An elderly man falls and strikes his head, immediately becoming comatose. He is brought to the emergency room of the nearest hospital, where a computed tomographic scan reveals a large acute subdural hematoma. It is determined that he must be transferred in order to receive appropriate care, but more than a half-dozen hospitals in the region are unable to accept him because their intensive care units or emergency rooms are full. Eventually, the patient is accepted at a trauma center hundreds of miles away. Although he undergoes a craniotomy immediately upon arrival, he remains neurologically devastated. He expires after his family decides to withdraw care.
Tragically, this true-life scenario occurred just within the last few years. Similar situations are said to be occurring with increasing frequency, suggesting a breakdown in the system of neurosurgical emergency care. It may seem convenient to lay the blame for this breakdown on a single source, such as pressures related to the Emergency Medical Treatment and Labor Act, the medical liability crisis, decreasing reimbursements for neurosurgical services, or inadequate numbers of neurosurgeons.
In reality, however, the situation is quite complex, and blaming inadequate neurosurgical emergency coverage on only one source is just as simplistic as stating that every headache is caused by a brain tumor. This article will explore the primary factors that impact neurosurgical emergency coverage, examine the relevant and available evidence, and consider the perils and possibilities of various paths toward change.
Scope of the Problem
Anecdotal Evidence Neurosurgeons and others involved with emergency care have been outspoken on the topic of neurosurgical emergency care, which has been the focus of presentations and sometimes intense debate in neurosurgical venues. Publications have delved into the subject; the newsletter of the AANS/CNS Section on Neurotrauma and Critical Care has devoted portions of several issues to the topic.
Scientific meetings also have provided an arena for discussion. At the annual meeting of the Eastern Association for the Surgery of Trauma in 2003, participants of one session discussed the topic, “Craniotomy in the Field: Why Does It Take Neurosurgeons Seven Years?” The double entendre is obvious: first, why is such a long training period required for such a “simple” procedure; and second, why does it take neurosurgeons so long to respond to calls about emergency patients? Some trauma surgeons have opined that trauma craniotomies are as easy to perform as appendectomies. Others feel that they should be credentialed to perform trauma craniotomies after being proctored on as few as 10-or even five-such procedures.
Through such discussions, barriers to the delivery of neurosurgical emergency care have become recognized, inspiring several studies which further characterized a system under stress.
Survey Data In a 1992 report by the U.S. Department of Health and Human Services Office of the Inspector General, 67 percent of hospitals reported that they experienced problems ensuring coverage for at least one of the specialty services offered in their emergency rooms. Neurosurgery was the specialty most likely to pose a problem, with 49 percent of hospitals that offer neurosurgical services reporting difficulty ensuring coverage. A follow-up report in 2001 found that neurosurgery retained the dubious distinction of being the service most likely to be associated with problems in obtaining specialist coverage.
A 2004 survey conducted by the American College of Emergency Physicians found that two thirds of hospital emergency departments reported problems with inadequate specialty on-call coverage-the same proportion as that described in the 1992 OIG report. Apparently, little progress was made during the 12 years that separated the two reports.
Data from the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey, reported in this issue of the Bulletin, showed that while the great majority of neurosurgeons were covering neurosurgical emergencies for at least one hospital, there were significant gaps in coverage. These gaps often fell along the lines of practice type, practice setting, trauma center level, and types of neurosurgical emergency services provided. Perhaps not surprisingly, neurosurgeons in private practice and those in a solo practice setting were less likely to provide emergency services. Level 3 trauma centers and hospitals without a trauma designation were less likely to offer neurosurgical emergency coverage. A significant finding was that nearly half of neurosurgeons who served on call limited their services in some way: Two thirds of respondents did not treat children, slightly less than one third did not treat cranial or spinal cases, and about 4 percent did not treat any trauma cases.
