Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline.

BACKGROUND AND OBJECTIVES: The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011 American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine guideline for infants and children and to clarify the BD/DNC determination process by integrating guidance for adults and children into a single guideline. Updates in this guideline include guidance related to conducting the BD/DNC evaluation in the context of extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury. METHODS: A panel of experts from multiple medical societies developed BD/DNC recommendations. Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal consensus process was used. This process relied on the panel experts' review and detailed knowledge of the literature surrounding BD/DNC to guide the development of preliminary recommendations. Recommendations were formulated and voted on, using a modified Delphi process, according to the 2017 AAN Clinical Practice Guideline Process Manual. MAJOR RECOMMENDATIONS: Eighty-five recommendations were developed on the following: (1) general principles for the BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC evaluation, and (7) special considerations for BD/DNC determination.

Prone Position Ventilation in Neurologically Ill Patients: A Systematic Review and Proposed Protocol.

OBJECTIVES: Prone positioning has been shown to be a beneficial adjunctive supportive measure for patients who develop acute respiratory distress syndrome. Studies have excluded patients with reduced intracranial compliance, whereby patients with concomitant neurologic diagnoses and acute respiratory distress syndrome have no defined treatment algorithm or recommendations for management. In this study, we aim to determine the safety and feasibility of prone positioning in the neurologically ill patients. DESIGN AND SETTING: A systematic review of the literature, performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2009 guidelines, yielded 10 articles for analysis. Using consensus from these articles, in combination with review of multi-institutional proning protocols for patients with nonneurologic conditions, a proning protocol for patients with intracranial pathology and concomitant acute respiratory distress syndrome was developed. MEASUREMENTS AND MAIN RESULTS: Among 10 studies included in the final analysis, we found that prone positioning is safe and feasible in the neurologically ill patients with acute respiratory distress syndrome. Increased intracranial pressure and compromised cerebral perfusion pressure may occur with prone positioning. We propose a prone positioning protocol for the neurologically ill patients who require frequent neurologic examinations and intracranial monitoring. CONCLUSIONS: Although elevations in intracranial pressure and reductions in cerebral perfusion pressure do occur during proning, they may not occur to a degree that would warrant exclusion of prone ventilation as a treatment modality for patients with acute respiratory distress syndrome and concomitant neurologic diagnoses. In cases where intracranial pressure, cerebral perfusion pressure, and brain tissue oxygenation can be monitored, prone position ventilation should be considered a safe and viable therapy.

Redefining Preventable Death-Potentially Survivable Motorcycle Scene Fatalities as a New Frontier.

BACKGROUND: The National Academies of Science, Engineering, and Medicine defined a roadmap to achieve zero preventable trauma deaths. In the United States, there are over 5000 motorcycle fatalities annually. Florida leads the nation in annual motorcycle crash (MCC) deaths and injuries. It is unknown how many are potentially preventable. We hypothesize that certain patterns of injuries in on-scene fatalities that are potentially survivable and aim to make recommendations to achieve the National Academies of Science, Engineering, and Medicine objective. MATERIALS AND METHODS: Miami-Dade County medical examiner reports of MCC deaths pronounced on scene, and emergency medical service or law enforcement reports from 2010 to 2012 were reviewed by board-certified trauma surgeons. Causes of death were categorized into exsanguination, traumatic brain injury or decapitation, crushed chest, or airway complications. Determination of potentially survivable versus nonsurvivable injuries was based upon whether the riders had potentially survivable injuries and had they been transported immediately to a trauma center. Traumatic brain injury cases were reviewed by a board-certified neurosurgeon. RESULTS: Sixty MCC scene deaths were analyzed. Ninety-five percent were men, 55% were helmeted, and 42% had positive toxicology. The median Injury Severity Score was 41 (Range 14-75, IQR 31-75). Nineteen (32%) deaths were potentially survivable, with death due to airway in 14 (23%) and exsanguination in 4 (7%) patients. CONCLUSIONS: One-third of on-scene urban motorcycle deaths are potentially survivable in a young patient population. ISS score comparison demonstrates the lower injury burden in those deemed potentially survivable. Automatic alert systems in motorcycles and first responder training to police are recommended to improve trauma system efficacy in reducing preventable deaths from MCCs.

