Neurocrit Care (2011) 15:477–480
DOI 10.1007/s12028-011-9539-2
ORIGINAL ARTICLE
How Does Care Differ for Neurological Patients Admitted
to a Neurocritical Care Unit Versus a General ICU?
Pedro Kurtz • Vincent Fitts • Zeynep Sumer •
Hillary Jalon • Joseph Cooke • Vladimir Kvetan •
Stephan A. Mayer
Published online: 26 April 2011
Ó Springer Science+Business Media, LLC 2011
Abstract
Background Neurological patients have lower mortality
and better outcomes when cared for in specialized neuro-
intensive care units than in general ICUs. However, little is
known about how the process of care differs between these
types of units.
Methods The Greater New York Hospital Association
conducted a city-wide 24-h ICU prevalence survey on
March 15th, 2007. Data was collected on all patients
admitted to 143 ICUs in 69 different hospitals.
This study was conducted on behalf of the GNYHA Critical Care
Leadership Committee.
Electronic supplementary material The online version of this
article (doi:10.1007/s12028-011-9539-2) contains supplementary
material, which is available to authorized users.
P. Kurtz
S. A. Mayer
The Departments of Neurology and Neurosurgery,
Columbia University, New York, NY, USA
V. Fitts
Z. Sumer
H. Jalon
The Greater New York Hospital Association (GNYHA) and
United Hospital Fund (UHF), New York, NY, USA
J. Cooke
Department of Medicine, Weill Cornell Medical Center,
New York, NY, USA
V. Kvetan
Division of Critical Care Medicine, Montefiore Medical Center,
Bronx, NY, USA
S. A. Mayer (&)
Division of Neurocritical Care, Neurological Institute,
Milstein Hospital Building, Suite 8-300 Center,
177 Fort Washington Avenue, New York, NY 10032, USA
e-mail: sam14@columbia.edu
Results Of 1,906 ICU patients surveyed, 231 had a primary
neurological diagnosis. Of these, 52 (22%) were admitted to
one of 9 neuro-ICU’s in NY and 179 (78%) to a medical or
surgical ICU. Neurological patients in neuro-ICUs were
more likely to have been transferred from an outside hospital
(37% vs. 11%, P < 0.0001). Hemorrhagic stroke was more
frequent in neuro-ICUs (46% vs. 16%, P < 0.0001),
whereas traumatic brain injury (2% vs. 24%, P < 0.0001)
and ischemic stroke (0% vs. 19%, P = 0.001) were less
common. Despite a lower rate of mechanical ventilation
(39% vs. 50%, P = 0.15), ICU length of stay was longer in
neuro-ICU patients (C10 days, 40% vs. 17%, P < 0.0001).
More neuro-ICU patients had undergone tracheostomy (35%
vs. 15%, P = 0.04), invasive hemodynamic monitoring
(40% vs. 20%, P = 0.002), and invasive intracranial pres-
sure monitoring (29% vs. 9%, P < 0.001) than patients
cared for in general ICUs. Intravenous sedation was less
prevalent in neuro-ICUs (12% vs. 30%, P = 0.009) and
more patients were receiving nutritional support compared
to general ICUs (67% vs. 39%, P < 0.001).
Conclusions Neurological patients cared for in specialty
neuro-ICUs underwent more invasive intracranial and
hemodynamic monitoring, tracheostomy, and nutritional
support, and received less IV sedation than patients in
general ICUs. These differences in care may explain
previously observed disparities in outcome between neur-
ocritical care and general ICUs.
Keywords Neurocritical care
Outcomes research
Introduction
Recent research on outcomes of critically ill neurological
patients suggests that admission to a specialized
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neurointensive care unit (neuro-ICU) is associated with
improved outcome [1–6]. Two groups studying patients
with intracerebral hemorrhage (ICH) found improved
hospital mortality and unchanged or reduced hospital
length of stay when patients were cared for in a neuro-ICU
[1, 2]. In patients with traumatic brain injury (TBI), five
studies have found that implementation of a neurocritical
care team or guideline-driven therapy has a positive impact
on mortality or functional outcome [3–7]. A wealth of data
has shown that dedicated stroke units in general are asso-
ciated with significantly improved survival and functional
recovery at 1 year [8]. Two studies showed that the intro-
duction of a neurocritical care team, including a full time
neurointensivist, was associated with significantly reduced
in-hospital mortality and length-of-stay in a mixed neuro-
critical care population [9, 10].
It remains unclear why neurological patients experience
better outcomes when treated in a neuro-ICU [11]. In
March of 2007, we conducted a comprehensive one-day
prevalence survey of 1,906 ICU patients hospitalized at 69
participating hospitals in the New York City region. The
objective of this analysis was to compare specific aspects
of care delivered to neurological patients in general and
neuro-ICUs.
Methods
The Greater New York Hospital Association and United
Hospital Fund conducted a city-wide ICU prevalence sur-
vey on March 15th, 2007. The study was granted a waiver
from the requirement for written informed consent because
specific patient identifiers were not recorded. Data was
collected on all patients admitted to 143 ICUs in 69
different hospitals over 24 h. All hospitals with ICU
capacity were included, regardless of status as a primary,
secondary, or tertiary care center. Admission source,
demographic information, primary diagnosis, ICU length
of stay, and specific monitoring techniques and therapeutic
interventions employed on the day of the survey were
recorded (the original survey instrument is available for
electronic download). For the purposes of this analysis, all
patients with a primary neurological diagnosis were com-
pared, depending on whether they were admitted to one of
nine specialized neurological or neurosurgical ICUs that
participated in the survey, as opposed to a non-neurological
medical or surgical unit. Designation as a specialty neuro-
ICU did not require staffing by full-time neurointensivists.
Intermediate level stroke units (i.e., 4:1 patient to nurse
ratio, with no mechanical ventilation) were not included in
the survey. Neurological patients with a primary diagnosis
of a medical complication (i.e., pneumonia, pulmonary
embolism) leading to ICU admission were excluded.
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Neurocrit Care (2011) 15:477–480
Differences in proportions were compared using the
chi-square and Fisher’s exact test.
Results
Of 1,906 ICU patients surveyed, 231 had a primary neu-
rological diagnosis. Of these, 52 (22%) were admitted to a
neuro-ICU and 179 (78%) to a general ICU. Patients in
neuro-ICUs were more likely to have been transferred from
an outside hospital (Table 1). Hemorrhagic stroke (sub-
arachnoid and intracerebral hemorrhage) was far more
common in neuro-ICUs, whereas traumatic brain injury
(TBI) and ischemic stroke were significantly less common.
Despite a slightly lower rate of mechanical ventilation
(39% vs. 50%), a significantly larger proportion of neuro-
ICU patients had a hospital length of stay (LOS) C10 days.
Neuro-ICU patients had more often undergone tracheos-
tomy, invasive hemodynamic monitoring (arterial line,
central venous catheter, or pulmonary artery catheter), and
intracranial pressure (ICP) monitoring with either an
external ventricular drain or parenchymal bolt than patients
cared for in general ICUs. The use of EEG monitoring was
similar, however. When comparing therapeutic interven-
tions, there was no difference in the use of intravenous (IV)
insulin infusion or analgesics, but the use of IV sedation
was significantly less prevalent in neuro-ICUs. Fewer
neuro-ICU patients had received blood transfusions and
more were receiving enteral or parenteral nutritional sup-
port compared to general ICUs. Do-not-resuscitate orders
were active in half as many neuro-ICU patients, but this
difference did not attain significance.
Discussion
Most studies that have analyzed the impact of treatment in
a neurocritical care unit have found associations with
reduced hospital mortality and improved functional out-
come. [1–3, 7, 9, 10] None of these studies have been able
to fully explain why specialty neuro-ICU care results in
improved outcomes. Despite the fact that fewer neuro-
ICU patients were mechanically ventilated, neurological
patients in our survey were more likely to have received
invasive intracranial or hemodynamic monitoring, trache-
ostomy, and nutritional support. Neuro-ICU patients were
also less likely to have received IV sedation or a blood
transfusion. Although these results are far from definitive,
they point to specific practices that may improve outcome
after brain injury.
Some of the observed differences in management
between neurological and general ICUs might reflect dif-
ferences in primary diagnosis. On the day that our snapshot
Neurocrit Care (2011) 15:477–480 479