In a 2001 survey of the membership of the American Association for the Surgery of Trauma, more than 40 percent of respondents complained that neurosurgeons did not answer pages promptly when they were on call for trauma, more than one third stated that neurosurgeons were too slow in taking patients to the operating room, and 44 percent complained that neurosurgeons were too reluctant to insert intracranial pressure monitors. More than 40 percent felt that specialists other than neurosurgeons, such as emergency physicians, should be allowed to insert intracranial pressure monitors.
In response to the increasing dissatisfaction of all parties involved in the provision of emergency coverage, various responses and actions have been initiated by the federal government, by hospitals, by neurosurgeons, and by other physicians.
The Federal Government Response:
The Emergency Medical Treatment and Labor Act
At its core, EMTALA requires hospitals that participate in the Medicare program-the vast majority of hospitals in the United States-to provide a screening examination (including ancillary services as needed) and necessary stabilizing treatment to patients presenting with emergency medical conditions, regardless of their ability to pay for these services. A hospital must also accept emergency transfers from other facilities if it has the ability to care for such patients and if the sending facilities declare that they are not able to care for them.
While EMTALA is discussed at length elsewhere in this issue, its relevance to neurosurgeons can be summarized as follows: When on call, neurosurgeons cannot refuse to see patients and cannot refuse transfers from other hospitals if the other hospital declares that patient to be an “emergency.” A transfer or consultation cannot be refused without good cause. If an on-call physician does refuse to accept a patient, the reason for the refusal must be documented and must be capable of withstanding subsequent scrutiny, such as genuine lack of availability of a physician because he or she is treating another patient.
Because EMTALA itself does not provide for reimbursement, a physician who is required to provide a patient with emergency treatment might not receive payment for those services. Ironically, this is true even if that patient has health insurance because, in a true emergency, there may not be time to obtain preauthorization from the insurance carrier. Waiting for preauthorization is permissible only if it does not delay treatment; if treatment is delayed, it could be inferred that emergency treatment was delayed for financial reasons, which is an EMTALA violation.
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EMTALA was crafted with the best of intentions. However, like many such measures, it soon caused more problems than it fixed. Anecdotes describing arbitrary and illogical interpretations of EMTALA, as well as tales of draconian penalties imposed on physicians who allegedly violated the law, created so much fear and insecurity that many physicians sought ways to avoid providing emergency care altogether. Although the number of physicians who have ever been fined for EMTALA violations is quite small–less than 2 percent of neurosurgeons said they had ever been investigated for an EMTALA violation, according to the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey–the pervasive fear that “it could happen to me” has made many physicians very cautious.
EMTALA Clarifications In September 2003 the Centers for Medicare and Medicaid Services clarified certain EMTALA provisions that had been of great concern to neurosurgeons. The following May, the CMS issued interpretive guidelines for their state and regional investigators. Briefly, surgeons now may be on call simultaneously at more than one hospital and may perform elective surgeries while on call. The clarifications also put to rest the persistent urban legend that the presence of a certain minimum number of specialists on a hospital’s staff mandates that those physicians provide continuous, “24/7” coverage of the emergency room.
It is permissible for a hospital’s on-call schedule to stipulate that emergency care will not be provided by certain specialties on certain days as long as policies and procedures are in place to deal with emergencies on those days, such as documented transfer arrangements with appropriate facilities. Such flexibility allows the hospitals in a given region to coordinate the allocation of their resources in order to provide the most comprehensive care with the greatest efficiency.
While these changes were welcome news to neurosurgeons, many hospitals and emergency physicians believe that these clarifications have “weakened” EMTALA and are now exacerbating the current emergency medical services “crisis.” It is more appropriate, however, to view these changes as clarifications that acknowledge the only conditions under which neurosurgeons and other specialists can continue to participate in the trauma system.
Importantly, neurosurgeons should bear in mind that EMTALA merely sets forth the minimum requirements for on-call coverage. States and hospitals may impose stricter rules.
