"The neurosurgical ER coverage situation is the biggest crisis I have seen in my 20-year career as a neurosurgeon."
"I am distressed by the number of patients who seem to be coming in from other hospitals (for whatever reason) and who are in much worse condition than if they had gotten care immediately."
"I had to voluntarily withdraw my cranial privileges because I was being swamped. Not only can we not find a new neurosurgeon to help me out, but our transfers [of patients] out have increased 300 percent since I stopped covering intracranial cases. It is clear that access to timely care is being dramatically affected (patients are being transported sometimes 100 miles away to get help; patients are waiting two months to see me in the office)."
"My partner and I are the only remaining neurosurgeons to cover a level 2 trauma center with 3,000 visits per year. One neurosurgeon is unable to cover because he cannot obtain malpractice insurance approved by the hospital. The other neurosurgeon who covered is retiring in two weeks."
These comments reflect some of the many concerns related to neurosurgical emergency and trauma coverage expressed by respondents to the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey. Solicited for participation in this Web-based survey were 3,213 neurosurgeon members of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons who were actively practicing in the United States.
The return of 1,031 completed surveys represents what Perception Solutions, the independent company which conducted the survey, called an "impressive" 32 percent rate of return. The sample size of 900 or more for most questions provides a 95 percent level of confidence that results are accurate within 5 percentage points. Simply said, one can be 95 percent certain that the answers observed in the sample also are true for all those whose participation in the survey was solicited.
Respondents were generous with their insights, offering more than 350 comments via open text fields. Moreover, greater than half the respondents volunteered their personal contact information and their availability for follow-up inquiries. These indicators, combined with the high rate of return, demonstrate neurosurgeons' intensity of feeling on the subject of neurosurgical emergency coverage.
"Numerous discussions at neurosurgical meetings large and small coupled with pleas for help from neurosurgeons across the nation have left no question that neurosurgeons as a group are concerned about who provides neurosurgical emergency coverage, how such coverage is provided, and a host of related issues, including patients' well-being," said James R. Bean, MD, a member of the AANS Executive Committee and immediate past chair of the AANS/CNS Washington Committee. "But until now there was little reliable, independent data available that could begin to give shape to the complex web of issues surrounding neurosurgical emergency coverage and aid us in developing guidance for our members."
Dr. Bean called the survey a valuable baseline study and observed that repeating it at intervals in the future would help organized neurosurgery identify trends in neurosurgical emergency care. "Our ultimate goal is to help neurosurgeons proactively address pressures that prevent the delivery of timely neurosurgical emergency care and empower them to implement changes in their local systems that ultimately will improve patient outcomes and accessibility to such care."
A Snapshot of Respondents
Survey results were representative of neurosurgeons across the United States. Nearly 50 percent of respondents were in private practice. Almost 30 percent were in full-time academic practice, while just over 16 percent were in private practice with an academic appointment. About 6 percent were with the federal government or "other."
Of the nine practice types the survey specified, all were represented. The majority of responses were from small groups of two to five neurosurgeons (37 percent) and medium groups of six to 20 neurosurgeons (24 percent).
Slightly more than half of all respondents took call at more than one facility. However, when asked what level of trauma care their hospital provides, they were asked to indicate the facility with the highest level of trauma care. The majority were on call for level 1 (42 percent) and level 2 (34 percent) trauma centers, which require neurosurgical availability. About 8 percent served at level 3 centers and 17 percent said their hospital had no trauma designation.
Although the survey did not specify geographic region, this information was available for 576 of the respondents who volunteered their contact information. There was representation from all geographic regions: South, 34 percent; Midwest, 28 percent; Northeast, 17 percent; Pacific, 13 percent; and Rocky Mountain, 7 percent. This information was judged statistically valid and is included in analysis of selected results.
The Developing Picture
A solid majority of neurosurgeons or their practices, 83 percent, still provide at least one hospital with "full" neurosurgical emergency coverage, defined as 24 hours a day, seven days a week, 365 days a year. However, a closer look at the data showed significant differences in call coverage by practice type and setting.
Full-time academicians in large or medium neurosurgical groups provided the highest percentage of full emergency coverage for a hospital, 98 percent, compared with other respondents.
The percentage of full coverage dropped to 77 percent for those in private practice and declined even further for those in solo practice (48 percent).
There also was a significant difference in the percentage of full neurosurgical emergency coverage by trauma center designation. The survey showed a span of 20 percentage points between respondents' coverage of a level 1 facility (93 percent) and a level 3 facility (73 percent); neurosurgical coverage of a hospital without a trauma designation was slightly less (72 percent).
Most neurosurgeons who covered emergency or trauma cases, 66 percent, said they were on call every third, fourth, or fifth to seventh night. But a significant number, 19 percent, were on call every night or every other night. When called, the majority of respondents, 60 percent, were required by their hospital to respond within 30 minutes; for another quarter of respondents, a "prompt" response was required.
