Intracranial hemorrhage (ICH) represents a heterogeneous group of diseases including subdural hemorrhage, epidural hemorrhage, intraparenchymal hemorrhage, and subarachnoid hemorrhage (SAH). ICH can result from trauma or can occur spontaneously in the case of SAH or intraparenchymal hemorrhage. The primary neurologic injury is complete at the time of presentation to the emergency department (ED). Therefore, initial focus in management is on early recognition of signs and symptoms of deterioration. Up to 23% of patients with spontaneous ICH will demonstrate continued deterioration within the first hours after arrival to the hospital (1). This risk of deterioration has resulted in the American Heart Association and American Stroke Association generating Class I recommendations that initial monitoring of patients with spontaneous ICH should take place in an ICU or dedicated stroke unit (2). In contrast, there are no published guidelines to inform disposition in ICH secondary to trauma. Newer literature has questioned the need for ICU admission in mild traumatic brain injury, including those with ICH, as only 3.1% required an ICU-level intervention (3). Despite this, a number of studies have shown that practice patterns vary widely, and a majority of patients with minor traumatic ICH are admitted to an ICU (3,4).
ICU capacity is under increasing strain in many healthcare systems, likely attributable to increasing patient acuity, an intensivist shortage, and decreased ICU bed availability (5). This has resulted in the need for prolonged critical care delivery in the ED in many healthcare systems, and the total annual hours of critical care delivered in U.S. EDs has recently increased by 217% (6). However, in critically ill stroke (including ICH) patients admitted to a neurologic ICU, ED length of stay greater than or equal to 5 hours was independently associated with poor outcome at hospital discharge (7). Similarly, a trend of worse outcomes associated with increasing ED boarding time has been demonstrated across multiple other disease states, and only 67% of ED to ICU admissions in the United States have an ED length of stay of less than 6 hours (6–13).
The University of Michigan Health System created the Joyce and Don Massey Family Foundation Emergency Critical Care Center (EC3) in 2015 with the goal of delivering high quality critical care in the ED (14). This ED-based ICU or resuscitative care unit (RCU) (15) is a 7,800-square-foot unit immediately adjacent to the main ED consisting of five resuscitation/trauma bays and nine patient rooms. The unit is staffed 24 hours per day by emergency medicine (EM) physicians, some of whom are boarded in critical care, as well as EM residents, critical care fellows, physician assistants, ED nurses with additional ICU training, and a nurse to patient ratio of 1:2 or 1:1. All patients presenting to the ED are initially managed by the main ED team, and patients requiring ongoing critical care can be transitioned to the EC3 team regardless of the availability of inpatient ICU beds (Fig. 1).
The RCU-minor ICH (mICH) protocol was implemented in September, 2017 as a collaborative effort between the Department of Emergency Medicine, Department of Neurosurgery, and Division of Acute Care Surgery at Michigan Medicine (University of Michigan) with the objective of providing timely and appropriate critical care and decreasing inpatient ICU utilization. We present a descriptive analysis of our initial experience with this novel strategy.
MATERIALS AND METHODS
A retrospective analysis of a prospectively obtained database was performed for patients who presented to the Michigan Medicine Adult ED from September 2017 to April 2019. The study size was arrived at by defining these dates. Approval of the study was provided by the University of Michigan Institutional Review Board.
Patients enrolled in the RCU-mICH protocol were identified through the use of a specific order set in the electronic medical record. All records were manually reviewed to ensure eligibility in the protocol. Inclusion criteria included neurosurgical assessment determining a relatively low-risk ICH, isolated neurologic injury, and Glasgow Coma Scale (GCS) score greater than or equal to 13. A relatively low-risk ICH included minor traumatic ICH and minor spontaneous ICH presumed secondary to hypertension. Determination of low-risk ICH was made jointly by the neurosurgical and EM team. This evaluation incorporated the clinical impression of nonconcerning features on CT (low hemorrhage volume with absence of significant mass effect or midline shift), as well as nonconcerning neurologic examination (GCS, 13–15). Exclusion criteria included active anticoagulation use, active dual antiplatelet therapy, signs of coagulopathy on laboratory values, significant polytrauma, or seizure activity. Patients with spontaneous SAH were not included.
While in the RCU, patients were comanaged by the EC3 and neurosurgery services. Patients on protocol had hourly neurologic assessments, blood pressure control as needed to maintain systolic blood pressure less than 160 mm Hg, and repeat head CT approximately 8 hours after initial CT. The decision on prophylactic antiepileptic medications was at the discretion of the neurosurgery service. ED disposition (admission to ICU, admission to floor bed, discharge from ED) was a joint decision between the EC3 and neurosurgery teams within 1 hour of repeat CT completion.
Age, gender, specific diagnosis, GCS on presentation, traumatic mechanism of injury, active anticoagulant use, active antiplatelet use, and international normalized ratio (INR) on presentation were captured. Time from presentation to the first CT, time from first CT to arrival in EC3, time between first CT and second CT, time from second CT to leaving ED, disposition, and need for vasoactive infusions in the ED were also captured. ED length of stay and hospital length of stay were recorded. Finally, 30-day outcomes including readmission at our institution, mortality, and need for neurosurgical procedure were captured.
