“I’m on call as we speak,” said James T. Goodrich, MD, pausing on a Friday afternoon for a brief telephone discussion of neurosurgical emergency coverage at a busy New York academic medical center.
Dr. Goodrich, the director of pediatric neurosurgery at Montefiore Medical Center in the Bronx and a professor of neurosurgery at Albert Einstein College of Medicine, is one of Montefiore’s five neurosurgeons.
In the last five years Montefiore, a level 1 trauma center for which there is neurosurgical emergency coverage at all times, has experienced a 45 percent increase in ER patients. According to a hospital statement, a program implemented in 1998 has helped handle the current 180,000 ER visits annually without becoming overwhelmed.
Through its “ICU without walls” program, the hospital established a rapid response team of 16 critical care specialists. These specialists, who are cross-trained in all critical care disciplines, are present at all times to treat patients in the intensive care unit and in the emergency room, as well as medical and surgical patients who become critically ill.
According to Montefiore’s director of critical care medicine, Vladimir Kvetan, MD, the program contrasts with the typical ICU, where “specialists practice only in their own discipline in a specific type of unit and only during daytime hours.”
Kvetan stated that the program’s objective is to expand services to patients and improve the quality of care without increasing the number of ICU beds. “Another important benefit…is that we treat continuously the most severely ill post-op neurosurgical, cardiothoracic, and general surgery patients,” he said. “Through our services, they get better care sooner. This frees up the OR more quickly for other patients.”
From a neurosurgeon’s perspective, the program does help extend care for neurosurgical patients in emergencies. “An intensivist is available to respond quickly and can order a computed tomographic scan and other tests,” said Dr. Goodrich. “But they can’t perform neurosurgical procedures, such as place intracranial pressure monitors.”
Neurosurgical residents also are part of the rapid response team. “The chief resident can start a case, but the attending still needs to oversee it,” Dr. Goodrich said. “So the program hasn’t affected the call schedule; we’re still on call 24/7.”
He has seen an increase in transfers of neurosurgical patients to Montefiore. “A level 1 trauma center is an enormous expense, and reimbursement hasn’t kept pace,” he explained. “The result is that relatively few hospitals are equipped to handle neurosurgical emergencies, and when either the facilities or the neurosurgeons to staff them aren’t available to care for patients locally, those patients come to us.”
While the benefits of the “ICU without walls” program are many, finding beds for neurosurgical patients in the intensive care unit remains a challenge. “The ICU bed crunch is real,” said Dr. Goodrich, a circumstance he attributed in part to changes in practice patterns, such as increased interventional work performed by neuroradiologists.
When asked if changing lifestyle expectations are contributing to the availability of neurosurgeons for emergencies, Dr. Goodrich conceded that operating on an epidural hematoma at 3 a.m. is always tough when one’s regular schedule starts at 7 a.m., but said that such a scenario is nothing new.
“The key thing is the environment,” he said. “Neurosurgeons practicing now have much greater medicolegal exposure, while at the same time reimbursement is declining.”
These twin pressures are particularly apparent with regard to emergency cases. “When we see a patient in the ER, we’re often not paid,” he observed. “Yet our liability exposure is enormous.”
The result is that neurosurgeons at both ends of the career spectrum are feeling squeezed. “Senior level neurosurgeons are retiring early, while others are limiting their practices,” he said. He related one example that hits close to home: “One of my best and brightest former residents recently told me that he is no longer doing cranial procedures. He didn’t even want to tell me–cranial work is a big part of what he trained for–but he saved $100,000 on his liability insurance premium and felt he had to make the practical decision.”
Manda J. Seaver is staff editor of the Bulletin.