Emergency neurosurgical care solutions: acute care surgery, regionalization, and the neurosurgeon: results of the 2008 CNS consensus session.

OBJECTIVE: Organized general surgery has recently proposed creation of a new acute care surgery subspecialty to include emergency care of basic neurosurgical and orthopedic surgical problems. Little is known about neurosurgical attitudes toward this proposal and alternative methods of improving access to emergency neurosurgical care. METHODS: During a consensus session at the 2008 Annual Meeting of the Congress of Neurological Surgeons (CNS), electronic data were collected regarding neurosurgeons' attitudes toward acute care surgery, emergency neurosurgical care regionalization, and other regulatory options. RESULTS: Ninety-nine attendees participated in polling, broadly representing private (45%) and academic (34%) practices from all regions of the United States. Eighty-nine percent reported taking emergency calls (75% at least twice per week), with the majority (57%) not receiving a stipend. Only 9% responded that routine emergency cases are frequently transferred from their hospital. The majority (60%) either agreed or strongly agreed that there are problems with neurosurgery emergency coverage in their region. Before the session, 89% were opposed to the acute care surgery initiative as a solution for neurosurgery emergency coverage and 85% favored regionalization of emergency care. Opinions did not change significantly following expert presentations and discussion. CONCLUSION: Neurosurgeons polled during a 2008 CNS consensus session opposed creation of an acute care surgery specialty within general surgery that covers neurosurgical emergencies, but they favored neurosurgical emergency care regionalization. The CNS consensus sessions provide a forum for discussing socioeconomic and professional issues important to neurological surgery and for formulating preliminary information and strategies of use to regulatory stakeholders in addressing these issues.

Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study.

OBJECTIVE: The absence of surgical subspecialty emergency care in the United States is a growing public health concern. Neurosurgery is a field lacking coverage in many areas of the country; however, this is generally thought to be of greater concern in rural areas. Because of decreasing numbers of neurosurgeons, medical malpractice, and liability concerns, neurosurgery coverage is becoming a public health crisis in urban areas. Our objective was to quantify neurosurgical emergency transfers to academic medical centers in Cook County, IL, including patient demographics, reasons for transfer, time lapse in transfer, and effects on patient condition. METHODS: Data on neurosurgery emergency transfers was gathered prospectively by all five of the academic neurosurgery departments in Cook County, IL, over a 2-month period. Patient demographics devoid of identifiers, diagnosis, transfer origin, time lapse of transfer, and patient condition at the time of transfer and at the receiving hospital were recorded. RESULTS: Two-hundred thirty emergent neurosurgical transfers occurred during the study period. The most common diagnoses were parenchymal intracerebral hemorrhage (33%) and subarachnoid hemorrhage (28%). Sixty-six percent of neurosurgical transfers to academic medical facilities originated at hospitals without full-time neurosurgery coverage. The mean time to transfer for all patients was 5 hours 10 minutes (standard deviation, 3 h 42 min; range, 1-20 h 12 min). A decline in Glasgow Coma Scale score was seen in 29 patients. A shortage of neurosurgical intensive care unit beds occurred on 55% of the days in the study. Only 19% of the emergency cases were related to cranial trauma, and only 3% of transfers came from Level 1 trauma centers. CONCLUSION: A combination of factors has led to decreases in availability of neurosurgical coverage in Cook County community hospital emergency departments. This has placed an increased burden on neurosurgical departments at academic centers, and, in some cases, delays led to a decline in patient condition. Eighty-one percent of the cases were not related to cranial trauma; thus, acute care trauma surgeons would be of little use. Coordinated efforts among local governments, medical centers, and emergency medical services to regionalize subspecialty services will be necessary to manage this problem.