OCTOBER 2016 | VOLUME 101 NUMBER 10 | AMERICAN COLLEGE OF SURGEONS Bulletin Contents

FEATURES COVER STORY: Young surgeons speak up: Stringent OR attire restrictions decrease morale without improving outcomes 10 Jacob Moalem, MD, FACS; Adnan A. Alseidi, MD, EdM, FACS; Joshua Broghammer, MD, FACS; James Suliburk, MD, FACS; Daniel D. Klaristenfeld, MD, FACS; Joseph V. Sakran, MD, FACS; Michael J. Sutherland, MD, FACS; and Patricia L. Turner, MD, FACS

The new Medicare physician reimbursement system: Building the Quality Payment Program 20 Christian Shalgian and Patrick V. Bailey, MD, FACS

ACS Committee on Trauma pledges to make zero preventable deaths a reality 23 Ronald M. Stewart, MD, FACS; Donald H. Jenkins, MD, FACS; Robert J. Winchell, MD, FACS; and Michael F. Rotondo, MD, FACS | 1

Get out the vote: Make a difference on issues of critical concern to surgery 29 Michael Carmody and Katie Oehmen

Two decades of humanitarian surgical outreach and capacity building in Kurdistan 33 Quyen D. Chu, MD, MBA, FACS; Gazi B. Zibari, MD, FACS; and A. Anand Annamalai, MD, FACS

OCT 2016 BULLETIN American College of Surgeons Contents continued

STATEMENTS ACS Clinical Research Program: Ethics Committee Town Hall on NRG GI002: Moving the needle industry representatives in the OR Statement on distractions in the toward TNT in locally advanced highlights issues outlined in ACS operating room 42 rectal cancer 61 statement 84 Statement on documentation and Thomas J. George, Jr., MD, FACP; Enrique Hernandez, MD, FACS; reporting of accidental punctures Christina Wu, MD; and Y. Nancy and Mark C. Weissler, MD, FACS and lacerations during surgery 45 You, MD, MHSc, FACS Dr. Ajit Sachdeva takes helm of the Statement on operating room Your ACS benefits: Maximize Society for Academic Continuing attire 47 your visibility and the benefits of Medical Education 87 Revised statement on health care Fellowship with the My Profile Web National Medical Association honors industry representatives in the page 63 Dr. Turner with Service Award 88 operating room 48 Elizabeth McAllister TQIP now in all 50 states and Revised statement on the Washington, DC 88 prevention of unintentionally A look at The Joint Commission: retained surgical items after Workplace bullying is a real Associate Fellows: Apply now surgery 50 problem in health care 65 for ACS Fellowship 89 Revised statement on safe surgery Carlos A. Pellegrini, MD, ACS joins effort to increase checklists, and ensuring correct FACS, FRCSI(Hon), FRCS(Hon), colorectal screening rates to 2 | patient, correct site, and correct FRCSEd(Hon) 80 percent by 2018 91 procedure surgery 52 NTDB data points: Stairway to Apply now for 2017 ACS-UW Revised statement on sharps heaven 67 Surgical Education Research safety 53 Richard J. Fantus, MD, FACS Fellowship 91 Revised statement on surgical Coming in November in JACS, technology training and NEWS and online now 91 certification 56 In memoriam: Barrett G. Haik, National Surgical Patient Safety MD, FACS 69 Summit participants stress COLUMNS teamwork, communication, James W. Gigantelli, MD, FACS and standards 92 Looking forward 8 Mary H. McGrath, MD, MPH, FACS, Chapter news 93 David B. Hoyt, MD, FACS to be honored with Distinguished Dispatches from rural surgeons: Philanthropist Award 71 MEETINGS CALENDAR Rural surgery and the volume ACS NSQIP Annual Conference Calendar of events 100 dilemma 57 inspires participants to innovate to Patrick L. Molt, MD, FACS make a difference 73 Jeannie Glickson and Diane Schneidman

V101 No 10 BULLETIN American College of Surgeons The American College of Surgeons is dedicated to improving the care of the surgical patient CLINICAL and to safeguarding standards of care in an optimal and ethical practice environment. CONGRESS