Table 1 differences between neurological patients admitted to a specialty neuro-ICU versus a general ICU
Variable Neuro ICU (N = 52) General ICU (N = 179) P

Length of stay C10 days 21 (40) 30 (17) <0.0001

Origin Inter-hospital transfer 19 (37) 20 (11) <0.0001
Admission Diagnosis TBI 1 (2) 44 (24) <0.0001
Ischemic stroke 0 (0) 34 (19) <0.001
Hemorrhagic strokea 24 (46) 29 (16) <0.0001
Otherb 27 (52) 72 (40) 0.18
Respiratory management Ventilated 20 (39) 91 (51) 0.06
Tracheostomyc 7 (35) 14 (15) 0.04
Monitoring CVP or A-line 21 (40) 35 (20) 0.002
EVD 7 (14) 1 (1) <0.001
ICP 8 (15) 16 (9) 0.18
EEG 2 (4) 10 (6) 1.00
Infusions Insulin 2(4) 16 (9) 0.38
Analgesics 7 (14) 22 (12) 0.82
Sedatives 6 (12) 53 (30) 0.009
Other Blood transfusion 0 (0) 15 (8) 0.026
Nutritional supportd 35 (67) 70 (39) <0.001
DNR order 2 (3.8) 15 (8.4) 0.37
Data are N (%)
TBI traumatic brain injury, EVD external ventricular drainage, ICP intracranial pressure, EEG electroencephalogram, DNR do not resuscitate
a
Subarachnoid and intracerebral hemorrhage
b
Includes brain tumor (N = 51), seizures (N = 9), alcohol withdrawal (8), hypoxic-ischemic encephalopathy (N = 5), and meningitis (N = 3)
c
Percentage of ventilated patients
d
Enteral or parenteral nutrition

