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The Development of Pediatric Neurocritical Care


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  • 1. August 2008 Inside This Issue The Development of Pediatric Neurocritical Care pediatric centers able to support a NICU (12). In addition, the technical expertise of PCCM will often be required for many young children. Finally, in contrast to adults, the care of critically ill children is delivered in more varied settings: major regional and local children’s hospitals with multidisciplinary PICUs, PICUs within adult medical centers, and in some locations, the general ICU of community hospitals. Rather than focus just on dedicated NICUs, we must develop systems that improve pediatric NCC across all settings as quickly as possible after the onset of a CNS insult. How can this be done? We must now evaluate the delivery of pediatric NCC and plan the future. In most PICUs, neurologic care is provided on a consultative basis by a general child neurologist, and even in the largest children’s hospitals, only a few child neurologists specifically practice NCC. We know that larger programs can support a dedicated critical care neurology service: At Children’s Hospital, Boston, our critical care neurology consult service saw 557 new consults and 3,539 follow-up visits in 2006 (13). We provided emergent consultations 24 hours per day. Smaller child neurology programs could not support this endeavor, but could have a dedicated critical care neurologist for continued on page 11 tensive care unit (NICU). Adult NCC has established itself as an approved subspecialty with training, fellowship programs, and research. The same advances occurred in pediatric critical care medicine (PCCM) and the pediatric ICU (PICU) (3, 4). Clinical research reveals that dedicated units (PICU, NICU), staffed by full-time intensivists, improve care with reduced mortality and morbidity rates and lengths of stay (5-10). Dedicated NICUs have survived because the diseases treated are frequent enough to allow separation from a multi-disciplinary ICU. However, our journey in pediatric NCC has been passive, following PCCM and adult NCC. It is now time that we take an active role and develop effective models for the delivery of pediatric NCC. Certainly following the adult experience, a dedicated NICU could be supported in the largest children’s hospitals, especially if we combine neurologic and neurosurgical cases (a neuroscience service). Alternatively, there could be a dedicated neuroscience team within a multi-disciplinary PICU. But can we practically follow the adult NICU, which is staffed by neurologists with subspecialty training in NCC or stroke? In pediatric neurocritical care, the disease spectrum is diverse. The reason for consultation by the Pediatric Neurocritical Care Medicine team (neurologist, PCCM specialist, and neurosurgeon), at the Children’s National Medical Center, was seizure or possible seizure in 132 (35.3%) cases and the most common diagnosis was status epilepticus in 70 (18.9%) versus SAH/ICH in 13 (3.5%) and stroke in 7 (1.9%) (11). Currently, most PICUs are closed units with patients admitted to the PCCM service and cared for around the clock by pediatric residents and critical care fellows. With the current workforce shortage, there may not be enough child neurologists available to provide this level of care even in By James J. Riviello, Jr., MD Neurocritical Care (NCC) has come a long way (1, 2). Technologic advanc- es in respiratory care, anesthesiology and post- operative care helped create the neurologic in- President’s Corner P. 2 By Cherylee W. Chang MD Note from the Editor P. 3 By Romergryko G. Geocadin MD Neurocritical Care Research Conference P. 4 By Matthew A. Koenig MD Advocacy for the Neurointensivist P. 5 By Wendy L. Wright MD Featured Program: Dresden Medical Center NICU P. 6 By Katja E. Wartenberg MD, PhD NINDS Research on TBI P. 7 By Lori Shutter MD Fellows Corner P. 8 By Susanne Muehlschlegel MD Neurointensive Care Nursing P. 9 By Sarah Livesay, MS, RN, APRNc and Susan Yeager, MS, RN, CCRN, ACNP Cardiac Arrest Conference P. 11 By G. Bryan Young MD Neurocritical Care Classifieds P. 13
  • 2. Currents August 2008 President’s Corner By Cherylee W. Chang MD It has been a very busy few months for the Neurocritical Care Soc- iety. Since the UCNS Neuro- critical Care (NCC) examination has been administered, directors of critical care pro- grams are attempting to understand the scope of practice of neurointensivists and how neurointensivists can staff specialty and multidisciplinary critical care units. This is a national challenge, but should become more defined as more NCC training programs are accredited and more individuals certified in NCC. Recently, an article appeared in Critical Care Medicine regarding the crisis of the shortage of the critical care workforce. [Krell K. Critical care workforce. Crit Care Med 2008; 36:1350- 1353]. The author specifically commented that critical care training is fragmented because of subspecialties such as neuro- critical care. He erroneously commented that fellows in neurocritical care are not eligible to sit for any critical care specialty board because “their exposure is too narrow”. This misperception highlights a widely held notion that neurointensivists do not know general critical care and that there is no certification process. I direct you to the response from the NCS in form of a Letter to the Editor that will be published shortly in Critical Care Medicine. With regard to NCC training, Wade Smith, MD is working with the NCS Accreditation Committee to establish and facilitate a uniform process for fellowship application. This will involve the input of fellowship directors particularly in creating a process for offers and acceptance which will likely include a web-based system. Look for more information in a future newsletter. The Certification Writing committee for the 2008 UCNS examination met and finalized the examination which will be offered again this winter. At this time, the UCNS has elected not to offer the examination in 2009. It will be offered again in 2010 and 2011. There continue to be ongoing concerns and queries regarding eligibility criteria for the UCNS examination. Although the current qualifications include Diplomates in good standing of the American Board of Medical Specialties in neurology, neurological surgery, internal medicine, anesthesiology, surgery, emergency medicine, pediatrics or equivalent certification by the Royal College of Physicians and Surgeons of Canada, the question remains as to whether Doctors of Osteopathy or physicians from countries other than the United States and Canada will eventually be able to take the examination. The NCS and the UCNS are aware of these concerns. It is important to note that it is the UCNS that determines these factors, not the NCS. With regards to NCC certification, the NCS had the choice to work with the UCNS that allows physicians from multiple specialties to sit for the exam. The other option for a recognized certification was by means of an ACGME certification through the American Board of Psychiatry and Neurology. This would have limited NCC certification to United States neurologists alone. Please continue to communicate your concerns, as change is feasible, but recognize the constraints that the NCS has with respect to this issue. Updates from my end include the NCS progress in participating in national endeavors pertaining to the neurologically critically ill patient. Many NCS members are serving as liaisons on various projects to further the mission of the NCS. These include: Organ donation and death by neurological criteria: The Medical Director’s Council of the Association of Organ Procurement Organizations has identified the need to standardize criteria for eligibility for organ donation based on the diagnosis of brain death. As we have seen recently in the lay press as well as the published literature, there is a large variation in practice and hospital criteria to diagnose brain death. Organ procurement agencies are being surveyed nationally and appropriate standards and criteria for donation eligibility will be