Midlevel practitioners can safely place intracranial pressure monitors

Neurosurgical coverage is a challenge for many trauma centers. Midlevel practitioners (MLPs) can extend coverage by sharing the workload. Our objective was to determine whether the complication rates for intracranial pressure (ICP) monitor placement were similar between neurosurgeons and MLPs.

After obtaining institutional review board approval, the trauma registry at a Level I trauma center was searched for all ICP monitors placed between June 2005 and March 2010. Complications were classified as major or minor. The study was designed as a noninferiority trial with a 5% absolute difference in major complications defined as acceptable, a priori. Time to monitor placement was a secondary outcome and was analyzed by Wilcoxon rank sum and multiple linear regression.

One hundred seven patients were identified. Fifteen patients were excluded (inserted by trauma surgeon or MLP under direct supervision, ventricular drain, or inserted at an outside facility). Of the remaining 92, 22 were inserted by neurosurgeons and 70 by MLPs. There was one major complication (cerebrospinal fluid leak) in a monitor placed by an MLP. The difference in complication rates was significantly less than 5% (1.4% vs. 0%, p = 0.0128). The minor complication rate was higher for MLPs (5.7% vs. 0%, p = 0.80). Craniotomy and placement on third shift were associated with shorter times to monitor placement. Nine monitors were inserted at the time of craniotomy, eight of them by the neurosurgeon.

ICP monitors can be safely placed by midlevel practitioners with major complication rates not different from those of neurosurgeons.