A step-down unit transfer protocol for low-risk aneurysmal ...

NEUROSURGICAL

FOCUS Neurosurg Focus 43 (5):E15, 2017

The benefit of interhospital transfer of patients with aneurysmal subarachnoid hemorrhage (SAH) has been well supported in the literature, and many now

advocate for the regionalization of care to improve patient outcomes.11,14 As SAH patients are routed and transferred to high-volume centers with specialized infrastructure and personnel, space has become increasingly limited, particularly in the ICU. However, many have suggested that ICU care should only be indicated if it improves out-comes.9,15,17 To this end, patients who have experienced SAH, particularly those with low-grade clinical severity (Hunt and Hess Grades I–III), may not require extended ICU stays. Rather, for select low-risk patients, care in a

step-down unit (SDU), defined as an intermediate ward conceived to treat patients no longer requiring full inten-sive care but needing closer monitoring than those in the general wards, may be appropriate.12

Across all fields of medicine, research has aimed to reduce the costs of care delivery while maintaining high standards for outcomes and patient safety. ICU care is a limited and costly resource, as ICU beds account for less than 10% of the nation’s inpatient beds but account for greater than 25% of hospital costs.2,5,17 By selecting SAH patients who can be safely and appropriately managed in the SDU, hospitals can reduce acute care costs without af-fecting safety or outcomes.2

ABBREVIATIONS GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; LOS = length of stay; NSICU = neurosurgical intensive care unit; SAH = subarachnoid hemorrhage; SDU = step-down unit; TBI = traumatic brain injury; TCD = transcranial Doppler.ACCOMPANYING EDITORIAL DOI: 10.3171/2017.8.FOCUS17536.SUBMITTED July 1, 2017. ACCEPTED August 15, 2017.INCLUDE WHEN CITING DOI: 10.3171/2017.8.FOCUS17448.

A step-down unit transfer protocol for low-risk aneurysmal subarachnoid hemorrhageAlexander G. Chartrain, BS,1 Ahmed J. Awad, MD,1 Christopher A. Sarkiss, MD,1 Rui Feng, MSc,1 Yangbo Liu, MS,1 J Mocco, MD, MS,1 Joshua B. Bederson, MD,1 Stephan A. Mayer, MD,2 Neha S. Dangayach, MD,1,3 and Errol Gordon, MD1,3

Departments of 1Neurosurgery and 3Neurology, Icahn School of Medicine at Mount Sinai, New York, New York; and 2Department of Neurology, Henry Ford Health System, Detroit, Michigan

OBJECTIVE Patients who have experienced subarachnoid hemorrhage (SAH) often receive care in the setting of the ICU. However, SAH patients may not all require extended ICU admission. The authors established a protocol on January 1, 2015, to transfer select, low-risk patients to a step-down unit (SDU) to streamline care for SAH patients. This study describes the results of the implemented protocol.METHODS In this retrospective chart review, patients presenting with SAH between January 2011 and September 2016 were reviewed for inclusion. The control group consisted of patients admitted prior to establishment of the SDU transfer protocol, while the intervention group consisted of patients admitted afterward.RESULTS Of the patients in the intervention group, 79.2% (57/72) were transferred to the SDU during their admission. Of these transferred patients, 29.8% (17/57) required return to the neurosurgical ICU (NSICU). There were no instances of morbidity or mortality directly related to care in the SDU. Patients in the intervention group had a mean reduced NSICU length of stay, by 1.95 days, which trended toward significance, and a longer average hospitalization, by 2.7 days, which also trended toward significance. In-hospital mortality and 90-day readmission rate were not statistically different between the groups. In addition, early transfer timing prior to 7 days was associated with neither a higher return rate to the NSICU nor higher 90-day readmission rate.CONCLUSIONS In this retrospective study, the authors demonstrated that the transfer protocol was safe, feasible, and effective in reducing the ICU length of stay and was independent of transfer timing. Confirmation of these results is needed in a large, multicenter study.https://thejns.org/doi/abs/10.3171/2017.8.FOCUS17448KEY WORDS aneurysmal subarachnoid hemorrhage; step-down unit; intensive care unit; transfer protocol; high-volume center

