Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2

Abstract

Background

Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study.

Methods

We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality.

Results

We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47).

Conclusion

PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.

Appendix

PRINCE Study Investigators

Argentina: Gustavo Domeniconi, MD, Sanatorio de la Trinidad San Isidro, Gran Buenos Aires; Luis Alberto Camputaro, Sanatorio San Jose, Buenos Aires; Milton Villalobos, Hospital Municipal San Miguel, Buenos Aires; Mariela Allasia, Hospital de Ninos O Allasia, Santa Fe; Fernando D Goldenberg, MD, Mario D Teran, MD, Foda Rosciani, MD, Hospital Italiano, Buenos Aires; Hector Alvarez, Hospital Escuela General San Martin, Buenos Aires; Marcelo Costilla, MD, Walter Videtta, MD, Hospital Nacional Alejandro Posadas, Buenos Aires; Diego Perez, Hospital de Trauma y Emergencia Dr. Federico Abete, Buenos Aires; Pablo Raffa, Hospital Interzonal General de Agudos, Buenos Aires; Walter Videtta, Hospital Eva Peron de Merlo, Buenos, Aires. Australia: Ian Seppelt, Nepean Hospital, Sydney; Helen Rodgers, Canberra Hospital, Canberra; Jody Paxton, Gold Coast University Hospital, Southport; Deepak Bhonagiri, Macquarie University Hospital, Sydney; Anders Aneman, Liverpool Hospital, Liverpool; Elizabeth Jenkinson, Royal Perth Hospital, Perth; Celia Bradford, B Med, Simon Finfer, MBBS; Elizabeth Yarad, RN, BN, Francess Bass, RN, BN, Naomi Hammond, RN, BN, Anne O’Connor, RN, Simon Bird, RN, Royal North Shore Hospital, Sydney; Roger Smith, St Vincent’s Hospital, Melbourne; Deborah Barge, The Royal Melbourne Hospital, Melbourne; Jane Shilkin, WPD Woods, MD, Brigit Roberts, Sir Charles Gairdner Hospital, Nedlands; Michael O’Leary, Royal Prince Alfred Hospital, Camperdown; Shirley Vallance, Alfred Hospital, Melbourne. Austria: Raimund Helbok, MD, Ronny Beer, MD, Bettina Pfaulser, MD, Alois Schiefecker, MD, Innsbruck Medical University, Innsbruck. Bahrain: Ayesha Almemari, Mafraq Hospital; Sajid Mukaddam, Salmaniya Medical Complex. Belgium Fabio S Taccone, MD, Hopital Erasme, Brussels; Xavier Wittebole, MD, Caroline Berghe, RN, Marie-France Dujardin, RN, Suzanne Renard, RN, Philippe Hantson, MD, Cliniques Universitaires Saint Luc, Louvain; Patrick Biston, CHU de Charleroi, Charleroi; Geert Meyfroidt, University Hospitals, Leuven. Brazil: Ivan Rocha Ferreira da Silva, MD, Janaina de Oliveira, MD, Hospital Copa D’Or, Rio de Janeiro; Alvaro Reao Neto, Instituto de Neurologia de Curitiba, Curitiba; Joao Roberto Sala Domingues, Hospital Samaritano, Sao Paulo; Pedro Mendes de Azambuja Rodrigues, São Lucas Copacabana Hospital, Rio de Janeiro. Canada: Jeanne Teitelbaum, MD, Mont real Neurological Institute, Montreal; Martin Chapman, MD, Vicki McCredie, MD, Nicole Marinoff, Adic Perez, Sunnybrook Health Sciences Unit, Toronto; Demetrios Jim Kutsogiannis, MD, University of Alberta Hospital, Edmonton; Francis Bernard, MD, Hopital Sacre-Coeur, Montreal; Andreas Kramer, MD, University of Calgary, Calgary. Chile: Jose I Moretti, MD, Hospital del Trabajador, Santiago; Sergio Aguilera, MD, Hospital Regional de Iquique, Iquique; Eugenio J. Poch, MD, Instituto de Neurocirugia Alfonso Asenjo, Santiago; Carlos Romero, MD, Hospital Clinico Universidad de Chile, Santiago. China: George K.C. Wong, MD, Chinese University of Hong Kong, Hong Kong; Jian Song, MD, Guozheng Xu, MD, Wuhan General Hospital, Wuhan. Colombia: Jorge H. Mejia-Mantilla, Humberto