Development and assessment of competency-based neurotrauma course curriculum for international neurosurgery residents and neurosurgeons.

OBJECTIVE: Traumatic brain injuries (TBIs) are a significant disease burden worldwide. It is imperative to improve neurosurgeons' training during and after their medical residency with appropriate neurotrauma competencies. Unfortunately, the development of these competencies during neurosurgeons' careers and in daily practice is very heterogeneous. This article aimed to describe the development and evaluation of a competency-based international course curriculum designed to address a broad spectrum of needs for taking care of patients with neurotrauma with basic and advanced interventions in different scenarios around the world. METHODS: A committee of 5 academic neurosurgeons was involved in the task of building this course curriculum. The process started with the identification of the problems to be addressed and the subsequent performance needed. After this, competencies were defined. In the final phase, educational activities were designed to achieve the intended learning outcomes. In the end, the entire process resulted in competency and outcomes-based education strategy, including a definition of all learning activities and learning outcomes (curriculum), that can be integrated with a faculty development process, including training. Further development was completed by 4 additional academic neurosurgeons supported by a curriculum developer specialist and a project manager. After the development of the course curriculum, template programs were developed with core and optional content defined for implementation and evaluation. RESULTS: The content of the course curriculum is divided into essentials and advanced concepts and interventions in neurotrauma care. A mixed sample of 1583 neurosurgeons and neurosurgery residents attending 36 continuing medical education activities in 30 different cities around the world evaluated the course. The average satisfaction was 97%. The average usefulness score was 4.2, according to the Likert scale. CONCLUSIONS: An international competency-based course curriculum is an option for creating a well-accepted neurotrauma educational process designed to address a broad spectrum of needs that a neurotrauma practitioner faces during the basic and advanced care of patients in different regions of the world. This process may also be applied to other areas of the neurosurgical knowledge spectrum. Moreover, this process allows worldwide standardization of knowledge requirements and competencies, such that training may be better benchmarked between countries regardless of their income level.

Oversight and Ethical Regulation of Conflicts of Interest in Neurosurgery in the United States.

BACKGROUND: Developmental incentives are fundamental to surgical progress, yet financial and professional incentives inherently create conflicts of interest (COI). Understanding how to manage COI held by neurosurgeons, industry, hospitals, and journal editors, without thwarting progress and innovation is critical. OBJECTIVE: To present an overview of COI associated with innovation in neurosurgery, and review ways to manage these in an ethically sound manner. METHODS: A review of the literature was performed to assess conflicts of interest that affect neurosurgical innovation, and review ways to manage COI of various parties while adhering to ethical standards. RESULTS: COI are inherent to collaboration and innovation, and are therefore an unavoidable component of neurosurgery. The lack of a clear distinction between clinical practice and innovation, ability to use devices off-label, and unstandardized disclosure requirements create inconsistencies in the way that conflicts of interest are handled. Additionally, lack of requirements to compare innovation to the standard of care and inherent bias that affects study design and interpretation can have profound effects on the medical literature. Conflicts of interest can have both direct and downstream effects on neurosurgical practice, and it is possible to manage them while improving the quality of research and innovation. CONCLUSION: Conflicts of interest are inherent to surgical innovation, and can be handled in an ethically sound manner. Neurosurgeons, device companies, hospitals, and medical journals can take steps to proactively confront bias and ensure patient autonomy and safety. These steps can preserve public trust and ultimately improve evidence-based neurosurgical practice.

Neurosurgical Coverage for Emergency and Trauma Call.