developed. Standardized criteria are essential to build public confidence in the organ donation process. Michael Souter, MD as a member of both organizations, is chiefly responsible for the Council’s solicitation of NCS input. He will serve as the liaison between the NCS and the Association of the OPOs. David Greer, MD will also be working with Dr. Souter. Page 2 Newsletter Advertising Display or Classified Contact: (952) 646-2034 continued on page 3 NCS Leadership 2008-2009 Officers Cherylee W.J. Chang MD, president Stephan A. Mayer MD, vice president Gene Sung MD, treasurer J. Claude Hemphill, III, MD, secretary Michael N. Diringer MD immediate past president Directors Neeraj Badjatia MD Anish Bhardwaj MD J. Ricardo Carhuapoma MD William M. Coplin MD Michael A. DeGeorgia MD Romergryko G. Geocadin MD Deborah M. Green MD Daryl R. Gress MD Christiana E. Hall MD Andrew W. Kofke MD Geoffrey Ling MD Edward Manno MD J. Javier Provencio MD Guy Rordorf MD Owen B. Samuels MD Wade S. Smith MD Thorsten G. Steiner MD Jose I. Suarez MD Michael T. Torbey MD Paul M. Vespa MD Wendy C. Ziai, MD Administrative Director Janel Fick Editor-in-Chief, Neurocritical Care Eelco F.M. Wijdicks MD Neurocritical Care Society 5841 Cedar Lake Road, Suite 204 Minneapolis, MN 55416 Phone: (952) 646-2034 Fax: (952) 545-6073 Website: Email:
  • 3. Currents August 2008 Page 3 Note From the Editor By Romergryko G. Geocadin, MD We are witnessing the NCS define its role in closely related subspecialties. Our lead article by Dr. Jim Riviello shows us the opportunities and the chall- enges in pediatric neurocritical care. As reflected in the column by our president Dr. Cherylee Chang, the NCS is also defining the role of neurocritical care in organ donation and brain death, in defining the post-cardiac arrest syndrome, in carotid stenting program accreditation and in the strategic planning with the AAN section of Critical Care and Emergency Neurology (CCEN). Other areas where neurocritical care is also significantly contributing are in translational research in traumatic brain injury (see article by Dr. Lori Shutter) and in neurologic outcome after cardiac arrest resuscitation (see article by Dr. Bryan Young). The regular sections of the newsletter continue to provide important updates. The column by Dr. Koenig features the First Neuro- critical Care Research Conference planned for 2009. For the nursing section, Sarah Livesay and Susan Yeager take us to the multiple nursing specialties at work in the neurocritical care environment. Dr Susanne Muehlschlegel provides very helpful advice on networking for fellows and all members of the NCS. The featured program section brings us an interesting article by Dr. Katja Wartenberg on Neuro-ICU program at the University of Dresden Medical Center in Germany. As we continue to move ahead, we also need to be aware of threats to our practice. The advocacy column by Dr. Wendy Wright provides us with the recent developments from the Center of Medicare and Medicaid Services (CMS), which may have a significant consequence on our ability to bill and provide critical care. As in the past issues, I am thankful to the contributors and the newsletter editorial group. I also encourage the NCS members to let us know of any meetings or any developments that may have an impact on the field of neurocritical care. We will work with you to develop articles for upcoming issues of Currents. . Carotid stenting accreditation pro- gram: The past-President of the Society of Interventional Radiology, David Sacks, MD, has been working with the specialties of neurology, radiology, neurosurgery and vascular surgery to create a multi-specialty accreditation program for centers performing carotid artery stent placement. The group will be working with the Intersociety Accreditation Commission to establish facility and quality measures. Thanks to the efforts of Buddy Connors, MD and Dr. Sacks, the NCS has been asked to participate in this endeavor. Our represent- ative is John Terry, MD, who will be working with representatives from the American Academy of Neurology (AAN), American Association of Neurological Surgeons/Cereb- rovascular Section (AANS) , American College of Radiology (ACR), American Society of Neuroradiology (ASNR), Society for Vascular Surgery (SVS), Society of Interventional Radiology (SIR), and the Society of Neurointerventional Surgery (SNIS). Post-cardiac arrest AHA statement: Romergryko Geocadin, MD has been the NCS liaison to the American Heart Association in the development of an AHA-ILCOR Statement on “Post-cardiac Arrest Syndrome”. This statement, authored by a multidisciplinary and international panel has completed peer review and the NCS has been asked to formally endorse this statement. American Academy of Neurology and NCS strategic plan: In October, at the Annual NCS Meeting in Miami, the Board of Directors will be working on a long-term strategic plan for the NCS. In a very timely coincidence, the American Academy of Neurology is evaluating how it can interface and support its subspecialty groups. The section executives of the Critical Care and Emergency Neurology Section, including Walter Koroshetz, MD and William Coplin, MD, will work with the NCS Board as we envision and create a strategic plan that will best support the NCS mission. First Neurocritical Care Research Conference: Jose Suarez, MD, chair of the NCS Clinical Trials Committee has been planning the research conference that will focus on research priorities, clinical trial design and tools in neurocritical care. An NIH grant seeking support for this conference has been submitted. This planned conference is highlighted in this issue of the newsletter. Finally, the 6th Annual NCS Meeting and the UCNS Review course is fast approaching. The planning committee lead by Vice- President Stephan Mayer, MD, and the scientific committee under the leadership of E. Claude Hemphill, MD have been creating a not-to-be-missed meeting in Miami. I look forward to seeing you there! Neurointensivist Certification Among Issues Facing NCS Quarterly Newsletter of the Neurocritical Care Society August 2008 Volume 3 - Number 3 Editor Romergryko G. Geocadin MD Baltimore, MD Editorial Board Stephan A. Mayer MD New York, NY Matthew A. Koenig MD Baltimore, MD Ashok Devasenapathy MD Hershey, PA Wendy L. Wright MD Atlanta, GA Robert G. Kowalski Ireland Janel Fick Minneapolis, MN Susanne Muehlschlegel MD Boston, MA Sarah Livesay MS, RN, APRNc Houston, TX Continued from page 2
  • 4. Currents August 2008 Page 4 Neurocritical Care Research Conference in September, 2009 in Houston, TX. The two-day conference, hosted by Dr. José Suarez, MD and sponsored by the Neurocritical Care Society, will bring together scientists on the forefront of research in neurocritical care. The primary goals are to identify research priorities in neurocritical care, draft a consensus statement, and establish a collaborative network to foster multi- center trials. “The overall goal of this interdisciplinary scientific symposium is to bring together scientists and physicians from diverse fields with a common interest in understanding and advancing research in neurocritical care diseases,” says Dr. Suarez. The planned establishment of a neurocritical care research consortium also coincides with the NIH-sponsored Neurological Emergencies Treatment Trials (NETT) consortium, which funds infrastructure for large, multicenter trials in neurological emergencies. The first two NETT-supported trials are scheduled to begin enrollment within the next year. Both developments promise to significantly increase collab- orative research in neurocritical care. The structure and administration of a neurocritical care research network will be a principle focus of the conference, in addition to defining a research agenda for multi-center studies. The planned network would potentially be modeled after success stories like ARDSNET, the NIH-funded consortium that supports trials in acute respiratory distress syndrome. “The idea is to have an executive committee, advisory committee, publications committee, and all the participating centers. The executive committee will be in charge of all the research networks from other