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Measures to improve availability of on-call specialists were proposed in Hospital-Based Emergency Care: At the Breaking Point, one of three Institute of Medicine reports released June 14. The IOM specifically called for the regionalization of certain emergency specialty services; improved reimbursement for emergency services; medical liability reform; and the creation of a new acute care surgery specialty. The American Association of Neurological Surgeons, together with the Congress of Neurological Surgeons, offered three of these recommendations to the IOM in February 2005. The AANS opposes the creation of an acute care surgical specialty, which, as the IOM described, would include neurosurgical and orthopedic procedures “that can be safely performed without the direct intervention of these specialists.”
Some of these measures are reflected in A Growing Crisis in Patient Access to Emergency Surgical Care, a position paper by the American College of Surgeons released June 23. Regarding regionalization, the ACS said it is “achieving some consensus on how to apply the trauma system model so that a blueprint can be developed for better regionalizing specialty care services that may be required in an emergency situation.” The ACS also noted that support for comprehensive medical liability reform is shared by “all medical and surgical specialty organizations” and expressed support for broad-based improved reimbursement—reform of the Medicare payment system, for example—rather than specifically for emergency services. The creation of an acute care surgery specialty was not mentioned in the report.
The AANS’ ongoing advocacy for comprehensive federal medical liability reform is well documented in the pages of the AANS Bulletin, as is the AANS’ position on improved reimbursement for emergency services, which specifies “reasonable compensation” for on-call neurosurgeons. The introduction of an acute care surgery specialty and the concept of regionalization as it relates to emergency specialty care have only recently been discussed, and these ideas are ripe for exploration.
Acute Care Surgery? Longing for Cooperation
The at a new surgical specialty was under serious consideration by several of
surgery’s national organizations was brought to the attention of Bulletin readers
in 2004 by Alex Valadka, MD, then chair of the AANS/CNS Section on Neurotrauma
and Critical Care. The proposed new breed of specialist, who perhaps would
be known as an emergency surgeon or an acute surgeon, would perform nontrauma
surgical emergencies as well as some emergent neurosurgical procedures including
craniotomies and insertion of intracranial pressure monitors. After noting
that neurosurgeons are the most qualified physicians to help patients with
injuries to or disorders of the nervous system, Dr. Valadka warned that “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.”
In fall 2005 the AANS Task Force on Neurosurgical Care and Physician Workforce Issues was commissioned. By spring 2006 the development of an acute care surgical specialty again was addressed in the Bulletin, this time by 2005–2006 AANS President Fremont Wirth, MD.
Dr. Wirth discussed the “developing crisis in delivery of neurosurgical emergency care” as well as the continuing efforts of the AANS to gather information and develop a plan for improving the situation. He acknowledged agreement among leadership that “neurosurgical care is best delivered by trained neurosurgical providers,” a position which in April was sanctioned with the Board of Directors’ approval of the AANS Policy Statement on Patient Safety:
The AANS affirms that patient safety is best achieved when surgical diseases affecting the nervous system are managed by neurological surgeons.
The development of an acute care surgical specialty, at least to the extent that it would expand into emergency neurosurgery, would run contrary to the AANS position on patient safety. Dr. Wirth stated that the “AANS has opposed this expansion for a number of compelling reasons, chief among them training and current evidence.” He also noted that “since most trauma surgeons work in level 1 trauma centers, additional training in neurosurgery—even if effective—is unlikely to benefit neurosurgical trauma patients because by definition neurosurgeons already are available at level 1 trauma centers.” He was, however, optimistic following an ACS-organized meeting of specialty leaders that consensus could be reached. “Our collective goal is to develop an effective, unified message to leadership in the U.S. Congress that will facilitate a solution to the delivery of appropriate emergency care to our patients,” he stated.