Of the 17 percent of respondents who did not provide full neurosurgical emergency
coverage, more than one third gave as their principal reason that there are
not enough neurosurgeons in their practice or location to provide full coverage.
Another 29 percent said "other"--several commenters indicated that
the underlying reasons were a combination of factors--while 17 percent cited
professional liability risk. Differences were starkly apparent between neurosurgeons
in private practice and those in full-time academic practice: 44 percent of
private practitioners cited as their principal reason too few neurosurgeons
in the practice or location compared with none of the academicians, and 18 percent
of private practitioners cited professional liability risk, compared with none
of the academicians.
The vast majority of respondents, 87 percent, said their professional liability insurance carrier did not provide a discount for limiting or eliminating some types of neurosurgical emergency services (but see "The Ohio Experience" in this issue for an explanation of how reducing risk by limiting services may result in a lower premium). Of those who had been sued, slightly more than one third said the suit was initiated by a patient seen through the emergency room. Spinal (27 percent) and cranial (27 percent) trauma cases together accounted for more than half of these lawsuits. When nontrauma cases are included, cranial lawsuits (50 percent) occurred more frequently than spinal suits by 10 percentage points. The remaining lawsuits involved pediatric trauma and nontrauma (7 percent) as well as a small percentage of other cases.
The likelihood of a lawsuit varied significantly by practice type and setting. Full-time academic practices, medium and large group practices, and large multispecialty practices were at significantly less risk of being sued than other practice types and settings. At greatest risk of being sued were those in private practice and those in a solo practice setting.
Interestingly, while neurosurgeons said they were sued most often for cranial and spinal cases, respondents limited pediatric services far more often. Nearly two thirds of respondents limited emergency coverage for children, including both trauma (31 percent) and nontrauma (34 percent) cases. Neurosurgeons also limited cranial trauma and nontrauma (15 percent) and spinal trauma and nontrauma (15 percent). About 4 percent of respondents did not take any trauma call. In summary, only 54 percent of neurosurgeons who provide emergency call coverage performed all neurosurgical services; nearly half of respondents, 46 percent, limited the types of cases they cover in some way.
Nearly half of those practicing at an academic medical center or at a level 1 or level 2 trauma center said they had noticed an increase in the number of neurosurgical trauma cases in the last two years. Nearly one third of respondents attributed this increase to on-call neurosurgeons who transfer patients under Emergency Medical Treatment and Labor Act rules to a "higher level of care" facility. The remaining two-thirds of respondents were fairly equally divided in their assessment of the cause, indicating that in their area:
- there are sufficient numbers of neurosurgeons, but some or all do not provide emergency call coverage;
- there are insufficient numbers of neurosurgeons available to provide full emergency call coverage; or
- neurosurgeons' withdrawal of cranial privileges has necessitated the transfer of all cranial emergencies to a facility where cranial services are provided.
One third of all survey respondents reported difficulty negotiating emergency contracts with their hospitals. Significant differences were reported among geographic regions, trauma center levels, practice settings and practice types. Those in the Rocky Mountain area reported experiencing the most difficulty (45 percent), closely followed by those in the Pacific region (43 percent) and in the South (41 percent). By trauma center designation, those practicing at a level 2 trauma center (41 percent) were most likely to have trouble negotiating call schedules, as were those in solo practice (53 percent) and those in solo practice with shared facilities (46 percent). There was a difference of 23 percentage points between private practitioners who reported difficulty negotiating their call schedules (41 percent) and those in full-time academic practice (18 percent).
Very few differences were found among all groups when asked what type of neurosurgical emergency call coverage their hospitals were requiring. There was a statistical tie at 32 percent for the top complaints: hospitals are insisting on full, "24/7/365" call coverage, and hospitals do not provide a stipend for call coverage. About 20 percent of respondents said their hospitals are insisting that they respond to non-neurosurgical emergencies. Despite the fact that most neurosurgeons across the board said they are required by their hospitals to respond to emergencies within 30 minutes, very few respondents (6 percent) said their hospitals were imposing an unreasonable or unrealistic response time.
"What all this means is that even though most neurosurgeons are still providing full neurosurgical emergency coverage, there are some cracks in the system," said Dr. Bean. "The picture that is forming suggests that some neurosurgeons are straining to provide emergency coverage, particularly those in private practice and in solo or small group settings, and that some patients, particularly trauma victims and children distant from a level 1 trauma center, may be at risk for not receiving timely and appropriate neurosurgical emergency care."
Shoring up the System: Stipends and PEs
The survey asked specifically about two measures undertaken by some facilities to shore up neurosurgical emergency coverage: paying stipends for on-call coverage and using physician extenders for some procedures.
Stipends About one third of respondents were compensated for emergency coverage by a stipend, which partially covers low reimbursement for emergency cases and lost revenue from elective cases. The likelihood of receiving a stipend varied by practice type, practice setting, and by trauma center designation. Neurosurgeons in private practice or in solo or small-group practice settings and those on call at level 1 or level 2 trauma centers were significantly more likely than others to receive stipends. Those practicing in the Pacific and Rocky Mountain regions also were more likely to receive stipends.