Statistical analysis was performed using GraphPad Prism v7 (GraphPad, San Diego, CA). Descriptive statistics were performed. A comparison of subgroups based on ED disposition was performed. One-way analysis of variance was performed for continuous data, and chi-square tests were performed for categorical data. A statistical significance level of p value of less than 0.05 was set for this analysis. A separate subgroup analysis of trauma patients was performed using similar methods.
A total of 101 patients were initially identified by use of the designated order set. Of these, five patients did not have evidence of ICH. Of the 96 patients with ICH, 55 met all inclusion and exclusion criteria and were included for analysis. Reasons for exclusion included coagulopathy (use of anticoagulants, dual antiplatelet therapy, or elevated coagulation variables on laboratory testing), seizure activity, and low GCS score.
Mean age was 67.1 ± 20.0 years with a median age of 72.6. Thirty-five patients (63.6%) were male. Twenty-seven patients (49%) were on a single antiplatelet medication. Mean GCS on presentation was 14.8 ± 0.5 with a median GCS of 15. Mean INR on presentation was 1.02 ± 0.1 with a median INR of 1.0. Thirty-six patients (65.5%) had a recent history of trauma. Twenty-three patients (42%) had predominantly subdural blood, 19 (35%) had intraparenchymal blood or contusions, eight (15%) had traumatic SAH, four (7%) had intratumoral hemorrhage, and one (2%) had predominantly intraventricular hemorrhage. These data are summarized in Table 1.
The timeline for patients in the ED is shown in Figure 2. Patients had an initial CT 86.6 ± 72.3 minutes (median 74.0 min) after arrival to the ED and 3.6 ± 2.0 hours (median 3.3 hr) elapsed between initial CT and transfer to the RCU. Time between the initial CT and repeat CT was 7.3 ± 3.3 hours (median 6.6 hr). Mean time in the RCU was 12.6 ± 6.1 hours (median 12.0 hr), with total ED/RCU time of 17.6 ± 6.6 hours (median 15.7 hr).
Nineteen patients (35%) were discharged from the ED, 22 (40%) were admitted to general care, and 14 (26%) were admitted to intensive care. The differences between these groups are summarized in Table 1. Discharged patients were more likely to have a traumatic mechanism (95%) as compared to those with general care dispositions (64%) and intensive care dispositions (29%) (p < 0.001). Inpatient length of stay was significantly longer in patients admitted to intensive care as compared to general care (10.8 vs 3.3 d; p = 0.003). In discharged patients, there was no mortality or neurosurgical interventions at 30 days, whereas three patients (16%) required readmission. Of general care patients, three patients (14%) died within 30 days, two patients (9%) required neurosurgical intervention, and four patients (18%) required readmission. Of patients admitted to intensive care, one patient (7%) died, five (36%) required neurosurgical intervention, and two (14%) required readmission.
In a subgroup analysis of 36 patients with a traumatic mechanism, 18 (50%) were able to be discharged from the ED. Fourteen (39%) were admitted to general care, and four (11%) were admitted to intensive care. In total, there were nine patients (25%) who required readmission, three patients (8.3%) who underwent neurosurgical intervention, and two patients (5.6%) who died within 30 days of presentation.
The management of patients with mICH can represent a treatment dilemma for physicians. Although mICH is generally regarded as a condition with a low-risk for decline, patients are typically admitted to an ICU for close observation. Many attempts have been made to stratify risk of ongoing bleeding or clinical deterioration in order to minimize “over-triage,” but none have been translated into widespread clinical practice (3). This dilemma has resulted in a wide variability in practice patterns and disposition from the ED for mICH. Prior to development of our RCU, typical practice at our institution consisted of all patients with mICH being admitted to the hospital, with most admitted to an ICU. This mirrors previous data by Nishijima et al (3), in which rates of discharge from the ED ranged from 0% to 7.3% across eight institutions. A study by the Transforming Research and Clinical Knowledge (TRACK)-traumatic brain injury group found the rate of discharge from the ED for mild traumatic brain injury with ICH was similarly low at only 11.1% (16).
The hesitation for ED discharge largely stems from inadequate data on the individual patient. Decisions on management must be based on initial CT and initial examination, and there is typically no sense of the “trend” of the patient. In this study, we evaluated the use of the RCU-mICH protocol at our institution to combat this issue. This protocol allows for expedited access to critical care nursing with neurologic checks performed every hour and tight blood pressure control. The protocol also provided a follow-up CT which was performed 8 hours after the initial scan. In total, the RCU-mICH protocol delayed the decision of ED disposition while providing ICU-level care and provided additional data on clinical and radiographic trends.