| Interview: ACS Medical Director of Trauma Programs J. Wayne Meredith,
MD
Manda J. Seaver
When specifically asked whether the Esposito and Moore articles represent the position of the college, Dr. Meredith pointed out that the JACS is a peer-reviewed journal with an editorial board independent of the college’s leadership so that, as is true of the AANS Journal of Neurosurgery, publication of an article does not imply the parent organization’s endorsement unless the article specifically states otherwise. In describing the college’s position on acute care surgery, he exercised caution. “Right now there is no such thing as an acute care surgery specialist,” he said. “We do perceive a growing multifactorial problem with the availability of specialists to perform [neurosurgical emergency] care, and we need to find solutions.” He added that the ACS is not supporting an entity—an acute care surgeon or general or emergency surgeon—that would replace a neurosurgeon. “Not a trauma surgeon in the country wants to do craniotomies,” said Dr. Meredith, who is himself a trauma surgeon as well as the immediate past chair of the ACS Committee on Trauma. “But we do need to know enough to determine when to call [a neurosurgeon].” Overall, Dr. Meredith expressed a desire for a collaborative spirit. “We need to restore cooperation in the house of surgery,” he said. “Let’s figure out what these patients need and do that.” In support of this strategy, he noted that on June 10 the college approved the addition of another neurosurgeon to the Committee on Trauma, a move that he hopes will lead to increased involvement of neurosurgeons in improving the delivery of emergency care to patients. He said the committee’s plan is to advocate for a system will lead to regionalization of trauma care. “There are many obstacles—EMTALA, workforce, politics, liability—and we need to get to the resources and work together,” he said. “There’s no way to manage without each other.” Manda J. Seaver is staff editor of the AANS Bulletin. |
In the meantime, some trauma surgeons embraced the development of an acute care surgical specialty, not only as a way to speed care to patients in the ER, but also as a means for revival of their own specialty. Two articles published in the April 2006 Journal of the American College of Surgeons discussed the creation of an acute care surgical specialty.
Thomas Esposito, MD, and colleagues asserted in “Making the Case for a Paradigm Shift in Trauma Surgery” that the trauma surgery specialty is “in the throes of an identity crisis that threatens its future.” Their literature review of the causes and implications of this identity crisis includes a table showing the Eastern Association for the Surgery of Trauma’s proposed major areas for inclusion in core curriculum and competencies for an acute care surgeon; “basic neurosurgical” appears under the heading “cognitive and technical principles of treating injuries.”
| AANS Policy Statement on Patient Safety (Statement approved by the AANS Board of Directors on April 22, 2006) The AANS affirms that patient safety is best achieved when surgical diseases affecting the nervous system are managed by neurological surgeons. This position statement (article ID 38148) and all AANS position statements are available in the online Library at www.AANS.org. |
It was “Eraritjaritjaka” that prompted a response from Dr. Valadka, Shelly Timmons, MD, and Richard Ellenbogen, MD. Their editorial, submitted to the JACS in June, challenged the authors’ emphasis on “saving the specialty of trauma surgery” and focused instead on the provision of “optimal care of neurosurgical patients in emergency departments.” They presented compelling evidence supportive of such care being managed by neurosurgeons and delivered via a regionalized system modeled on the military’s system of triaged care.
Valadka and colleagues recognized that neurosurgical emergency care involves a great deal more than trauma and called for “a team approach to repair what is broken.” The authors argued that “it is not the neurosurgeon who needs to be supplanted or the trauma surgeon who needs to be reinvented [but rather the] emergency care system which needs to be re-engineered!” They further acknowledged that “thoughtful and equitable regionalization and interspecialty cooperation are essential in any plan to optimize the individual components and overall delivery of emergency care,” and stated that “neurosurgeons…are eager to share in an open and honest dialogue.”
The ACS discussed the acute care surgical specialty in two articles published in the July issue of the ACS Bulletin. Executive Director Thomas R. Russell, MD, called acute care surgery “one of the more controversial ideas under discussion.” He recognized the need for thorough training as well as the input of all specialties in the training curriculum “if we do pursue the development of this specialty,” but focused much of his attention on consensus-building: “Ultimately, we must stay centered on achieving some sort of consensus about which approaches will ensure that surgical patients receive appropriate care by the right person at the right time and in the right place.”
The second article summarized practical advantages and disadvantages of the proposed specialty. For example, an “advantage” of the acute care surgeon’s expanded role is the increased attractiveness of the specialty, which is expected to assist with the recruitment and retention of trauma surgeons. How does this balance the “disadvantage” of the significant challenge of providing this new specialist with adequate training? Author Gregory S. Cherr, MD, called “learning the subtleties of urgent neurosurgical and orthopedic intervention” a “daunting” task and wondered “how this might be accomplished in a brief fellowship rotation.” Further exploration of the proposed specialty will be offered during a symposium with “open mic” to be presented at the 2006 Clinical Congress in October.
While a longing for cooperation and a desire to care for neurosurgical emergency patients appear to be the common ground with respect to the development of an acute care surgical specialty, the concept of regionalization enjoys comparatively widespread support.
Regionalization of Emergency Specialty Services
Regionalization of emergency specialty services is proposed as a solution
to a variety of emergency system ills, among them the availability of on-call
specialists. While there is a good deal of consensus on the concept, the details
of implementing such a system remain to be determined, although some models
have been proposed.