survey was conducted, patients with hemorrhagic stroke
were over-represented in neuro-ICUs, whereas patients
with ischemic stroke and traumatic brain injury were vastly
under-represented. This probably reflects practice patterns
that emphasize inter-hospital transfer of subarachnoid and
intracerebral hemorrhage patients to specialized centers for
neurosurgical intervention. By contrast, trauma patients in
the New York region are more likely to be taken directly to
a level I trauma center and admitted to a general trauma or
surgical ICU, and ischemic stroke patients are most often
admitted to primary stroke centers and cared for in an
intermediate level stroke unit. To eliminate referral bias as
a potential confounder, future studies should compare
clinical practices within specific diagnostic groups. More
research is needed to better understand disparities in
regionalization of care, particularly for patients with trau-
matic brain injury.
ICP monitoring and hemodynamic management focused
on avoiding that hypovolemia and hypotension are hall-
marks strategies for minimizing secondary brain injury
[11]. Our data suggests that neurological patients tend to
undergo more invasive hemodynamic monitoring in neuro-
ICUs. Early tracheostomy of neurocritical care patients has
been associated with rapid liberation from mechanical
ventilation and reduced ICU length of stay in observational
studies [12, 13]. Neurological patients are at high risk for
aspiration and undernutrition. These complications may be
minimized by the early initiation of early tube feeding, and
neurointensivists often advocate this practice, despite the
lack of evidence that this strategy improves long-term
outcome [14].
Although our data suggest that neurointensivists may
be more likely to perform early tracheostomy and initiate
early tube feeding, this association may also simply
reflect the fact that neuro-ICU patients in our survey were
twice as likely to have an ICU LOS of C10 days. Other
studies have shown conflicting results regarding resource
utilization and LOS. Suarez et al. [10] and Varelas et al.
[9] found reduced LOS in neuro-ICUs, while Mirski et al.
[2] and Diringer and Edwards [1] reported unchanged and
increased hospital LOS, respectively. The impact of a
specialized neuro-ICU on LOS and resource utilization
may vary depending on the specific types of patients
cared for, physician preferences, the availability of step-
down beds, and practice patterns in comparator units.
At present, it remains inconclusive whether neuro-ICUs
are associated with increased or decreased resource
utilization.

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Other ‘‘best practices’’ may also be more likely to be
performed in ICUs that focus exclusively on neurological
patients. Daily interruption or reduction of intravenous sed-
atives has been proven to decrease ventilation days and
mortality in patients with respiratory failure [15]. Neuro-
critical care units routinely incorporate interruption of
sedation into daily practice not only for this reason, but also to
permit accurate serial neurological assessments. Restrictive
blood transfusion strategies have been shown to reduce
mortality in a mixed population of ICU patients [16]. Anemia
is extremely common after all forms of brain injury.
Although our data provide preliminary evidence that neuro-
intensivists may be less likely to perform blood transfusions,
because of the small number of observations and lack of data
on pre-transfusion hematocrit, this is far from conclusive.
The frequency of do-not-resuscitate (DNR) status on the
day of our survey was low, which probably reflects the fact
that DNR patients tend not to be treated in ICUs [17].
Therapeutic nihilism is considered an important cause of
poor outcome from coma, and aggressiveness of care has
been considered a possible cause of improved outcome
when care is provided in a specialized neuro-ICU.
Our study is far from definitive, and has a number of
important limitations. It was a one-day snapshot survey in
the New York City region, which may limit its validity and
generalizability. We had no access to standardized disease
severity or outcome prediction scores, we had limited access
to laboratory data, and there was no patient follow-up. Lack
of detail regarding end-of-life management and goals of care
is another important deficiency. However, our standardized
data collection instrument and the large number of hospitals
surveyed does provide a unique opportunity to address the
question of why better outcomes occur when neurological
patients are treated in specialized units. More research in this
area is clearly needed.
Acknowledgments The authors wish to thank the many physicians
and nurses who participated in the Greater New York Hospital
Association/United Hospital Fund ICU Survey. GNYHA, a trade
association representing 150 hospitals throughout New York State,
New Jersey, Connecticut, Pennsylvania, and Rhode Island, and UHF,
a private not-for-profit health services research and philanthropic
organization, formed a partnership in 2005 to support hospitals’
quality improvement efforts. This survey was part of the initiatives
they partner on in the area of critical care.
Conflict of interest The authors have no potential conflicts of
interest to report.
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