EDITOR-IN-CHIEF Letters to the Editor Diane Schneidman should be sent 2016 with the writer’s DIRECTOR, DIVISION OF name, address, INTEGRATED COMMUNICATIONS e-mail address, and OCTOBER 16–20 Lynn Kahn daytime telephone WALTER E. WASHINGTON CONVENTION CENTER number via e-mail to SENIOR EDITOR WASHINGTON, DC Tony Peregrin dschneidman@facs. org, or via mail to EDITORIAL & PRODUCTION ASSISTANT Diane S. Schneidman, Matthew Fox Editor-in-Chief, Bulletin, American CONTRIBUTING EDITOR College of Surgeons, Jeannie Glickson 633 N. Saint Clair St., SENIOR GRAPHIC DESIGNER/ Chicago, IL 60611. PRODUCTION MANAGER Letters may be edited Tina Woelke for length or clarity. Permission to publish EDITORIAL ADVISORS letters is assumed Charles D. Mabry, MD, FACS unless the author Leigh A. Neumayer, MD, FACS indicates otherwise. Marshall Z. Schwartz, MD, FACS Mark C. Weissler, MD, FACS

FRONT COVER DESIGN Tina Woelke

Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. ©2016 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382.

16-1814_CC2016_Bulletin_3.75x9.83in_v6.indd 1 2/12/2016 4:11:45 PM Officers and Staff of the American College of Surgeons