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Our institution operates a 16-bed NSICU with a team of critical care physicians, critical care fellows, and nurse practitioners and a 1:2 nursing-to-patient ratio. Our SDU is a 4-bed unit with a 1:4 nursing-to-patient ratio. Because of the trend toward the regionalization of SAH care and changing referral patterns in our hospital network, there has been a dramatic increase in the number of SAH pa-tients transferred to our center in recent months. In re-sponse to this, an SDU transfer protocol was introduced to streamline patient care for patients meeting low-risk criteria beginning on January 1, 2015. For this retrospec-tive study, we hypothesized that our SDU transfer protocol for select, low-risk SAH patients is safe and feasible, and it reduces ICU utilization.

MethodsStudy Population

The retrospective study protocol and a waiver of con-sent were approved by our institutional review board.

All patients admitted to the NSICU with a diagnosis of SAH (ICD code 430) between January 2011 and Sep-tember 2016 were screened for this retrospective study. January 2011 was chosen as the start date of the study, as this is when the electronic medical record system was initiated at our institution (Mount Sinai Hospital). Patients with SAH of nonaneurysmal etiology were excluded from the study, as were patients who died within 72 hours of admission. Patients were divided into 2 groups based on the date of the transfer protocol implementation (January 1, 2015). Those who were admitted prior to this date were categorized as the control group. Those admitted after-ward were categorized as the “intervention group.” Age, sex, comorbid medical conditions, Glasgow Coma Scale (GCS) score, Hunt and Hess grade, and modified Fisher grade were recorded at the time of admission.3,4 Aneu-rysm characteristics and treatment were collected. Dates identifying transfers to and from the NSICU, SDU, and ward were gathered from the medical record, as were the dates of discharge and the location of discharge. Hospital course complications were also obtained from the medical record.

Transfer ProcedurePatients in the control group (i.e., prior to the interven-

tion) followed the previously established practice of re-maining in the NSICU for the duration of the vasospasm period (i.e., through Day 14 of admission). Once patients were deemed to be beyond the vasospasm period, a high level of medical stability needed to be reached for transfer to a general ward.

For the intervention group, criteria for transfer to the SDU were assessed daily and included the following: 1) Hunt and Hess Grade III or better, 2) completed diagnos-tic angiography since admission, 3) aneurysm secured or protected if found, 4) stable neurological examination for longer than 24 hours, 5) no concern for impending symp-tomatic vasospasm (i.e., elevated or up-trending trans-cranial Doppler [TCD] ultrasound velocities), and 6) no elevation in intracranial pressure (ICP) for > 24 hours. If each of these criteria were met, patients were deemed

eligible for transfer to the SDU. The need for an exter-nal ventricular drain did not preclude transfer to the SDU. Management in the SDU included daily TCD measure-ments and hourly neurological examinations. The NSICU physicians continued to serve as the primary providers for patients in the SDU. If a patient’s medical or neurological status worsened or became complicated, the patient was evaluated and, if deemed necessary, transferred back to the NSICU for higher level care. Criteria for transfer back to the NSICU included any of the following: 1) evidence of symptomatic vasospasm, 2) rapidly increasing TCD ul-trasound velocities, 3) uncontrolled elevated ICP, 4) neu-rological deterioration, or 5) general medical deterioration requiring ICU care.

Outcome MeasuresThere were two primary outcomes for the study. The

first primary outcome was safety and feasibility of the SDU transfer protocol, measured by mortality and morbid-ity of patients transferred to the SDU. The second primary outcome was ICU utilization, measured by NSICU length of stay (LOS). These were chosen as the primary outcome measures to assess whether the transfer protocol clinical criteria were effective in identifying eligible patients for transfer and reducing ICU bed utilization. The secondary outcomes included the following: hospital LOS, mortal-ity rate, 90-day readmission rate, and Glasgow Outcome Scale (GOS) score at discharge. GOS score at discharge was graded based on discharge location: home (Score 5), acute (Score 4), subacute (Score 3), long-term nursing fa-cility (Score 2), and death (Score 1).