Hospital Responses
In the United States, the number of registered hospitals exceeds the number of practicing neurosurgeons certified by the American Board of Neurological Surgery. Therefore, it is physically impossible for every hospital to have its own neurosurgeon always available to handle emergencies. To make matters worse, early retirement and other reasons for leaving practice recently caused a decline in the number of board-certified practicing neurosurgeons (see “Too Many? Too Few,” www.AANS.org, article ID 21462).
The decreased availability of neurosurgeons for emergency coverage has created major problems for hospitals because the EMTALA obligation to provide emergency coverage falls on hospitals, not on the physicians who practice there. Thus, hospitals are forced to find solutions to the problems of arranging neurosurgical coverage for their emergency rooms.
Hospitals have responded to this challenge in varying ways. At institutions where a requirement of medical staff membership is emergency room coverage, hospitals may attempt to force neurosurgeons to take as much call as the hospital needs. If only one or two neurosurgeons are on staff at a smaller facility, this requirement to cover the emergency room can quickly become overwhelming.
Stipends for On-Call Services Other hospitals have recognized the burden that emergency call places on neurosurgeons, including the frequent need to cancel billable activities involving insured patients in order to care for emergency patients who frequently have no financial resources. These facilities have begun to offer compensation, often through per diem stipends, to those who serve on call.
In 2001, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons adopted a position statement that supports compensation to neurosurgeons for serving on call (see “Improving Access to Emergency Neurosurgical Services” in this issue). While the statement does not specify a level of compensation, it does state that such compensation should supplement any reimbursement that the neurosurgeon may receive for professional services rendered as a result of on-call obligations.
Until recently, little if any data existed regarding the prevalence and amount of on-call stipends for neurosurgeons. The results of the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey shed light on the provision of stipends and provide neurosurgeons with valuable data that they can use in discussions with their hospitals. The survey found that one third of neurosurgeons received some compensation for emergency call coverage. However, there was wide variation by practice type, practice setting, trauma center level, and region in terms of who was compensated and the amount received. In general, compared with neurosurgeons in full-time academic practice, neurosurgeons in private practice were twice as likely to receive compensation for emergency coverage.
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“Blaming inadequate neurosurgical emergency coverage on only one source is just as simplistic as stating that every headache is caused by a brain tumor.” |
Some have bemoaned the payment of on-call fees, complaining that they represent a loss of physicians’ sense of community obligation to cover emergency rooms and provide uncompensated care. Furthermore, neurosurgeons have been accused of demanding fees that are so exorbitant, they are “bankrupting” the entire trauma care system. Others, however, point out that decreasing reimbursements–which often are pegged to federally created Medicare reimbursement schedules–combined with skyrocketing practice expenses, out-of-control liability insurance premiums, and multiplying unfunded regulatory mandates (like EMTALA requirements), have radically changed the landscape of medical practice from what it was in years past. Gone is the margin by which neurosurgeons could provide uncompensated care and absorb or cross-subsidize the losses associated with emergency room coverage.
Others point out that payment of some type of stipend is already a very common practice for hospitals that transfer funds to medical schools in exchange for clinical services; one might say that the discussion of stipends for emergency call simply puts different labels on the services and funds.
Neurosurgeons’ Responses
Stipends can take the sting out of neurosurgeons’ financial losses incurred through their provision of emergency care. However, as the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey demonstrated, most neurosurgeons (nearly 70 percent) do not receive such compensation.
Some neurosurgeons have resigned from hospital staffs in order to avoid the potentially untenable position of being on call simultaneously for several different facilities. For those in small communities, resigning from the only hospital in the area means relocating one’s practice and family, often leaving the region without neurosurgical services. Others have downgraded their category of medical staff membership, such as from “Active” to “Courtesy.” The most common reason given for such a change is that, at many hospitals, physicians in the “Courtesy” category are not required to cover emergency call.
