Academic Center ERs Bear Brunt of Chicago-Area Transfers – Study Suggests Problem Will Worsen

Academic medical centers traditionally have acted as safety nets for community emergency rooms. Most Chicago-area emergency rooms have enjoyed complete neurosurgical coverage until recently, when a significant increase in transfers of neurosurgical ER cases from community hospitals to academic centers has been noted.

In order to quantify transfers and evaluate their impact on patients’ outcomes, data was collected for one month at a single academic center in Chicago, Rush University Medical Center. In addition, historical data on transfers was analyzed. Further, to gain insight into the underlying causes of the transfers, a survey on neurosurgical ER coverage in the Chicago area, including Cook and other surrounding counties, was undertaken. Results of these studies suggest that neurosurgical ER coverage is declining in northeast Illinois, and that in Cook County the lack of neurosurgical ER coverage has become a public health concern which must be addressed.

Neurosurgical ER Transfers to Rush UMC:
One 28-Day Period
Data on neurosurgical ER transfers in a four-week period were gathered. The condition of each patient at the outside emergency room was obtained from transfer records and compared to the patient’s condition on arrival at Rush UMC. Only dramatic changes in the patient’s condition were considered significant.

In the 28 days studied, Rush UMC fielded 23 requests for transfer and accepted all cases (see table 1). Thirteen patients were transferred from emergency rooms in Cook County. The time period for patient transfer–from admission at the outside emergency room to arrival at Rush UMC–ranged from 3.5 hours to 9 hours, with a mean time of 6 hours.

Twelve patients were transferred from emergency rooms that did not have neurosurgical coverage. The condition of four of these 12 patients was significantly worse upon arrival at Rush UMC than at evaluation at the outside emergency room. Each of these patients was awake and alert at the outside emergency room.

By the time of arrival at Rush, three of the four patients had developed anisocoria. A computed tomographic scan on arrival documented that two patients with subdural bleed had experienced significant enlargement of their hematomas and had declined from a Glascow coma scale score of 15 to a score of 7. One patient with hydrocephalus went from GCS 15 to GCS 5. The CT scan of the fourth patient, who experienced both subarachnoid hemorrhage and hydrocephalus, showed no evidence of rebleeding, but the patient declined from GCS 12 to GCS 3.

All four of these patients underwent emergency surgery upon arrival; two of them died. The two surviving patients experienced significant impairment.

Comparative Data:
Neurosurgical ER Transfers in 2002 and 2004
In order to determine whether a trend in the number of neurosurgical transfers exists, the number of transfers to Rush UMC from January through September 2004 was compared with the number of transfers in same period in 2002 (see table 2). The number of transfers in this two-year period rose from 116 to 224, a 97 percent absolute increase. The number of transfers from hospitals without neurosurgical ER coverage increased from 25 to 125, an increase of 400 percent; most of these transfers, 80 percent, originated at Cook County hospitals.

Survey Data: Neurosurgical ER Coverage in Chicago-Area
Community Hospitals A telephone survey of emergency department directors and medical staff offices of all 74 active emergency rooms in Cook and its

surrounding counties provided additional data associated with neurosurgical ER coverage. A representative of the Illinois State Medical Society independently rechecked our data.

Neurosurgical ER coverage is considered to be present if a neurosurgeon was on call more than 50 percent of the days in each month. All of the responses regarding current neurosurgery coverage were the same on each query with two exceptions: One hospital erroneously had stated that they had no neurosurgery coverage, and another reported that it had lost coverage since the first inquiry. Past neurosurgical ER coverage is defined by an affirmative answer to the question, “Have you traditionally had neurosurgical ER coverage over the last 10 years?”

As table 3 demonstrates, neurosurgical ER coverage declined in several counties. Kane County experienced a 50 percent decline in coverage, while Kankakee and Will counties experienced a 100 percent decline, leaving them without neurosurgical ER coverage.

In Cook County, where 53 active emergency rooms are available to serve the county’s more than 5 million people, eight emergency rooms are at academic centers and 45 are at community facilities. In the past, 40 of the 45 emergency rooms in community facilities had neurosurgical coverage, but today only 20 are covered–a 50 percent decline. Eleven community emergency rooms lost neurosurgical coverage in the last two years.

Is Medical Liability at the Root of the Problem?
Most of the emergency department directors responding to our survey cited medical liability concerns as the causal factor in the loss of neurosurgery coverage. In fact, Illinois has been labeled a crisis state by the American Medical Association and Doctors for Medical Liability Reform, a coalition of medical specialties. Some data suggest that problems concerning medical liability are particularly pressing in Cook County.

A March 2004 survey of Illinois neurosurgeons conducted by the Illinois State Neurosurgical Society showed that 90 percent of the respondents had been sued, and that there was an average of five medical liability claims per neurosurgeon. According to Crain’s Chicago Business, in 2003 there were 1,066 medical liability cases filed in Cook County, while only 60 such cases were filed in Lake and DuPage counties. Even after adjusting for population, medical liability actions are five times more common in Cook County than in adjacent well-populated counties. According to ISMIE, the largest underwriter of professional liability insurance in Illinois, the average premium to be paid in 2005 by a mature neurosurgeon in Cook County will be $235,000 for $1 million in coverage.

Given that in 2003 there were 46 settlements in malpractice actions in Cook County above $2 million, and 11 were $10 million or higher, according to Chicago Lawyer, it becomes clear why $1 million of liability insurance in Cook County seems inadequate to the many neurosurgeons who have left the county, retired, or restricted their practices–some no longer perform intracranial procedures, for example–in order to limit their liability exposure.

According to our survey of ER directors, long waits for ambulance transfer service, long ambulance rides, and prolonged searches for beds available in the intensive care unit have become common. Although neurosurgical ICU bed availability was not addressed in this study period, their availability has become a problem at all Cook County academic centers despite efforts to increase their number. Transferred patients have filled additional beds quickly.

Steps are being taken to address what evidence suggests is a growing problem. Neurosurgical department chairs of all of the Cook County academic programs met recently to discuss neurosurgical ER coverage, and it was noted that the problem of increased numbers of transferred patients is an experience shared by all of the academic medical centers in Cook County. In order to further define the scope of the problem, each center will begin collecting data on emergency transfers and evaluate the impact it has on patients. This data will be pooled, analyzed, and summarized for report to the Illinois State Medical Society and the state trauma commission. Recommendations will be made to enact changes in the current emergency and transfer systems to accommodate the shrinking number of neurosurgeons available in community hospital emergency rooms.

It is clear that the lack of neurosurgical ER coverage in Cook and some surrounding counties is straining the emergency system and that patients are being adversely affected when their treatment must be delayed while appropriate care is sought. Unfortunately, this problem might be expected to worsen. According to the AANS Journal of Neurosurgery, the average neurosurgeon retires around age 61. At 14 of the 20 community hospitals in Cook County that still have neurosurgical ER coverage, the average age of neurosurgeons is 61.

Richard W. Byrne, MD, is a member of the Chicago Institute of Neurosurgery and Neuroresearch and an associate professor of neurosurgery at Rush Medical College, Rush University Medical Center, Chicago, Ill. Bradley T. Bagan, MD, is a neurosurgical resident at Rush University Medical Center.

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