Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study

The absence of surgical subspecialty emergency care in the United States is a growing public health concern. Neurosurgery is a field lacking coverage in many areas of the country; however, this is generally thought to be of greater concern in rural areas. Because of decreasing numbers of neurosurgeons, medical malpractice, and liability concerns, neurosurgery coverage is becoming a public health crisis in urban areas. Our objective was to quantify neurosurgical emergency transfers to academic medical centers in Cook County, IL, including patient demographics, reasons for transfer, time lapse in transfer, and effects on patient condition.

Data on neurosurgery emergency transfers was gathered prospectively by all five of the academic neurosurgery departments in Cook County, IL, over a 2-month period. Patient demographics devoid of identifiers, diagnosis, transfer origin, time lapse of transfer, and patient condition at the time of transfer and at the receiving hospital were recorded.

Two-hundred thirty emergent neurosurgical transfers occurred during the study period. The most common diagnoses were parenchymal intracerebral hemorrhage (33%) and subarachnoid hemorrhage (28%). Sixty-six percent of neurosurgical transfers to academic medical facilities originated at hospitals without full-time neurosurgery coverage. The mean time to transfer for all patients was 5 hours 10 minutes (standard deviation, 3 h 42 min; range, 1-20 h 12 min). A decline in Glasgow Coma Scale score was seen in 29 patients. A shortage of neurosurgical intensive care unit beds occurred on 55% of the days in the study. Only 19% of the emergency cases were related to cranial trauma, and only 3% of transfers came from Level 1 trauma centers.

A combination of factors has led to decreases in availability of neurosurgical coverage in Cook County community hospital emergency departments. This has placed an increased burden on neurosurgical departments at academic centers, and, in some cases, delays led to a decline in patient condition. Eighty-one percent of the cases were not related to cranial trauma; thus, acute care trauma surgeons would be of little use. Coordinated efforts among local governments, medical centers, and emergency medical services to regionalize subspecialty services will be necessary to manage this problem.