Neuro-emergent care and traumatic brain injury
Most neurological emergencies are highly time-dependent for minimizing brain injury. Being able to make rapid decisions is especially important. Despite this need, neuro-emergent care is not available in most rural areas in New Mexico, which results in delayed treatment decisions when "time is brain" is crucial. Due to a lack of neurological and neurosurgical expertise in rural New Mexico, there is far too frequently an unnecessary emergent triage toward tertiary referral centers. This generates transport costs and places undue burden on the patient, the patient's family, and the states only comprehensive Stroke and Trauma Center at UNMH, frequently limiting access to care for patients who need it. The efficacy of ischemic stroke care delivery via telehealth technology has been proven to have equal outcomes for patients cared for in rural hospitals by remote stroke consultants versus care provided at primary stroke centers.(4)
Eighty percent of traumatic brain injury (TBI) patients have mild TBI (mTBI), 10% have evidence of intracranial bleeding (complicated mTBI), and only 0.3% need surgical intervention.(5) In many U.S. hospitals, standards of care consist of transferring all mTBI patients (about 1.7 million) to hospitals that provide neurosurgical care.(6) However, studies showing that the 1.3 million annual TBI emergency department visits found that neurosurgical intervention was needed in only 0.13% to 0.3% of these patients.(6) The practice of transferring all neuro-emergent patients consumes valuable resources with unproven efficacy. In some cases, patients are transported long distances by air only to be discharged soon after arrival often due to the earlier misinterpretation of radiographs.(7) In the context of limited neurosurgical resources and escalating healthcare costs, the negative impact of this practice on health care costs and patient satisfaction needs to be fully understood.(8) Nonoperative management of mild injury could be equally well managed by providers outside the discipline of neurosurgery. Our proposed telehealth infrastructure represents the first step in this direction.
Unnecessary transfers of neuro-emergent conditions are common in the current practice environment. Hesitancy to care for these emergencies locally results from the lack of specialty care and practitioner knowledge, both physician and nurse, of cerebral emergencies. With telehealth and expanded provider education, we can bring neurospecialty care to the bedside of every patient and enable regional hospitals to provide better service locally. This will save money, provide better health care, and result in better health for urban and particularly rural patients. The emergent transfer of all mTBI patients to UNMH has compromised the care the Trauma Center can provide by filling this relatively small hospital with patients who do not benefit from being there, while limiting access for other patients who would more likely benefit from this level of care.
It is difficult to provide timely access to TBI care in rural and many urban areas. Neuro-emergent care is often limited to Level I trauma centers located in major cities. Rarely is this level of care available in rural settings, yet the current practice of transferring rural mTBI patients to tertiary referral centers does nothing to overcome disparities in outcomes. In Level I trauma centers, neurosurgical consultation is readily available without further burden to the patient or the consulting provider and somehow has become the standard of care for complicated mTBI. However, there is no evidence to support that this practice improves outcomes.(15)