Traditionally, neurosurgeons have responded to calls to treat new patients or address emergent, acute neurosurgical pathology in the hospitals they staff as part of their duty to the medical profession and community. Due to increasing financial pressures placed upon neurosurgical practice from hospitals and regulatory mandates, remuneration for neurosurgeon availability to serve on trauma call has become more frequent and is increasingly seen as essential. In this study, we present the first peer-review published survey of neurosurgical emergency and trauma call coverage patterns, scope, schedules, compensation, liability exposure, and call cessation. We surveyed all practicing neurosurgeon members of the American Association of Neurological Surgeons and Congress of Neurological Surgeons with a 24% response rate. The vast majority of respondents (86%), through their practice, provide 24/7/365 trauma coverage at their primary hospital site. About a third (29%) of respondents have been sued by a patient seen in the emergency department. Twenty percent of respondents anticipate retiring within the next 2 yr. Understanding trauma call coverage, remuneration, and the barriers to taking call provide needed transparency to neurosurgeons who are providing emergency, life-saving services for patients across the country. An understanding of supply and demand forces governing call coverage also assists the field in necessary workforce planning and innovation in providing access to needed, timely acute neurosurgical care.

Leadership in American Surgery: Women are Rising to the Top.

OBJECTIVE: To celebrate the increasing representation of women as leaders in American surgery and provide suggestions for increasing diversity in leadership. BACKGROUND: Women were barred from entering the practice of medicine or surgery until the mid 1800's when Elizabeth Blackwell led the way as the first woman admitted to medical school. Although the numbers of women practicing medicine and surgery have increased exponentially since Dr Blackwell graduated, the number of women in leadership positions has remained low until recently. METHODS: An analysis of the literature on the history of women in surgery and the websites of the major surgical societies. RESULTS: More women are now rising to leadership positions in surgery, both in academics and within surgical organizations. The American College of Surgeons and many other surgical societies, as well as an increasing number of academic departments of surgery have realized that women can be inspiring and capable leaders. However, increasing the number of under-represented minority women in leadership positions remains an opportunity for improvement. CONCLUSIONS: Great progress has been made in the advancement of women into leadership positions in surgery. To continue this trend and increase the number of under-represented minority women in surgery will require attention to recruitment, mentorship, and sponsorship.

Greening the Operating Room: Results of a Scalable Initiative to Reduce Waste and Recover Supply Costs.

Operating rooms generate 42% of a hospital's revenue and 30% of hospital waste. Supply costs are 56% of a total operating room (OR) budget. US academic medical centers use 2 million pounds ($15 million) of recoverable medical supplies annually. Forming a multidisciplinary leadership team, we analyzed sources of waste focusing on our Department of Neurosurgery. We developed an 8-wk pilot project to recycle "blue wrap," the number 5 plastic polypropylene material that is ubiquitously used in ORs across the country to wrap instrument pans and implant trays for sterilization. Blue wrap can be baled and sold to recyclers where the material is pelletized and transformed into plastic products. During the 39 d of the pilot, we collected 1247 pounds of blue wrap (32 lbs collected daily). The cost of the pilot was $14 987 that includes a new baler ($11 200) and 5 transport carts ($3697). The revenue received from baled blue wrap was 8 cents per pound. Cost avoidance yielded $31 680.00 in savings. Implementation of this pilot across our main hospital would yield $5000 in revenue annually and $174 240 in cost avoidance. This project can be replicated at other centers and not only reduces the environmental footprint, but also helps generate additional revenue by recycling a necessary packing material that would otherwise require payment for disposal.

Maintenance of Certification: Perceptions and Attitudes of Neurosurgeons.

