NeuroCritical Care Unit: Optimizing Outcomes for Neurologically Injured Patients

Recently, a patient with no history of head trauma lapsed into a coma and was admitted immediately to her local community hospital. The team of physicians assigned to the case conducted a thorough workup for vascular, infectious and toxic disorders, but the underlying cause of the patient’s coma remained elusive. The patient was then transferred to the University of Maryland Medical Center’s NeuroCritical Care Unit (NCCU), where specialists reviewed the case in detail with the team of physicians from the community hospital. In light of the clinical findings to date and a reexamination of the patient’s history, UMMC’s neurointensivists decided to explore an endocrine source of coma and discovered the patient had a nonfunctioning thyroid. In receiving supplemental thyroid medication, the patient gradually regained full consciousness within days.

More of this kind of collaboration between UMMC and the communities it serves is a goal of Neeraj Badjatia, M.D., M.S., chief of neurocritical care at UMMC and an associate professor of neurology at the UM School of Medicine. “We want community-based physicians to feel they can always call us if they hit a wall.” The program he envisions will become ever more responsive to community needs and is already taking shape in several ways.

Intensive care for nontraumatic neurologic injury

The focus of the NCCU is intensive care for individuals with nontraumatic neurologic injury, including cerebrovascular diseases, CNS tumors and disorders of the spine, and for patients recovering from neurosurgical procedures. In addition to coma of unknown cause, conditions typically treated are subarachnoid hemorrhage, subdural hematoma and intracerebral hemorrhages, status epilepticus, myasthenia gravis and other complex neuromuscular disorders. Patients with traumatic neurologic injuries continue to receive care at the R Adams Cowley Shock Trauma Center.

Bringing intensivist expertise to neurocritical care. Dr. Badjatia, a neurologist by training, completed a two-year neurocritical care fellowship program in 2003 and earned the neurointensivist certification granted by the United Council of Neurologic Subspecialties (UCNS). UCNS-certified neurointensivists, who now number less than 500 in the United States, train to provide comprehensive tertiary neurologic and primary care to patients whose conditions can affect several organ systems. Most candidates are neurologists, but many are surgeons, neurosurgeons, anesthesiologists or internists. Dr. Badjatia undertook his fellowship at Massachusetts General Hospital and remained on staff for two additional years before moving to Columbia University, where he headed one of the largest neurocritical care training programs in the United States, under the auspices of Columbia and Cornell Universities.

Since arriving at UMMC in July 2012,Dr. Badjatia has overseen the expansion of the NCCU from 12 beds to 22, making it one of the largest such units in the country. The unit is staffed by eight attending critical-care trained physicians, two of whom are on duty at any given time. Rounding out the staff are fellows in critical care, house staff from neurology and neurosurgery, critical-care nurse practitioners and nurses, with a ratio of one nurse for every two patients. A team of six stroke neurologists is also available for NCCU support.

UMMC also has an accredited fellowship program for neurocritical care, and will enroll its first fellow in July 2013. With the combined programs of the NCCU and the R Adams Cowley Shock Trauma Center, UMMC expects to have 40 critical care fellows in training by 2014.

Advances in neurocritical care

Vital management tools. In addition to the clinical areas mentioned above, another interest of Dr. Badjatia’s is therapeutic hypothermia, or targeted temperature management. Up to 70% of individuals with brain injury can experience high fever that is unresponsive to conventional antipyretic treatments. The NCCU uses cooling devices to achieve rapid stabilization of temperature, which is known to improve patient survival rates and neurologic outcomes. In instances of cardiac arrest, too, the American Heart Association now recommends therapeutic hypothermia during resuscitation to help prevent adverse neurologic sequelae. To meet the growing need for this intervention among its local and regional communities, the NCCU is acquiring additional cooling devices. Other exceptional evaluative and treatment modalities available in the NCCU include continuous electroencephalographic monitoring for seizure activity, augmented with around-the-clock video surveillance; and continuous renal replacement therapy.

Using institutional knowledge to improve NCCU care. While at Columbia, Dr. Badjatia managed an outcomes database — one of the largest of its kind — for subarachnoid hemorrhage. He has been joined at UMMC by a colleague from Columbia, Gunjan Parikh, M.D., who also contributed to the database project. Working with the UMMC neurology and neurosurgery departments, the NCCU team is developing a database to document and assess the progress of all patients with cerebrovascular disorders up to three months following their stay. Analysis of acquired data will help to improve the quality of care and lead to consistently optimal patient outcomes.

NEERAJ BADJATIA, M.D., M.S., has overseen the expansion of the NCCU from 12 beds to 22, making it one of the largest such units in the country. To schedule an appointment, please call 1-866-408-6885.