Henri R. Ford, MD, FACS AMERICAN COLLEGE OF Officers Los Angeles, CA Advisory Council SURGEONS FOUNDATION Gerald M. Fried, MD, FACS, FRCSC Shane Hollett J. David Richardson, MD, FACS Montreal, QC to the Board Executive Director Louisville, KY of Regents ALLIANCE/AMERICAN PRESIDENT James W. Gigantelli, MD, FACS COLLEGE OF SURGEONS Andrew L. Warshaw, MD, FACS Omaha, NE (Past-Presidents) CLINICAL RESEARCH PROGRAM Boston, MA B. J. Hancock, MD, FACS, FRCSC Kathryn D. Anderson, MD, FACS Kelly K. Hunt, MD, FACS IMMEDIATE PAST-PRESIDENT Winnipeg, MB Eastvale, CA Chair Ronald V. Maier, MD, FACS Enrique Hernandez, MD, FACS W. Gerald Austen, MD, FACS CONVENTION AND MEETINGS Seattle, WA Philadelphia, PA Boston, MA Robert Hope FIRST VICE-PRESIDENT Director Lenworth M. Jacobs, Jr., MD, FACS L. D. Britt, MD, MPH, Walter J. Pories, MD, FACS Hartford, CT FACS, FCCM DIVISION OF EDUCATION Greenville, NC Ajit K. Sachdeva, MD, SECOND VICE-PRESIDENT L. Scott Levin, MD, FACS Norfolk, VA Philadelphia, PA FACS, FRCSC Edward E. Cornwell III, John L. Cameron, MD, FACS Director MD, FACS, FCCM *Mark A. Malangoni, MD, FACS Baltimore, MD Washington, DC Philadelphia, PA Edward M. Copeland III, MD, FACS EXECUTIVE SERVICES SECRETARY *Leigh A. Neumayer, MD, FACS Gainesville, FL Maxine Rogers Director, Leadership Operations William G. Cioffi, Jr., MD, FACS Tucson, AZ A. Brent Eastman, MD, FACS Providence, RI Linda G. Phillips, MD, FACS Rancho Santa Fe, CA FINANCE AND FACILITIES TREASURER Galveston, TX Gay L. Vincent, CPA Gerald B. Healy, MD, FACS Director David B. Hoyt, MD, FACS *J. David Richardson, MD, FACS Wellesley, MA Chicago, IL Louisville, KY HUMAN RESOURCES EXECUTIVE DIRECTOR R. Scott Jones, MD, FACS AND OPERATIONS Marshall Z. Schwartz, MD, FACS Charlottesville, VA Michelle McGovern Gay L. Vincent, CPA Philadelphia, PA Director 4 | Chicago, IL Edward R. Laws, MD, FACS CHIEF FINANCIAL OFFICER Anton N. Sidawy, MD, FACS Boston, MA INFORMATION TECHNOLOGY Washington, DC LaSalle D. Leffall, Jr., MD, FACS Brian Harper Howard M. Snyder III, MD, FACS Washington, DC Interim Director Officers-Elect Philadelphia, PA LaMar S. McGinnis, Jr., MD, FACS DIVISION OF INTEGRATED (take office October 2016) Beth H. Sutton, MD, FACS Atlanta, GA COMMUNICATIONS Wichita Falls, TX Lynn Kahn David G. Murray, MD, FACS Director Courtney M. Townsend, *Steven D. Wexner, MD, FACS Syracuse, NY Jr., MD, FACS Weston, FL JOURNAL OF THE AMERICAN Galveston, TX Patricia J. Numann, MD, FACS COLLEGE OF SURGEONS PRESIDENT-ELECT Syracuse, NY Timothy J. Eberlein, MD, FACS *Executive Committee Hilary A. Sanfey, MB, Carlos A. Pellegrini, MD, FACS Editor-in-Chief BCh, MHPE, FACS Seattle, WA DIVISION OF MEMBER SERVICES Springfield, IL Richard R. Sabo, MD, FACS Patricia L. Turner, MD, FACS FIRST VICE-PRESIDENT-ELECT Board of Bozeman, MT Director Mary C. McCarthy, MD, FACS Governors/ Seymour I. Schwartz, MD, FACS M. Margaret Knudson, MD, FACS Dayton, OH Rochester, NY Medical Director, Military Health SECOND VICE-PRESIDENT-ELECT Executive Committee Frank C. Spencer, MD, FACS Systems Strategic Partnership New York, NY Girma Tefera, MD, FACS Fabrizio Michelassi, MD, FACS Andrew L. Warshaw, MD, FACS Director, Operation Giving Back Board of Regents New York, NY CHAIR Boston, MA PERFORMANCE IMPROVEMENT *Valerie W. Rusch, MD, FACS Will Chapleau, RN, EMT-P New York, NY Diana L. Farmer, MD, FACS Director CHAIR Sacramento, CA VICE-CHAIR Executive Staff DIVISION OF RESEARCH AND *Michael J. Zinner, MD, FACS EXECUTIVE DIRECTOR OPTIMAL PATIENT CARE Boston, MA Steven C. Stain, MD, FACS Clifford Y. Ko, MD, MS, FACS Albany, NY David B. Hoyt, MD, FACS VICE-CHAIR Director SECRETARY DIVISION OF ADVOCACY John L. D. Atkinson, MD, FACS David P. Winchester, MD, FACS Rochester, MN Daniel L. Dent, MD, FACS AND HEALTH POLICY San Antonio, TX Frank G. Opelka, MD, FACS Medical Director, Cancer James C. Denneny III, MD, FACS Medical Director, Quality Alexandria, VA Francis D. Ferdinand, MD, FACS Michael F. Rotondo, MD, FACS Wynnewood, PA and Health Policy Medical Director, Trauma Margaret M. Dunn, MD, FACS Patrick V. Bailey, MD, FACS Dayton, OH James W. Fleshman, Jr., MD, FACS, FASCRS Medical Director, Advocacy Timothy J. Eberlein, MD, FACS Dallas, TX Christian Shalgian St. Louis, MO Susan K. Mosier, MD, FACS Director James K. Elsey, MD, FACS Lawrence, KS Atlanta, GA

V101 No 10 BULLETIN American College of Surgeons Author bios*

*Titles and locations current at the time articles were submitted for publication.

a b c

d e | 5

f g h

DR. ALSEIDI (a) is a hepatobiliary and DR. BROGHAMMER (d) is urologist DR. FANTUS (g) is vice-chairman, pancreatic (HPB) and endocrine surgeon, and assistant professor of urology, department of surgery; medical director, and director, HPB fellowship, Virginia department of urology, University of trauma services; and chief, section of surgical Mason Medical Center, Seattle, WA. He is a Kansas Medical Center, Kansas City. critical care, Advocate Illinois Masonic member of the Young Fellows Association He is a member of the YFA ACS GC. Medical Center. He is clinical professor of (YFA) of the American College of Surgeons surgery, University of Illinois College of (ACS) Governing Council (GC). MR. CARMODY (e) is Government Medicine, Chicago, and Past-Chair, ad hoc Affairs Coordinator, ACS Division Trauma Registry Advisory Committee, DR. ANNAMALAI (b) is a hepatobiliary of Advocacy and Health Policy. ACS Committee on Trauma (COT). and transplant surgeon, Comprehensive Transplant Center, Cedars Sinai DR. CHU (f) is professor of surgery, DR. GEORGE (h) is associate professor, Medical Center, Los Angeles, CA. department of surgery; vice-chair, academic division of hematology and oncology, affairs; and chief, division of surgical University of Florida (UF), Gainesville; DR. BAILEY (c) is Medical Director, oncology, Louisiana State University Health director, GI (Gastrointestinal) Oncology Advocacy, ACS Division of Advocacy Sciences Center-Shreveport (LSUHSC-S). Program and Experimental Therapeutics and Health Policy, Washington, DC. Incubator, UF Health Cancer Center; and chair, NRG Oncology Colorectal Cancer Committee, National Clinical Trials Network.