disciplines, and clinical outcome measures. The second day is geared toward identifying research priorities important to advance the field of neurocritical care and includes both structured symposia and an un- structured forum for consensus-building. “The idea is to come up with various areas of research in various neurocritical care diseases. By doing this we can convince NINDS that we're interested in several clinical trials and not just one,” says Dr. Suarez. Clinical Trials Monitor By Matthew A. Koenig MD The Neuroscience Cent- er at the St Luke’s Episcopal Hospital and Baylor College of Med- icine will host the First Approximately 150 people will be invited to attend the research conference, including heads of neurocritical care units and prominent researchers. Four slots each will also be reserved for promising trainees and junior faculty. These individuals will be chosen by review of applications by the conference organizing committee. The members of the committee are: Jose I Suarez (Chair), Romergryko Geocadin, Christiana Hall, Peter Leroux, Stephan Mayer, Paul Vespa, Christine Wijman, and Osama O Zaidat. Recordings of the conference will also be available on the Neurocritical Care Society website and relevant public- ations will appear in Neurocritical Care. “We wanted to keep this conference small and free to attendees. By keeping the conference attendance small and selected we'll be able to address all the important issues more efficiently. Otherwise it'll turn into another big conference without any major directives”, says Dr Suarez. The conference will be funded in part by a grant from the Neuroscience Center at St. Luke’s Episcopal Hospital, which is affiliated with Baylor College of Medicine. Dr. Suarez is seeking additional funding from the NIH via the R13 mechanism. In addition, represen- tatives from the NIH/NINDS will be invited to attend. “The idea behind getting NIH funding is to have NINDS representatives attend and hear what our priorities are and why we think a research network is the way to go to enhance research in neurocritical care ... Having NINDS full support for the creation of the network will allow us to have funding for the administrative issues of the network and also to provide seed funding for each participating center,” says Dr. Suarez. First Neurocritical Care Research Conference Planned for 2009 administrative issues and will also be reviewing proposals. The advisory committee will be in charge of presenting ideas for research and giving feedback to the executive committee about future directions,” says Dr. Suarez. The first day of the conference will feature emerging research opportunities in neurocritical care, funding mechanisms, successful models of collaborative Jose Suarez, MD, of the Neuroscience Center at the St Luke’s Episcopal Hospital and Baylor College of Medicine, which will host the First Neurocritical Care Research Conference in September, 2009 in Houston, TX. “The idea is to come up with various areas of research in various neurocritical care diseases. By doing this we can convince NINDS that we're interested in several clinical trials and not just one,” -Jose Suarez, MD
  • 5. Currents August 2008 Page 5 “No Pay for Performance” Measures and the Consequences for Patient Care By Wendy L. Wright MD were required by the Centers of Medicare and Medicaid Services (CMS) to keep track of 1) 30 quality measures in order to receive the annual payment update, and 2) seven “reportable events.” These events were deemed to be “preventable” if evidence-based guidelines were followed. CMS will sometimes boldly refer to them as “never events.” CMS is even so kind as to provide the medical evidence right on the website for easy access for the health care worker. Even in the name of research for this article, I didn’t find the person (or persons, I suspect) whose job it is to keep track of this data and I really have no idea what it entails. But what I can tell you that is that it’s about to get a lot more serious. Beginning on October 1, 2008, Medicare won’t reimburse for 8 “reportable conditions” (I can’t bring myself to call them “never events”) if they are acquired in the hospital. What are they? The FY08 list, with the amount of money that CMS says that the cost per hospitalization is as follows: - Object inadvertently left in after surgery ($63,631/hospital stay) - Air embolism ($71,636) - Blood incompatibility ($50,455) - Certain types of falls and trauma ($33,894) - Catheter-associated urinary tract infection ($44,043) - Stage III or IV decubitus ulcer ($43,180) - Vascular catheter-associated infection ($103,027) - Mediastinitis after coronary artery bypass graft surgery ($299,237) Everyone gets a little uneasy when you hear the phrase “not getting paid.” But that is just one of many problems. The patient safety heavy-hitters are worried about both the unintended consequences and about the rapid escalation of the “no pay for performance” aspect of the P4P movement. Dr. Peter Pronovost shares his concerns in a recent article (Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for “preventable complications” JAMA 2008;299(18):2197-2199), including that we just don’t know if withholding payment is either safe or necessary, because we don’t have the data. Dr. Pronovost warns that “Nonpayment for complications that are not truly preventable may destroy trust in quality improvement programs, reduce access for patients at risk for the these conditions,… reduce the frequency of diagnosis after admission, and misinform the public when safety and quality measures are publicly reported.” He suggests that the CMS start with evaluating the risks and benefits of the “no pay” program for just central-line associated bloodstream infections and retained foreign bodies as a way to advance the science of quality improvement and measurement, and not take any shortcuts. Alarm bells sounded around the country on April 14th of this year when CMS posted a press release saying they were considering expanding the reporting list. Yes, before the first year of reporting was even complete, and before a single dollar in payments had been withheld on a nationwide basis. They wanted to add an additional 43 quality measures in order for hospitals to qualify for the annual payment update and add 9 new conditions to the list of reportable “no pay” events. Remember, these reportable events for which payment will be withheld are based on the idea that the conditions are preventable if evidence-based guidelines are followed. Hold on to your seatbelts, ladies and gentlemen, this is where the ride gets a little bumpy. What are these conditions? Wrong-site, wrong-patient, wrong-surgery? No, this column’s purpose is not to offer practice advice, but let’s just say that if you are billing for those mistakes, good luck to you on that. Here is the proposed FY09 list, and the reported cost per hospital stay: - Legionnaires disease ($86,014) - Extreme blood sugar derangement -Diabetic ketoacidosis ($42,974), nonketotic hyperosmolar coma ($35,215),diabetic coma ($45,989), hypoglycemic coma ($36,581) - Surgical site infections following certain elective procedures, including: -Total knee replacement ($63,135) and laparoscopic gastric bypass ($180,142) - Clostridium difficile associated disease ($59,153) - Deep vein thrombosis/pulmonary embolism ($93,750) - Ventilator-associated pneumonia ($135,795) - Iatrogenic pneumothorax ($75,089) - Stapholococcus aureus septicemia ($84,976) And, I saved my favorite for last: -Delirium ($23,290) This section is provided to offer commentaries and discussion of all aspects of advocacy for the practice of neurocritical care. For questions, comments or suggestions for future articles, email Wendy L. Wright MD at I was blissfully insul- ated from the paper- work rustling on Oct- ober 1, 2007. That was the day hospitals across the country Advocacy for the Neurointensivist continued on page 12 I don’t even know where to start with that, except that the reaction from organized medicine was swift and cohesive. The Society of Critical Medicine, for example, responded in a letter with several other societies and selected a few of the above- mentioned conditions and the flawed logic used on CMS’s website to provide “data” on the