Madrinan-Navia, MD, Jorge E Martinez, MD, Maria Elena Ochoa, MD, Diego Bautista, MD, Monica Varga, MD, Monica Gomez, MD, Fundacion Valle del Lili, Cali; Juan Diego Ciro, MD, Bladimir Gil, MD, Rodrigo Murillo, MD, Clinica Las Americas, Medellin; Olga Hernandez, MD, Instituto Neurologico de Colombia, Medellin. Costa Rica: Jorge Ramirez-Arce, MD, Surgical Intensive Care Unit, CCSS, San Jose. Croatia: Tomislav Breitenfeld, KBC Sestre milosrdnice, Zagreb. Cuba: Angel J. Lacerda Gallardo, Hospital General Roberto Rodriguez, Moron. Dominican Republic: Hubiel J Lopez Delgado, MD, Jose Rafael Yunen Gonzalez, MD, Manuel Hache-Marliere, CEDIMAT, Santo Domingo. Ecuador: Diego Barahona Pinto, Hospital de Los Valles, Quito; Miguel Llano, MD, Hospital de Especialidades de la FF.AA., Quito; Estuardo Salgado, Clinica La Merced, Quito; Manuel Jibaja, MD, Hospital Eugenio Espejo, Quito. England: Judith C Wright, James Cook University Hospital, Middlesbrough; Daniel Harvey, Nottingham University Hospitals, Nottingham; Vishwajit Verma, Royal London Hospital, London; Philip Hopkins, MD, Alexander Chan, King’s College Hospital, London; Jessie Welbourne, Derriford Hospital, Plymouth; Susan Dowling, Whiston Hospital, Merseyside. Finland: Ari Katila, Turku University Hospital, Turku. France: Sigismond Lasocki, CHU-Angers, Angers. Germany: Katja Wartenberg, MD, Martin-Luther-University Halle-Wittenberg; Carsten Hobohm, MD, University of Leipzig, Leipzig; Sven Poli, MD, University of Tuebigen, Tubigen; Ingo Schirotzek, UKGM, Giessen; Julian Bosel, MD, Silvia Schoenenberger, Susanne Francken, Simon Shieber, Alexander Kern, University of Heidelberg, Heidelberg. Guatemala: Joel Falla and Edgar Avalos Herrera, Hospital General San Juan de Dios, Guatemala City. India: P. C. Gilvaz, Jubilee Mission Medical College, Thrissur; Keshav Goyal, MD, Navdeep Sokhal, MD, Jyoti Sohal, MD, All India Institute of Medical Sciences, New Delhi; Deepesh G. Aggarwal, Saifee Hospital, Mumbai; Banambar Ray, MD, Saroj Pattnaik, MD, Apollo Hospitals, Bhubaneswar; Sanchita Garg, Fortis Hospital, Mohali; Subhal Dixit, Sanjeevan Hospital, Pune; Raj Rawal, Hope Neuro Care Hospital, Ahmadabad; Srinivas Samavedam, Madhu Madhusudan, Care Hospitals, Hyderabad; Gunchan Paul, Dayanand Medical College, Pohir; Sanghamitra Mishra, IMS & SUM Hospital, Bhubaneswar; Patil Shushma, Ruby Hall Clinic, Pune; Urvi Shukla, Aditya Birla Memorial Hospital, Pune; Vandana Sinha, GNRC Hospitals,Dispur; Ponniah Vanamoorthy, Global Health City, Chennai; Sonali Vadi, Global Hospital, Mumbia;. Iran: Majid Mokhtari, IHH, SBUMS, Tehran. Italy: Frank Rasulo, Spedali Civili Hospital, Brescia; Marianna Pegoli, Ospedale Bellaria IRCCS delle Scienze Neurologiche, Bologna; Federico Bilotta, Ospedale Policlinico Umberto I, Rome. Japan: Masao Nagayama, MD, PhD, International University of Health and Welfare Atami Hospital, Atami; Hitoshi Kobata, Osaka Mishima Emergency Critical Care Center, Osaka. Lithuania: Saulius Vosylius, Vilnius University Hospital, Vilnius. Malaysia: Jafri Malin Abdullah, Center for Neuroscience Services and Research,Universiti Sains Malaysia-P3Neuro, Kubang Kerian. Mexico: Juvenal Franco Granillo, Centro Medico ABC, Mexico City; Julio Cesar Mijangos-Mendez, Hospital Civil De Guadalajara, Guadalajara. The Netherlands: Janneke Horn, Academic Medical Center, Amsterdam; Marcella C A Muller, MD, PhD, Medisch Centrum Haaglanden, The Hague; Michael Kuiper, Medical Center Leeuwarden, Leeuwarden; Wilson F Abdo, MD, PhD, Radboud