Acute Care Neurosurgery: An Evolving Practice Model

Dr. Anthony M. DiGiorgio
Dr. Anthony M. DiGiorgio
Dr. John F. Burke
Dr. John F. Burke
Dr. Geoffrey T. Manley
Dr. Geoffrey T. Manley

Neurosurgery patients often require treatment in the intensive care unit (ICU). Traditionally, the scope of practice for neurosurgeons included acute and postoperative critical care for their patients and thus, neurosurgeons have not needed special privileges for ICU admission. This practice has been challenged over the past decade and poses a threat to neurosurgery being able to provide total patient care for a variety of conditions. Here, we briefly review the history of neurosurgical involvement in critical care, describe the current challenges facing neurosurgery and propose a model of acute care neurosurgery that integrates emergent neurosurgery and ICU care into a new neurosurgical specialty.

Neurosurgery’s involvement in critical care emerged from the need to manage complex neurosurgical conditions, such as traumatic brain injury (TBI) or ruptured intracranial aneurysms. Control of ICU decision-making expanded the scope of neurosurgical practice. This is reflected in early literature on these topics largely coming from neurosurgeons, such as work on cerebral edema1 and vasospasm2. Indeed, neurosurgery’s leadership in the ICU started a cycle of greater clinical involvement and increased translational research that resulted in better patient care and improved outcomes. In this respect, the ICU was integral to the growth of our field.

Involvement in neurosurgical ICU care comes at a cost. Performing emergency cases and managing critically ill patients make building an elective practice challenging. Furthermore, sub-specialization within neurosurgery has shifted training away from general skills and knowledge required to manage ICU patients, such as placing central lines and managing ventilator settings. These difficulties coincided with the development of neurocritical care (NCC) as a distinct field specifically dedicated to the management of neurosurgical and neurological patients in the ICU.

The shifting nature of the NCC field is reflected in the continuously evolving neurocritical care certification requirements.3 Current uncertainty surrounding critical care accreditation is unfortunate, because there has never been a more pressing need for neurosurgeons in the ICU. This is especially apparent in the critical care management of TBI — a very complicated patient population that has traditionally been managed exclusively by neurosurgeons. Despite this, today only approximately a third of patients with severe TBI are currently cared for in neurocritical care units; the remaining two-thirds are evenly split between trauma ICUs and general ICUs.4 The reasons for this is multi-factorial and include demands on the time of a neurosurgeon, availability of NCC staffing, the need for ICU beds for postoperative neurosurgical patients, etc. Whatever the reason, the process of relinquishing our role in critical care has led to neurosurgeons frequently serving as the consulting team in cases of TBI. Some neurosurgeons, preferring an exclusively elective practice, may welcome this. However, our field risks losing vital critical care skill, leaving the primary treatment of these patients to physicians without surgical expertise.

We posit that maintaining critical care involvement is vital for the long-term health of our field, and here we propose a model of how to maintain and better integrate critical care into modern neurosurgery. This model is based on the specialty of “acute care surgery”, which the fields of general surgery and trauma surgery created in response to many of the same challenges described above.5 In this model, a small group of surgeons (within the department of surgery) are responsible for all emergent surgical procedures as well as simultaneously staffing the ICU. This model has led to many beneficial outcomes for general surgery departments, including offloading the call and critical care duties to dedicated acute care surgeons, increasing the elective case volume by non-acute care specialty surgeons, faster times to OR for emergent surgeries, decreased wait times for urgent surgeries, decreased length of stay for emergency room admissions, improved outcomes in acute care cases, protocolization of trauma care and overall financial gain for hospitals.6-8

Adapting this model to neurosurgery, we propose the creation of a new subspecialty, acute care neurosurgery (ACNS), that will allow neurosurgeons who are well adept in handling neurosurgical emergencies to focus specifically on these cases.9 Practically, each department or group will define a set of ACNS neurosurgeons, who will cover all urgent/emergent surgeries, while also being the primary provider on all neurosurgical patients within the ICU. Under this model, the ICU would become a “dual-staffed” unit with both a neurocritical care (NCC) team and a neurosurgical (NSU) team. Each team could manage patients alone (such as NCC for an ischemic stroke after tPA or NSU for a postoperative brain tumor), but would regularly act as consultants on the other team’s patients. For example, a hemorrhagic stroke needing an EVD could be managed with NCC as primary and NSU as consultant while a severe TBI could be managed by NSU with NCC as a consult service. This model fosters a collaborative effort between the NCC and NSU teams, encouraging co-rounding on the most complex patients, ensuring efficient use of resources and improving outcomes.10

A variant of this model would mandate that all ACNS neurosurgeons have full critical care accreditation, acting as a member of the NCC call pool. In this case, the critical care physicians function as both the primary physician on both neurosurgical and NCC patients. The neurosurgeon under this model would be the physician in charge of all aspects of the neuro-ICU, including stroke care, intracerebral hemorrhages, transverse myelitis, etc. This model is currently used at many institutions, but we advocate that the NCC neurosurgeon take call for ACNS neurosurgical cases, while simultaneously staffing the ICU. The advantages of this approach would be to firmly establish neurosurgery at the center of all aspects of emergent neurological conditions. Both models provide the benefit of a dedicated surgeon for ACNS, mirroring the improved outcomes realized by general surgery.