Statistical MethodsThe marginal comparison of covariates and outcomes

between the control and intervention groups was complet-ed using a 2-sample t-test for continuous outcomes and chi-square test for categorical outcomes.

For multivariate analysis, linear regression was ap-plied when continuous variables were used as outcomes, including NSICU LOS, hospital LOS, and average dis-charge GOS score. Logistic regression was applied when categorical variables were used as outcomes, including hospital mortality rate and readmission rate. Patient inclu-sion in either the control or intervention group was used as the primary covariate. Age, sex, modified Fisher grade, Hunt and Hess grade, and GCS score, and the presence of medical comorbidities, including coronary artery disease, hypertension, and diabetes mellitus, were also included in the regression models, for adjustment. The p values of the marginal comparisons were calculated to show the crude difference of each variable between the 2 groups. Those variables with a p value < 0.05 were considered to have a significant difference between control and intervention groups. The p value for the primary covariate in each model was generated to indicate the relationship between each outcome and the primary covariate after adjusting by age, sex, modified Fisher grade, Hunt and Hess grade, GCS, and the presence of medical comorbidities, includ-ing coronary artery disease, hypertension, and diabetes mellitus. A p value of < 0.05 indicated a significant as-

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sociation after adjustments. An estimation of the param-eters in each model was generated and used to explain the direction of change.

Subgroup AnalysisPatients in the intervention group were split into 3 sub-

groups: 1) those who were not transferred to the SDU, 2) those who were transferred to the SDU within 7 days of admission, and 3) those transferred to the SDU after 7 days of admission. These groups were analyzed to as-sess for any differences in 90-day readmission rate. In ad-dition, for those who were transferred to the SDU, early transfer (within 7 days) versus later transfer was assessed for any association with the need to return to the NSICU.

ResultsA total of 215 patients were admitted to the Mount

Sinai Hospital NSICU with a diagnosis of SAH between January 2011 and September 2016. Patients were exclud-ed because of nonaneurysmal etiology (n = 70) or death within 72 hours of admission (n = 8, 4 patients from each group). After applying exclusion criteria, a total of 137 pa-tients were included, 65 patients before the intervention was implemented (control group) and 72 patients after the transfer protocol was in place (intervention group).

Baseline patient characteristics, including modified Fisher grade, Hunt and Hess grade, age, sex, comorbid conditions, and aneurysm characteristics were not signifi-cantly different between the 2 groups, with some excep-tions (Table 1). A greater proportion of patients in the in-tervention group presented with aneurysms of the posterior circulation. The intervention group was also more likely to have an aneurysm treated by endovascular means than was the control group, which follows the national trend favor-ing first-line endovascular embolization of ruptured aneu-rysms. In the intervention group, 79.2% (57/72) of patients were transferred to the SDU during their admission. The