UMC, Nijmeden. New Zealand: Colin McArthur, MD, Lynette Newby, Auckland City Hospital, Auckland. Pakistan: Madiha Hashmi, Aga Khan University, Karachi; Seemin Afshan Shiraz, Sheikh Khalifa General Hospital, Lahore. Panama: Guadalupe Castillo Abrego MD, Caja de Seguro Social Hospital, Panama City. Peru: Ermitaño Bautista Coronel, Hospital Nacional Hipolito Unanue, Lima; Oscar Saldarriaga Rivera, Hospital Guillermo Almenara Irigoyen, Lima; Juan Luis Cam Paucar, Instituto Nacional de Ciencias Neurologicas, Lima; Oscar Gomez, Hospital Nacional Dos de Mayo, Lima. Philippines: Jose Emmanuel Palo, The Medical City, Manila; Johnny Lokin, University of Santo Tomas Hospital, Manila. Poland: Agnieszka Misiewska-Kaczur, MD, PhD, ZPZOZ Silesian Hospital, Cieszyn. Portugal: Celeste Dias, Hospital Sao Joao, Porto; Pedro Amorim, Sonia Andre, Hospital de Santo Antonio, Porto. Puerto Rico: Gloria Rodriguez-Vega, MD, HIMA San Pablo, Caguas. Russia: Alexey Gritsan, Krasnoyarsk Regional Hospital, Krasnoyarsk; Yulia Titova, Sklifosovsky Research Institute for Emergency Medicine, Moscow. Saudi Arabia: Ahmed Al Jabbary, MD, Amer Rashed Al Zahrani, MD, Lucie Pelunkova, RN, Hebaa Zraiki, RN, Ahmad M Deeb, King Abdulaziz Medical City, Riyadh; Ali Al Bshabshe, Aseer Central Hospital, Abha; Hosam Al-Jehani, King Fahad University Hospital, Dammam; Faisal Al-Suwaidan, MD, King Fahad Medical City, Riyadh. Slovenia: Viktor Svigelj, MD, University Medical Centre, Ljubljana. Spain: Luis A Ramos-Gomez, MD, Hospital General de La Palma, Santa Cruz de Tenerife; Gerardo Aguilar, Rafael Badenes, Hospital Clinico Universitario de Valencia, Valencia; Juan Antonio Llopart Pou, Hospital Universitari Son Espases, Palma de Mallorca; Elizabeth Zavala, Hospital Clinic, Barcelona; Francisco Bernal Julian, Laura Galarza Barrachina, Barbara Vidal Tegedor, Susana Altaba Tena, Hospital General Universitario de Castello, Castello; Oliva Romero Krauchi, Hospital Son Espases, Palma de Mallorca; Gonzalo Tamayo, Cruces University Hospital, Barakaldo; Baltasar Sanchez, Hospital Universitari Mutua Terrassa, Barcelona; Raul-Ismael Gonzalez Luengo, Complejo Hospitalario de Leon, Leon. Sri Lanka: S. Puvanendiran, General Teaching Hospital. Switzerland: Paolo Merlani, Ospedale Regionale, Lugano. Thailand: Denchai Laiwattana, Bangkok hospital Trat, Bangkok; Panuwat Promsin, Siriraj Hospital, Bangkok;. Turkey: Bijen Nazliel, Gazi University Faculty of Medicine, Ankara. USA: Evert Eriksson, MD, Julio Chalela, MD, MUSC, Charleston, SC; David W Miller, MD, University of Alabama at Birmingham; Raul Guisado, MD, San Jose Regional Medical Center, San Jose, CA; Errol Gordon, MD, Mt Sinai Medical Center, NYC, NY; Harrish H K Murthy, MD, Audrey Paulson, Good Samaritan Hospital, San Jose, CA; Venkatakrishna Rajajee, MD, Kyle Sheehan, MD, Craig Williamson, MD, Ron Ball, University of Michigan, Ann Arbor, MI; Patrick Allan, MD, Good Samaritan Hospital, Dayton, OH; Jennifer Berkeley, Sinai Hospital of Baltimore, MD; Susanne Muehlschlegel, MD, Raphael Carandang, Willey Hall, University of Massachusetts Medical School (UMASS), Worcester, MA; Aarti Sarwal, Wake Forest Baptist Medical Center, Winston-Salem, NC; Jose I Suarez, MD, Chethan P Venkatasubba Rao, MD, Alexandros Georgiadis, MD, Eusebia Calvillo, RN, Rahul Damani, MD, Nelson Maldonado, MD, Benedict Tan, MD, Pramod Gupta, MD, Christos Lazaridis, MD, Eric M Bershad, MD, Baylor College of Medicine, Houston, TX; Safdar Ansari, MD, Julie Martinez, University of Utah, Salt lake City, UT; Eduardo