The IOM report specifically called for “hospitals, physician organizations and public health agencies to collaborate to regionalize critical specialty care on-call services.” Directing patients to the nearest facility with the best resources to handle their needs will improve health outcomes, mitigate overcrowding, reduce costs, and ensure specialty coverage at the regionalized facility, the report stated.
The ACS report advocated building a system of regionalized care based on the trauma system model. The system not only would alleviate overcrowded emergency departments, but also “would be particularly appropriate for services provided by specialties with workforce numbers in the few hundreds or thousands, such as neurological and hand surgery.”
Two recent AANS presidents have tackled this topic: Robert A. Ratcheson, MD, in his 2005 Presidential Address, and Fremont P. Wirth, MD, in the last issue of the AANS Bulletin.
Dr. Ratcheson offered several reasons, in addition to improving on-call availability, for fostering regionalization:
[Regionalization] would necessarily promote the formation of neurosurgical teams and enhanced teamwork. It should allow resources to be centralized to serve the needs of patients rather than the desires of hospitals. It may ameliorate the problem of physician fatigue and allow more efficient utilization and greater development of subspecialty skills. It can go a long way toward meeting society’s demands for reasonably rested, well-educated, and up-to-date neurosurgeons who are constantly available, and it can be organized to ease the burden of trauma call, which is exacerbated by the availability of too few individuals covering multiple hospitals. It may allow lifestyle considerations to be addressed in more satisfactory ways and encourage more women to enter neurosurgery. I think this is a change that will be good for neurosurgeons, and most importantly, for our patients.
Dr. Wirth observed that “the crisis in emergency care with respect to neurosurgery has as much to do with distribution of neurosurgical trauma care as with a shortage of it.” He noted the many factors underlying the problems with delivery of care, some of which have been mentioned here—medical liability, lack of reimbursement—and some that have not: lack of neurosurgical unit intensive care beds, lack of appropriate imaging or neurosurgical endovascular capabilities, and lack of adequately trained personnel to assist in the complex care of neurosurgical patients.
“It is likely that the [AANS Task Force on Neurosurgical Care and Physician Workforce Issues] will recommend some reorganization of the system for providing neurosurgical care,” he stated. “Such an approach has the potential for improving the quality of life for neurosurgical providers as well as enhancing the availability of high quality neurosurgical care for our patients.”
Most recently, Valadka and colleagues offered support of the regionalized emergency care concept as well as two possible models, one based on the U.S. military’s medical system and the other on the emergency system in the Pacific Northwest. They described the military’s sophisticated and efficient triage system as allowing neurosurgeons to be strategically located in well-equipped facilities and patients quickly delivered to them, or using telemedicine and teleradiology to provide neurosurgical expertise to those in remote locations. They cited the Pacific Northwest for its “very well-developed emergency system…in which complex patients are rapidly stabilized at community hospitals and then evacuated as needed to a level 1 or level 2 trauma center.”
Valadka and colleagues suggested that “regionalization, a plan which eliminates redundancy, provides patient safety nets, and lessens competition for limited resources, will ultimately improve quality and safety and also save money…it simply needs to be championed at a national level by all surgeons.”
Both the proposed specialty of acute care surgery and regionalization of emergency specialty services are likely to be among the topics addressed in the recommendations of the AANS Task Force on Neurosurgical Care and Physician Workforce Issues.
Manda J. Seaver is staff editor of the AANS Bulletin.
For More Information
• AANS Position on Improving Access to Emergency Neurosurgical Services,
www.AANS.org, Article ID 9760
• Cherr GS: Acute care surgery: Enhancing outcomes or fragmenting care? ACS Bulletin 91(7):40–43, 2006
• Esposito TJ, Rotondo M, Barie PS, Reilly P, Pasquale MD: Making the case for a paradigm shift in trauma surgery. J Am Coll Surg 202(4):655–67, 2006
• A Growing Crisis in Patient Access to Emergency Surgical Care, www.facs.org/ahp/emergcarecrisis.pdf
• Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka. J Am Coll Surg 202(4):698–701, 2006
• Ratcheson RA: Fast forwarding: The evolution of neurosurgery. The 2005 presidential address. J Neurosurg 103:585–590, 2005
• Russell, TR: From my perspective. ACS Bulletin 91(7):4–5, 2006
• Valadka AB: The ER: Who is answering call? In some hospitals, not neurosurgeons. AANS Bulletin 13(4): 6–12, 2004. www.AANS.org, Article ID 26358
• Wirth FP: The moral of the story: Neurosurgery’s professionals offer best neurosurgical emergency care. President’s Message. AANS Bulletin 15(1):3–4, 2006. www.AANS.org, Article ID 38188