TABLE 1. Demographics and admission characteristics

VariableControl Group

Intervention Group

p Value

No. of patients 65 72 NAMean age in yrs 53.9 (13.2) 53.3 (12.2) 0.757Male sex 25 (38.5) 21 (29.2) 0.250Total no. of aneurysms treated 71 75 NAAneurysm location* 0.031 Anterior/posterior Anterior 61 (85.9) 54 (72.0) Posterior 10 (14.1) 21 (28.0) Laterality 0.545 Left 24 (33.8) 23 (30.7) Right 24 (33.8) 32 (42.7) Midline 23 (32.4) 20 (26.7) Artery 0.612 A1 3 (4.2) 3 (4.0) ACoA 21 (29.6) 16 (21.3) AICA 1 (1.4) 1 (1.3) Basilar tip 2 (2.8) 3 (4.0) ICA terminus 2 (2.8) 2 (2.7) ICA-AChA 1 (1.4) 3 (4.0) ICA-ophthalmic 2 (2.8) 0 (0.0) ICA-paraclinoid 2 (2.8) 3 (4.0) ICA-PCoA 21 (29.6) 14 (18.7) ICA-superior hypophyseal 0 (0.0) 2 (2.7) M1 2 (2.8) 0 (0.0) M2 1 (1.4) 1 (1.3) MCA bifurcation 4 (5.6) 7 (9.3) Mid-basilar 0 (0.0) 1 (1.3) PCA 0 (0.0) 1 (1.3) Pericallosal 2 (2.8) 3 (4.0) PICA 4 (5.6) 11 (14.7) Pontine perforator 1 (1.4) 0 (0.0) SCA 1 (1.4) 2 (2.7) Vertebral 1 (1.4) 2 (2.7)Aneurysm treatment* 0.004 Endovascular embolization 43 (60.6) 63 (84.0) Craniotomy & clipping 20 (28.2) 10 (13.3) Expectant management 8 (11.3) 2 (2.7)CAD 2 (3.1) 4 (5.6) 0.390HTN 27 (41.5) 31 (43.1) 0.498DM 3 (4.6) 3 (4.2) 0.610Admission GCS score 0.858 3–8 11 (16.9) 13 (18.1) 9–12 12 (18.5) 16 (22.2) 13–15 42 (64.6) 43 (59.7)Admission H&H grade 0.149 I–III 52 (80) 51 (70.8) IV or V 13 (20) 21 (29.2)

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TABLE 1. Demographics and admission characteristics

VariableControl Group

Intervention Group

p Value

Admission MF grade 0.065 0–2 23 (35.4) 16 (22.2) 3–4 42 (64.6) 56 (77.8)SDU transfer NA 57 (79.2) NAReturned to NSICU NA 17 (29.8)† NA

AChA = anterior choroidal artery; ACoA = anterior communicating artery; AICA = anterior inferior cerebellar artery; CAD = coronary artery disease; DM = diabe-tes mellitus; H&H = Hunt and Hess; HTN = hypertension; ICA = internal carotid artery; MCA = middle cerebral artery; MF = modified Fisher; NA = not appli-cable; PCA = posterior cerebral artery; PCoA = posterior communicating artery; PICA = posterior inferior cerebellar artery; SCA = superior cerebellar artery.Values are presented as the number of patients (%) unless stated otherwise. Boldface type indicates statistical significance.* Values are the number of aneurysms (%).† The denominator is the number of patients who were transferred to the SDU (n = 57).

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average day of transfer to the SDU was Day 9.5 (SD 7.7) of admission. Of the patients transferred to the SDU, 29.8% (17/57) returned to the NSICU during their admission. Of these, 9 patients returned because of suspected symptom-atic vasospasm, 5 returned for routine postoperative moni-toring following a subsequent procedure (2 for a ventricu-loperitoneal shunt and 3 for diagnostic angiography), and 2 returned because of culture-positive CSF infection. There were no emergency or unscheduled returns to the operat-ing room. Additional days spent in the NSICU after return from the SDU were included in the calculated NSICU LOS. Hospital course complications are presented in Table 2 and were not significantly different between the groups.

Unadjusted outcome measures comparing the 2 groups are described in Table 3. Hospital LOS was significantly longer in the intervention group prior to adjustments for pa-tient demographics, SAH severity measures, and medical comorbidities. Multivariate analysis of outcome measures was applied to adjust for age, sex, modified Fisher grade, Hunt and Hess grade, and Glasgow Coma Scale score, and the presence of medical comorbidities, including coro-nary artery disease, hypertension, and diabetes mellitus (Table 4). The primary outcome measure, NSICU LOS, was shorter in the intervention group by 1.95 days (95% CI -4.23 to 0.33 days), after adjusting for these covariates, and trended toward significance (p = 0.092). Paradoxical-ly, hospital LOS was longer in the intervention group by 2.7 days (95% CI -0.31 to 5.71), and also trended toward significance after multivariate adjustment (p = 0.080). The mortality rate was lower in the intervention group (5.6% vs 12.3%), although after adjustment the estimated odds of in-hospital death for patients in the intervention group were 0.49 (95% CI 0.11–2.19) times the odds for control group patients and therefore were not significantly differ-ent between the groups. The estimated odds of 90-day re-admission for intervention group patients were 1.96 (95%

CI 0.48–8.01) times the odds for control group patients, after adjustment.

