Introduction: Intensive care unit (ICU) admission and staffing account for more than 1% of U.S. GDP and a significant amount of medicare expenditures (1),(2). Studies show potential savings using intensivist staffing in the ICU (1),(3). These studies include very few neurosurgical wards or patients (1). Slight improvement in patient outcomes have been shown in the neuroscience ICU, but in largely nonsurgical patients (4). For neurosurgical patients, decreased cost and length of stay when patients have been shown after floor admission (5). This study adds information (6) about variables predictive of ICU admission and intensivist staffing.

Methods: Charts of 505 patients undergoing common cranial based procedures were reviewed. Patient demographics, medical history, and opperating room data were predictive variables. ICU level interventions and intensivist interventions were dependent variables. Paired t-test and Fisher exact test identified variables that differed significantly among patients requiring ICU level and intensivist interventions. Significant variables were evaluated using logistic regression to identify predictors for ICU and intensivist intervention.

Results: Intensive care unit interventions occurred in 233 (46%) patients. Intensivist interventions occurred in 69 patients (14%). Variables predictive of ICU admission were increased OR time, nonelective case, history of hypertension, and general anesthesia. Increased blood loss, increased OR time, nonelective case, ASA class 4 or 5, and intraoperative complication predicted intensivist intervention. These predictive factors were retrospectively applied to identify patients who may not need intensivist or ICU level interventions to identify potential cost savings. Intensivist billing and ICU versus floor cost were analyzed. This showed between $88,444 and $279,562 could be saved.

Conclusions: Increased OR time, nonelective case, history of hypertension, and general anesthesia predicted the need for ICU level intervention. Increased blood loss, increased OR time, nonelective case, ASA class 4 or 5, and intraoperative complication predicted the need for intensivist intervention. Cost savings range from $88,444 and $279,562.

Patient Care: This study adds to current literature that suggests patients may not need or benefit from routine ICU admission and compulsory involvement of critical care physicians in their care. As such, patients may benefit by having safe care provided soley by their neurosurgeon and potentially in a floor setting. This may provide adequate care at a reduce billing cost to patients.

Learning Objectives: By the conclusion of this session, participants will be able to: 1)Identify key studies leading to ICU staffing patterns 2)Recognize Leapfrog ICU staffing patterns and recommendations 3)Recognize key pre-operative and intraoperative findings that may predict need for ICU admission after cranial based procedures 4)Identify how these findings may lead to reduction in costs to patients.

References: 1)Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review. JAMA. 2002;288(17):2151-2162. 2) Logani, Sachin, Adam Green, and James Gasperino. "Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act." Critical Care Research and Practice 2011 (2011): 1-7. Web. 3) Pronovost, Peter J., Dale M. Needham, Hugh Waters, Christian M. Birkmeyer, Jonah R. Calinawan, John D. Birkmeyer, and Todd Dorman. "Intensive Care Unit Physician Staffing: Financial Modeling of the Leapfrog Standard*." Critical Care Medicine 32.6 (2004): 1247-253. Web. 4)Diringer, Michael N., and Dorothy F. Edwards. "Admission to a Neurologic/neurosurgical Intensive Care Unit Is Associated with Reduced Mortality Rate after Intracerebral Hemorrhage." Critical Care Medicine 29.3 (2001): 635-40. Web. 5)Beauregard, Curtis L., and William A. Friedman. "Routine Use of Postoperative ICU Care for Elective Craniotomy: A Cost-benefit Analysis." Surgical Neurology 60.6 (2003): 483-89. Web. 6)Hanak, Brian W., Brian P. Walcott, Brian V. Nahed, Alona Muzikansky, Matthew K. Mian, William T. Kimberly, and William T. Curry. "Postoperative Intensive Care Unit Requirements After Elective Craniotomy." World Neurosurgery (2012): Web.