Author: Thomas Rosenthal
The innovative Critical Care Resuscitation Unit (CCRU) at the University of Maryland Medical Center (UMMC) provided care to patients with spontaneous intracerebral hemorrhage (sICH) that was similar to that of the Baltimore hospital’s traditional, specialty Neuro-Critical Care Unit (NCCU), according to a new study.
The CCRU also enabled a more rapid transfer to the UMMC for patients with life-threatening sICH and had mortality outcomes comparable to those of the NCCU.
“The CCRU allowed for an increased number of patients with intracranial hemorrhages to be admitted to the medical center,” said Katie Brooke Andersen, MS, CRNP, the lead author of the study. “The CCRU expedited the transfer of patients to the medical center. Patient outcomes were similar regardless of initial unit of admission.” The study was presented at the 2018 annual meeting of the Society of Critical Care Medicine (abstract 295).
The CCRU patients had more continuous arterial pressure monitoring within six hours of arrival (77% vs. 25% for the NCCU patients; P<0.001). They also achieved faster time to a goal blood pressure of three consecutive systolic pressures between 140 and 160 mm Hg (139 [range, 36-491] minutes vs. NCCU patient times of 224 [range, 87-638] minutes; P=0.047). There was a nonsignificant difference in mortality rates, 20% for the CCRU and 24% for the NCCU (P=0.48).
Follow-on Study From Shock-Trauma Study
The results of the study mirrored the results of a study conducted a year after the CCRU’s opening in 2013, to assess the unit. A team of surgeons at the UMMC created the original concept—modeling it on the UMMC’s R. Adams Crowley Shock Trauma Center (STC)—to admit critically ill adult nontrauma patients to the appropriate operating room (OR) and ICU bed as quickly as possible, with an aim to improve patient outcomes.
Before the CCRU was launched, the STC’s fast intake and treatment strategy had existed only for patients who suffered critical injuries in vehicular accidents or catastrophic events. Additionally, prior to the CCRU, patients with time-sensitive critical illness from community hospitals were transferred based on the availability of ICU beds, said Thomas Scalea, MD, FACS, MCCM, the physician-in-chief at the STC, and system chief for critical care services as well as the Francis X. Kelly Distinguished Professor in trauma surgery at the UMMC. The lack of immediately available specialty ICU beds delayed transfer to definitive care and worsened patient outcomes, he said.
A year after the CCRU’s inception, transfers to the hospital increased 64.5% while transfers of critically ill surgical patients jumped 93.6% (J Am Coll Surg 2016;222:614-621). The study also found lower median times for arrival and to the OR (118 vs. 223 minutes and 1,113 vs. 3,424 minutes, respectively; P<0.001 for both), as well as a significantly reduced median length of stay (13 vs. 17 days; P<0.001). There was a trend toward lower mortality (14.6% vs. 16.5%; P=0.27).
“The critical care resuscitation unit dramatically increased the volume of critically ill surgical patients,” Dr. Scalea noted in the first-year study. “This benefit seems to be most marked in patients needing an urgent operation. This might be a paradigm shift expediting the transfer of patients with time-sensitive critical illness to an appropriately resourced specialty center.” When an NCCU bed is not available, sICH patients are admitted to the CCRU.
Continuing the evaluation in the more recent study, Ms. Anderson and her co-authors wanted to determine if the CCRU provided faster access and delivered care comparable to the NCCU for sICH patients with a life-threatening emergency, requiring urgent transfer to a tertiary care hospital with a dedicated neurologic ICU where they could receive immediate resuscitation.
“The CCRU admits and stabilizes these patients and transfers them to the appropriate ICU when a bed becomes available,” Ms. Andersen said. “As a multispecialty unit, the CCRU strives to provide every time-sensitive critical illness with the same expert care that the patient would receive in a specialty unit. Continuum of care from the CCRU to NCCU promotes enhanced patient care.”