The subgroup analysis of the intervention group re-vealed no statistically significant differences between the 3 groups (Table 5). There was no appreciable difference in 90-day readmission rate for those who were not trans-ferred, those transferred within 7 days of admission, and those transferred after more than 7 days of admission. In addition, there was no statistically significant difference in the rate of return to the NSICU between those transferred within 7 days and those transferred after 7 days of admis-sion.

DiscussionTo the best of our knowledge, this is the first study in-

vestigating the intrahospital transfer of low-risk patients with nontraumatic SAH to an SDU. Compared with a control population, institution of a transfer protocol to the SDU for low-risk patients with SAH resulted in a re-duction in the average NSICU LOS by approximately 2 days. This amounts to an appreciably improved NSICU bed availability, which is of utmost importance, as the care of SAH becomes centralized at high-volume centers. The total hospital LOS, however, was, on average, 2.7 days longer after the institution of the protocol. This dramatic increase may be partially explained by the fact that our medical center saw an increase in the number of patients with SAH transferred to our institution from approximate-ly 30 cases per year prior to January 2015 to about 100 cases per year afterward, which may have contributed to a loss of efficiency.

TABLE 2. Hospital complications

VariableControl Group

Intervention Group

p Value

No. of patients 65 72 NAVasospasm requiring IA therapy 12 (18.5) 17 (23.6) 0.300Hydrocephalus EVD required 35 (53.8) 44 (61.1) 0.246 VPS required 8 (12.3) 15 (20.8) 0.135Acute respiratory failure 33 (50.8) 37 (51.4) 0.539Tracheostomy required 9 (13.8) 9 (12.5) 0.507Pulmonary edema 3 (4.6) 5 (6.9) 0.418Pulmonary embolism 0 (0.0) 1 (1.4) 0.526DVT 4 (6.2) 8 (11.1) 0.237Pneumonia 9 (13.8) 8 (11.1) 0.410SICM 3 (4.6) 4 (5.6) 0.557Ventriculitis 5 (7.7) 6 (8.3) 0.572

DVT = deep venous thrombosis; EVD = external ventricular drain; IA = intra-arterial; SICM = stress-induced cardiomyopathy; VPS = ventriculoperitoneal shunt.Values are presented as the number of patients (%).

TABLE 3. Unadjusted transfer protocol outcomes

VariableControl Group

Intervention Group

p Value

Mean NSICU LOS in days 13.0 (6.4) 12.0 (8.3) 0.414Mean hospital LOS in days 16.6 (7.6) 19.9 (10.2) 0.036Discharge GOS score 0.716 1–3 35 (53.8) 31 (43.1) 4–5 30 (46.2) 41 (56.9)90-day readmission (%) 4 (6.2) 8 (11.1) 0.347

Values are presented as the number of patients (%) unless stated otherwise. Boldface type indicates statistical significance.

TABLE 4. Adjusted transfer protocol outcomes

VariableParameter Estimation OR

95% CI (lower, upper bounds)

Adjusted p Value

Mean NSICU LOS in days

−1.95 −4.23, 0.33 0.092

Mean hospital LOS in days

2.70 −0.31, 5.71 0.080

Death (GOS Score 1) 0.49 0.11, 2.19 0.35190-day readmission 1.96 0.48, 8.01 0.348

Adjusted by age, sex, modified Fisher grade, and Hunt and Hess grade.

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Of the patients transferred to the SDU, 17 (29.8%) re-quired return to the NSICU. However, 5 of these patients returned for routine monitoring following planned proce-dures and not due to a neurological decline. Among the patients who returned to the NSICU, there were no deaths or morbidity due to care in the SDU. This suggests that despite some patients needing to return to the NSICU, the monitoring in the SDU was appropriate and safe for all patients. Moreover, this suggests that the clinical eligibil-ity criteria that we applied were rigorous and conservative enough to capture only the low-risk patients.