  • 6. Currents August 2008 Page 6 The historical growth and organization of academic medical centers in Germany is quite different from what I was used to during my residency and fellowship training in the US. Many German university hospitals are built as separate buildings on a common campus or in different parts of town representing the notion of the different subspecialties to inhabit their own buildings. This concept includes the emergency services of which each department provides their own as opposed to one central emergency room. At the University of Dresden, the emergency medical service (EMS) led by an emergency care trained physician contacts the different subspecialized emergency departments according to the presumed diagnosis and delivers the patient directly to the specialists. Following this development, each department also created its own intensive care unit. The Neurocritical Care Unit (NICU) at the University of Dresden Medical Center was founded in 1997 through the efforts of the new chairman of the Department of Neurology, H. Reichmann, MD, PhD. Initially, the NICU dedicated 6 beds to specialized neurological intensive care with the capacity for mechanical ventilation and 6 beds to comprehensive stroke patient management. With the development of a separate 8-bed-stroke unit in 1999 the 6 available beds became the neurological intermediate care unit. The spectrum of diseases treated encompasses cerebrovascular emerg- encies, status epilepticus, brain tumors, infectious, autoimmune, and neuro- muscular disorders requiring NICU care as well as medical complications of neurological patients. State-of-the-art cardiac and neurological monitoring include less invasive technology such as the PICCO system, end-tidal CO2, continuous SvO2, temperature, ICP/CPP, near infrared spectroscopy, continuous EEG, SSEP, BAER, TCD, carotid Doppler, CT perfusion, MRI perfusion and conventional angiography studies. Our NICU offers 24-hours access to diagnostic and interventional angiography in cooperation with the Dept. of Neuro- radiology led by R. von Kummer, MD, PhD. Also provided are controlled surface and intravascular hypothermia and normo- thermia therapies and continuous renal review of the problem list, and the neurological examination of all NICU patients. With my introduction of an organ-system-based approach and focus on outcome, code status, discharge planning, and more intense participation of the nursing staff, these rounds were reorganized to determine the diagnostic and therapeutic goal for each patient and the structure of the day. One member of the NICU team replacement therapy. Compassionate specialized bedside care is provided through certified neuro registered nurses with staffing at one nurse to two patients. Six neurology residents provide coverage for the NICU in 8-hour shifts during the week and 12-hour shifts during the weekend. Each resident spends one year in the NICU as part of their residency training with the opportunity to rotate through the cardiac care unit for 3 months. A board-certified Neurocritical Care at the University of Dresden Medical Center in Germany: Perspective of a US-trained Neurointensivist By Katja E. Wartenberg, MD, PhD attending neurologist supervises them during the weekdays. During off-hours and weekends four or five more advanced residents with neurocritical experience who are on call from home provide support. The NICU is a closed unit. The week day starts with rounds at 7:00 am which include the sign-out from the night to the morning shift, continued on page 12 NICU staff from left to right: Kerstin Fischer, RN; Hjoerdis Hentschel, MD, PhD; Steffi Luczak, RN; Sylvia Knoch, RN; Kristin Barlinn, MD; Corinna Piotkowski, RN; Yvonne Heitele, RN; Katja Wartenberg, MD, PhD; Imanuel Dzialowski, MD, PhD Neuro-Intensive Care Featured Program
  • 7. Currents August 2008 Page 7 ifying therapeutic interventions. Treat- ments having strong pre-clinical data have not demonstrated efficacy in large clinical trials. In an attempt to improve future research endeavors the National Institute of Neurological Disorders and Stroke (NINDS) has sponsored two recent workshops. The first was held in May 2000, and focused on reviewing prior research activities in an attempt to learn from the past.1 Although multiple topics were discussed, a key area of concern was the need to identify patient subgroups in order to select appropriate therapeutic interventions. The fundamental problem in the care of TBI is the clinical variability among the patients. Current management uses a “one size fits all” treatment paradigm adding therapies in a linear step wise fashion. Recently clinicians involved in the care of TBI are transitioning to “targeted management” of specific conditions that develop during the physiologic responses to injury. This requires us to reconsider how to classify patients and address the multifaceted aspect of this complex condition. Current classification systems are usually based on either some measure of injury severity, pathoanatomic or pathophysiologic findings, physical mechanism of injury, or prognostic modeling schemes. These systems have limitations, and do not take into consideration many clinical confounders (eg, associated injuries, coagulopathies, intoxication, seizures), neuroimaging, biomarkers, or bioinformatics. The IMPACT trial helped reinforce the importance of all these prognostic indicators, the need to capture this information when designing research studies, and the current limitations in TBI classification.2 In an effort to address this issue, the By Lori Shutter, MD The pathophysiology of traumatic brain injury (TBI) is heterogeneous, which contributes to the challenges in ident- ■ Development of more complex statistical and bioinformatics techniques. ■ A need to address issues unique to specific patient populations (pediatric, geriatric, blast, polytrauma). Their final conclusion was that patho- anatomical features should become the cornerstone for a new TBI classification system in order to develop targeted therapies and optimize translational research. This goal is achievable over the next few years with the coordinated efforts of many people involved in the care of TBI patients. As neuro- intensivists, we should support and actively assist in this effort. References: 1. Narayan RK, Michel ME, Ansell B, et al. Clinical trials in head injury. J Neurotrauma 2002;19:503-57. 2. Maas AIR, Marmarou A, Murray GD, et al. Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. J Neurotrauma 2007;24:232-238. 3. Saatman KE, Duhaime AC, Bullock R, et al. Classification of traumatic brain injury for targeted therapy. J Neurotrauma 2008;25:719- 738. NINDS Focus on Facilitating Translational Research in TBI NINDS sponsored another workshop in October 2007. The panel advisors were divided into 3 multidisciplinary teams and included international representation. Their goal was to summarize current knowledge and develop an improved TBI classification system based on diagnostic and prognostic information to guide therapy and enhance research efforts. A summary of these efforts was published in July 2008.3 Recommendations that came out of this workshop include: ■ Establishment of a TBI patient databank to identify patterns of injury at all levels of severity, correlate this information with demographics and injury mechanisms, collect data on clinical information and patient management (eg, monitoring, therapeutic interventions, imaging, biomarkers), and allow this data to be shared across research centers. To this end, common data elements must be identified. ■ Inclusion of all levels of injury severity into clinical trials. ■ Standardization of neuroimaging grading and inclusion of more details on lesion patterns. ■ An increased role of MRI to obtain an- atomical information. ■ Identification of genomic and proteomics factors relevant to TBI. ■ Identification of appropriate treatment endpoints and outcome measures. Lori Shutter, MD, is Associate Professor of Neurology and Neuro- surgery and Director of the Division Neurocritical Care at the University of Cincinnati College of Medicine in Cincinnati, OH.
