On March 20-21, 2015, there was a fantastic conference on neuromonitoring at Overlook Medical Center in Summit, NJ. If you didn’t attend, you really missed out! Not to worry, though…I’m writing today to tell you a little about the conference. We had a truly outstanding group of speakers, including:
Drs. Chuck Yingling, W. Bryan Wilent, Tony Sestokas, Michael Hopkins, Cheryl Wiggins, Larry Wierzbowski, Adam Doan, Marat Avshalumov, Payam Andalib, Christin Hung, Edgar De Peralta, Joseph Moreira, Dr. Nicholas Qundah, Ms. Sabrina Galloway and Mr. Sameer Juniad.
It was nearing the end of the conference before I thought to take any photos, but here are a few for you to see (click to enlarge):
With all these amazing speakers, and the very interesting topics that they presented, it would be difficult to identify the best part of the conference. There was one talk, however, that seemed to strike such a chord with the attendees, it actually got a fairly long applause, and I swear that some people even gave it a standing ovation…it certainly deserved one!
The title of that talk was “Case Management and Communication in IONM” and it was delivered by my friend and colleague, Dr. Michael Hopkins.
This wasn’t just any old talk…It was more like a mission statement delivered with a sense of purpose and passion so urgent that it sounded more like a manifesto. Dr. Hopkins took the dominant model for delivering neuromonitoring care and literally exposed everything that’s wrong with it, and he told everyone in the audience what they can do to optimize patient care.
The concepts that he presented are rather controversial, but they are also very important to me…and they should be important to you…if you care about your career, if you care about this field, if you care about your patients. Given the importance of the topic, I’ve decided to dedicate this post to bringing his talk to a wider audience. Unless otherwise noted or implied, all of the following material is the work of Dr. Hopkins, who was kind enough to let me view his slides so I could accurately reconstruct his talk.
As a prerequisite to this discussion, the reader would benefit significantly from reading the ASNM Practice Guidelines for the Supervising Professional.
Two Categories of Provider in Neuromonitoring:
The “Guidelines” describe 2 categories of provider:
1. IONM-P (Professional): the provider of real time technological supervision, interpretation, and diagnostic/therapeutic (interventional) suggestions or recommendations during IONM.
“Physician or other Qualified Healthcare Professional’’ is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.
An excellent question for my readers to consider, by the way, is what constitutes a Qualified Healthcare Professional? Does the DABNM fit the bill?
2. IONM-T (Technical): performs technical component. Involves placement of appropriate electrodes, data acquisition, data recording, troubleshooting problems, and providing a description of the recordings.
…the technological component may be carried out in whole or in part by an appropriately experienced/credentialed IONM-T.
Delegation of Responsibility:
According to the Guidelines…
All three of these patient care components (technological, interpretive, and interventional) fall within the duties and responsibilities of the IONM-P; however, the technological component may be carried out in whole or in part by an appropriately-experienced/credentialed IONM-T.
The practice of IONM is a patient care activity. IONM patient care includes preoperative patient evaluation, IONM planning, intraoperative care, postoperative patient follow-up, and the management of personnel and instrumentation that support these activities.
Overall responsibility for IONM performance rests with the IONM-P. Almost all IONM care is either provided personally by an IONM-P or is provided by an IONM-T supervised by an IONM-P. The IONM-P may delegate appropriate technological monitoring tasks to the IONM-T(s).
Models for Delivering IONM:
As you probably know, there are two models for delivering/performing intraoperative neuromonitoring in the USA:
- Local or In-House Model – Neuromonitoring services are performed by hospital employees. All persons involved in delivering neuromonitoring care are physically present in the hospital during monitored surgeries. Typically, technologists work in the operating room, while oversight is provided directly by a physician who remain physically close and available for consult. This is rather similar to an anesthesia model whereby a CRNA is present in the OR, and an attending anesthesiologist is always close-at-hand.
- Contract Model – Neuromonitoring services are contracted-out by the hospital to a private company who the hospital considers to be a vendor. Neuromonitoring care is delivered by a technologist who is physically present in the hospital/OR, while oversight is provided via telecommunication link (chat window) with an reader/interpreter who is not in close proximity to the hospital, and not available to be physically present in the hospital.