Assuring clinical competence throughout the career of a neurosurgeon is of paramount importance for patient safety. We present the first comprehensive survey of all neurosurgeons board certified through the American Board of Neurological Surgery (ABNS) to evaluate perceptions of Maintenance of Certification (MOC). We administered a validated, online, confidential survey to 4899 neurosurgeons (2435 ABNS diplomates participating in MOC, 1440 diplomates certified prior to 1999 [time-unlimited certificates], and 1024 retired diplomates). We received 1449 responses overall (30% response rate). Our study found that most respondents believe that neurosurgeons should be required to participate in continuing professional improvement following initial board certification (75%). Most believe that specialty boards, working in conjunction with specialty societies, should require diplomates to participate in programs meant to promote continuous professional development (73%). The majority of respondents (76%) believed that self-assessment tests constituted a meaningful professional development activity, in addition to periodic case log reviews (33%) or quality improvement projects (32.6%). A plurality of respondents (44%) do not feel that the MOC process as currently structured provides them with value. There were no differences between those who were "grandfathered" and those who actively participate in MOC and no differences between those in private practice versus those in academics. The ABNS is cognizant of diplomate concerns and is actively developing new MOC paradigms to ensure that the process achieves both the goals of meeting the public interest and assuring that the quality of American neurosurgery remains exemplary.

Recognized focused practice: Does sub-specialty designation offer value to the neurosurgeon?

Vehicles for life-long assessment such as Maintenance of Certification tend to focus on generalist neurosurgical knowledge. However, as neurosurgeons advance in their careers, they tend to narrow their practice and increase volumes in certain specific types of operations. Failing to test the type of procedures most relevant to the practitioner is a lost opportunity to improve the knowledge and practice of the individual neurosurgeon. In this study, we assess the neurosurgical community's appetite for designations of board-recognized Recognized Focused Practice (RFP). We administered a validated, online, confidential survey to 4,899 neurosurgeons (2,435 American Board of Neurological Surgery (ABNS) Diplomates participating in MOC, 1,440 Diplomates certified prior to 1999 (grandfathered), and 1,024 retired Diplomates). We received 1,449 responses overall (30% response rate). A plurality of respondents were in practice 11-15 years (18.5%), in private practice (40%) and participate in MOC (61%). 49% of respondents felt that a RFP designation would not be helpful. For the 30% who felt that RFP would be helpful, 61.3% felt that it would support recognition by their hospital or practice, it would motivate them to stay current on medical knowledge (53.4%), or it would help attract patients (46.4%;). The most popular suggestions for RFP were Spine (56.2%), Cerebrovascular (62.9%), Pediatrics (64.1%), and Functional/Stereotactic (52%). A plurality of neurosurgeons (35.7%) felt that RFP should recognize neurosurgeons with accredited and non-accredited fellowship experience and sub-specialty experience. Ultimately, Recognized Focused Practice may provide value to individual neurosurgeons, but the neurosurgical community shows tepid interest for pursuing this designation.

The Aging Neurosurgeon: When Is Enough, Enough? Attitudes Toward Ceasing Practice and Testing in Late Career.

OBJECTIVE: To present the first wide-scale survey to assess perceptions of testing the aging neurosurgeon. PATIENTS AND METHODS: This study included 4899 neurosurgeons, 2435 American Board of Neurological Surgery Diplomates participating in Maintenance of Certification (MOC), 1440 Diplomates certified before 1999 (grandfathered), and 1024 retired Diplomates. We developed an online confidential survey conducted from March 1, 2016, to May 31, 2016. We received 1449 responses overall (30% response rate). RESULTS: Most respondents (938; 65%) were aged 50 years and older. Overall, most respondents (718; 50%) believe that the aging neurosurgeon (65 years and older) should undergo additional testing, including cognitive assessment or a review of cases, in addition to a standard (MOC) examination. Nine hundred fifty-six (67%) respondents believed that there should be no absolute age cutoff at which neurosurgical practice is forced to end. Six hundred six (42%) respondents believed that MOC should be tailored to accommodate the aging neurosurgeon. Most respondents (766; 59%) believed that MOC should consist of a review individual case logs and patient outcomes for the aging neurosurgeon. CONCLUSION: Appropriately assessing the aging neurosurgeon is important to protect patient safety and also maximize the capacity of an aging neurosurgical workforce. This first of its kind survey of neurosurgeon diplomates of the American Board of Neurological Surgery provides important information as to what mechanisms can be created to fairly evaluate aging neurosurgeons. Although this is a study of neurosurgeons, the implications of these findings are widely applicable across specialties, and additional research on testing for aging and competency is needed across specialties.