  • 8. Currents August 2008 Page 8 dull conversation with people you have never met before. We do it every day, and often don’t even know we are doing it. Networking is a necessity in professional and personal life. It is what’s needed to find the job you’ve been looking for, recruit new fellows, connect with old friends, get introduced to new faces, find research collaborat- ors, or even just come across a great restaurant, or a new book to read. Cell phones and internet have changed the way we network these days. In fact, every homepage (for example a neurocritical care fellowship program homepage) is a networking tool. Effective networking is easier said than done. People have different person- alities. Some are naturally shy, and others are outgoing and seen at every party, but both types of people can be very effective networkers, as long as they find their own style of networking. In order to learn how to network, internal workshops offered by your employer’s faculty development program may be a way to go. Or you might find handbooks useful, for example “The Networking Survival Guide” by Diane Darling or many others. And to answer the question right away, YES, you as a fellow or resident should already start thinking about developing your networking skills. Now is the right time, especially with the Neurocritical Care Society Meeting coming up in Miami from Oct 22-25, 2008. In fact, my fellowship director taught me that annual meetings are not only about the science. They are also about the networking opportunities. If you are looking for a fellowship position or job after residency or fellowship, the Fellows Corner You might meet an important future collaborator or colleague. 4. What to talk about: Come prepared with three neutral questions, for example: “Are you from this area?” “Are you presenting anything?” 5. What not to talk about: personal stuff, sex, religion, and politics. 6. How long to talk to a new person you just met: 3-8 minutes, otherwise you appear clingy or desperate. 7. Do not arrive hungry. It’s difficult to juggle food with handshaking and business card exchanges. 8. Always keep your drink in your left hand. Otherwise your handshake will feel clammy. 9. Handshakes: very important and leave a first impression: no soft and clammy handshakes. Two pumps, and let go. 10. Networking wardrobe: when in doubt, go up a notch. 11. Put your name badge on the right side of your chest (the eye naturally flows up the right arm as you are shaking hands). There is lots of networking to learn and plenty opportunity to do so. Use it in Miami. See you there. Happy Networking. Networking: Tips and Pitfalls to Avoid upcoming NCCS meeting is THE perfect setting for it. Although growing each year, it is still considered one of the more “intimate” meetings, during which there will be ample opportunity to network. Here are some important networking tools (adapted with permission from D. Darling): 1. Do your homework: prepare yourself before you go to the meeting. Who do you want to meet? Why? Read about them and their role at their program. 2. Business cards: Have them on you in your right pocket, at the poster session and at the party at night. Put the ones you get in the left pocket, so that you don’t give out somebody else’s. 3. Work the room: as you step into the room, look around. Walk up to people you know. If you want to meet a specific person, ask someone you know to introduce you. An introduction is like an endorsement. Be interested. Don’t forget the “lone wolf” in the corner. Don’t assume that he/she is not important just because he/she is standing alone. By Susanne Muehlschlegel, MD Ever heard about “networking”? You pro- bably imagine a boring cocktail party trying to figure out a way to leave early. BUT: not so fast! Networking is far more than having a For this column, we welcome contributions (national and inter- national) on topics relating to fellows. If are willing to write an article, or for comments, questions or suggestions, please email Susanne Muehlschlegel, MD at: Important Upcoming Dates Further recommended reading: □ How to work a room: Secrets on effective networking: □ Sign up for networking newsletter and periodic networking tips: American Neurological Association 133rd Annual Meeting Sept. 21-24, 2008 Salt Lake City, UT American Society of Anesthesiologists 2008 Annual Meeting Oct. 18-22, 2008 Orlando, FL Neurocritical Care Society 6th Annual Meeting Oct. 22-25, 2008 Miami Beach, FL Society of Critical Care Medicine 38th Critical Care Congress Jan. 31-Feb. 4, 2009 Nashville, TN International Stroke Conference 2009 Feb. 18-20, 2009 San Diego, CA
  • 9. Currents August 2008 Page 9 Multiple Specialties Among Neuro-ICU Nurses By Sarah Livesay, MS, RN, APRNc, and Susan Yeager, MS, RN, CCRN, ACNP If you happen to work alongside Advanced Practice Nurses (APNs) as you care for your Neurocritical Care patients, you may find yourself wading through alphabet soup as you try to figure out APN titles: ANP….FNP….ACNP….CNS….CRNA…. what does it all mean? What are the qualifications and training of the APNs you work with, and furthermore, what can they do? The national certifying bodies of Advanced Practice Nurses recognize four specialties as APNs – Nurse Practitioners, (NP) Clinical Nurse Specialists, (CNS) Nurse Midwives (NM) and Certified Registered Nurse Anesthetists (CRNA). All of these APNs have in common at minimum the completion of a masters degree in nursing, with clinical hours in the specialty, and a national certifying exam upon completion of the program. The certification must be maintained through demonstrated minimum practical hours and continuing education credits. In the Neurocritical Care unit, the two roles that are likely the most familiar are that of the NP and the CNS. The NP role has been around since the 1960’s and focuses on the management of acute and chronic illnesses and disease prevention to a variety of age ranges in a variety of care settings. The CNS role was also introduced in the 1960’s and has evolved over time. Currently, the CNS is a diverse role that may focus on population management, development of protocols and clinical pathways, management of outcomes, coordination of care, education and clinical management of patients depending on practice setting. Nurse practitioner specialization is broken down into four categories which include: Neonatal, Family, Adult, and Acute Care. Family and Adult NP training traditionally focus on the diagnosis/management/health maintenance and illness prevention of acute and chronic diseases. The FNP and ANP may be found in outpatient or inpatient settings depending on their scope of practice in their state. In 1994, Acute Care Nurse Practitioners were introduced as another specialty area of practice. The focus of this training is on the care of adults with complex acute, critical, and chronic health conditions. The population in acute care practice includes acutely and critically ill patients experiencing episodic illness, exacerbation of chronic illness, or terminal illness. . The ACNP practices in any setting in which patient care requirements include complex monitoring and therapies, high-intensity nursing intervention, or continuous nursing vigilance with the range of high-acuity care. While most ACNP's practice in acute care and hospital based settings, care settings also include sub-acute care, and emergency care. NPs may work independently or in collaboration with a physician colleague depending on the individual state law. Collaboration means that a NP works under his/her license with responsibility for his/her actions but alongside a physician colleague. This collaboration is formalized under a written agreement called a Standard Care Arrangement (SCA). A SCA is a legal document that is mutually agreed upon by the NP and a collaborating physician that outline guidelines of care and scope of practice. Collaborating physicians are those that are licensed to practice medicine and agree work with an APN to mutually establish a protocol for patient care. Nurse Practitioners traditionally focus primarily on clinical