Still other neurosurgeons have chosen to limit the types of neurosurgical services they perform at a hospital. Frequently the services limited are cranial surgery or treatment of pediatric patients. A common reason for relinquishing such privileges is that doing so decreases exposure to lawsuits. For some, a perceived advantage of limiting one’s practice to treatment of spinal disorders is the decreased burden of emergency call. The frequency and urgency of emergencies involving the spine are not nearly as great as those of trauma and other emergencies affecting the brain and skull.
Professional Liability Insurance Premiums Another commonly cited disincentive to neurosurgeons’ participation in emergency care is the effect of such participation on professional liability insurance premiums. It is widely believed that on-call service increases these premiums. At least one neurosurgeon in a western state was told by his insurance company that he could cover the emergency room no more than 10 nights per month or his premiums would increase to prohibitive levels.
Other neurosurgeons have related that their professional liability insurance carriers have offered discounted premiums to those who limit their neurosurgical services to “less risky” procedures. In Texas, at least some insurers lower their premiums if neurosurgeons do not perform cranial work, but colleagues in other parts of the country report that their insurers do not offer such a discount.
While it seems clear that at least some insurers do charge less if neurosurgeons do neither cranial nor emergency work, the inconsistency of the available data suggests that such reduced rates may be a regional or carrier-specific phenomenon (see “The Ohio Experience” in this issue).
Neurosurgeons who limit the scope of their practices, however, should be aware that the CMS has stated that physicians who practice in a narrow subspecialty may still be competent in their larger specialty, especially in terms of possessing more skill and expertise than emergency physicians when it comes to dealing with emergency conditions. Thus, a neurosurgeon whose elective practice is limited to spinal disease may still be expected to have more knowledge and expertise than an emergency physician when it comes to treating acute subdural hematomas. In an attempt to solve this problem, hospitals may soon specify required core privileges for many specialties.
Specialty Hospitals Some neurosurgeons have created their own specialty hospitals. The majority of these facilities focus on elective spine care and on other nonemergency neurosurgical conditions. From the surgeon’s point of view, a major benefit of these hospitals is that they allow physicians to practice in a more controlled setting. However, the proliferation of these centers has raised concerns that they “cherry-pick” insured patients who are comparatively healthy, increasing the proportion of sicker, uninsured, and emergency patients who must be cared for at local safety net hospitals.
Moreover, when neurosurgeons move their practices to the specialty hospitals, fewer neurosurgeons remain available to share the responsibility of covering their area’s emergency rooms. Such concerns prompted Congress to pass an 18-month moratorium on physicians referring patients to new specialty hospitals in which they have an ownership or investment interest. The moratorium, which went into effect in January 2004, does not apply to facilities that already are in existence. In September 2004, the Medicare Payment Advisory Commission reported initial findings suggesting that while patient volumes declined in many hospitals because of the growth of physician-owned specialty facilities, most of the affected hospitals were able to remain profitable and recoup lost business.
Physician Extenders Other neurosurgeons have broadened their use of physician extenders. Use of PEs, including physician assistants and nurse practitioners, helps neurosurgeons continue to provide emergency care. Expanded roles for PEs include emergency room assessment and critical care management. Some neurosurgeons even have taught their PEs to insert intracranial pressure monitors. The propriety of these actions has become the subject of controversy. In terms of patient care, the most important concern seems to be that PEs have “adequate supervision,” although the exact meaning of that term remains a matter of debate.
The 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey found that the vast majority of neurosurgeons did not use PEs, but far more of those in full-time academic practice used them compared with those in other practice types. Interestingly, 42 percent of respondents said PEs should be trained to perform trauma-related procedures such as placement of intracranial pressure monitors or subdural drains. Of the few private practice neurosurgeons who did use PEs, all but one thought they should be trained to perform trauma-related procedures.
