709 Establishment of an Early ICU De-escalation Pathway Using the Modified Frailty Index Among Angiogram-Negative Subarachnoid Hemorrhage Patients

Abstract

INTRODUCTION: Angiogram-negative subarachnoid hemorrhage (ANSAH) may have a benign clinical course. Our standard practice is to observe ANSAH patients for a prolonged period in the ICU. Previous work has established frailty as a strong predictor of ANSAH outcomes. METHODS: A retrospective cohort analysis was performed among patients admitted between 2011 and 2022 with non-traumatic subarachnoid hemorrhage and initial angiogram (DCA) negative for source. Primary endpoints were in-hospital complications, discharge home, and length-of-stay (LOS). Cost analysis was performed using hospital charges. RESULTS: 101 patients were included with an average age of 59.7 ±1.2 years, Hunt and Hess score of 2.0 ± 0.1, and 51 (50.5%) with a perimesencephalic hemorrhage distribution. 2 patients had a subsequent DCA showing aneurysmal etiology, both of whom would have been considered high risk. 38 (37.6%) were frail, 38 (37.6%) required an EVD, and 68 (67.3%) were intact on arrival. Multivariate analysis showed that frailty but not age or perimesencephalic distribution predicted the 3 primary endpoints (p < 0.039) while lack of EVD predicted LOS (p = 0.004) and intact neurologic exam predicted discharge home (p = 0.043). Low-risk patients (40/101, 39.6%) had no deaths, significantly reduced odds of any complication (OR 0.14, 95%CI: 0.04-0.44, p < 0.001), increased odds of discharge home (OR 9.98; 95%CI: 2.19-45.46, p < 0.001), and shorter LOS (7.8 ± 0.4 v. 14.7 ± 1.1 days, p < 0.001). Assuming a 6-day ward stay after 1-day of ICU observation, early de-escalation of low-risk ANSAH patients would, on average, save $20,177.70 per patient. CONCLUSIONS: Non-frail ANSAH patients who are neurologically intact and without an EVD are likely to have a benign clinical course and may benefit from early ICU de-escalation.