care. Examples of clinical care include the ability to perform health histories and consultations, to diagnose and treat a variety of acute and chronic health issues, to interpret laboratory and x-ray results, and depending on the state law, to have varying degrees of prescriptive privileges. NPs also utilize invasive interventions and procedures to promote physiologic stability. NPs perform a wide variety of skills and procedures, with the skill set of a NP dependent on the foundational training, specific patient population, and specialty-based area of practice. Examples of invasive procedures that can be provided by NPs that specialize in neurologic critical care include but are not limited to: intubations, central and arterial lines, lumbar punctures/drains, spinal fluid extraction, intrathecal antibiotic insertion, shunt reprogramming, ventriculostomies, and intraparenchymal drains insert- ion/discontinuation. Though the primary focus for NPs is on providing clinical care, NPs also are trained in research, education, and leadership aspects. The Clinical Nurse Specialist traditionally manages health problems in patient populations and is considered an expert in evidence-based nursing practice. The CNS role is often described including practitioner, consultant, educator, administrator and researcher and these roles are generally Susan Yeager Neurointensive Care Nursing Sarah Livesay continued on page 10
  • 10. Currents August 2008 Page 10 Cardiac Arrest Meeting Focuses on Neurologic Outcomes uded: 1. a review of the AAN Guidelines for prognosis of comatose survivors of cardiac arrest (2006), along with its shortcomings; 2. the potential use of other/additional clinical, electrophys- iological, functional neuron-imaging, neur- ochemical markers and neuropsychological means of assessing integrated brain function; 3. more on the specifics of outcome determination; 4. our perspectives on new therapies. Experimental work on new developments in neuroprotection were discussed. Outcome determination is a developing field that deserves greater attention than has been given. There are more refined methods than the traditional single-value Glasgow Outcome Scale and Cerebral Performance Category. Quality of Life and multidimensional assessment measures need to be considered. There were several lessons for neurologists: 1. “The brain is only half of the story”: the effects of post-arrest status of other organs are equally important. 2. We need to refine our prog- nostic tools for more accurate deter- mination of different levels of outcome. 3. Neurologists are more than prognos- ticators: we should be participatory and collaborative with other specialties in developing outcome-improving strategies. Therapeutic hypothermia is only the beginning. 4. We should be aware of the societal and cost-effective implications of our endeavors. 5. We should contribute to better outcome assessment measures. At the end of the meeting a committee with representatives from the various disciplines was formed to develop an AHA consensus statement that will facilitate better definitions, refine collaborative goals and objectives toward better global and neurologic outcome assessment. Stay tuned. G. Bryan Young, MD FRCPC, is Professor of Neurology at the University of Western Ontario and consultant in the University Hosp- ital in London Ontario, Canada. Continued from page 9 applied to three spheres of influence; patient/family, nurse/caregiver and hospital/organization. Traditionally the CNS focuses on system change, education and standardizes patient care through multiple methods including policies, protocols, and order set development. Depending on scope and practice by state, the CNS may focus on diagnosis and medical management of individual patients or serve to standardize care to the wider patient population. The CNS role has developed and has primary roots in the acute care setting, however CNSs now practice in many outpatient settings as well. Much like a NP, the CNS is educated and certified in a certain practice area (adult health, critical care, psychiatric/mental health, pediatrics, gerontological care and public health). CNSs educated within this past decade may be eligible for limited prescriptive authority and may diagnose and treat disease states in patients according to the scope of practice in their state. Some institutions, depending on state regulation of practice, have blended roles where CNS’s and NP’s may function across traditional role lines. The state boards of nursing regulate APN practice and also dictate scope and function. For example, the degree of prescriptive authority for a NP or CNS is usually based on the state board of Nursing and contributes to varying practice from region to region. In the Neurocritical Unit, your APNs may have a mixture of titles and be providing daily medical management for patients, helping to manage personnel, developing policies and protocols, engaging in research, providing patient, nurse or physician education or likely providing a combination of services. APNs, with varied back- grounds, titles and roles may work together depending on the practice setting to identify trends in patient care that need improvement, and work to develop protocols and education to improve the care for that individual patient as well as all patients to follow. Any questions or requests for literature on APN practice can be directed to the Nursing Committee, please contact Susan Yeager at: Mixture of Nursing Titles in the NICU The American Heart Association hosted an Emergency Cardiovasc- ular Care Consensus Conference in Washing- By G. Bryan Young, MD ton, D.C. from May 5-6, 2008. Dr. Lance Becker, director of the University of Pennsylvania Center for Resuscitative Science organized and chaired the conference and Dr. Romergryko G. Geocadin, director of the Neuroscience Critical Care Unit, Johns Hopkins Bayview Medical Center, co-chaired the section on neurologic and long-term functional outcomes of the conference. The meeting brought together international experts in cardiac arrest resuscitation that included represen- tatives from the AHA, ILCOR, FDA, NHLBI, NINDS, Neurocritical Care Society and several other organizations. The NCS was well represented by M. Diringer, W. Koroshetz, R. G. Geocadin, C. Graffagnino, M. Koenig, M. Torbey and G. B. Young. Along with the NCS members were other internationally renowned brain injury and outcome experts such as R. Lazar, (Columbia University), W.T. Longstreth, (University of Washington), N. Schiff (Cornell University), N. Thakor (Johns Hopkins University), M. Holm (University of Pittsburgh), and N. Bircher, (University of Pittsburgh). The neurologic outcome section provided a comprehensive discussion of brain injury in relation to outcomes after cardiac arrest resuscitation. The other sections of the conference included definitions, impact of systemic injury (non-neurologic) to outcome and the socio-economic impact of cardio- pulmonary arrest and resuscitation. The primary objective of the conference was to review and revise/improve assessment tools for determining outcomes after cardiopulmonary resuscitation. The conference also reviewed the current status of cardio- pulmonary resuscitation and discussed opportunities to enhance the care and outcomes of victims of cardiac arrest. The neuro-intensive care aspects incl-
