the care of femoral, brachial and radial puncture sites. Neurological examinations and vital signs are assessed every 2 h and telemetry is available. Patients' families and other visitors have unlimited visiting privileges.
The variables analyzed were divided into eight major categories: age, gender, diagnosis, length of stay, postoperative floor, delayed neurological and non-neurological complications and total hospitalization cost. The demographic characteristics are summarized in table 1.
Total costs were calculated by adding direct and indirect costs, which total the actual cost to the hospital for the procedure and care of the patients. Reimbursement figures were not included in this analysis. Indirect costs include a portion of the total costs of running the hospital—that is, computer systems, administration, equipment hardware. Direct costs include those which can specifically be traced back to the patient—that is, costs of the radiation technologist time, disposable supply items, etc. The procedural costs were then subtracted from the total cost to give a more accurate picture of the cost difference related to where the patient was transferred during the post-procedure period. Procedural costs include all costs directly related to the procedure (such as the cost of the coils, stents or other procedure-related equipment). Statistical analysis was done using a two-tailed Student t test.
One hundred and thirty-eight consecutive patients formed the original cohort. Eleven patients were excluded, including eight patients who had thromboembolic events during the procedure and were therefore transferred directly to the NICU, one patient who had respiratory distress in the PACU requiring reintubation and two patients who had unrelated perioperative procedures during their hospitalization which altered the total costs of their hospitalizations. One patient had a ventriculoperitoneal shunt placed the following day secondary to a previous subarachnoid hemorrhage attributable to another aneurysm and the other patient underwent delayed repair of an unrelated pseudoaneurysm during the hospitalization. A total of 127 patients were analyzed for the endpoints of interest; 71 patients were admitted to the step-down unit and 56 patients were admitted to the NICU.
Two patients who were sent to the step-down unit had neurological complications within 24 h of their procedure. One patient became aphasic the evening of an elective internal carotid artery stent placement as stage one of a staged stent-assisted coiling procedure. The aphasia was first noticed by the patient's family and was brought to the attention of the nursing staff. The patient was taken as an emergency to the endovascular suite where a cerebral angiogram revealed no major vessel occlusion. She was started on abciximab and therefore transferred to the NICU where her symptoms completely resolved. The patient was discharged home on the third postoperative day with no neurological deficits and returned for stage two 1 month later, which was carried out with no complications. Another patient developed a headache with nausea and vomiting the evening following the procedure. A CT scan of the head revealed a small intraparenchymal hemorrhage (<1.5 cm). The patient was monitored for an extra day in the step-down unit and was discharged home after the nausea and headache had resolved. The patient had no neurological deficits at the time of discharge. Follow-up imaging 1 month later revealed resolution of the intraparenchymal hemorrhage.
There were three non-neurological complications in patients admitted to the step-down unit and four non-neurological complications in patients admitted to the NICU. The non-neurological complications occurring in patients admitted to the step-down unit were one case of asymptomatic hyponatremia, one with a femoral hematoma and one with a postoperative urinary tract infection. Among the patients admitted to the NICU, one patient developed delayed respiratory distress which did not require intubation, one patient had asymptomatic hyponatremia and two patients had urinary tract infections. None of these conditions would have excluded admission to the step-down unit (table 2).
The average length of stay for all patients admitted to the step-down unit immediately postoperatively was 21.7 h compared with 24.9 h for the NICU; this difference was statistically significant (p=0.016).
There were significant total cost savings of $3417 (p=0.012) for patients admitted to the step-down unit compared with those admitted to the NICU. The mean (SD) total cost for patients admitted to the step-down unit was $19 299 ($6955) compared with $22 716 ($8062) for those admitted to the NICU. The mean (SD) total cost less procedural costs per patient was $8442 ($4062) for those admitted to the step-down unit and $10 631 ($4727) for patients admitted to the NICU; this difference was also statistically significant (p=0.005).
The cost-effectiveness of numerous medical practices has been analyzed by medical economists for many years. With increasing limits on medical resources, it is important to identify the practice which produces the best evidence-based result and also to choose from among the effective interventions those that are the least expensive.
Although it is conventional to admit patients to an ICU after most surgical and endovascular intracranial procedures, this practice has little support in the medical literature. It may stem from a traditional belief that all intracranial procedures should be monitored post-procedure in a high-level ICU setting. However, several studies have demonstrated the safety of postoperative care in a neurosurgical ward following intracranial surgery, provided the patient has had an uneventful recovery in the post-anesthesia care unit.1–3 In addition, admission to a step-down unit admission is commonly used after carotid endarterectomy, which has resulted in a significant decrease in length of stay as well as hospital cost without increasing the risk to patients.2 ,3
In endovascular procedures, Gaughen and colleagues showed that patients can be safely and effectively monitored in a step-down unit following uncomplicated elective coiling of an intracranial aneurysm.4 In this study all patients necessitating ICU admission were identified in the immediate post-procedural recovery period. These authors limited their study to patients with aneurysm and did not address issues of cost.
Numerous studies have looked at the cost-effectiveness of coiling versus clipping of unruptured aneurysms. All have shown a shorter length of stay and significantly lower costs in patients undergoing coiling.5–7 However, no studies have looked at a cost analysis comparing patients admitted to the NICU with those admitted to a step-down unit following all elective neurointerventional procedures including intracranial aneurysms, tumors, arteriovenous malformations and dural arteriovenous fistulas.
The ‘room’ charges at UAB Hospital are generated on a per day basis, with the patient being charged based on their location at 23:59 h. Therefore, the difference in length of stay which we observed had no effect on the actual cost in this cohort. However, earlier discharge could increase bed availability for more patients, again having a net positive financial effect for the hospital.
The decreased length of stay in patients admitted to the step-down unit may be due to a number of factors. The nurses who care for patients in the step-down unit are probably more adept at the discharge process as more of their patients are routinely discharged. Nurses in the NICU are also more likely to have another critically ill patient who would require more attention, therefore delaying the discharge process. There is also more space for the patient to begin ambulating earlier. The private bathroom allows patients to have their Foley catheter removed early, therefore necessitating ambulation early. All of these factors could potentially affect the timeliness of a patient's discharge.
As discussed above, the routine use of an ICU following other major procedures including elective craniotomy has not been found to be more beneficial than the step-down unit in retrospective studies. Some institutions have sent routine awake craniotomy patients home the same day and found no attributable complications of the practice.8
This retrospective study indicates that patients undergoing elective neurointerventional procedures may not need postoperative intensive care monitoring. Admission to a step-down unit with properly trained nurses has been shown to be equally safe and more cost-effective, while reducing length of stay. The results must be tempered by the fact that this is a retrospective study with a number of potential biases. Only one surgeon at one institution was included in the study. The practice in some institutions and situations may necessitate admission to the NICU because of inadequately trained and prepared staff. However, this study provides supportive evidence that admission to a step-down unit following elective neurointerventional procedures is safe and cost-effective.
This study would not have been possible without the assistance of Darlene Green who assisted in data collection.
Competing interests None.
Ethics approval Ethics approval was provided by the University of Alabama, Birmingham IRB.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.