continued on next page

OCT 2016 BULLETIN American College of Surgeons Author bios continued

i j k l

m n o 6 |

p q r s

DR. GIGANTELLI (i) is director, Truhlsen DR. JENKINS (l) is professor of surgery DR. MOLT (p) is a general surgeon, Eye Institute; interim chairman and professor, and vice-chair for quality, department of Fairfield Memorial Hospital, IL. department of ophthalmology and visual surgery, University of Texas Health Sciences sciences; and assistant dean of governmental Center at San Antonio (UTHSCSA); he is MS. OEHMEN (q) is ACS Professional affairs, College of Medicine, University of Chair, ACS COT Performance Improvement Association-SurgeonsPAC Associate, ACS Nebraska Medical Center, Omaha. He is a and Patient Safety Committee. Division of Advocacy and Health Policy. member of the ACS Board of Regents (B/R). DR. KLARISTENFELD (m) is a DR. PELLEGRINI (r) is chief medical MS. GLICKSON (j) is Communications colorectal surgeon, Southern California officer, UW Medicine, and vice-president for Associate, ACS Division of Integrated Permanente Medical Group, San Diego, medical affairs, University of Washington, Communications, Chicago, IL. CA, and member, YFA ACS GC. Seattle. He is a Past-President of the ACS. DR. HERNANDEZ (k) is The Abraham Roth MS. McALLISTER (n) is Administrative DR. ROTONDO (s) is chief executive officer, Professor and Chair, department of obstetrics, Coordinator, ACS Division of University of Rochester Medical Faculty gynecology, and reproductive science; and Member Services, Chicago, IL. Group and Vice-Dean for Clinical Affairs, professor of pathology, Temple University, and a professor of surgery, University of Philadelphia, PA. He is a member of the ACS DR. MOALEM (o) is an endocrine Rochester. He is Medical Director, ACS B/R and the ACS Committee on Ethics. surgeon and associate professor of Trauma Programs, and Past-Chair, ACS COT. surgery, University of Rochester Medical Center, NY, and Chair, YFA ACS. continued on next page

V101 No 10 BULLETIN American College of Surgeons Author bios continued

t u v w

x y z aa | 7

bb cc dd ee

DR. SAKRAN (t) is assistant professor of DR. SUTHERLAND (y) is associate DR. WU (cc) is assistant professor, division surgery, Johns Hopkins University, Baltimore, professor of surgery, University of Arkansas of medical oncology, and gastrointestinal MD, and a member of the YFA ACS GC. for Medical Sciences, Little Rock, and a oncology disease specific research group member of the YFA Governing Council. leader, The Ohio State University, Columbus. MS. SCHNEIDMAN (u) is Editor-in- Chief, Bulletin of the American College of Surgeons, ACS DR. TURNER (z) is Director, ACS DR. YOU (dd) is associate professor, section Division of Integrated Communications. Division of Member Services. of colorectal surgery, department of surgical oncology, and medical director, Familial MR. SHALGIAN (v) is Director, ACS DR. WEISSLER (aa) is Joseph P. Riddle High Risk Gastrointestinal Cancer Clinic, Division of Advocacy and Health Policy. Distinguished Professor, department of University of Texas MD Anderson Cancer otolaryngology-head and neck surgery, DR. STEWART Center. She is Vice-Chair, ACS Clinical (w) is the Dr. Witten B. and chief, division of head and neck Research Program Education Committee. Russ Chair in Surgery, professor of surgery surgery, University of North Carolina and anesthesia, and chair, department of School of Medicine, Chapel Hill. He is DR. ZIBARI (ee) is the Malcolm Feist Chair surgery, UTHSCSA. He is Chair, ACS COT. Past-Chair, ACS Board of Regents. in Transplantation Surgery, LSUHSC-S. DR. SULIBURK He is director, John C. McDonald (x) is assistant professor DR. WINCHELL (bb) is chief, division Regional Transplant Center, and Director, of surgery, department of surgery, Baylor of trauma, burns, acute and critical care, Advanced Surgery Center, Willis-Knighton College of Medicine, Houston, TX. He department of surgery, Weill Cornell Medical Health System, Shreveport, LA. is a member of the YFA ACS GC. College; director, trauma center, New York- Presbyterian Weill Cornell Medical College, NY; and Chair, Trauma Systems Evaluation and Planning Committee, ACS COT.