  • 11. Currents August 2008 Page 11 Pediatric Neurology the Next Frontier in Neurocritical Care their general consult service. A dedicated pediatric NICU is important since it will drive the field forward with advances in clinical care, training, education, and research. This pediatric NICU must have continuous EEG with bedside trending software, portable CAT scanning, and adjacent neuroimaging for both clinical and research purposes. Using the example of traumatic brain injury, research using various MRI sequences is needed for other disorders (14,15). We have learned much about the pathophysiology of CNS insults from adults, but must specifically study the effects of insults to the developing brain. Dedicated research protocols will permit the development of evidence-based practice guidelines, which ultimately, have a broader impact across various practice settings. Training and education must occur at all levels of medical education. Training in pediatric NCC is currently available to the child neurology resident or practicing child neurologist through additional ICU experience, fellowship training in existing adult NCC programs or by continuing medical education. We need to create dedicated fellowship programs in pediatric critical care neurology. But we must also teach NCC to the child neurology resident, since early exposure to intensive care helps create interest and recruit trainees, and general child neurology to the medical student, since most decisions to enter child neurology are made during medical school (12). NCC started as a collaborative effort among the specialists primarily caring for neurologic disorders in the ICU. This model should continue in the pediatric NICU: the PCCM specialist with a neurologic interest, the pediatric neurosurgeon, and the critical care child neurologist, each contributing their individual expertise. In the ideal staffing situation, all three neurocritical care specialists would be part of the patient care team and make rounds together. Until more child neurologists are trained in critical care, our adult neurocritical care colleagues could take an active role in their institutions and work closely as resources for existing PICU and child neurology staffs. The NCS created a working group for pediatric NCC, is conducting a survey of its practice by child neurology and will next survey PCCM. Our goal is to identify those interested and to develop education and training programs and practice guidelines. Education and training programs will increase the number of critical care child neurologists to staff a dedicated NICU, a neuroscience team within a PICU, or be the critical care resource for either a critical care neurology consult team or general child neurology consult service. The type of service created will vary based on institutional needs and resources. Practice guidelines will standardize care across these various settings. Speaking for the few child neurologists involved in pediatric NCC, we believe that NCC must be developed as a subspecialty of child neurology and that a collaborative effort among these neurologists, neurologically oriented PCCM specialists and pediatric neurosurgeons will accomplish these goals. REFERENCES: 1.Rincon F, Mayer SA. Neurocritical Care: A distinct discipline? Current Opinion in Critical Care 2007:13:115-121. 2. Zakaria A, Provencio JJ, Lopez GA. Emerging subspecialties in Neurology: Neurocritical care. Neurology 2008;70:e68-69. 3. Downes JJ. The historical evolution, current status, and prospective development of pediatric critical care. Crit Care Clin 1992;8:1-22. 4. Epstein D, Brill JE. A history of pediatric critical care medicine. Ped Research 2005;58:987-996. 5. Pollack MM, Katz RW, Ruttimann UE, Getson PR. Improving the outcome and efficiency of intensive care: the impact of an intensivist. Crit Care Med 1988;16:11-17. 6. Mirski MA, Chang CWJ, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care. Journal Neurosurg Anesthesiol 2001;13:83-92. 7. Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracranial hemorrhage. Crit Care Med 2001;21:635-640. 8. Suarez JI, Zaidat OO, Suri MF, Feen ES, Lynch G, Hickman J, Georgiadis A, Selman WR, Length of stay and mortality in neuocritically ill patients: impact of a special neurocritical care team. Crit Care Med 2004;32:2311-2317. 9. Varelas PN, Conti MM, Spanaki MV et al. The impact of a neurointensivist-led team on a semi-closed neurosciences intensive care unit. Crit Care Med 2004;32:2191-2198. 10. Suarez JI. Outcome in neurocritical care: Advances in monitoring and treatment and effect of a specialized neurocritical care team. Crit Care Med 2006;34(Suppl):S232- S238. 11. Bell MJ, Carpenter J, Au AK, Keating RF, Myseros J, Yaun A, Weinstein S. Development of a pediatric neurocritical care service. Neurocrit Care 2008; 12. Werner RM, Polsky D. Comparing the supply of pediatric subspecialists and child neurologists. J Pediatr 2005;146:20- 25. 13. LaRovere KL, Riviello JJ. Emerging subspecialties in Neurology: Building a career and a field. Neurology 2008;70 (part 1):e89-91. 14. Ashwal S, Holshauser BA, Tong KA. Use of advanced neuroimaging techniques in the evaluation of pediatric traumatic brain injury. Dev Neurosci 2006;28;309-326. 15. Sigmund GA, Tong KA, Nickerson JP, Wall CJ, Oyoyo U, Ashwal S. Multimodality comparison of neuroimaging in traumatic brain injury. Pediatr Neurol 2007;36:217-226. Continued from page 1 James J. Riviello, Jr., MD, is the George Peterkin Endowed Chair in Pediatrics and Professor of Pediatrics and Neurology; Section of Neurology and Developmental Neuroscience and Kellaway Section of Neurophysiology; Departments of Pediatrics and Neurology, Baylor College of Medicine, Houston, Texas.
  • 12. Currents August 2008 Page 12 Continued from page 6 leaves the NICU at 8:30 am to take part in the morning report of the entire neurology department to present all new admissions. During morning report all neuroimaging obtained in the past 24 hours is reviewed by a neuroradiologist, and all decisions regarding interventions and difficult cases are discussed. All x-rays are reviewed with a radiologist at noon. Once a week all nosocomial infections are reviewed with a member of the department of hospital hygiene, and all infections, cultures, and antibiotic therapy regimen are discussed with a microbiologist. Sign-out rounds to the afternoon shift and the NICU-experienced senior resident on call start at 3:00 pm. The vital signs, laboratory values, and medication list of every patient are reviewed and the NICU patients examined by a resident once per shift. The morning team is responsible for arrangement of routine imaging, consultations, and performance of bedside procedures. The CT and MRI scanners are located in a different building, and every desired scan requires transportation of the patient by ambulance accompanied by the resident and the nurse (if mechanically ventilated). The ventilators are managed by the resident and the nursing staff. A physiotherapy team provides care six days a week. Patients with cerebrovascular disorders in anticipation or need of a neurosurgical intervention such as placement of an EVD, shunt, or craniotomy are primarily admitted to the neurosurgical service within the surgical ICU (22 beds) or the anesthesiological ICU (13 beds). Therefore, the majority of patients with subarachnoid hemorrhage, subdural haematoma, intracerebral hemorhage, and traumatic brain injury are cared for by medical staff of the departments of visceral and trauma surgery as well as anesthesiology under guidance of “Reportable Conditions” Reimbursement Changes on the Horizon Dresden Medical Center Neurointensive Care neurosurgeons. The neurologist is usually consulted to assist with seizure management, altered mental status, or for determination of prognosis or brain death. As of 2007 the University of Dresden established the first German certified stroke center (Dresden University Stroke Center=DUSC, certification: DIN-ISO 9001:2000) in cooperation with the departments of neurosurgery, neuro- radiology, anaesthesiology, cardiology, and Center for Vasculature. The goal of the stroke center is to provide high-quality care and integration of different specialties in the care of complex patients. A telemedicine network SOS-NET was also initiated to cover twelve hospitals in the eastern part of Saxonia. These hospitals seek advice on every acute stroke patient 24 hours a day and 7 days a week. This telemedicine network has increased admissions to the NICU. More improvements are underway such as a center for acute care in neurology and internal medicine. As we continue to improve the structure and quality of neurovascular care and expand the multidisciplinary team approach, we also strive to build a neurovascular research program and extend our interactions on the national and international