The mortality rate was lower in the intervention group, although the difference was not statistically significant. Nonetheless, this demonstrates that the transfer protocol does not increase the mortality risk. The dichotomized GOS score at discharge was similar between the groups, indicating that the transfer protocol did not appreciably af-fect clinical outcome. Finally, the 90-day readmission rate was higher in the intervention group (11.1% vs 6.2%), but the difference was not statistically significant, suggesting that it did not appreciably affect long-term complication rates in this patient population.

Subgroup analysis assessing the timing of transfer ei-ther before or after 7 days did not reveal any statistically significant difference in need to return to the NSICU or in 90-day readmission rate. This suggests that both early and late transfers to an SDU are equally safe and that, once a patient meets the clinical criteria for transfer eligibility, the process can proceed.

Similar studies evaluating the effectiveness of admit-ting select low-risk patients to SDUs rather than to ICUs exist primarily in the traumatic brain injury (TBI) lit-erature. Nishijima and colleagues investigated whether traumatic intracranial hemorrhage, including traumatic SAH, could be cared for in non-ICU settings for low-risk patients.9 The authors categorized patients into high-risk and low-risk groups based on their need for critical care intervention prior to formal admission. Of the 58.4% of patients who were deemed to be low risk, only 3.2% were incorrectly categorized but were safely treated with trans-fer back to ICU-level care. The authors concluded that low-risk patients could be safely admitted to a non-ICU setting for observation using their selection criteria. Sub-sequent studies by the same group confirmed these same results in a larger, multicenter retrospective cohort and outlined a clinical decision rule for this patient popula-

tion.7,8,10 A study by Levy and colleagues built on these results by showing that isolated traumatic SAH in the set-ting of mild TBI is not associated with poor outcomes and may not require ICU admission.6

Bardes and colleagues performed a similar study in which patients with mild TBI who met low-risk criteria were cared for in the SDU without repeat imaging rather than in an intensive care setting with serial CT scans.2 The authors identified alternative criteria that included GCS score, age, and anticoagulant medication use and arrived at the conclusion that select low-risk patients could be safely treated in the SDU setting, echoing previous investi-gations.8,16 Similar findings of safe and cost-effective care in a non-ICU setting have also been reported in low-risk traumatic subdural hemorrhage and after elective neuroin-terventional procedures.1,13

Our study has several limitations. It was conducted retrospectively and is, therefore, subject to the limitations of electronic medical record review. In addition, it was completed at a single center, which limits its applicability, although our medical center serves a large, diverse popu-lation and receives transfers from a wide catchment area. Finally, the time periods for the control and intervention groups are, by nature of the study, not matched. It is pos-sible that additional changes to care protocols and person-nel may have influenced the results of the study.

ConclusionsThis retrospective study demonstrates that a transfer

protocol for select low-risk SAH patients from the NSICU to the SDU is feasible, safe, and effective. Further inves-tigation with a large randomized trial is needed to con-firm our results. Future research is also needed to identify SDU-transferred patients with a high likelihood of need-ing to be returned to the NSICU.

References 1. Albertine P, Borofsky S, Brown D, Patel S, Lee W, Caputy A,

et al: Small subdural hemorrhages: is routine intensive care unit admission necessary? Am J Emerg Med 34:521–524, 2016

2. Bardes JM, Turner J, Bonasso P, Hobbs G, Wilson A: De-lineation of criteria for admission to step down in the mild traumatic brain injury patient. Am Surg 82:36–40, 2016

3. Claassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Cope-land D, et al: Effect of cisternal and ventricular blood on risk of cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke 32:2012–2020, 2001

4. Frontera JA, Claassen J, Schmidt JM, Wartenberg KE, Temes R, Sander Connolly E, et al: Prediction of symptomatic va-sospasm after subarachnoid hemorrhage: the modified Fisher scale. Neurosurgery 59:21–27, 2006

5. Groeger JS, Guntupalli KK, Strosberg M, Halpern N, Rapha-ely RC, Cerra F, et al: Descriptive analysis of critical care units in the United States: patient characteristics and inten-sive care unit utilization. Crit Care Med 21:279–291, 1993