OCT 2016 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

ver the course of the last year, many Fel- To address this problem, the College’s statement rec- lows, Associate Fellows, and Resident Mem- ommends that OR scrubs be worn outside of the hospi- Obers of the American College of Surgeons tal’s OR area only when worn under a clean lab coat or (ACS) have taken to the ACS Communities to other appropriate cover up and even then should only voice concern that the hospitals where they prac- be worn only within the hospital perimeter. Further- tice have imposed restrictive guidelines regarding more, the ACS encourages surgeons to wear clean pro- proper attire in and out of the operating room (OR). fessional attire (not scrubs) during all patient encoun- As an organization that is dedicated both to serving ters outside of the OR. To facilitate enforcement of the the professional interests of our members as well guideline on wearing scrubs only within the perimeter as to safeguarding the well-being of the surgical of the hospital, the ACS also suggests the adoption of patient, the ACS sought to determine whether the distinctively colored scrub suits for OR personnel. restrictions at these institutions were reasonable and appropriate. This issue of the Bulletin includes an article on the Head covering efforts of the Young Fellows Association of the ACS to Another concern that led to the development of OR attire gauge young surgeons’ reaction to the protocols and guidelines is the debate over proper covering of the head. to study the scientific evidence supporting or refuting The College maintains that during invasive procedures, 8 | the need for these restrictions (see page 10). Also in this the mouth, nose, and hair on the skull and face should issue is the College’s “Statement on operating room be covered to avoid potential wound contamination, and attire” (see page 47). A task force led by ACS Regent that the surgical mask should never be allowed to dangle L. Scott Levin, MD, FACS, and comprising members from the face during an operation. of the ACS Committee on Perioperative Care and the Large sideburns and ponytails should be covered or Council on Surgical and Perioperative Safety devel- contained; however, we found no evidence to suggest oped the statement, which is based on the principles that leaving ears, a limited amount of hair at the nape of professionalism, common sense, decorum, and the of the neck, or modest sideburns uncovered contributes available evidence. The Board of Regents approved the to wound infections. In fact, covering the ears may be guidelines in July. detrimental to patient care by making communication more difficult. Therefore, contrary to the guidelines set forth at some institutions, the College maintains that Turning the “green tide” the surgical skullcap provides sufficient coverage of the One of the behaviors that led members of the patient head when worn with a mask and proper eyewear and safety community to develop OR attire restrictions in accordance with other patient safety protections. We is the rising “green tide” of hospital personnel who have found no evidence to suggest that the bouffant arrive at and leave their work area and institutions head covers mandated under some guidelines provide at the start or the end of their shifts or breaks in more effective coverage. Indeed, as the photo on page 9 their OR scrubs. It has become commonplace in shows, hair is as likely to creep out of bouffant hats as cities such as New York, NY, and Chicago, IL, to any other head covering. see droves of hospital personnel emerging from medical center campuses and entering restaurants, stores, and subway stations while still in their green Keep it clean scrubs. When patients and their families see health Further debate has centered on how frequently care professionals wearing greens in environments scrubs need to be changed, especially since they are that are anything but sterile, it raises red flags about often worn under impermeable OR gowns. The ACS patient safety and welfare. maintains that scrubs and hats worn during dirty or

