Early Mobilization in Aneurysmal Subarachnoid Hemorrhage Accelerates Recovery and Reduces Length of Stay

BackgroundPatients with aneurysmal subarachnoid hemorrhage (aSAH) frequently suffer from vasospasm. We analyzed the association between absence of early angiographic vasospasm and early discharge.MethodsAll aSAH patients treated from August 1, 2007, to July 31, 2019, at a single tertiary center were reviewed. Patients undergoing diagnostic digital subtraction angiography (DSA) on post-aSAH days 5 to 7 were analyzed; cohorts with and without angiographic vasospasm (angiographic reports by attending neurovascular surgeons) were compared. Primary outcome was hospital length of stay; secondary outcomes were intensive care unit length of stay, 30 day return to the emergency department (ED), and poor neurologic outcome, defined as a modified Rankin Scale (mRS) score >2.ResultsA total of 298 patients underwent DSA on post-aSAH day 5, 6, or 7. Most patients (n=188, 63%) had angiographic vasospasm; 110 patients (37%) did not. Patients without vasospasm had a significantly lower mean length of hospital stay than vasospasm patients (18.0±7.1 days vs 22.4±8.6 days; p<0.001). The two cohorts did not differ significantly in the proportion of patients with mRS scores >2 at last follow-up or those returning to the ED before 30 days. After adjustment for Hunt and Hess scores, Fisher grade, admission Glasgow Coma Scale score, and age, logistic regression analysis showed that the absence of vasospasm on post-aSAH days 5–7 predicted discharge on or before hospital day 14 (OR 3.4, 95% CI 1.8 to 6.4, p<0.001).ConclusionLack of angiographic vasospasm 5 to 7 days after aSAH is associated with shorter hospitalization, with no increase in 30 day ED visits or poor neurologic outcome.

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Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences

Neurosurgical FOCUS ◽

10.3171/foc.1997.2.2.1 ◽

1997 ◽

Vol 2 (2) ◽

pp. E1

Author(s):

Christopher L. Taylor ◽

Zhong Yuan ◽

Warren R. Selman ◽

Robert A. Ratcheson ◽

Alfred A. Rimm

Keyword(s):

New York ◽

Subarachnoid Hemorrhage ◽

Mortality Rate ◽

Length Of Stay ◽

Older Patients ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Hospital Length Of Stay ◽

Annual Number ◽

Geographical Differences ◽

The Cost

The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

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Safety and Feasibility of an Early Mobilization Program for Patients With Aneurysmal Subarachnoid Hemorrhage

Physical Therapy ◽

10.2522/ptj.20110334 ◽

2013 ◽

Vol 93 (2) ◽

pp. 208-215 ◽

Cited By ~ 38

Author(s):

Brian F. Olkowski ◽

Mary Ann Devine ◽

Laurie E. Slotnick ◽

Erol Veznedaroglu ◽

Kenneth M. Liebman ◽

...

Keyword(s):

Heart Rate ◽

Subarachnoid Hemorrhage ◽

Physical Therapist ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Early Mobilization ◽

Therapeutic Exercise ◽

Mean Flow ◽

Functional Training ◽

Prolonged Monitoring ◽

Mean Flow Velocity

BackgroundSurvivors of aneurysmal subarachnoid hemorrhage (SAH) are faced with a complicated recovery, which typically includes surgery, prolonged monitoring in the intensive care unit, and treatment focusing on the prevention of complications.ObjectiveThe purpose of this study was to determine the safety and feasibility of an early mobilization program for patients with aneurysmal SAH.DesignThis study was a retrospective analysis.MethodsTwenty-five patients received early mobilization by a physical therapist or an occupational therapist, or both, which focused on functional training and therapeutic exercise in more progressively upright positions. Participation criteria focused on neurologic and physiologic stability prior to the initiation of early mobilization program sessions.ResultsPatients met the criteria for participation in 86.1% of the early mobilization program sessions attempted. Patients did not meet criteria for the following reasons: Lindegaard ratio >3.0 or middle cerebral artery (MCA) mean flow velocity (MFV) >120 cm/s (8.1%), mean arterial pressure (MAP) <80 mm Hg (1.8%), intracranial pressure (ICP) >15 mm Hg (1.8%), unable to open eyes in response to voice (0.9%), respiratory rate >40 breaths/min (0.6%), MAP >110 mm Hg (0.3%), and heart rate <40 bpm (0.3%). Adverse events occurred in 5.9% of early mobilization program sessions for the following reasons: MAP <70 mm Hg (3.1%) or >120 mm Hg (2.4%) and heart rate >130 bpm (0.3%). The 30-day mortality rate for all patients was 0%. Participation in the early mobilization program began a mean of 3.2 days (SD=1.3) after aneurysmal SAH, and patients received an average of 11.4 sessions (SD=4.3). Patients required a mean of 5.4 days (SD=4.2) to participate in out-of-bed activity and a mean of 10.7 days (SD=6.2) to walk ≥15.24 m (50 ft).ConclusionsThe results of this study suggest that an early mobilization program for patients with aneurysmal SAH is safe and feasible.

