By Eelco Wijdicks, MD, PhD; Alejandro Rabinstein, MD; Sara Hocker, MD; and Jennifer Fugate, DO
Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
The Neurosciences Intensive Care Unit (neuro-ICU) at Mayo Clinic Rochester was arguably one of the first combined neurology-neurosurgery intensive care units in the U.S. The idea to build a dedicated neuroscience unit in Saint Marys Hospital originated with the Sisters of St. Francis, who recognized that patients with severe traumatic brain injury and post craniotomy required very close neurological monitoring. The Mayo Clinic quickly honored the Sisters’ devotion to patients, and in 1958 the neuro-ICU opened in Saint Marys Hospital. There was a strong impetus to train nurses in the more complex care of these patients. As was the case with virtually every intensive care unit in the country, these units were initially open. However, in 1993, a more organized plan of care for all critically ill neurology patients began in the 20-bed neuro-ICU to provide close evaluation and co-management of selected neurosurgery patients.
Over the last two decades, there have been gradual but important changes. The neurocritical care group provides a primary service with a number of major responsibilities. First and foremost is the care of the critically ill neurologic and neurosurgical patients, from A to Z, from top to toe, from ICP to SCD. A devoted team, led by a 24/7 neurointensivist, provides close bedside care with a major emphasis on the clinical neurologic manifestations of deterioration and specific treatment of a number of major neurologic emergencies. The model of care in our neuro-ICU is closed: all orders in patients under our care are written by our team, in agreement with neurosurgery when pertinent. Anesthesia support is available for supervision of invasive procedures, but procedures are performed by the neurocritical care fellow. All admissions to the neuro-ICU are selected on the basis of the acuteness of the neurologic condition. All stroke patients with with large-vessel occlusions requiring endovascular intervention receive specialized neurocritical care. Major acute stroke care is provided by the neurocritical care team, which is physically in the radiology suite examining the patient, interpreting the CTA and CT perfusion scans, and remaining on-site during the procedure to provide additional decision making in conjunction with the interventionalist. Currently, all critically ill neurosurgical patients are under the close care of the neurointensive care team. The neurointensive care team also manages patients in the emergency department before they are admitted to the unit ― closing the commonly perceived gap between care in the ED and neuro-ICU.
A unique component of our division is a separate hospital service that provides acute neurological consultations to all other surgical and medical adult intensive care units including general medical, general surgical, cardiovascular, general trauma, transplant and oncology cases. This has allowed us to develop expertise in the neurology of critical illness with its constantly changing challenges (from early transplant-associated neurotoxicity to ECMO and CAR-T treatment).
Mayo Clinic’s Rochester campus has four neurointensivists who share call. (A fifth neurointensivist will join our division in 2019.) The rounding team consists of the consultant, neuro-ICU fellow, a day and night resident (12-hour shifts), nurse practitioner or physician assistant, meurology ICU pharmacist, charge nurse and clinical nurse specialist. Our neurointensivists have a strong academic record, and all have published and been cited extensively. We participate actively in research including participation in clinical trials. We have a research coordinator dedicated to our ICU.
For many years, we have had a fellowship program. Under the guidance of the consultant, the fellow is directly responsible for the care of patients with acute neurological emergencies. Our fellows have exposure to all forms of neurologic emergencies such as traumatic brain injury at a level 1 trauma center, acute ischemic stroke, including endovascular treatment, intracerebral hemorrhage, subarachnoid hemorrhage, coma, status epilepticus and acute neuromuscular diseases, among many other challenging complex disorders. Our fellows learn to manage systemic consequences of complications from acute neurologic injury but also receive full training in general critical care working with other critical care fellows during their several rotations in other surgical and medical ICUs. Before starting their clinical rotations, our fellows participate in a mandatory “boot camp” to learn all necessary procedures and the basics of ICU care. The fellows must also direct end-of-life care conferences and family communications. Moreover, they are asked to lead the consultative neurocritical care service when not serving as the fellow in the neuro-ICU or rotating through the other ICUs. Fellows also staff acute neurology cases seen by senior residents in the emergency department throughout the second year of fellowship and lead rounds. We have deliberately decided to open only one position per year to ensure that our fellows receive the best possible training and the optimal degree of mentorship. (Eager and energetic fellows can expect a good boost to their CV.)
We enjoy a cordial, collegial relationship with the nursing staff and other allied healthcare workers; all of us are fully congruent to Mayo model of care. We all tremendously enjoy our work, treasure our long friendships, and strive to provide the best outcome for patients in the midst of a major acute event. We closely support distressed families whose loved ones are admitted to the unit and prepare them for possible secondary complications and offer realistic predictions of the recovery trajectory. When recovery is unachievable, we facilitate palliative and pastoral care. We have all the proven and tested technology available to us, but we stay true to our neurology roots, which drives our decisions. At Mayo Clinic, the practice of neurocritical care is part of our fabric, it is something that is always there, and we are proud to do it.
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