Neurosurgical emergency and trauma services: legal, regulatory, and socioeconomic barriers.

Neurosurgical coverage for hospital emergency and trauma call has been a growing controversy for several years. Hospital emergency department surveys show difficulty either in getting coverage of specialty services in the emergency room (ER), or trouble finding neurosurgeons to whom to refer emergency problems. The American College of Emergency Physicians surveyed 4444 hospital emergency departments in 2004, finding 66% reported inadequate on-call specialist coverage.5 Neurosurgery was one of the specialties identified with an ER call coverage problem. In the emergency call debate, several circumstances contribute to problems with neurosurgical emergency call coverage. First, the number of practicing neurosurgeons is limited, amounting to approximately 3000 board-certified and perhaps another 1500 noncertified or training neurosurgeons available to cover more than 4500 acute care hospitals, so that constant coverage at all hospitals is not feasible. No neurosurgeon can be expected to be on continuous call, and not all hospitals can be continually covered. Second, a number of neurosurgeons subspecialize, limiting clinical services for areas such as pediatrics or cranial surgery, and may not cover emergency call for categories of service they do not routinely provide in daily elective practice. Third, Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, clumsily trying to enforce ER specialty coverage, may have paradoxically created coverage problems where none may have previously existed. By initially interpreting regulations before 2002 to prohibit coverage of multiple hospitals simultaneously, or prohibiting routine surgery while on call in the emergency department, the Centers for Medicare and Medicaid Services created threats of sanctions for routine practice that may have caused some to reduce, rather than expand call coverage. These regulations were clarified in 2002, reversing the previous interpretation, and recognizing that 365 day per year neurosurgery ER coverage may not be feasible or required for every hospital.2 Fourth, threat of professional liability is perceived by some as a deterrent to neurosurgical emergency coverage. Fifth, neurosurgeons have increasingly expected hospital compensation for what, heretofore, was voluntary coverage of ER call, an exchange for their time and to cover nonreimbursed emergency services. In 2004, an Emergency and Trauma Services survey was conducted by the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS).3 Surveys were sent to 3213 AANS/CNS members; 1031 were returned (a 32% response rate), giving the responses a high level of validity. A second AANS survey was conducted in 2006, entitled the “Workforce Survey,” asking many similar questions regarding emergency services coverage, with a 770 of 2550, or 30%, response rate.4 The results from these two surveys form the basis for this presentation. Fifty percent of the respondents to the survey were in a private practice, 30% in academic practice, and 15% in a mixed academic and private practice. Most were in small (2–5 members, 35%) or medium-sized groups (6–20 members, 25%). Only 12% were in solo practice. The mix of respondents corresponded closely to the distribution of AANS membership. Forty percent of respondents worked or took call at a Level 1 trauma center. Thirty-five listed a Level 2 trauma center as their primary affiliated institution, and 25% listed either a Level 3 hospital or no designation. Thus, respondents were approximately equally distributed between major trauma centers and secondary, or minor, trauma centers. The distribution allowed a balance of perspectives between neurosurgeons in major trauma referral centers and those serving smaller community hospitals. One question of particular importance was how many neurosurgeons take emergency call. A growing perception among ER physicians and academic medical centers is the difficulty in finding a neurosurgeon to accept an emergency patient, and an increased volume of emergency transfers from smaller private hospitals to large academic medical centers. The 2004 survey showed that 83% of responding neurosurgeons or their practice group provided 365 day per year call. Copyright © 2007 by The Congress of Neurological Surgeons 0148-703/07/5401-0149