Neurotrauma: Current Trends and Future Needs
Timothy R. Harrington, MD
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
Neurotrauma accounts for a significant proportion of the general trauma population and for as many as 50% of trauma deaths. As trauma systems have become successful, the demand for specialty coverage of those systems has increased. The workload involved has begun to affect the ability of neurosurgeons to function in their specialty, particularly if working independently or in a small group practice. Methods used by neurosurgeons to minimize this impact have been countered by hospital systems demanding that 24-hour coverage continue. Optimal neurotrauma care of the patient has thereby suffered. This article explores a potential solution to this problem through the development of regional neurotrauma centers.
Key Words: Emergency Medical Treatment and Labor Act (EMTALA), neurotrauma, trauma care systems
As trauma systems have proliferated across the United States, they have undoubtedly increased the survival rates for seriously injured persons. Every section of the country now has some version of a trauma triage system. Since 1980 the need for “specialist” consultation and treatment has grown commensurate with this expansion of trauma systems.
Neurotrauma represents a significant portion of the trauma population. Thirty to 50% of trauma victims require evaluation, treatment, or both for head or spinal trauma. In fact, the existing trauma system has been so successful that almost all motor vehicle accidents and more than trivial traumas (i.e., simple fractures) are triaged to trauma centers because “specialty” consultation is “known” to be available on a 24-hour basis.
Problems have arisen in neurotrauma because of the overall success of this system. Although the number of neurosurgeons has reached a balance with traditional needs, the additional burden of neurotrauma call as it has evolved was not anticipated. Most of this burden reflects the success of the development of the trauma triage system. Some of it, however, reflects the growing needs of the trauma population, especially as neurosurgery has expanded its treatment venues from traditional traumatic brain injuries into complex spinal fractures.[6,19]
Interpretation and enforcement of federal statutes (i.e., Emergency Medical Treatment and Labor Act [EMTLA]) also have limited the options for neurosurgeons covering trauma systems to consolidate patients or patient care when they are on call. Some “call” issues have been resolved by successful lobbying by organized specialist associations at the federal level.[7,11,15] Nationally, however, local interpretation of the responsibility of the “on-call” or “on-staff” neurosurgeons still varies widely.
Economic and Social Mechanisms of Coping
Recently, economic and social issues have taken center stage among neurosurgeons at both local and national levels. Mechanisms of coping to ensure adequate treatment of trauma victims involve both economic and social factors and in many cases have placed “management” (i.e., hospital or trauma directors) and private physicians at odds. Hospitals and management tend toward one of two directions to manage this problem. In the first approach, neurosurgeons and other specialists are paid for coverage, either directly or through incentives for practice arrangements to assure that the specialists are available to their trauma and emergency services. In Arizona, the estimated cost to the hospital for this coverage is $374,381 per neurosurgeon per year. The second approach strictly interprets federal statutes such as EMTLA (i.e., You are on staff; you must cover the emergency room and the trauma service.)
Specialists and, in this instance, neurosurgeons, have responded with similar economic and social steps. They may contract for services to cover the expenses of trauma call. This method is controversial as reflected by recent opinion articles in the Joint Trauma Newsletter regarding the obligations of physicians toward hospitals and patient care.[12,18]
Specialists also may drop all coverage and cherrypick hospitals that do not mandate neurosurgical coverage. This strategy works well for these neurosurgeons. While their competitors are tied up in the emergency room recovering from a night on trauma call, they can use their elective time to see patients in the office and to work a more remunerative elective surgical schedule.
The third option is for neurosurgeons to join larger groups with guaranteed income from hospital sources or teaching services with coverage by residents and fellows. This strategy increases an individual’s influence with hospital and insurance and malpractice vendors. This strategy reflects “strength in numbers.”
Problems with Neurotrauma Physician Coverage
At both the federal and local level, increased funding for trauma systems appears to be on the horizon. Most of the funding, however, is for system development and emergency care. Little, if any, outside funding is available to reimburse physicians’ expenses. Even these funds are at risk because their usual source is a “tobacco tax” or similar nonsecure sources of revenue. Therefore, physicians usually must be reimbursed by a hospital’s general services fund or by billing insurance companies. In my experience in Arizona, direct- billing reimbursement tends to range from 30% to 70% of the physician’s cost, depending on the location of the trauma hospital. The balance of losses is furnished by the hospital system or is written off by the physician. The risks of malpractice (i.e., costs) also may increase with emergency coverage and are becoming a major factor in neurosurgical decisions to cover emergency systems.
In 1995 the Brain Trauma Foundation published guidelines for the treatment of traumatic brain injury (revised and updated in 2001).[4,16] Similar but less formal recommendations have been proposed for spinal injury and pediatric trauma care. These recommendations have been distilled from the best available research and treatment paradigms. The guidelines establish a baseline for neurotrauma care in the United States and internationally. Unfortunately, except in a few selected geographical areas in the United States, there is no incentive to enforce these recommendations. Education and peer pressure have failed. Only enforcement has succeeded in the universal adoption of these guidelines by neurosurgeons. For example, intracranial pressure monitoring (ICP) is a basic “treatment” modality shown to improve outcomes of traumatic brain injury. Surveys by the Joint Trauma Committee and the Congress of Neurological Surgeons (CNS)/American Association of Neurological Surgeons (AANS) have shown that fewer than 50% of patients who would fit the criteria for ICP monitoring-a basic requirement for head injury treatment-actually undergo the procedure. [3,9,17] This finding suggests that other fundamental treatment paradigms are also being ignored. Because no formal review is conducted in most instances, the conclusion must be that fewer than 50% of traumatic brain injury patients nationally are being treated by the “best possible” modalities.
