Neurosurgical Coverage: Essential, Desired, or Irrelevant for Good Patient Care and Trauma Center Status

Summary and Background Data:As a result of many factors, the availability of neurosurgeons (NS) to care for trauma patients (TP) is increasingly sparse. This has precipitated a crisis in access to neurosurgical support in many trauma systems, often placing undue burden on level I centers. This study examines the profile of head-injured (HI) trauma patients and their actual need for the specific expertise of a neurosurgeon. Methods:The National Trauma Data Bank (NTDB) was queried for specific information relating to the volume, nature, timeliness, and outcome of HI TP. Study patients were identified by reported International Classification of Diseases, 9th Edition (ICD-9) codes denoting open (OHI) or closed head injury (CHI) in isolation or in combination with other injuries. Results:Total number of NTDB patients studied was 731,823, of which 213,357 (29%) had a reported HI. CHI represented 22% of all TP and 74% of HI. OHI was reported in 8% of all TP and was 26% of HI. Craniotomy (crani) was performed in 3.6% of all HI (1% of all TP). This was in 2.8% of OHI and 2.6% of CHI. Mean Glasgow Coma Scale score (GCS) of crani patients was 9, and 13 for the noncrani group. Subdural hematoma occurred in 18% of HI (5% of TP), with 13% undergoing crani. Epidural hematoma occurred in 10% of HI (3% of all TP), with 17% undergoing crani. Median time to OR for all cranis was 195 minutes (195 for CHI; 183 for OHI). Of all cranis, 6.5% were performed within 1 hour of hospital admission. intracranial pressure (ICP) monitoring was reportedly used in 0.7% of TP and 2.2% of HI. Conclusions:Care of TP with HI rarely requires the explicit expertise and immediate presence of a neurosurgeon due to volume and nature of care. HI was diagnosed in <30% of TP reported to the NTDB. Over 95% required nonoperative management alone, with only 1% of all TP and 2%–4% of HI TP requiring crani and/or ICP monitoring. Immediate availability of NS is not essential if a properly trained and credentialed trauma surgeon or other health care provider can appropriately monitor patients for neurologic demise and effect early transfer to a center capable of, and committed to, operative and postoperative neurosurgical care. A subgroup of patients known to have a high propensity for the specific expertise of a neurosurgeon may be able to be identified for direct transport to these committed centers.

[1]  P. Barie,et al.  The position of the Eastern Association for the Surgery of Trauma on the future of trauma surgery. , 2005, The Journal of trauma.

[2]  B. Enderson,et al.  REPEAT HEAD CT AND NEUROSURGICAL CONSULTATION FOR MINOR TRAUMATIC HEAD INJURY IS NOT INDICATED IN NEUROLOGICALLY STABLE PATIENTS WITH GCS OF 14 OR 15 , 2004 .

[3]  B. Aarabi,et al.  DECOMPRESSIVE CRANIECTOMY DECREASES REFRACTORY INTRACRANIAL HYPERTENSION , 2004 .

[4]  Kimberly A Davis,et al.  Mechanism of injury does not predict acuity or level of service need: field triage criteria revisited. , 2003, Surgery.

[5]  K. Ko,et al.  Training protocol for intracranial pressure monitor placement by nonneurosurgeons: 5-year experience. , 2003, The Journal of trauma.

[6]  G. O’Keefe,et al.  23-Hour observation solely for identification of missed injuries after trauma: is it justified? , 2002, Journal of Trauma.

[7]  A. Valadka,et al.  How Well Do Neurosurgeons Care for Trauma Patients? A Survey of the Membership of the American Association for the Surgery of Trauma , 2001, Neurosurgery.

[8]  K. Nagy,et al.  The utility of head computed tomography after minimal head injury. , 1999, The Journal of trauma.

[9]  D. M. Gannon,et al.  Emergency craniotomy in a rural Level III trauma center. , 1997, The Journal of trauma.

[10]  A. Laupacis,et al.  Variation in ED use of computed tomography for patients with minor head injury. , 1997, Annals of emergency medicine.

[11]  R. Derlet,et al.  Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. , 1997, The Journal of emergency medicine.

[12]  R. Chesnut.  Guidelines for the management of severe head injury: what we know and what we think we know. , 1997, The Journal of trauma.

[13]  R. Chesnut.  Guidelines for the management of severe head injury. Introduction. , 1997, Journal of neurotrauma.

[14]  H. Karamanoukian,et al.  Can patients with minor head injuries be safely discharged home? , 1993, Archives of surgery.

[15]  J. Morris,et al.  The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. , 1992, The Journal of trauma.

[16]  S. K. Mohanty,et al.  Are CT scans for head injury patients always necessary? , 1991, The Journal of trauma.

[17]  T. Esposito,et al.  Why surgeons prefer not to care for trauma patients. , 1991, Archives of surgery.

[18]  D. Livingston,et al.  The use of CT scanning to triage patients requiring admission following minimal head injury. , 1990, The Journal of trauma.

[19]  S. Stein,et al.  The value of computed tomographic scans in patients with low-risk head injuries. , 1990, Neurosurgery.

[20]  R G Dacey,et al.  Neurosurgical complications after apparently minor head injury. Assessment of risk in a series of 610 patients. , 1986, Journal of neurosurgery.

[21]  J. Miller,et al.  Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. , 1981, The New England journal of medicine.

[22]  K L Mattox,et al.  What price commitment? , 1977, JACEP.

[23]  Director,et al.  The Leapfrog Group ’ s Patient Safety Practices , 2003 : The Potential Benefits of Universal Adoption Research , 2004 .

[24]  R. Gamelli,et al.  Perception of differences between trauma care and other surgical emergencies: results from a national survey of surgeons. , 1994, The Journal of trauma.