Introduction
Creation of a pediatric neurosurgical service in the community has challenges unique from establishing such a service in an academic setting. I outline the challenges in creating a pediatric neurosurgical service within a large city-owned hospital. Critical equipment system-related and man-power issues were identified.
Methods
The NACHRI designated children's hospital (Memorial Hospital for Children) serves southern Colorado. Coverage was not provided by the community neurosurgeons. Therefore, children requiring neurosurgical management traveled to Denver or elsewhere. A pediatric neurosurgeon was hired to establish a clinical service in 2004.
Results
Equipment such as endoscopy, frameless stereotaxy, ICP monitors, and shunt components were obtained easily. Familiarizing the OR/ICU staff with the equipment, however, required months as this technology was rarely utilized by the other surgeons. System-related concerns were many and mostly educational involving the ER, PICU, NICU, and floor. Identifying anesthesiologists with pediatric expertise and desire was critical. Unexpected system-related benefits compared to a university-based Children's Hospital were lack of resistance for imaging studies requiring sedation or invasive studies (angiography), outstanding intraoperative support for spinal instrumentation cases, very rapid transport to OR of trauma patients, and speed of anesthesia. Man-power issues of no cross-coverage remain problematic primarily because of insurance premium increases to provide pediatric coverage. Any increased burden by nonresidents is offset by the support of other specialties (emergency room physicians, intensivists, and trauma surgeons). Physician extenders require a large amount of education and oversight before reducing clinical burden.
Conclusion
Creating a pediatric neurosurgical service within a community hospital requires financial support from the hospital, a system capable of and willing to care for children with complex problems and other specialties, and physician extenders competent to assist with the service. The medicolegal/insurance landscape hinders more complete coverage within our system. A tremendous educational effort is required to establish and maintain a safe and functional service.
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