Interpretation of surgical neuromonitoring data in Canada: a survey of practising surgeons

Abstract

Intraoperative neuromonitoring is a specialized skill set performed in the oper ating room to reduce the risk of neurologic injury. There appears to be a short age of qualified personnel and a lack of Canadian guidelines on the perform ance of the task. We distributed a webbased survey on the attitude of the surgeons to the interpretation of intraoperative neuromonitoring data among surgeons who use the technique. At present, most of the interpretation is per formed by either technologists or by the surgeons themselves. Most surgeons would prefer professional oversight from a neurologist or neurophysiologist at the doctoral level. There is a lack of personnel in Canada with the appropriate training and expertise to interpret intraoperative neuromonitoring data. Summary Intraoperative neuromonitoring (IOM) is a rapidly expanding field designed to reduce the risk of neurologic injuries during surgical procedures. In Can ada, there is no recognized standard for the field. In the United States there is a much wider use of IOM than in Canada, and the field is more established. The U.S. model is driven in large part by the demands of the payers -Medi care, Medicaid and the private insurance industry. These payers require that the interpretation of the IOM is performed by a suitably qualified individual with a medical degree and that this individual is someone other than the oper ating surgeon. The American Medical Association states that IOM is a part of the practice of medicine (AMA policy H410.957). In practice, there is a tech nologist in the operating room (OR) who places the electrodes and operates the dedicated IOM equipment. A neurologist who is most often, but not always, outside of the OR interprets the data, using a realtime data connec tion. The practice guidelines require the realtime interpretation by a medical professional with training in IOM.

Interpretation of surgical neuromonitoring data in canada: author response

“…A recent British study, which used a modified synoptic reporting system i n v o l v i n g m o r e t h a n 3 6 0 0 0 patients and 297 trainees, found that only 41% of the trainees achieved a colonoscopy completion rate of 90% after 200 colonosco pies. 1 This result is consistent with the recommendation by Cancer Care Ontario of a minimum of 300 cases to achieve competency.…”

Where does Intraoperative Neurophysiological Monitoring stand in Canada in 2016?

“…According to the American Medical Association, Policy H-410.957, IONM is the practice of medicine and its interpretation requires a suitably qualified practitioner (Policy H-35.971 and confirmed by the IONM Workgroup of the AMA in 2013). This policy was referenced by Norton et al [1] in the author response to Wilkinson & Kaufmann's letter to the editor [3]. However, because there are no standards of care for IONM in Canada and IONM has not been declared to be the practice of medicine, the vast majority of surgical centers in Canada do not use the services of a qualified clinical neurophysiologist.…”

“…It is a paradox that given the advanced nature of IONM in the USA compared to IONM in Canada, it is incomprehensible that CANM, without a shred of evidence to support its position, is opposed to applying the established and regulated American service delivery models to Canada. In response to Wilkinson & Haufmann [3], Norton et al [1] It is worthy to note that Canadian patients are becoming more and more informed about surgical outcomes and medical malpractice. For better or for worse, patients are becoming more litigious, as represented by an increased number of lawsuits across Canada, judging surgeons and in extension IONM technologists, accountable for medical malpractice.…”

“…A recent article published in the Canadian Journal of Surgery by Norton JA et al [1] has drawn the attention of the IONM community, especially in Canada. In October 2015, the American Society of Neurophysiological Monitoring (ASNM) eNewsletter of IONM, patients will be afforded with a system that negates the need for "interpreter" oversight (be that from a PhD, neurologist, or any other professional) and will be provided with true realtime interpretation of neurophysiological signals by the IONM professional present in the operating room… There has been much debate over whether the interpretation of IONM signals constitutes the "practice of medicine" although no matter which side of the argument one falls, there can be no debate over the fact that neurophysiological signal abnormalities require prompt recognition and immediate interventional actions in order to avoid harm to the patient [4].…”

A Strategic View for Intraoperative Neuromonitoring in Canada 2017

“…Second, the response rate from the survey is unknown. 4 Without knowing the proportion of the target population represented by the survey data, the results lack statistical rigor. These are classic pitfalls in survey-style research and compromise any major conclusions drawn from this work.…”