Responses of Other Specialties
Some neurosurgeons have found it impossible or undesirable to care for emergency or critically ill patients without assistance from other specialties. Neurocritical care, for example, is a rapidly growing subspecialty that has formed its own professional society and is moving toward creation of its own certifying board. So far, however, trauma surgeons continue to be the group that most frequently provides care for patients with brain or spine injuries when neurosurgeons are not involved.
Reports from the United States and from other countries have described treatment of neurotrauma patients by non-neurosurgeons, including insertion of intracranial pressure monitors and performance of trauma craniotomies. Several centers have published data intending to show that placement of intracranial pressure monitors by other physicians or by midlevel practitioners is as safe as insertion by neurosurgeons. Some of these authors analyzed only placements of fiber-optic monitors into the subdural space (which is not a technique recommended in the Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury), but others reviewed insertions of ventriculostomy catheters.
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“Gone is the margin by which neurosurgeons could provide uncompensated care and absorb or cross-subsidize the losses associated with emergency room coverage.” |
A report from rural America describes a group of trauma surgeons and an orthopedic surgeon who were distant from the nearest neurosurgical facility and who received special neurosurgeon-directed cranial surgery training, which included laboratory sessions with cadavers. These surgeons created a burr hole (which was occasionally enlarged) in each of eight patients who exhibited rapid neurological deterioration and who were thus deemed too unstable for fixed-wing transport to the nearest neurosurgical facility, a trip which lasts a minimum of one hour each way. These eight patients were among a total of 60 head-injured patients with a Glasgow coma scale score of 13 or less who were treated during the 75 months of the review period. The neurosurgeon was consulted by phone for all cases. A radiologist assisted with determining the location for the burr holes. Immediately after surgery, the patients underwent air evacuation to the neurosurgical facility. At a minimum follow-up interval of one year after injury, one patient had died, two had Glasgow outcome scale scores of 4, and the remaining five had GOS scores of 5.
This reasoned and cautious approach contrasts with the much more aggressive stance adopted by other trauma surgeons. After seeing neurosurgical midlevel practitioners or interns routinely inserting intracranial pressure monitors, the more aggressive trauma surgeons may assume that they also should be allowed to do those procedures. Others have been influenced by military general surgeons, who may have had to perform cranial procedures on deteriorating patients when prompt transport to a neurosurgeon was not possible. Even in such cases, however, neurosurgical involvement is usually sought to the greatest extent possible, such as by phone or radio.
Should trauma surgeons be given a green light to perform invasive cranial procedures without the knowledge of the nearest neurosurgeon? It is important to note several reports describing the poor performance of non-neurosurgeons who attempted to evacuate acute extra-axial hematomas. Many such operations were deemed inadequate because only a small amount of the clot was removed, perioperative bleeding was not controlled, or the hematoma was not found. Clinical outcomes were better when patients were immediately transferred to a neurosurgical center than when they first underwent attempted surgery by a non-neurosurgeon. On the other hand, deterioration was rare among patients who were sent immediately to the nearest neurosurgeon without first undergoing a craniotomy by a non-neurosurgeon. These reports suggest that patients would be served better by rapid detection of their mass lesions and expeditious transfer to a neurosurgeon rather than by delaying definitive care while a non-neurosurgeon attempts a craniotomy.
Frequently overlooked in these debates is that insertion of an intracranial pressure monitor or performance of a craniotomy is often only a small, initial step in a lengthy, complicated stay in an intensive care unit. In many ways, knowing what to do with these patients in the intensive care unit is just as important–if not more so–than resuscitating and stabilizing them.
Of relevance to neurosurgeons is that, according to at least one survey, the aggressiveness with which trauma surgeons wished to perform neurosurgical procedures was related to their dissatisfaction with local neurosurgeons’ responses to the needs of trauma patients. Interestingly, while one might expect that the availability of neurosurgery residents in a hospital would ease the need for trauma surgeons to perform neurosurgical procedures, the survey indicated that the presence or absence of neurosurgery residents did not seem to be related to trauma surgeons’ desire to perform such procedures. This same survey found that many trauma surgeons would prefer greater involvement of neurosurgeons–or even a primary role for neurosurgeons–in caring for neurotrauma patients.