In the Local model of IONM, two providers are physically present in the hospital. Because both are physically present, it is possible to designate an IONM-T to perform only the technical component of IONM, while also employing and IONM-P, who is ultimately responsible for all aspects of patient care, and is available to assist in any and all aspects of IONM delivery as needed. This model fits nicely into the Guidelines, with clear designations for role and responsibilities of an IONM-T and IONM-P.
On the other hand, in the second model of IONM delivery, only one provider is physically present in the hospital, while the other contributes to patient care remotely via telecommunication and necessarily cannot be physically present in the OR to assist.
By a very wide margin, the dominant model of neuromonitoring in the United States is the “Contract” model, and that was the focus of Dr. Hopkins’ talk.
The roles and responsibilities of the IONM-P and IONM-T, as described in the Guidelines, fit very nicely in the Local Model of IONM delivery. While is tempting to apply the IONM-T and IONM-P roles and responsibilities to the Contract Model, it simply is not feasible. For practical purposes, and in the interest of patient care, it simply doesn’t work. Indeed, the only way to provide safe and quality care in the Contract Model of IONM is for the on-site individual to be appropriately-trained and capable of performing certain duties that fall into the scope of the IONM-P.
AMEN! From this point, Dr. Hopkins proceeds with a plan for how to best provide patient care in IONM under the contract model.
Let me warn you…for some readers what you are about to read will seem like a no-brainer….for others, it will seem crazy. I will get hate mail over this post, because the topic is much more important than it seems. There are a lot of politics hiding inside this topic, and there’s a ton of money tied up in keeping the status quo. I won’t say anything more than that, because I want to focus on the rest of Dr. Hopkins’ talk.
1. Preoperative Preparations:
For any Contract IONM Provider, getting into a hospital is a logistical nightmare. You don’t work at the hospital. You may not know where to park, where credentialing is, where the OR is, how to get into the OR, how to get scrubs, how/when/where to find biomedical engineering, what the local idiosyncratic rules are, how to connect to the internet, etc, etc. And guess what…? No one at the hospital gives a damn whether you know any of those things. You are expected to be in surgery, on time, every single day?
Did your kid get sick this morning? No one cares. Did you get a flat tire on the way to work? No one cares. Did you hit traffic? Park in the wrong lot? Get lost? Have trouble with security? Scrubs 3 sizes too small? No…one…cares!
You need advanced preparation. Make sure your credentialing is up to date. Plan on things going wrong. Arrive early. Stay in communication with the OR desk. Tell them when you arrive.
2. Preoperative Patient Interview:
It is important to recognize that the pre-operative patient interview is not meant to act as a medical examination, per se, and findings that are inconsistent with the surgeon’s H&P should not be added to the medical record. The purpose of the interview is to meet the patient, introduce the IONM team/IONM plan, and to acquire relevant information that will guide expectations and interpretation of IONM findings intraoperatively.
The patient interview should be focused and specific to IONM modalities being monitored. You don’t need a comprehensive medical examination. Here’s what you do need:
- Basic demographic info (age, sex, weight etc.)
- Primary complaint and disease etiology
- Neurological status*
- Comorbidities (esp. diabetes, hypertension, obesity/edema)
- Previous relevant surgical/medical history
3. Preoperative Communication with Anesthesia:
Communication with the anesthesia team from the moment they enter the room to begin setting up the case is necessary to optimize patient care and ensure favorable outcomes. Its importance cannot be overstated.
The content and quality of this conversation will set the tone for the relationship between IONM and Anesthesia throughout the case, and over time will strongly influence the willingness of anesthesia staff in the hospital to work together with monitoring productively, rather than simply tolerate our presence in the OR.
Allowing anesthesia to develop bad habits and little communication will make it harder and harder for your peers to work cooperatively with the anesthesia team down the road.
Talk to them about your monitoring plan, and how anesthesia can optimize IONM. Be prepared to discuss and cite literature and experience. Tell them about your needs for establishing baselines and placement of bite blocks. Discuss special concerns for anesthesia and IONM (BP/ positioning/ comorbities/ allergies etc).
