E. Lee Murray, MD, and
Monico Peter Baňez, MD, MBA, FACP, SFHM
CHAPTER CONTENTS
•Models of a Hospital Neurology Service
OVERVIEW
Hospital neurology is a rapidly growing subspecialty. In addition to hospital-based general neurologists, there has also been an expansion of hospital-based specialty care services, including stroke centers, epilepsy centers, and neuro-critical care services.
There is a clear need for more neurologists of all types, but particularly hospital neurologists. Neurologic diagnoses make up between 10% and 20% of admissions to hospitals,1 and a disproportionate number of delayed discharges have primary neurologic diagnoses.2 Hospital neurology services can help to improve the quality and efficiency of care.
Where will the hospital neurologists come from? A diverse group is a product of diverse pathways. A few will do defined hospital neurology fellowships, some will have completed stroke or neuro-critical care fellowships, whereas others will be general neurologists.
In this book, we use the term hospital neurologist. An equivalent term is neurohospitalist. Other predominately hospital-based neurologists include stroke neurologists and neurointensivists.
MODELS OF A HOSPITAL NEUROLOGY SERVICE
The organization of a hospital neurology service depends greatly on the features of the practice, including institution size, patient volume, referral patterns, and community culture (see Table 1.1).
Table 1.1 Models of a hospital neurology practice
TRAINING AND SUBSPECIALTIES IN HOSPITAL NEUROLOGY
Presently, most hospital neurologists are residency-trained in general neurology with substantial experience in inpatient care. Depending on the size and mission of the hospital, additional training and/or experience may be needed; a stroke fellowship is particularly valuable. Large centers that are specifically designated as stroke centers may require stroke fellowship training for at least some of the hospital neurology staff.
Most trauma is best cared for by comprehensive trauma centers with neurosurgical coverage. A small subset of neurologists is involved in emergency evaluation and management of neurologic trauma.
A summary of training for specific practice concentrations is presented in Table 1.2.
Table 1.2 Practice concentrations for neurology
ABMS, American Board of Medical Specialties; ABPN, American Board of Psychiatry and Neurology; ABPMR, American Board of Physical Medicine and Rehabilitation; UCNS, United Council for Neurologic Subspecialties.
NEUROLOGY MIDLEVEL PROVIDERS
Neurology nurse-practitioners and physician assistants have been used in clinics to help especially with follow-up visits, but there are increasing numbers of midlevel providers who are trained and skilled in hospital neurology and neuro-critical care. These providers are a valuable part of the neurology team, not as a substitute for neurology physicians but rather as colleagues who share in the care of hospitalized patients. In addition, nurse practitioners provide much of the post-hospital care.
ORGANIZATIONAL ISSUES IN HOSPITAL NEUROLOGY
Deciding how to organize a hospital neurology practice or whether to participate in one is complicated. Some of the major concerns are:
Scope of responsibilities: There is sometimes a disconnect between the scope of practice of the hospital neurologist and the expectations of the facility. Areas of special concern can include pediatrics, trauma, medical coverage of neurosurgical patients, and psychiatric care. The scope of practice should be clear to both the provider and the facility.
Work and call schedule: Most hospitals are accustomed to shift workers. Generally, shifts of longer than 12 hours are uncommon, especially for busier hospitals, and if 24 or more hours are required, contingency plans for overflow need to be defined.
Caseload: Providers need to be rewarded for hard work, but high caseloads correlate with more errors, worse outcomes, and poorer patient satisfaction scores. A reasonable workload needs to be assured with defined plans regarding how the system will deal with excessive volume.
Quality improvement: Performance on quality measures will be an increasingly important metric on which practice assessment and compensation will be at least partly based.
Compensation: Compensation is most commonly based on a combination of caseload, work hours, quality indicators, and regional norms for comparative practice. Most systems are moving away from purely volume-based compensation.