The creation of an ACNS specialty would re-establish neurosurgical presence in the ICU. However, changing neurosurgical practice in this way would also create new challenges that should be considered. First, it is unclear whether and how neurosurgeons should achieve ICU accreditation. Second, in order to manage critically ill patients, the ACNS neurosurgeons would have to spend significant amounts of time away from the operating room compared to their colleagues focusing on elective subspecialties. Third, there may be periods in which responsibility for critical care and surgical patients conflict, bringing concern about adequate staffing to cover both the OR as well as the ICU. Finally, if a highly complex case presents as an emergency (cerebral aneurysm, spinal fracture causing significant deformity, etc.), neurosurgeons in other subspecialties would need to be recruited for the case.

We argue that each of these issues is easily overcome with institutional support. For example, the department may elect to financially compensate the ACNS neurosurgeon for the additional call in addition to RVU-based pay. Also, with enough staffing, our general surgery colleagues have shown that covering both the ICU and the OR is not only achievable, but also improves outcomes with much higher volumes of ACS cases in general surgery than in neurosurgery11-14. ACNS services should involve a strong complement of residents and/or advanced practice providers, allowing seamless coverage of both the ICU and OR when needed. Finally, for complex cases, the ACNS neurosurgeon may wish to work with a specialist, if appropriate. Ultimately, this is no different than a pediatric neurosurgeon having a vascular co-surgeon for a complex AVM or a neurosurgeon specializing in degenerative spine co-scrubbing a case with a deformity surgeon. Such collaborations are commonplace in modern neurosurgery and are not evidence that sub-specialization should be abandoned.

Unfortunately, for multiple reasons both within and outside of neurosurgery, neurosurgeons are slowly being pushed out of the ICU. As a field, we have to ask ourselves: Is the ICU worth fighting for? On the one hand, our involvement in the ICU may seem unnecessary and a waste of neurosurgical resources that could be better spent in the operating room. Indeed, ceding control of patients who are critically ill may be financially efficient in the short run. On the other hand, losing control of patients and their critical care is perhaps the biggest threat to our field. In order to have a say in which aneurysms get clipped vs. coiled, which fractures get open vs. MIS procedures, which tumors get resected vs. radiated, we must be involved in all aspects of patient care. Neurosurgeons are trained to anticipate problems, to solve them before issues arise, and to provide the highest quality care – no matter what it takes. These principles guided our field to great success, and now is not the time to abandon them. Now is time to carefully consider how we expand neurosurgery and develop a new acute care neurosurgery specialty that provides total patient care to the sickest and most vulnerable patients in neurosurgery.

Addendum

The 2019-2020 outbreak of novel coronavirus (COVID-19) has strained critical care resources in the United States. Neurosurgeons, while not typically on the front lines, have been integral in management of critical care units. While purely elective cases are being indefinitely delayed, many neurosurgical cases are more urgent and must be triaged when resources become available.15 Additionally, although shelter-in-place laws have curtailed trauma in the community, patients are still presenting with neurosurgical pathologies. In some institutions, overflow critical care beds have become de facto neurocritical care units and wards are utilized as step-down units. Collaboration with colleagues and administration is critical to ensure critical care bed availability when resources are stretched thin.

While traditional critical care physicians are a vital resource, acute care neurosurgeons can offload purely neurosurgical patients from these overworked services. There is no room for redundant critical care staffing during a crisis and neurosurgeons are well-equipped to handle our own ICU patients. Whether it is collaborating with the ICU teams to determine bed and ventilator availability or offloading purely neurosurgical patients, the expertise of the acute care neurosurgeon will be welcome.

Lastly, it is imperative that neurosurgeons follow all isolation and PPE guidelines. Safety of the health care staff must always be a top priority. Trauma patients represent a unique challenge in the COVID-19 pandemic. All trauma patients, especially those unable to provide a history, should be assumed to be COVID-19 positive until proven otherwise. Infection control precautions should be taken during care of these patients and neurosurgeons must adhere to the local, regional and national guidelines.

COVID-19 has thrust the concept of emergent vs. elective surgery to the fore, and it is clear that hospitals need standardized definitions of emergent, urgent and elective procedures. Neurosurgeons should take this moment to define “neurosurgical emergencies”, to more efficiently determine which cases proceed when hospital resources are strained. Over the next months to years, surgical acuity grading scales will be proposed and refined, and neurosurgeons should lead this effort. If there is ever a time to organize acute care neurosurgery, now is it.

References

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