An assessment of data and methodology of online surgeon scorecards.

OBJECTIVE Recently, 2 surgeon rating websites (Consumers' Checkbook and ProPublica) were published to allow the public to compare surgeons through identifying surgeon volume and complication rates. Among neurosurgeons and orthopedic surgeons, only cervical and lumbar spine, hip, and knee procedures were included in this assessment. METHODS The authors examined the methodology of each website to assess potential sources of inaccuracy. Each online tool was queried for reports on neurosurgeons specializing in spine surgery and orthopedic surgeons specializing in spine, hip, or knee surgery. Surgeons were chosen from top-ranked hospitals in the US, as recorded by a national consumer publication ranking system, within the fields of neurosurgery and orthopedic surgery. The results were compared for accuracy and surgeon representation, and the results of the 2 websites were also compared. RESULTS The methodology of each site was found to have opportunities for bias and limited risk adjustment. The end points assessed by each site were actually not complications, but proxies of complication occurrence. A search of 510 surgeons (401 orthopedic surgeons [79%] and 109 neurosurgeons [21%]) showed that only 28% and 56% of surgeons had data represented on Consumers' Checkbook and ProPublica, respectively. There was a significantly higher chance of finding surgeon data on ProPublica (p < 0.001). Of the surgeons from top-ranked programs with data available, 17% were quoted to have high complication rates, 13% with lower volume than other surgeons, and 79% had a 3-star out of 5-star rating. There was no significant correlation found between the number of stars a surgeon received on Consumers' Checkbook and his or her adjusted complication rate on ProPublica. CONCLUSIONS Both the Consumers' Checkbook and ProPublica websites have significant methodological issues. Neither site assessed complication occurrence, but rather readmissions or prolonged length of stay. Risk adjustment was limited or nonexistent. A substantial number of neurosurgeons and orthopedic surgeons from top-ranked hospitals have no ratings on either site, or have data that suggests they are low-volume surgeons or have higher complication rates. Consumers' Checkbook and ProPublica produced different results with little correlation between the 2 websites in how surgeons were graded. Given the significant methodological issues, incomplete data, and lack of appropriate risk stratification of patients, the featured websites may provide erroneous information to the public.

Does the Open Payments Database Provide Sunshine on Neurosurgery?

BACKGROUND: The Open Payments Database (OPD) was launched by the Centers for Medicare & Medicaid Services in 2014. Through this online searchable database, the public can explore physician-industry interactions. To date, there is no published literature on the accuracy of the database for neurosurgeons or any physician specialty. OBJECTIVE: To study the accuracy of published records and scope of industry-neurosurgeon relationships between neurosurgeons and industry within the OPD. METHODS: We searched 4.3 million records in 2013 and 11.41 million records in 2014 in the OPD for board-certified neurosurgeons verified by the American Board of Neurological Surgery. Delimit software was used to condense these data, Microsoft Access for database queries, and STATA to perform descriptive analyses. RESULTS: Of the 3240 neurosurgeons in the OPD in 2013, 2020 were identified correctly as neurosurgeons within the database (62%). Of the 3593 neurosurgeons in the OPD in 2014, 2433 were identified correctly as neurosurgeons (68%). Within the OPD in 2013, there were 72 066 attributed records for neurosurgeons; within the 2014 OPD, there were 160  563 attributed records for neurosurgeons. Total payments to neurosurgeons in 2013 (for the 9 months published in OPD): $61  802  659.37; in 2014: $117  127  824.00. CONCLUSION: The OPD details physician interactions with industry and has multiple inaccuracies. Publicly availing inaccurate information through a searchable governmental website that can be accessed by patients and journalists alike has the potential to tarnish individual neurosurgeons and undermine professional credibility. ABBREVIATIONS: CMS, Centers for Medicare & Medicaid ServicesOPD, Open Payments Database.