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For Further Information Emergency Room Coverage: What Every Neurosurgeon Should Know. Informational packet available on the Web site of the AANS/CNS Section on Neurotrauma and Critical Care, www.neurosurgery.org/sections/TR/emc.pdf. EMTALA regulations and interpretative guidelines: www.cms.hhs.gov/providers/emtala/default.asp. Kaups KL, et al. “Intracranial Pressure Monitor Placement by Midlevel Practitioners,” Journal of Trauma, Injury, Infection, and Critical Care 1998; 45:884-886. PubMed ID: 9820697. Ko K, et al. “Training Protocol for Intracranial Pressure Monitor Placement by Nonneurosurgeons” Journal of Trauma, Injury, Infection, and Critical Care 2003; 55:480-484. PubMed ID:14501890. Rinker CF, et al. “Emergency Craniotomy in a Rural Level III Trauma Center.” Journal of Trauma, Injury, Infection, and Critical Care 1998; 44:984-989. PubMed ID: 9637153. Valadka AB, et al. “How Well Do Neurosurgeons Care for Trauma Patients?” Neurosurgery 2001; 48:17-25. PubMed ID:11152343. Wester K. “Decompressive Surgery for ‘Pure’ Epidural Hematomas.” Neurosurgery 1999; 44:495-500. PubMed ID:10069586. Wester T, et. al. “Decompressive Surgery in Acute Head Injuries: Where Should It Be Performed?” Journal of Trauma, Injury, Infection, and Critical Care 1999; 46:914-919. PubMed ID:10338412. |
When the opinions of neurosurgeons were solicited on this topic in the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey, one third of respondents said that general surgeons should be trained to insert intracranial pressure monitors where neurosurgeons were unavailable. Only 20 percent thought they should be trained to perform emergency craniotomies in the same circumstance.
A New Surgical Specialty? The desire of general surgeons to expand their role in the management of neurotrauma may filter down to general surgical residency training. A major revamping of trauma surgeons’ training is receiving serious consideration by the American Board of Surgery, the American College of Surgeons, the American Association for the Surgery of Trauma, and similar organizations.
The revised scheme would call for several years of broad-based surgical training, followed by several years of training concentrated in a new specialty that might be called “emergency surgery” or “acute surgery.” In addition to trauma, these new specialists would be expected to handle nontrauma surgical emergencies, such as abscesses or gastrointestinal obstructions. Such a plan is relevant to neurosurgeons because these new trainees additionally would receive instruction in neurosurgery and orthopedics, with the expectation that, in addition to appendectomies and splenectomies, they would be able to perform emergency craniotomies and insert intracranial pressure monitors.
Who Will Be Answering Call?
When we consider the future of neurosurgical emergency care, we must be aware that every one of us shapes that future every day. Ideally, neurosurgeons, hospitals, and other physicians on hospital medical staffs would be able and willing to work together to find ways to provide appropriate emergency care. However, if neurosurgeons are not involved (for whatever reason) in crafting solutions to these problems, other specialists are more than willing to step in and fill the niche vacated by neurosurgeons. Will we allow this loss of a major part of our professional identity?
Neurosurgical critical care, emergency craniotomies, and spinal cord injuries historically have been the exclusive province of neurosurgeons. Most, if not all, neurosurgeons believe that our extensive training has rendered us the most qualified to best help patients with these injuries. Ultimately, as a profession we must determine whether neurosurgeons will continue to play a dominant role in neurosurgical emergencies, or if instead someone else will answer when the ER calls.
Alex B. Valadka, MD, FACS, is chair of the AANS/CNS Section on Neurotrauma and Critical Care, professor of neurosurgery at Baylor College of Medicine and chief of neurosurgery at Ben Taub General Hospital in Houston, Texas.