Guest Blog from:
J. Adair Prall, MD; South Denver Neurosurgery, Littleton, CO (top left)
Jason Hauptman, MD; Department of Neurosurgery, UCLA, Los Angeles, CA (top right)
Shelly D. Timmons, MD, PhD; Department of Neurosurgery, Geisinger Medical Center, Danville, PA (lower left)
Deborah L. Benzil, MD; Mount Kisco Medical Group, Mount Kisco, NY (lower right)
- Control of elevated intracranial pressure
- Ventilator management, and
- Sepsis care.
In an effort to further improve critical care outcomes, many hospitals have employed a closed-model system for their ICUs, in which only certain critical care staff may admit or write orders on patients. Although this model has been shown to improve care among general medical ICU patients – providing more continuous physician presence in the ICU, more rapid response to changes in critically ill patients, and more continuity in a given patient’s care – this improvement has not been demonstrated among neurosurgical patients.
For decades, care of the critical, neurologically injured patient has been a part of the foundation of neurosurgical training and certification. Junior residents spend many hours each day and night, in addition to their regular duties on any given service, learning from staff and senior residents about the basic tenets of critical care. Until recently, it was not an explicit rotation or been thought of as an opportunity for additional or fellowship training, due to the fact that all residents have had so much experience in the ICU throughout their training.
Many hospitals have adopted the ideas promulgated by various groups (including The Leapfrog Group) who claim that only specialists who have passed an exam, which is sponsored by a board not recognized by the American Board of Medical Specialties (ABMS), should be allowed to admit and write orders in ICUs. The goal of such restriction is to enhance patient safety and outcomes. However, this has had the unintended consequence of depriving many patients of the specialists who understand their disease process the best – namely neurosurgeons, who are the most qualified physicians to take care of the neurologically injured patient in the ICU.
In both community hospitals and academic settings, many neurosurgeons have expressed concerns about the impact this limited access to ICUs has on the delivery of quality patient care. This restriction may prevent neurosurgeons from providing the optimal care to their patients and, over time, may impact their ability to maintain the necessary skills to treat the sickest patients. In neurosurgical training programs, limited access to the ICU could lead to an inability to teach residents the critical care skills that are (and have always been) foundational to the care of all neurosurgical patients.
In order to try to assess the perceived impacts of ICUs with limited access, a survey was recently distributed by the Council of State Neurosurgical Societies (CSNS). The survey asked neurosurgeons, both in the community hospitals and academic medical centers, about their ICUs and the impacts on those who have limited access to them. With over 500 respondents to the survey, the results are quite concerning:
- 46 percent of community neurosurgeons reported limited or no access to their primary ICU;
- One-half of community neurosurgeons with limitations to ICU access felt that this was jeopardizing their ability to maintain their critical care skills;
- One-third of program directors reported limited access to ICUs in their primary residency training institution; and
- 31 percent of program directors thought limited access to ICUs had a negative impact on their residents’ training.
Most neurosurgeons are not forced to transfer their patients to another physician at the door of the ICU. Nor must they await their discharge to the floor to care for them again. Nevertheless, the survey responses indicate that many neurosurgeons have been exposed to limited-access ICUs and feel that this negatively impacts their patients and the maintenance of their skills.
For some time, having observed these changes in ICU access in some areas of the country, the leaders of organized neurosurgery have been requesting a voice in the discussion over who should be caring for patients in the ICU. Just this year, AANS president, Dr. Robert Harbaugh and others, met with representatives of The Leapfrog Group to discuss these issues and how to work to include neurosurgeons in their list of physicians qualified to care for neurosurgical patients in the ICU. Changes in the Leapfrog Group standards will be forthcoming in the future, which will recognize the importance of neurosurgeons in caring for their own patients in the neuro-ICU.
While limiting ICU access to those practitioners most experienced in this type of care may seem to be a valid concept to improve patient safety and outcomes, the evolution of the neuro-ICU saga should serve as a cautionary tale for policy makers. All physicians who are adequately trained and who know their patients best are in the best position to provide the most effective, quality care.
1. Carson SS, Stocking C, Podsadecki T, et al. Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of ‘open’ and ‘closed’ formats. JAMA : the journal of the American Medical Association 1996;276:322-8.
2. Checkley W, Martin GS, Brown SM, et al. Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study*. Critical care medicine 2014;42:344-56.
3. Hackner D, Shufelt CL, Balfe DD, et al. Do faculty intensivists have better outcomes when caring for patients directly in a closed ICU versus consulting in an open ICU? Hospital practice 2009;37:40-50.
4. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA : the journal of the American Medical Association 2002;288:2151-62.
5. Ueno Y, Imanaka H, Oto J, Nishimura M. Change in Ratio of Observed-to-Expected Deaths in Pediatric Patients after Implementing a Closed Policy in an Adult ICU That Admits Children. Critical care research and practice 2012;2012:674262.
6. Tinti MS, Haut ER, Horan AD, et al. Transition to a semiclosed surgical intensive care unit (SICU) leads to improved resident job satisfaction: a prospective, longitudinal analysis. Journal of surgical education 2009;66:25-30.