Does initial point of care influence neuro-ICU outcomes?

Most of the conditions that eventually get treated in theNeuro-ICUsettingrequireinitialdiagnosisandmanagementin the Emergency Department. As hospitals increasinglydevelop networks and other inter-hospital lines of referral,this initial evaluation and treatment often takes place in acenter that does not have local expertise in NeurocriticalCare, advanced neuroimaging, or a Neurosurgeon. If, bychance or by geographic necessity, a patient is brought byEMS to such a ‘‘non-Neurocritical Care’’ ED, does thisadversely affect outcomes?This is a big question, and it potentially applies to a hostof conditions, including ischemic stroke, intracerebralhemorrhage (ICH), subarachnoid hemorrhage (SAH), andneurotrauma. The answer to this question might alter theways in which initial EMS triage and initial ED care areorganized as regional approaches to emergency care arefurther developed in the future.In this issue of Neurocritical Care, Naval and Car-huapoma examine the impact of initial point of care onclinical outcomes among patients with ICH treated in theNeuro-ICU at Johns Hopkins Hospital. Although this arelatively small retrospective study of 125 patients, there isa strong suggestion from these data that initial treatment inthe ED at Hopkins was associated with better outcomes.The authors show the outcomes at hospital discharge wereimproved in the Hopkins ED group across multiplefavorable levels of the modiﬁed Rankin Scale, and theassociation between Hopkins ED treatment and good out-come remained after controlling for ICH and IVH volumes,age, and GCS in a logistic regression model.Studies can often raise more questions than they answer,and the current paper by Naval and Carhuapoma is noexception. Many of the new questions raised by this studyarise from one central question: what does treatment in theHopkins ED (vs. another ED) really mean? Is this simply ademonstration of the excellent emergency room care pro-vided at a world-famous hospital in a busy inner-city area(as compared to other, less notable facilities)? Or is it morespeciﬁcally a demonstration of the added value of Neuro-intensivist or Neurosurgical intervention at an earlier pointin the care of critically ill patients with ICH? Perhaps theeffect seen here is that of inferior care at the outside EDscompared to standard care at the Hopkins ED (as comparedto standard care at the outside EDs compared to superiorcare at the Hopkins ED). Examples of possible inferior caremight include delayed triage, delayed diagnosis, or delayedor inadequate treatment or blood pressure or coagulopathy.Yet another explanation might be that the association seenhere is purely based on the longer time between ED arrivaland ICU admission that is by deﬁnition built into triage atone facility and ICU treatment at another. Of course, thereal answer is likely to be multifactorial, resulting fromsome combination of these and other explanations.If being brought to a Neurocritical Care center from thebeginning is in fact better than being brought to a non-Neurocritical Care center, would it make sense to bypassnon-Neurocritical Care centers during EMS transport, atthe potential cost of delaying initial evaluation and treat-ment? Would better medical informatics networks andapplications such as remote imaging access and telemedi-cine [1–3] improve outcomes for these patients and alsoavoid the risks of prolonged transport prior to initialevaluation?To what extent does the lack of familiarity with speciﬁcmedical interventions drive the association between