4. Preoperative Communication with Surgery:
Face time with the surgeon is critically important. Talk to the surgeon about the plans for surgery, IONM and anesthesia. Ask about their preferred communication style (during stimulation, when requesting tceMEPs, etc.). Identify special considerations (desired level of BP during critical stages, any other concerns). Review of patient films when possible.
Ideally, we would always have the opportunity to speak with the surgeon in the holding area and cover many of these points, however this is often not possible. If that is the case, a great strategy is to approach the surgeon when he/she is reviewing the films. Establishing a rapport and a mutual strategy will decrease the likelihood of communication lapses during the procedure itself, at which time the stress of the surgery and tensions may have escalated significantly.
There are as many different monitoring plans as there are patients and there are tremendous variations in surgeon expectations regarding almost all aspects of IONM (how to report screw stimulation, where and when to place return electrode for monopolar stimulation, when to acquire tceMEPs throughout the procedure, expectations regarding need for phase reversal/direct cortical stim for supratentorial tumors, direct cranial nerve stim during brainstem cases, etc.)
Comunication style must be appropriate to the context (new surgeon, complexity/risks associate with case type).
1. Intraoperative Communication with Anesthesia:
Intraoperative communication with anesthesia should be more than just updating the patient’s vitals and anesthetic regimen. Focus on data that we can provide to facilitate anesthetic management. For example, even if we are not monitoring EEG, per se, a well-trained neurophysiologist should be able to assess whether the patient is in burst suppression and there is room to decrease sedation level (this can be discussed in the context of quick and easy emergence/extubation post-operatively if the anesthesiologist is unwilling to adjust regimen for IONM data acquisition purposes), or conversely, when a patient is getting “light” and is approaching risk of recall. Likewise, if we are monitoring EMG, we can often assess whether the patient is reacting to pain and may require higher levels of narcotic, even if they are adequately sedated.
Run upper extremity SSEPs whenever possible in order to provide information to the anesthesia team about patient positioning, either due to potential brachial plexopathy, compression at the ulnar notch/axilla, etc.
In return, a dialogue of this nature will greatly increase the likelihood that anesthesia will be willing to make adjustments to their regimen when we request it from them. Focus on shared goals of Anesthesia and IONM and emphasize IONM data that inform anesthetic management.
2. Intraoperative Communication with Surgery:
An important key for any surgery is the timing of communication with the surgeon. As we all know, part of our job is to understand the flow of a case, the critical points during a procedure, etc. It’s important when delivering routine information that we not only speak in a way that is natural, but use vernacular familiar to the surgeon. In other words, talks about data in the context of surgical levels, rather than a list of myotomes. State the relevance of baseline data to the surgery being performed.
For example, you could say, “I have reliable motor and sensory data from both arms and the left foot. So, I can monitor the spinal cord, but I’m having trouble getting any motors from the right side below the hand, and my SSEPs from both feet are of low amplitude. This patient is very myelopathic so I’m not surprised about the data. I’ll keep working to optimize my signals but I want to make sure you understand what we’re starting with.”
It really helps build rapport with the surgeon if you acknowledge the surgical stage in the context of a request to acquire any disruptive EP. You could say, for example, “I see you are about to distract the disc space at C5-6. Can I update my motors before we begin the decompression?” This approach teaches the surgeon about why we ask for things when we do, and it shows that you’re paying attention and you know what’s going on. This also diminishes the likelihood that you will hear the surgeon say, “I haven’t done anything yet, why do you need to check motors?”
3. Communicating ALERTS to the Surgeon:
Alerts do not have to be dramatic. The way in which the alert is presented to the surgeon should correspond with the nature of the alert. Use an approach of graded severity. Ask yourself, do the following scenarios require the same level of concern for the surgeon?
- SSEP drop from left ulnar during a posterior lumbar case.
- latency shift of BAEPs on surgical side during microvascular decompression.
- precipitous drop in tceMEPs following corrective maneuvers during scoliosis case.
- sustained Neurotonic train activity from facial nerve during acoustic neuroma.
The significance of the alert has to be made clear. You must rise up above the cognitive and acoustic noise in the room. Walking to the O.R. table may help.