Smith Singares, MD, Advocate Christ Medical Center, Oak Lawn, IL; Edward Manno, MD, J Javier Provencio, MD, Burhan Chaudhry, MD, Moneen McBride, Cleveland Clinic Foundation, Cleveland, OH; Raj Dhar, MD, Debra Roberts, MD, PhD, Michelle Allen, RN, Barnes-Jewish Hospital, St Louis MO; Hermann C Schumacher, Lehigh Valley Health Network, Allentown, PA; Wassim Habre, MD, Corzer Chester Medical Center, Chester, PA; Kevin Sheth, MD, David Greer, MD, Kimberley Kunze, Yale University School of Medicine, New Haven, CT; Panayiotis Varelas, MD, PhD, Lauren Tack, Henry Ford Hospital, Detroit, MI; N Stevenson Porter, Rhode Island Hospital, Providence, RI; Christopher Junker, George Washington University, Washington, DC; Michael Rodricks, MD, Misti Tuppeny, MSN, RN, Cherlynn Basignani BSN, RN, Sarah Napolitano, MS, CHES, Gabriella Anderson, BA, Karin Donaldson, LPN, Florida Hospital, Orlando, Fl; Rhonda Davis, Shannon Sternberg, Greenville Health System, Greenville, SC; Elias A Giraldo, Drexel University, Philadelphia, PA; Huy Tran, MD, University of New Mexico, Albuquerque, NM; William M Coplin, MD, St Anthony Hospital, Denver, CO; Neeraj Badjatia, MD, University of Maryland, Baltimore, MD; Ahmed Fathy, Miami Valley Hospital, Dayton, OH; Rwoof A Reshi, MD, University of Minnesota, Minneapolis, MN; Jordan Bonomo, MD, University of Cincinnati, Cincinnati, OH; David Seder, MD, Lauren S Connolyy, RN, BSN, Barbara McCrum, RN, BSN, Maine Medical Center, Portland, ME; Teresa Carter, Sutter Roseville Medical Center, Roseville, CA; Miriam Treggiari, MD, University of Washington, Seattle, WA; Matthew Dickinson, MD, Centura St Anthony Hospital, Lakewood, CO; Richard A Rison, PIH Health, Whittier, CA; Marek Mirski, MD, PhD, Johns Hopkins University, Baltimore, MD; Sayona John, Thomas P Bleck, MD, Rush University Medical Center, Chicago, Il; Ali Malek, MD, Tiffany Trim, RN, Murline Smith, RN, St Mary’s Medical Center, West Palm Beach, FL; M Kamran Athar, MD, Fred Rincon, MD, Thomas Jefferson University Hospital, Philadelphia, PA; Laith Altaweel, Inova Fairfax, Falls Church, VA; Paul Vespa, MD, PhD, UCLA Medical Center, Los Angeles, CA; Gene Sung, MD, Benjamin Emanuel, DO, University of Southern California, Los Angeles, CA; Eric Eskiogly, MD, Physicians Regional Healthcare System, Naples, Fl; Molly McNett, PhD, RN, CNRN, Metro Health Medical Center, Cleveland, OH; Anakara V Sukumaran, MD, Houston Methodist Hospital, Houston, TX; Lori Shutter, MD, University of Pittsburgh/UPMC, Pittsburgh, PA; Dave Milzman, MD, Georgetown University, Washington, DC; Stuart Glassner, University of Florida, Jacksonville, Fl; Kristine O’Phelan, MD, University of Miami, Miami, FL; Eric Rosenthal, MD, Massachusetts General Hospital, Boston, MA; J C Hemphill III, MD, PhD, Mohan Kottapally, MD, Wade S Smith, MD, PhD, Nerissa Ko, MD, Scott A Josephson, MD, Anthony Kim, MD, Neel S Singhal, MD, PhD, Ahmad Ahmad, MD, Michele Meeker, University of California San Francisco, CA; Karen G Hirsch, MD, Stanford University, Palo Alto, CA; Mohan Kottapally, MD, San Francisco General Hospital, San Francisco, CA; Deepak Nair, MD, OSF Saint Francis Medical Center, Peoria, IL; Sherry Chou, MD, Gabriela Santos, Sarah Clark, Steven Feske, MD, Galen Henderson, MD, Farzaneh Sorond, MD, Henrikas Vaitkevicius, MD, David Chung, MD, Jennifer Kim, MD, Mary Amatangelo, RN, NP, Brigham and Women’s Hospital, Boston, MA; Gregory Kapinos, MD, MS, North Shore – LIJ Health System, Long Island, NY; Michel Torbey, MD, Wexner Medical Center at The Ohio