Boarding Takes a Toll on Stroke Patients

By Betsy Bates Elsevier Global Medical New

HONOLULU - Stroke patients held in the emergency department for 5 hours or more before being admitted to a neurologic intensive care unit had poorer neurologic outcomes than did those transferred more quickly, according to a Columbia University study presented at the annual congress of the Society of Critical Care Medicine.

Dr. Fred Rincon of the Columbia University, New York, neurological intensive care unit (Neuro-ICU) explained that "boarding" of critically ill patients in emergency departments is a "common and increasing" practice in the face of ICU bed shortages across the United States.

On average, patients nationwide spend 6 hours in emergency departments (EDs) before being transferred to specialized ICU care, he said.

"Why is this important for all of us dealing with neurological emergencies? Because time lost is brain lost," said Dr. Rincon during his oral presentation.

He and his associates analyzed 27 months of data from Columbia University's Specialized Program of Translational Research in Acute Stroke registry, identifying 519 patients who presented with stroke symptoms to the ED during that time.

Of these, 76 required admission to the neuro-ICU, the majority diagnosed with ischemic stroke (37) or intracerebral hemorrhage (36). Patients with such conditions as migraine, status epilepticus, and transient ischemic attack also were included in the study if they were admitted to the neuro-ICU in unstable condition.

The mean age of patients admitted to the neuro-ICU was 65 years. Most were Hispanic, reflecting the catchment area of the medical center in New York City.

The median time spent in the ED was 5 hours, with a range of 3-8 hours.

On admission, the patients' scores on the National Institutes of Health Stroke Scale (NIHSS) (within a range of 0-44) included 16 patients with mild symptoms (6 or less); 27 with scores between 7 and 13, and 33 with scores of 14 or greater, representing moderate to severe strokes.

The median hospital length of stay for neuro-ICU patients was 7 days, with a range of 3-15 days.

In a univariate analysis, remaining in the ED for 5 hours or more was significantly associated with poor outcome, assessed using discharge NIHSS and a discharge modified Rankin Score (67% of patients vs. 33%, with a P value of .01).

In a multivariate analysis, the association persisted, with a lengthy emergency department stay conferring a fivefold increased risk of a poor neurologic outcome even after adjustment for known predictors of poor neurologic outcome, such as age and admission NIHSS score.

The only other independent risk factor associated with poor outcome was a higher admission NIHSS score, Dr. Rincon explained.

Several audience members commented on the need for more study on potential consequences of prolonged emergency department stays when ICU beds are unavailable.

One physician said that the issue is "always a battle" between administrators and clinicians but one that has multifactorial causes and potential solutions.