With use of the RCU-mICH protocol, 35% of patients were able to be discharged from the ED safely, representing a notable increase when compared with previous studies in which ED discharge rates ranged from 0% to 11.1% (3,16). Only three of the discharged patients required readmission within 30 days. A further 40% of patients were admitted to a general care floor, with only the remaining 26% of patients requiring an inpatient ICU admission, lower than previously published rates of inpatient ICU utilization of 50%–97% (3). In addition, only one patient admitted to the ICU (7%) had a total inpatient length of stay less than 2 days. When used as a criterion for “over-triage,” this represented an improvement compared with data from the National Trauma Data Bank (4). Avoidance of “short-stay” ICU admissions may allow more appropriate resource utilization of inpatient ICU beds for patients with more substantial critical care requirements.
The average time to RCU from initial triage was 5 hours, with average total ED length of stay of 17.6 hours. This allowed patients to receive ICU-level care during the important initial stages of ICH. Previous studies have shown management of systolic blood pressure during these “golden hours” of treatment is critical (17), and improved outcomes have been observed with time-to-ICU of less than 5–6 hours (7,8). It is feasible that this model of early critical care delivery to patients with mICH in an RCU may prevent detrimental outcomes previously observed for patients with prolonged ED boarding times (7).
Several important limitations of this study are recognized. This was an observational study conducted at a single quaternary referral center in the United States, and further research is needed to determine the external generalizability of results. The observational nature of this study can suggest association but cannot prove causation. Patients were excluded if anticoagulated, on dual antiplatelet therapy, significant polytrauma, seizure activity, additional critical care requirements (i.e., mechanical ventilator management), or clinician discretion, and thus applicability of results to additional patient populations is limited.
Initial management of ED patients with minor ICH in a RCU (ED-based ICU) appears feasible. Use of this strategy was associated with a substantial rate of discharge from the ED (35%) with no mortality or subsequent neurosurgical interventions within 30 days and a low rate of admission to an inpatient ICU (26%). Although prolonged ED length of stay has been associated with worse outcomes for patients with ICH, use of this strategy was associated with rapid initiation of ICU-level care, which may help alleviate the challenge of increasing ED boarding time of critically ill patients facing many institutions. Additional research is warranted to explore the value of this care delivery model in other systems.
We would like to acknowledge the support from the Department of Emergency Medicine, Department of Neurosurgery, and Division of Acute Care Surgery at Michigan Medicine (University of Michigan) in development and implementation of the RCU-mICH protocol.
1. Fan JS, Huang HH, Chen YC, et al. Emergency department neurologic deterioration in patients with spontaneous intracerebral hemorrhage: Incidence, predictors, and prognostic significance. Acad Emerg Med. 2012; 19:133–138
2. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al.; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2015; 46:2032–2060
3. Nishijima DK, Haukoos JS, Newgard CD, et al. Variability of ICU use in adult patients with minor traumatic intracranial hemorrhage. Ann Emerg Med. 2013; 61:509–517.e4
4. Bonow RH, Quistberg A, Rivara FP, et al. Intensive care unit admission patterns for mild traumatic brain injury in the USA. Neurocrit Care. 2019; 30:157–170
5. Halpern SD. ICU capacity strain and the quality and allocation of critical care. Curr Opin Crit Care. 2011; 17:648–657
6. Herring AA, Ginde AA, Fahimi J, et al. Increasing critical care admissions from U.S. Emergency departments, 2001-2009. Crit Care Med. 2013; 41:1197–1204
7. Rincon F, Mayer SA, Rivolta J, et al. Impact of delayed transfer of critically ill stroke patients from the emergency department to the neuro-ICU. Neurocrit Care. 2010; 13:75–81
8. Chalfin DB, Trzeciak S, Likourezos A, et al.; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007; 35:1477–1483
9. Singer AJ, Thode HC Jr, Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011; 18:1324–1329
10. Bhat R, Goyal M, Graf S, et al. Impact of post-intubation interventions on mortality in patients boarding in the emergency department. West J Emerg Med. 2014; 15:708–711
11. Carr BG, Kaye AJ, Wiebe DJ, et al. Emergency department length of stay: A major risk factor for pneumonia in intubated blunt trauma patients. J Trauma. 2007; 63:9–12
12. Hung SC, Kung CT, Hung CW, et al. Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department. Crit Care. 2014; 18:485
13. Cha WC, Cho JS, Shin SD, et al. The impact of prolonged boarding of successfully resuscitated out-of-hospital cardiac arrest patients on survival-to-discharge rates. Resuscitation. 2015; 90:25–29
14. Gunnerson KJ, Bassin BS, Havey RA, et al. Association of an emergency department–based intensive care unit with survival and inpatient intensive care unit admissions. JAMA Netw Open. 2019; 2:e197584
15. Leibner E, Spiegel R, Hsu CH, et al. “Anatomy of resuscitative care unit
: Expanding the borders of traditional intensive care units.” Emerg Med J. 2019; 36:364–368
16. Ratcliff JJ, Adeoye O, Lindsell CJ, et al.; TRACK-TBI investigators. ED disposition of the glasgow coma scale 13 to 15 traumatic brain injury patient: Analysis of the transforming research and clinical knowledge in TBI study. Am J Emerg Med. 2014; 32:844–850
17. Powers AY, Pinto MB, Aldridge AM, et al. Factors associated with the progression of conservatively managed acute traumatic subdural hemorrhage. J Crit Care. 2018; 48:243–250