State University, Columbus, OH; D Ethan Kahn, Christiana Care Health System, Wilmington, DE; Cherylee Chang, MD, Matthew Koenig, MD, The Queen’s Medical Center, Honolulu, HI; Mark Gorman, MD, Fletcher Allen Health Care, Burlington, VT; James R Langdon, MD, University of Tennessee Medical Center, Knoxville, TN; Jonathan Dissin, MD, Einstein Medical Center, Philadelphia, PA; Laura Cross, Harry Peled, MD, St Jude Medical Center, Fullerton, CA; Jan Claassen, MD, PhD, Columbia University, NYC, NY; Abbas Ali, MD, AJ Layon, MD, Angela Miller, MBA, SSBB, The Geisinger Medical Center, Danville, PA; Eileen Maloney Wilensky, Monisha Kumar, MD, Joshua M Levine, MD, University of Pennsylvania, Philadelphia, PA; Ivan L Maldonado, Ministry St Joseph’s Hospital, Marshfield, WI; Michael Schneck, MD, Loyola University, Chicago, IL; Abhijit Lele, MD, University of Kansas Medical Center, Kansas City, KS; Anand K Sarma, MD, Medical College of Virginia, Richmond, VA; Moussa F. Yazbeck, MD, John Muir Health, Walnut Creek, CA; Greg Johnston, Emory University Hospital, Atlanta; Adrian A Jarquin-Valdivia, TriStar Centennial Medical Center, Nashville, TN; Lindsey Johnson MD, Halifax Health, Port Orange, FL; Lauren Kuisle, Swedish Medical Center, Aurora, CO; Rehan Sajjad, Aurora St Luke’s Medical Center, Milwaukee, WI; Scott Glickman, Six Points Neuroscience; Rachel Garvin, Augusto Parra, MD, University of Texas Health Science Center San Antonio; Michele DeFilippis, Morristown Medical Center, Morristown; Jeffrey J Fletcher, Bronson Methodist Hospital, Kalamazoo, MI; W David Freeman, MD, Mayo Clinic, Jacksonville, FL; Vivek A. Rao, MD, Redwood City Medical Center, Redwood City, CA; Huitzilin Mauricio Olmecah, Loma Linda University Medical Center, Loma Linda, CA; Guy Dugan, MD, Alexian Brothers Medical Center, Elk Grove Village, IL; Irene B Medary, MD, Orlando Health, Orlando, FL; Robert Hoesch, MD, PhD, Intermountain Medical Center, Salt Lake City, UT; Scott S Brehaut, MD, Faxton St. Luke’s Healthcare, Utica, NY; Arash Afshinnik, MD, Ochsner Health System, New Orleans, LA; Melissa Moreda, Carmelo Graffagnino, MD, Daniel T Laskowitz, MD, Duke University Medical Center, Durham, NC; Andrew Naidech, MD, Brandon Francis, MD, Michael Berman, BA, Northwestern University, Chicago, IL; Eljim Tesoro, MD, University of Illinois at Chicago, IL; Joshua Medow, MD, University of Wisconsin, Madison, WI; Dedrick Jordan, MD, PhD, Univeristy of North Carolina at Chapel Hill, NC; Venkatesh Aiyagari, MD, The University of Texas Southwestern Medical Center, Dallas, TX; Axel Rosengart, MD, NYPH-Weill Cornell Medical College, New York, NY; Michael De Georgia, MD, University Hospitals Case Medical Center, Cleveland, OH; Susana Bowling, MD, Summa Health System, Akron, OH; Mohamed Sharaby, Barnett Nathan, MD, The University of Virginia Health System, Charlottesville, VA; Ryan Landry, RN, Cullen Hebert, MD, Our Lady of the Lake RMC, Baton Rouge, LA; Kathleen E Hubner, St Vincent’s Hospital, Indianapolis, IN; Navaz Karanjia, MD, University of California at San Diego, CA; Bradley Hightower, MD, Kathie Cummings, Jennifer Kirkwood, University of Oklahoma Health Sciences Center, Oklahoma City, OK; Jeffrey I Frank, MD, University of Chicago, Chicago, IL; Ameer Hassan, MD, Olive Sanchez, Valley Baptist Hospital, Harlingen, TX; Steve Cordina, MD, University of South Alabama, Mobile, AL. Venezuela: Jacobo Elias Mora, Hospital Universitario Luis Razetti, Puerto La Cruz. Vietnam: Tuan Van Bui, Cho Ray Hospital, Ho Chi Minh City.