Hospitalists, Neurosurgeons Team Up to Improve Outcomes

Nancy A. Melville

March 31, 2014

LAS VEGAS — A pilot program to implement quality improvement and patient safety initiatives for patients undergoing neurosurgery is bringing hospitalists and neurosurgeons together in a novel collaboration at the University of California (UC) medical centers.

Whether the innovative model will be embraced across the field of neurosurgery, however, remains to be seen.

"We created this interdisciplinary collaboration and decided that we wanted to standardize practices across all 5 UC medical centers to hopefully improve neurosurgical outcomes and care experiences," Catherine Lau, MD, assistant professor at UC San Francisco (UCSF) School of Medicine, told Medscape Medical News.

"Because of its high-risk nature, neurosurgery tends to have high rates of adverse events. While neurosurgeons address the problems well, progress in reducing those events has been stalled by a lack of training and expertise in quality improvement, as well as a lack of time and resources," she explained.

Dr. Lau presented the details of the program here at Hospital Medicine 2014.

Dr. Catherine Lau

For the pilot program, hospitalists at UCSF and UC Los Angeles partnered with anesthesiology and neurosurgery leaders to identify areas in neurosurgery that could benefit from expanded best-practices interventions focusing on improved outcomes for neurosurgery patients.

They came up with a toolkit consisting of 4 key components:

  • Standardizing the use of preadmission patient education materials using an Emmi program;

  • Improving communication and safety awareness with a postoperative debriefing;

  • Developing a postoperative clinical care checklist to reduce mortality and complications, including neurologic deficits, venous thromboembolism, delirium, and unexpected returns to the operating room; and

  • Identifying areas for improvement with patient focus groups.

The toolkit is being implemented at all UC sites, starting in July 2013 through June 2016, and researchers are collecting data on the program's impact.

In terms of the specific components, Dr. Lau said the main challenges have been with postoperative debriefing.

"I think the biggest challenge we've had so far is changing behavior and making sure providers actually are doing the debriefing," she said.

"I think they're just not accustomed to doing it, but we've worked on insuring that they understand why it needs to be done and that if performed correctly it should take less than a minute."

Otherwise, things have gone smoothly.

"There hasn't been a lot of resistance to this on the part of the neurosurgeons and I think a big reason for that is that we have had them at the table all along," Dr. Lau said.

"We make sure they're involved in all meetings to provide input. We're not doing things on our own and then telling them 'this is what you must do'."

Despite the potential benefits, the program's concept nevertheless suggests a delegation of some duties that is contrary to core principles of neurosurgery training, said Robert Harbaugh, MD, director of the Institute of the Neurosciences and distinguished professor and chair of the Department of Neurosurgery at Pennsylvania State University in Hershey.

Dr. Harbaugh, who is also president-elect of the American Academy of Neurological Surgeons, said, "On the positive side, I think it's always better to have more hands on deck. If you have someone with a sole responsibility to look after neurosurgery patients in the hospital who has the kind of hospital medicine expertise that a hospitalist does, that's a good thing. That person can focus on quality improvement initiatives in a way that would otherwise be difficult for neurosurgeons, both faculty and residents."

"On the negative side, however, it's important that we don't train neurosurgery residents that their job is to operate and it's someone else's job to take care of patients afterward," he said.

 
It's important that we don't train neurosurgery residents that their job is to operate and it's someone else's job to take care of patients afterwards. Dr. Robert Harbaugh
 

"I know that's not the goal of this program, but I think it's a potential risk."

As demonstrated by neurosurgery residents' protests to duty-hour restrictions, the specialty has a staunch commitment to continuity of care.

"One of our long-standing traditions in neurosurgery, and one of the reasons neurosurgeons' residence is 7 years long, is that residents are trained be physicians as well as surgeons," Dr. Harbaugh explained.

That doesn't mean they don't need plenty of help, but the handing off of some tasks to another physician causes Dr. Harbaugh to hesitate.

"It makes perfect sense to have a team concept with faculty, residents, physician assistants, and nurses all working together," he said.

"Where I would differ with this program is whether we need a hospitalist who becomes the physician caretaker for neurosurgical patients after they leave the operating room. That's the only part I would quibble with, and I'm sure others in neurosurgery have the same concerns."

Dr. Lau and Dr. Harbaugh have disclosed no relevant financial relationships.

Hospital Medicine 2014. Abstract 201. Presented March 24, 2014.

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