V101 No 10 BULLETIN American College of Surgeons recommendations. Mark R. Chassin, MD, MPP, MPH, Chassin, R. Mark recommendations. ACS the with aligned are activities oversight regulatory and policies their that to ensure Commission Joint The and Services &Medicaid for Medicare Centers the with collaborating is also College the recommendations, conversation. to this contributor aconstructive to being forward we look statement, this produced has College the that have developed recently. Now organizations other that on protocols largely based are some institutions at implemented guidelines attire professional The Nationwide adoption daily. of disposed be should caps paper and daily, sanitized and cleaned be should caps cloth All soiled. not visibly even if cases to subsequent prior changed be should cases or contaminated dirty during worn caps and scrubs Furthermore, operation. an after members family with speaking before certainly and feasible as soon as changed be should cases contaminated To ensure the widespread implementation of our of our implementation To widespread the ensure South Carolina since its FDA approval in April 2014. Dr. Gillespie was assisted by otolaryngology–head and neck neck and otolaryngology–head by assisted 2014. was in April Dr. Gillespie FDA approval its since Carolina South M. Boyd Gillespie, MD, MSc, FACS, performing the first Inspire Upper Airway Stimulation device implantation in implantation device Stimulation Airway Upper Inspire first the performing FACS, MD, MSc, Gillespie, Boyd M. surgery residents and fellows wearing various types of OR attire at the Medical University of South Carolina. South of University Medical the at attire OR of types various wearing fellows and residents surgery EXECUTIVE DIRECTOR’S REPORT DIRECTOR’S EXECUTIVE send them to Dr. Hoyt at [email protected] at Hoyt Dr. to them send please issues, other or this about suggestions or comments you have If goal. that achieve to us help will for surgeons policy dress prehensive for acom recommendations These patients. for our environment care surgical optimal an to providing and safety patient to commitment strong our reflects consensus. to achieve out groups to other reaching be We sense. common and will evidence available on the based are that to adoptpolicies programs verification to work with willing is and College’sthe perspective to sympathetic he is that indicated has Commission, FACP, officerThe of Joint executive chief and president The ACS “Statement on operating room attire” attire” room ACSThe on operating “Statement ♦ OCT 2016 BULLETIN OCT American College of Surgeons of College American .

PHOTO BY ALISON PADLAN-GILLETTE - | 9 OR ATTIRE RESTRICTIONS

Young surgeons speak up: Stringent OR attire restrictions decrease morale without improving outcomes

by Jacob Moalem, MD, FACS; Adnan A. Alseidi, MD, EdM, FACS; Joshua Broghammer, MD, FACS; James Suliburk, MD, FACS; Daniel D. Klaristenfeld, MD, FACS; Joseph V. Sakran, MD, FACS; Michael J. Sutherland, MD, FACS; and Patricia L. Turner, MD, FACS

V101 No 10 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

variability in hospitals across the country. Furthermore, HIGHLIGHTS the rigor with which these policies are enforced has been inconsistent, with some centers lacking any mech- • Describes how OR attire restrictions anism to verify compliance after implementation. At have become more widespread other institutions, full compliance with attire protocol • Outlines the process and results of a study has been incorporated into the preoperative checklist, conducted by the YFA of the ACS, which assessed preventing the start of a procedure until full compli- surgeons’ reactions to the OR attire restrictions ance is achieved. • Examines the possible effects of the OR Many surgeons have expressed concerns about a attire restrictions on patient safety lack of data to support these changes, leading in some instances to vocal opposition and frustration.2,3 Sur- • Urges surgeons to demonstrate a geons and nurses alike have complained of significant commitment to professionalism regarding dress in and out of the OR infringements on their comfort, autonomy, and abil- ity to concentrate. Some members of the perioperative team have refused to comply with these guidelines, | 11 whereas others have relented due to a perception of ationwide and with increasing frequency, depart- powerlessness. ments of perioperative services have been Nmodifying internal policies regarding appropri- ate attire in the operating room (OR). This movement YFA intercedes has gained momentum since January 2015 when the The Young Fellows Association (YFA) of the Ameri- Association for periOperative Registered Nurses can College of Surgeons (ACS) is composed of ACS (AORN) published a set of recommendations on OR Fellows who are 45 years old and younger.4 The YFA attire (see sidebar, page 12).1 Despite extensive criti- is structured to promote diversity, to seek feedback, cism for lack of scientific rigor and the authors’ own and to encourage participation among young Fellows description of many of the supportive studies as “quasi- so that the ACS leadership can better understand the experimental” or “non-experimental,” these were needs of this important and growing constituency. The the first (and only) set of specialty society-endorsed YFA Governing Council (GC) comprises 15 members recommendations on this issue to be accepted by reg- who are carefully selected following open nominations ulatory agencies such as the Centers for Medicare & and who reflect the diversity of the College in terms of Medicaid Services (CMS).1,2 geography, specialty, gender, and ethnicity.5 In response to growing complaints from Fellows regarding restrictions on OR attire, the YFA GC The surgical team responds decided to investigate the variability in perioperative To comply with AORN’s recommendations, many sur- policy changes and the rationale and driving forces gery departments and health systems have adopted behind them with an eye toward critical appraisal of increasingly stringent policies designed to minimize the data upon which these policies are based. A key goal the exposed areas of skin and hair of members of the was to characterize the perception of young Fellows perioperative services team as a means of reducing regarding the effect these changes will have on patient the risk and incidence of surgical site infections (SSIs). safety, SSI rates, and the morale and overall function These policies have been implemented with marked of the operative team.