6. Levy AS, Orlando A, Hawkes AP, Salottolo K, Mains CW, Bar-Or D: Should the management of isolated traumatic sub-arachnoid hemorrhage differ from concussion in the setting of mild traumatic brain injury? J Trauma 71:1199–1204, 2011

7. Nishijima DK, Haukoos JS, Newgard CD, Staudenmayer K, White N, Slattery D, et al: Variability of ICU use in adult

TABLE 5. Intervention subgroup analysis: transfer protocol outcomes by timing

VariableNot

Transferred

SDU Transfer From Admission p

Value≤7 Days >7 Days

No. of patients 15 (20.8) 28 (38.9) 29 (40.3) NAReturned to NSICU NA 11 (19.3) 6 (10.5) 0.38290-day readmission 3 (20.0) 3 (10.7) 2 (6.9) 0.610*

Values are presented as the number of patients (%).* Significance of chi-square statistic produced by the cross-tabulation of trans-fer within 7 days and transfer after 7 days. Patients who were not transferred were excluded from this calculation.

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patients with minor traumatic intracranial hemorrhage. Ann Emerg Med 61:509–517, 517.e1–517.e4, 2013

8. Nishijima DK, Sena M, Galante JM, Shahlaie K, London J, Melnikow J, et al: Derivation of a clinical decision instru-ment to identify adult patients with mild traumatic intracrani-al hemorrhage at low risk for requiring ICU admission. Ann Emerg Med 63:448–456, 456.e1–456.e2, 2014

9. Nishijima DK, Sena MJ, Holmes JF: Identification of low-risk patients with traumatic brain injury and intracranial hemorrhage who do not need intensive care unit admission. J Trauma 70:E101–E107, 2011

10. Nishijima DK, Shahlaie K, Echeverri A, Holmes JF: A clini-cal decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission. Injury 43:1827–1832, 2012

11. Nuño M, Patil CG, Lyden P, Drazin D: The effect of transfer and hospital volume in subarachnoid hemorrhage patients. Neurocrit Care 17:312–323, 2012

12. Prin M, Wunsch H: The role of stepdown beds in hospital care. Am J Respir Crit Care Med 190:1210–1216, 2014

13. Richards BF, Fleming JB, Shannon CN, Walters BC, Har-rigan MR: Safety and cost effectiveness of step-down unit admission following elective neurointerventional procedures. J Neurointerv Surg 4:390–392, 2012

14. Rosner J, Nuno M, Miller C, Palestrant D, Schievink WI, Alexander MJ, et al: Subarachnoid hemorrhage patients: to transfer or not to transfer? Neurosurgery 60 (Suppl 1):98–101, 2013

15. Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM: Rationing critical care beds: a systematic review. Crit Care Med 32:1588–1597, 2004

16. Washington CW, Grubb RL Jr: Are routine repeat imaging

and intensive care unit admission necessary in mild trau-matic brain injury? J Neurosurg 116:549–557, 2012

17. Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EA, et al: Variation in critical care services across North America and Western Europe. Crit Care Med 36:2787–2793, e1–e9, 2008

DisclosuresThe authors report the following. Dr. Mocco: consultant for Rebound Medical, Endostream, Synchron, Cerebrotech; owner-ship in Apama, The Stroke Project, Endostream, Synchron, Cere-brotech, NeurVana, and NeuroTechnology Investors. Dr. Mayer: consultant for Idorsia Pharmaceuticals and Edge Pharmaceuticals.

Author ContributionsConception and design: Gordon, Chartrain, Awad, Sarkiss, Bed-erson, Mayer, Dangayach. Acquisition of data: Feng. Analysis and interpretation of data: Chartrain. Drafting the article: Char-train. Critically revising the article: Gordon, Chartrain, Awad, Sarkiss, Feng, Mocco, Dangayach. Reviewed submitted version of manuscript: all authors. Statistical analysis: Chartrain, Liu. Study supervision: Gordon, Mocco, Bederson, Mayer, Dangayach.

CorrespondenceErrol Gordon, Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave., Annenberg Bldg., 8th Fl., NSICU, New York, NY 10029. email: [email protected].

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