Timing of Tracheostomy and Association with Ventilator Liberation, Length of Stay, and Discharge Outcomes in Neurocritical Patients.

Introduction: Tracheostomy is frequently performed in neurocritical patients to facilitate airway management and ventilator liberation. However, the optimal timing of tracheostomy remains controversial, particularly in stroke patients, where earlier intervention may impact recovery and healthcare resource utilization. This study evaluates the association between early (<14 days) versus late (>14 days) tracheostomy and key clinical outcomes in stroke and non-stroke neurocritical care patients. Methods: A retrospective cohort study was conducted in a neuro-intensive care unit at an urban, quaternary care hospital. Adult patients (≥18 years) who underwent both percutaneous tracheostomy and gastrostomy between 2007 and 2013 were included. Demographics, admission Glasgow Coma Scale (GCS), hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, reintubation rates, tracheostomy-related complications, costs, and discharge disposition were compared between stroke and non-stroke patients, as well as between early and late tracheostomy groups. Multivariable regression and competing risks models were used to adjust for confounders. Results: Among 290 patients (145 stroke, 145 non-stroke), early tracheostomy was associated with significantly shorter ICU LOS (21.7 vs. 27.6 days, p < 0.01), reduced hospital LOS (32.4 vs. 38.9 days, p < 0.01), and lower total hospital costs ($121,645 vs. $157,304, p < 0.01) in stroke patients. Late tracheostomy was associated with a 2.7-fold increase in reintubation risk (p = 0.02) and 40% lower likelihood of discharge to rehabilitation (p < 0.01). In non-stroke patients, late tracheostomy was linked to longer ICU LOS (35.5 vs. 22.1 days, p < 0.01), extended hospitalization (50.8 vs. 32 days, p < 0.01), and increased costs ($206,184 vs. $128,788, p < 0.01). Tracheostomy-related complications were more frequent in early tracheostomy stroke patients (22.1% vs. 7.3%, p = 0.03), but this did not impact overall discharge outcomes. Conclusions: Early tracheostomy in neurocritical patients, particularly those with stroke, is associated with shorter ICU stays, lower reintubation rates, and improved discharge to rehabilitation. While early tracheostomy carries a higher risk of procedural complications, its benefits in ICU efficiency and recovery support its role in evidence-based airway management strategies. Future prospective studies should focus on refining patient selection criteria for early tracheostomy and evaluating long-term functional outcomes in neurocritical care populations.