The alert must be correlated with surgical events in a non-threatening way. Avoid words that suggest blame. Don’t use unnecessary qualifying phrases or disclaimers when you know an alert is iatrogenic. If you must qualify an alert, it means you have not ruled out all possible sources of error, and you should present it as such.
Patient care is most important. Do not risk compromising patient care. When the consequences of decision making are most serious, the surgeon should be notified as soon as any clinical concern arises, even if the implications not fully clear: Better to discuss than to say nothing.
4. General Considerations for Perioperative Communication:
A frequent challenge we face and particularly when working in a “new” OR, or one that is not accustomed to working with IONM, is the need to establish ourselves as patient care providers and distance ourselves from assumptions that we are “Vendors”. An excellent way to impede this is by making small talk and chit-chat throughout a case about topics that are not directly related to patient care.
You are not there to make the surgeon happy. You’re not there to tell jokes, or contribute to the conversation about last night’s game. You’re not part of the crowd. You are there to take care of the patient. Period. Leave the rest of that nonsense to the sales reps. Of course, as we build relationships with the OR staff over time we can engage in these conversations but we should establish first and foremost that we’re a member of the OR team and our first priority is patient care. Save the chit chat for when you have built a strong relationship with the OR staff as a reliable, professional expert in your field.
Keep in mind that people are watching you. Frequent checking of your cell phone (even if it is work-related cell phone use), leaving to take breaks during exposure, hasty escapes from the OR suite post-operatively, dried blood at needle insertion sites… All of these practices will undermine our efforts to integrate with the OR staff and place us in the category of “tech” at best, and “liability” at worst.
Take the time to educate hospital staff that we are patient care providers, not Vendors!
There is a quote that was made by a neurosurgeon. He said, “Ketchup is Ketchup”. The purpose of this statement was essentially to liken the wide variety of IONM Contract providers with the wide variety of ketchup brands you can buy in the supermarket. They may have different labels and different price tags, but essentially they’re all the same thing. Is he right?
This is my comment, not Hopkins…
It seems that all IONM companies say the same thing… “We’re the best. We have the most advanced technology. We have the best techs. We have board-certified neurologists. Etc, etc..” Am I right? At the end of the day, most companies send an IONM-T to do a job that requires both an IONM-T and an IONM-P. No wonder we’re likened to ketchup. Most of the field performs sub-par work. No one stands out.
The Contract Model of IONM does not fit the mold of the Local Model of IONM, but many people in our field try to make it fit. It simply cannot work to the benefit of the patient/surgeon/hospital to send contract “tech”, and IONM-T, to perform neuromonitoring without the ability to do the lion’s share of the IONM-P’s responsibilities. In order to provide the highest quality of patient care in the Contract Model, we need to have onsite providers who are highly educated, highly competent and highly capable individuals. Anything less is a tragedy. It’s doomed to fail.
“Ketchup is Ketchup” – Except when it’s not.
Well, there it is. Like I said, there were some reeeaaaally good talks at this conference. I don’t mean to detract from the others, but the content of this talk was moving. You know, there’s a small circle of us in the Philadelphia area that have been thinking and acting and providing this way for decades. We all came from a small private practice called Surgical Monitoring Associates… a practice that maintained very high standards. We were trained from the ground-up as professionals, decision makers, IONM-Ps. I was part of that group. Michael Hopkins was part of that group. Several of the speakers at the Atlantic Health Conference were part of that group. Probably half the audience was trained in or by that group. In some ways, Dr. Hopkins was preaching to the choir. Our small group has been saying this for years.
But we were a small group in a limited geographic region. I know there are other small groups out there that are like us. Bernie Cohen’s group and Chuck Yingling’s group are two examples that come to mind – private practices who believe in the importance of having an IONM-P or equivalent onsite, in the OR. The rest of the country, the bulk of the folks out there performing IONM, it’s all is a mixed bag. So, when anyone stands waaaay back and looks down the line of IONM providers and what we, as a collective group, bring to the table across the country as a whole, how could you blame them for just seeing ketchup?
- Skinner SA, Cohen BA, Morledge DE, McAuliffe JJ, Hastings JD, Yingling CD, McCaffrey M.Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring. J Clin Monit Comput. 2014 Apr;28(2):103-11.