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A step-down unit transfer protocol for low-risk aneurysmal subarachnoid hemorrhage

Neurosurgical FOCUS ◽

10.3171/2017.8.focus17448 ◽

2017 ◽

Vol 43 (5) ◽

pp. E15 ◽

Cited By ~ 6

Author(s):

Alexander G. Chartrain ◽

Ahmed J. Awad ◽

Christopher A. Sarkiss ◽

Rui Feng ◽

Yangbo Liu ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Length Of Stay ◽

Readmission Rate ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Intervention Group ◽

Retrospective Chart Review ◽

Low Risk ◽

Control Group ◽

Step Down ◽

Transfer Protocol

OBJECTIVEPatients 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.METHODSIn 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.RESULTSOf 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.CONCLUSIONSIn 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.

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Costs of Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/01.neu.0000371980.08391.71 ◽

2010 ◽

Vol 67 (2) ◽

pp. 345-352 ◽

Cited By ~ 16

Author(s):

Chia-Hung Chou ◽

Shelby D. Reed ◽

Jennifer S. Allsbrook ◽

Janet L. Steele ◽

Kevin A. Schulman ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Length Of Stay ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Endovascular Coiling ◽

Billing Data ◽

Surgical Clipping ◽

Physician Billing ◽

Symptomatic Vasospasm ◽

Hospital Stays ◽

The Impact

Abstract OBJECTIVE To assess the impact of vasospasm on costs, length of stay, and mortality among inpatients with aneurysmal subarachnoid hemorrhage. METHODS We combined hospital accounting and physician billing data for a consecutive cohort of 198 patients who underwent surgical clipping or endovascular coiling for subarachnoid hemorrhage repair. We considered patients with transcranial Doppler (TCD) velocity of 120 cm/s or greater in the middle cerebral artery to have TCD-defined vasospasm and patients with delayed ischemic neurological deficit to have symptomatic vasospasm. We compared outcomes of patients with TCD-defined vasospasm (n = 116) and those without (n = 73) and patients with symptomatic vasospasm (n = 62) and those without (n = 127), adjusting for demographic and clinical characteristics. RESULTS In adjusted analyses, the incremental cost attributable to TCD-defined vasospasm was 1.20 times higher (95% confidence interval, 1.06–1.36; P = .004) than for patients without TCD-defined vasospasm. Length of stay was an estimated 1.22 times longer for patients with TCD-defined vasospasm (95% CI, 1.07–1.39; P < .01). For symptomatic vasospasm, adjusted costs were 1.27 times higher (95% CI, 1.12–1.43; P < .001) and length of stay was an estimated 1.24 times longer (95% CI, 1.09–1.40; P < .01) for patients with vasospasm than for those without. There was no significant relationship between either type of vasospasm and in-hospital mortality. CONCLUSION Patients with subarachnoid hemorrhage and TCD-defined or symptomatic vasospasm incur higher inpatient costs and longer hospital stays than those without vasospasm.

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Reducing length of stay in aneurysmal subarachnoid hemorrhage: A three year institutional experience

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2017.03.049 ◽

2017 ◽

Vol 42 ◽

pp. 66-70 ◽

Cited By ~ 12

Author(s):

Ali Alaraj ◽

Ahmed E. Hussein ◽

Darian R. Esfahani ◽

Sepideh Amin-Hanjani ◽

Victor A. Aletich ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Length Of Stay ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Institutional Experience

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Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences

Journal of Neurosurgery ◽

10.3171/jns.1997.86.4.0583 ◽

1997 ◽

Vol 86 (4) ◽

pp. 583-588 ◽

Cited By ~ 61

Author(s):

Christopher L. Taylor ◽

Zhong Yuan ◽

Warren R. Selman ◽

Robert A. Ratcheson ◽

Alfred A. Rimm

Keyword(s):

New York ◽

Subarachnoid Hemorrhage ◽

Mortality Rate ◽

Length Of Stay ◽

Older Patients ◽

Aneurysmal Subarachnoid Hemorrhage ◽

New York State ◽

Hospital Length Of Stay ◽

Annual Number ◽

The Cost

✓ The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York state were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

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