Many survey respondents commented on how emergency cases are disruptive to respondents' regular clinical and surgical schedule and why stipends are helpful.
One respondent who did not receive a stipend explained the situation this way: "I am not paid to take call and in fact, [taking emergency call] is clearly a money-losing proposition. I can't bill enough for [cases that] come through the ER to offset the time spent and the ill effect it has on my [elective] practice... it is high-liability work and as one of the few independent, solo practitioners, one of my greatest concerns is that my [professional liability insurance] rate could force me [out of solo practice]."
Another respondent, who received a stipend, commented, "The hospital is helping to cover costs by paying an on-call stipend...As with most of us, the stipend allows me to continue in practice."
While stipend amounts varied somewhat by region, trauma designation, practice type and practice setting, analysis revealed a weighted average stipend of $866 per day. About a quarter of those who received a stipend received $1,001 to $1,500 per day, and this range held true with the following exceptions. Those in the Pacific region were more likely to receive $750 per day or less. Those on call at level 3 trauma centers were as likely to receive $500 per day or less as $1,001 to $1,500 per day. Full-time academicians and those in "other" practice types were more likely to say they were "not paid by the day." By practice setting, all large neurosurgical groups that received stipends were paid $501 to $750 per day, while small multispecialty groups were significantly more likely to receive $2,001 to $3,000 per day.
Physician Extenders Three questions looked at current practices and opinions regarding the use of physician extenders, a collective term that commonly refers to physician assistants and nurse practitioners, although a few respondents commented that they included residents in their responses to these questions. Slightly less than one third of respondents said they currently were using a PE to first evaluate emergency patients. Even less, about 15 percent, said they currently use a PE to perform invasive neurosurgical trauma services such as placement of intracranial pressure monitors. However, 42 percent of respondents thought that PEs should be trained to perform trauma-related invasive procedures.
Two questions involved the training of general surgeons to perform some neurosurgical procedures. When asked if general surgeons should be trained to insert intracranial pressure monitors where neurosurgeons are not available, one third of respondents said yes. Affirmative responses dropped to one fifth when asked if general surgeons should be trained to perform emergency craniotomies where neurosurgeons are not available.
The survey recorded several comments related to this topic, which has been the subject of much debate particularly in neurotrauma and critical care circles. Two respondents volunteered summaries of their viewpoints:
- "I feel we need to train physician assistants and nurse practitioners to provide initial neurosurgical evaluation and care under the direct supervision of a neurosurgeon who is available and can review X-rays...via teleradiology. We should train these people and certify them so that they, and neurotrauma, remain under the direct control of neurosurgery. This is the only way I see to extend care in the face of a decreasing neurosurgical workforce and increasing demand while preserving the quality of care we want our patients to receive."
- "Neurosurgeons need to remain intimately involved in providing neurosurgical care coverage and neurocritical care, and it is a mistake to start the slippery slope [by which] we remove our involvement. The problem is that we need help, including liability exclusion for trauma care (good Samaritan type help); better reimbursement for [trauma procedures]...; and training of more neurosurgeons [as there are] not enough...to cover all the trauma centers without stressing the system."
Complete survey results, including additional data analysis, are expected to be available this spring at www.AANS.org.
"Our intention in conducting this survey was to provide neurosurgeons and their practices with detailed and practical information related to neurosurgical emergency care," said Dr. Bean.
"While we recognize that one survey alone cannot provide exhaustive data or solve this complex problem, we believe it is a step in the right direction."
Manda J. Seaver is staff editor of the Bulletin.
|Trauma Center Levels
|While state emergency medical services authorities
designate trauma centers, a hospital can ask the American
College of Surgeons Committee on Trauma to verify that it
meets the criteria for a level 1, level 2, level 3, or level 4
trauma center. "Essential" and "desirable" criteria for each
of the four levels of verification are delineated in Resources
for Optimal Care of the Injured Patient, published by the
ACS. A listing of verified trauma centers is available at
www.facs.org/trauma/verified.html; a brief summary of criteria for each level follows.
At the apex of emergency care is the level 1 trauma center, a
comprehensive regional resource that can provide total care
for every aspect of injury. Key elements include 24-hour inhouse
coverage by general surgeons and prompt availability
specialists, including neurosurgeons.
The level 2 trauma center can initiate definitive care for all
injured patients. Key elements include 24-hour immediate
coverage by general surgeons and coverage by specialists,
The level 3 trauma center has demonstrated an ability to provide
prompt assessment, resuscitation, stabilization of injured
patients, and emergency operations. Key elements include 24-
hour immediate coverage by emergency medicine physicians,
the prompt availability of general surgeons and anesthesiologists,
and transfer agreements with level 1 and level 2 trauma
centers for patients who require more comprehensive care.
The level 4 trauma center has demonstrated an ability to
provide advanced trauma life support prior to transfer of
patients to a trauma center that can provide more