In terms of personnel, equipment, expertise, and expense, the neurological head or spinal trauma population represents a small but significant portion of the overall neurotrauma population (ranging from 39 to 53% locally; Harrington TH, unpublished data, 2003). The concept that all trauma centers should be able to deliver the same level of neurological, head, and spinal care does not appear to be working. Therefore, it would be logical to examine alternate approaches.
Before the development of national trauma systems, large teaching or university medical centers provided expert neurotrauma care in selected locales. This care, however, was only available locally. In the three decades since trauma systems were initially proposed, the development of emergency medical technicians, trauma triage, and evacuation systems have provided one solution to this dilemma. If combined with the available triage systems, the development of super-regional neurotrauma centers similar to the original large teaching universities or medical centers could fulfill the role of adequate delivery systems.
In effect, super-regional neurotrauma centers already exist across the country in the form of large teaching hospitals or medical centers staffed by large groups of neurosurgeons and spine surgeons. These centers have developed for either educational or financial reasons, and they are in the best position to undertake this job. Most such institutions are already subsidized by local or federal dollars.
What has changed in the last decade that would allow this type of system to work? First, super-regional teaching or neuromanagement centers driven by economic or social needs, a “band-together” concept, have been established. Second, regional trauma triage and transport systems have been established in almost every locale in the United States.
What does a regional neurotrauma system require? First, cooperation is necessary. Cooperation involves the necessary physician specialties; the hospital administration; and local, state, and federal coordination. Nationally, burn and pediatric centers are good examples. Second, validation and inspection by an outside body are needed. Again, burn centers, in cooperation with the American College of Surgeons, have shown the way. The Joint Trauma Committee of the CNS/AANS or the American College of Surgeons Committee on Trauma would be an appropriate start in this direction for validation. Third, funding by both medical centers and the regional trauma triage systems is necessary. Fourth, a standard organization that could be used nationally must be developed (see The Case for Designated Neurotrauma Referral Centers in the United States in this issue).
Benefits of Regional Neurotrauma Centers
The benefits of such a system would be widespread. In terms of patient care, any improvement beyond 50% compliance with the trauma guidelines for traumatic brain injury would be a major accomplishment. Physician practices would also benefit. Physicians interested in trauma and intensive care management could become involved with these centers, while physicians who prefer to practice in a more controlled environment would be able to continue their normal practices. This option would relieve some of the current antagonism between physicians and hospital administrators. Third, financial resources would likely be conserved by increasing the efficacy of the treatment. Finally, research on head and spinal injury treatment would be enhanced by centralizing the care for trauma.
In terms of patient care and physician involvement and availability, the current trauma system is better than any previous system. Nonetheless, by using the examples of the emergency medical triage systems and some of the current international systems, the system can still be improved. The systems are regionalized while their control is centralized. They are funded and their efficacy can be evaluated. Establishing regional neurotrauma centers and validating their efficacy will enhance the system that has been evolving since the 1970s.
- Arizona Department of Health Services: Arizona Emergency Medical Services and Trauma System Plan 2002-2005. Phoenix, AZ: Arizona Department of Health Services, 2000
- Bass RR, Gainer PS, Carlini AR: Update on trauma system development in the United States. J Trauma 47:S15-S21, 1999
- Bullock R: Joint Section on Neurotrauma and Critical Care. Neurosurgery News Fall:14, 2001
- Bullock RM, Chesnut RM, Clifton GL, et al: Part 1: Guidelines for the management of severe traumatic brain injury. J Neurotrauma 17:451-471, 2000
- Duval J: Trauma: The canary in the mine. Arizona Health Futures Fall:1, 2001
- Friedlich DL, Feustel PJ, Popp AJ: Workforce demand for neurosurgeons in the United States of America: A 13-year retrospective study. J Neurosurg 90:993-997, 1999
- Grol R: Improving the quality of medical care. Building bridges among professional pride, payer profit, and patient satisfaction. JAMA 284:2578-2585, 2001
- Harrington TR: Neurosurgical manpower needs–achieving a balance. Surg Neurol 47:316-325, 1997
- Hesdorffer DC, Ghajar J, Iacono L: Predictors of compliance with the evidence-based guidelines for traumatic brain injury care: A survey of United States Trauma Centers. J Trauma 52:1202-1209, 2002
- Hoyt T: Who wants to be an EMTALA surveyor. Neurosurgery News Fall:15, 2001
- Marion D: Joint section of neurotrauma and critical care. Chairman’s message. Neurosurgery News Fall:13, 2002
- McVicker J: Trauma contracts improve trauma care: Trauma stipends may not. Neurotrauma and Critical Care Newsletter Fall:4, 2002
- Narayan RK, Kishore PR, Becker DP, et al: Intracranial pressure: To monitor or not to monitor? A review of our experience with head injury. J Neurosurg 56:650-659, 1982
- Nathes AB, Jurkovich GJ, Cummings P: The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA 283:1990-1994, 2000
- Neurosurgery://On-Call [Internet]: Emergency medical treatment and labor act. http://www.neurosurgery.org/socialeconomic/emtala.html, 2003 (The website link is provided for your convenience only. Barrow Neurological Institute neither endorses nor is responsible for the content in any way.)
- The Brain Trauma Foundation, The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care: Guidelines for the Management of Severe Head Injury. New York: Brain Trauma Foundation, 1995
- Valadka AB, Andrews BT, Bullock MR: How well do neurosurgeons care for trauma patients? A survey of the membership of the American Association for the Surgery of Trauma. Neurosurgery 48:17-25, 2001
- Wilberger J: Neurosurgeons and their responsibilities to trauma centers. Neurotrauma and Critical Care Section Newsletter Fall:5, 2002
- Workforce Committee: Socio-economic: CSNS: Meeting News. Council of State Neurosurgical Societies, Philadelphia, PA, September 20, 2002