level. Katja Wartenberg, MD, PhD is attending physician in Neurocritical Care and Cerebrovascular Diseases at the Carl Gustav Carus University Hospital in Dresden, Germany. She earned her medical degree in Charite, Medical Faculty of Humboldt University in Berlin, Germany and completed her neurology residency at Georgetown University in Washington DC and at Carl Gustav Carus University Hospital in Dresden, Germany. She completed a fellowship training in neurocritical care at the New York Presbyterian Medical Center- Columbia University in New York, NY. iatrogenic pneumothorax, VAP and Legionnaires disease had all fallen off the “no pay” list. Only 13 quality measures were added to the reporting list. Unintended consequences will still come, of course. Some will be obvious - how many Med- icare patients will be getting elective total knee replace- ments? Can we can even anticipate all of the conseq- uences at this stage? CMS says that these “no pay” measures are to promote quality health care. In case you are wondering what patient safety legislation or tragic event kicked all this off, the “no pay” measures are actually provided for under the Deficit Reduction Act of 2005. Reducing the deficit is a noble goal, but who will then pay for the care provided? And what type of liability will come from the idea that a hospital acquired DVT is “preventable?” In the end, doctors will do what doctors do, and that is take care of patients. I know almost nothing of business models, but I know that it is bad for hospitals not to get paid. And this doesn’t sound like a sustainable model for delivery of care to patients. As neurointensivists, we have an immediate struggle. We care for a patient population at high risk for DVT, yet many patients are not good candidates for anticoagulation. What will be the financial impact of not getting reimbursed for DVTs? That sounds like it would be worth documenting as a group. And will we make our hospitals falsely look less “safe” with reporting? Perhaps we will need to lead the data collection efforts on any increase in anticoagulation-related hemorrhages from those trying to escape the same fate. Longer-term, we will want to keep track of any future plans for the “no pay” list, in case delirium, for example, is reconsidered, and be ready to respond with medical facts as to why this is not a sound idea. Links to the CMS’s press releases regarding this topic will be posted on the advocacy page of the NCS website. Continued from page 5 “evidence” that shows that these are preventable conditions. They also high- lighted some of the probable unintended consequences and the adverse effect they would have on patient care. I would like to think that this helped hold back the flood- gates. The final ruling on the FY09 proposal was handed down on August 4th , and del- irium, Staph septicemia, C. diff,
  • 13. Currents August 2008 Page 13 Neurocritical Care Classifieds * More details available at the NCS website All Classified advertisements must be renewed every six months. Only ads that are renewed prior to the next newsletter will be included. Medical Positions Posted* Neurointensivist - Oregon Health & Science University Contact: Anish Bhardwaj, MD, FAHA, FCCM Director, Neurosciences Critical Care Program Email: Director of Neurocritical Care – Cleveland Clinic Contact: Joe Vitale, Senior Director of Physician Recruitment Email: Neurointensivist Faculty Position -Cedars-Sinai Contact: Felicia Mayes, Sr. Administrative Services Associate Department of Neurosurgery at Cedars-Sinai Email: Neurointensivist - UTSW Contact: Wengui Yu, MD, PhD Chief, Division of Neurological Critical Care Email: Neuro-Intensivists - Henry Ford Hospital Contact: Panayiotis N. Varelas, MD, PhD Director NICU Email: NCC/Stroke position - Washington University Contact: Michael Diringer, MD Director, Neurology/Neurosurgery Intensive Care Unit Email: Neurointensivist, Assistant Professor of Neurology & Neurosurgery – CA Contact: Critical Care Neurologist / Neurointensivist – Cleveland Clinic Contact: Joe Vitale, Senior Director of Physician Recruitment Email: Pediatric Neurocritical Care Specialist - Boston Contact: Gretchen E. Horan Email: Stroke/NCC Neurologist - Minneapolis Contact: Stasi Johnson Email: Neurointensivist – Los Angeles – SCPMG Contact: Zoriy Elterman Email: Neurology / JCAHO Certified Stroke Center / Call1:5 Contact: Corey McDonald Email: Neurointensivist in Paradise - Queens Medical Center Contact: Helen Aldred E-mail: Neuro-Hospitalist Position at Marshfield Clinic Contact: Sandy Heeg Email: NCC or Vascular Neurologist – Michigan Contact: Cadace Lee Email: Neurocritical Care Position at Roosevelt Hospital/Manhattan Contact: Dr. Chandra Sen ( Dr. Rup Swarup ( and Dr. Alex Berenstein ( NEUROINTENSIVIST: Sinai Hospital of Baltimore Contact: Michael A. Williams, MD, FAAN, Medical Director, Brain & Spine Institute. Sinai Hospital of Baltimore 2401 W. Belvedere Ave. Baltimore, MD 21215 Tel: 410-601-6125 Neurointensivist - Sacred Heart Medical Center Nancy Dunlap, CMSR Manager Physician Resource Planning Email: Neurointensivist - University of Utah Health Sciences Contact: Dr. Stefan-M. Pulst Chair, Department of Neurology Email: and cc: Neuro-Intensivist - Medical University of South Carolina Contact: Sunil Patel, MD, Clinical Chair, Department of Neurosciences, Email: or Julio Chalela, MD, Medical Director Neuro-Intensive Care Unit, Email: Neurointensivists Faculty Position - Emory University Hospital Contact: Owen Samuels, MD Director of Neurosciences Critical Care Email: Academic Position – Neurointensivist – Stanford Univ. School of Medicine Contact: Christine A.C. Wijman, MD, PhD, Director, Stanford Neurocritical Care Stanford Stroke Center 701 Welch Road, Suite 325 Palo Alto, CA 94304-1705 University of Minnesota Faculty Contact: Dr. Mustapha Ezzeddine, c/o Joni Lemeiux University of Minnesota, Department of Neurology Stroke Center MMC 295 420 Delaware Street S.E. Minneapolis, Minnesota 55455 Neurocritical Care Faculty Position - University of Chicago Medical Center Contact: Jeffrey I. Frank, MD Director, Neuromedical/Neurosurgical Intensive Care and Stroke Email: Neurocritical Care Fellowship Positions Posted* Neurointensivist Fellow - Emory Contact: Owen Samuels, MD Program Director Email: Neurosciences ICU Fellowship: Henry Ford Contact: Panayiotis N. Varelas, MD, PhD Director NICU Email: 2008 Fellowship - University of Virginia Contact: Bart Nathan, MD Fellowship Director, NeuroIntensive Care Email: Stroke & Neuro-Intensive Care Fellowship - California Pacific Medical Center Contact: Jack C. Rose, MD Director, Neuro-intensive Care and Vascular Neurology Fellowships Email: NNICU Fellowship Availability - Wash. University Contact: Yekaterina Axelrod, MD NNICU Fellowship Director Or Contact: Michael N. Diringer, MD Email: Mount Sinai NYC Neuro-Critical Care Fellowship Contact: Jennifer Frontera, MD Neuro-Critical Care, Departments of Neurosurgery and Neurology Email: The Hospital Italiano de Buenos Aires - Neurointensive Care Training Contact: Luis A Camputaro MD, FCCM, FAHA Email: Website: University of Minnesota Fellowship - Neurocritical Care Contact: Mustapha Ezzeddine, MD c/o Pat Bulgerin, Fellowship Coordinator Dept of Neurology, University of Minnesota Email: Neurology Fellowship - Thomas Jefferson University Medical Center Contact: Rodney D. Bell, MD, Chief, Division of Cerebrovascular Disease and Neurocritical Care Tel: (215) 955-6488 Email: Cleveland Clinic Neurocritical Care Fellowship – Ohio Contact: J. Javier Provencio, MD Program Director, Neurocritical Care Fellowship Email: Neurocritical Care Fellowship - Oregon University Contact: Anish Bhardwaj, MD, FAHA, FCCM Director, Neurosciences Critical Care Program Email: Washington University Fellowship – Neurology Contact: Michael N. Diringer, MD Email: University-Chicago Neurocritical Care Fellowship Contact: Axel J. Rosengart, MD, PhD Email: 2008 Fellowship – Univ. of Miami Miller School of Medicine Contact: Madeline Noto Email: UT Southwestern Medical Center Contact: Wengui Yu, MD, PhD E-mail: Neurointensive Care – UCLA Contact: