Evaluation of Optimal Triage Mechanism for Hospitalized Patients with Aneurysmal Subarachnoid Hemorrhage

Abstract

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a potentially life-threatening neurologic condition. Significant secondary complications after the initial hemorrhage variably occur in a delayed fashion, leading to the highest risk period for mortality. For this reason, most patients are monitored in the neuroscience intensive care unit for upwards of 14-21 days post hemorrhage to prevent delayed detection of a critical complication in a less monitored environment. Given the variability in post hemorrhage complications, lengthy neuroscience intensive care unit (ICU) stays for all patients is arguably considered a poor utilization of critical care resources and cost ineffective. Unfortunately, practice guidelines do not specify the recommended ICU length of stay after aSAH. The Queen’s Medical Center (QMC) in Honolulu, Hawaii is home to the only dedicated neuroscience ICU in the Pacific Basin. Neurocritical care resources at QMC are limited considering it serves the majority of patients in the state with complex neurological illnesses and injuries. Effective utilization of neuroscience ICU beds at QMC is essential to delivering crucial care to those in need. Purpose: The purpose of this DNP project was 1) to analyze clinical characteristics of aSAH patients at QMC, 2) determine triage criteria for safe transfer to the floor on day seven, 3) and evaluate the performance of the floor transfer criteria. Methods: All spontaneous aSAH patients hospitalized at QMC during a four-year period were retrospectively reviewed. The aim of this project was to derive triage criteria for safe transfer to the floor on day seven. Results: Clinical characteristics of patients who were deemed not appropriate for floor transfer on day seven were compared to those appropriate for floor transfer on day seven. Significant variables in the univariate analysis were included in the multivariable model to predict appropriate criteria for floor transfer on day seven. The multivariable model demonstrated that coil embolization as method of aneurysm treatment, non-middle cerebral artery aneurysm location, no external ventricular drain, no other neurosurgical intervention day one through seven, and no cerebral vasospasm on neuroimaging day one through seven were predictors of appropriate floor transfer on day seven. The performance and accuracy of the floor transfer criteria was assessed by calculating the area under the receiver operating characteristic (ROC) curve, which was 0.875. Although the area under the ROC curve indicates positive performance of the floor transfer criteria, future prospective testing on a larger cohort of aSAH patients is warranted to further validate the model.