OCT 2016 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

PARTIAL LIST OF Survey development AORN RECOMMENDATIONS FOR OR ATTIRE Based on existing discussions in the online ACS General Surgery Community, the YFA GC created • Head, hair, ears, facial hair, and nape of a Web-based electronic survey designed to collect neck should be covered when entering the demographic information, data related to changes in semi-restricted and restricted areas. OR attire policies, and the perceived impact of these • Nondisposable head coverings should be changes.6 To our knowledge, this study is the only covered with a disposable head cover. formal investigation of surgeon perceptions related to these policy changes. • Nondisposable head coverings should be laundered For this study, we asked the members of the YFA in a health care-accredited laundry facility. to share their opinions regarding the recent policy • Arms should be covered with long-sleeved changes. We also asked the leadership of the YFA jacket in semi-restricted areas. GC and its three Past-Chairs to voice the opinions of • Scrub attire should be worn that covers their constituents related to the recent policy changes, 12 | arms when prepping the patient or when in addition to performing an independent critical preparing and packaging sterile items in the appraisal of the AORN recommendations and their clean assembly area of sterile processing. scientific validity. We then compared the constituent opinions of the YFA GC members with those of the YFA • Jewelry that cannot be contained or confined membership at large. The survey also contained open- within the scrub attire should not be worn ended questions to enable collection of qualitative data. in the semi-restricted or restricted areas. A limited version of the survey was posted online in the YFA Community, which at the time of the survey had 5,736 subscribers. Two reminder messages were posted on the Communities page, and the survey remained open for comment for two weeks. In addition to completing the survey, members of the YFA GC were tasked with expressing the global viewpoint of their constituency after care- fully reviewing the AORN guidelines to appraise their content. They also were asked to interview lead- ers in their perioperative services departments to determine the key factors that led to recent changes in OR attire policy.

YFA member responses A total of 317 YFA members completed the survey. Respondents were from a mix of all surgical spe- cialties; the highest response rate was from general surgeons (26.9 percent), followed by colon and rectal (10.4 percent), trauma (7.6 percent), plastic (6.3 percent),

V101 No 10 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

FIGURE 1. YFA MEMBER PERCEPTIONS REGARDING NEW OR ATTIRE POLICIES

| 13

and minimally invasive/bariatric surgeons (6 percent). • Requirement that all OR personnel cover arms and Respondents were distributed fairly evenly among those exposed skin (12 percent) in private practice (24 percent), part of a multispecialty group (30 percent), or at an academic institution (43 per- • Prohibition on rings (7 percent) cent). Reflective of the demographics within our YFA community, most surgeons who reported an academic • Mandated use of shoe covers (7 percent) rank were assistant or associate professors (51 percent and 28 percent, respectively). Our surgeons are geographi- Other respondents disclosed guidelines prohibit- cally diverse, representing all regions of the U.S. Of the ing mesh sneakers or mandates that socks be worn respondents, 65 percent were male. in the OR. Two participants indicated that earrings Commonly reported new OR attire restrictions were banned from the OR. Some respondents reported imposed in the last year include the following: guidelines prohibiting undershirts, whereas others reported requirements that undershirts be worn. Two • Ban on cloth surgical caps (70 percent) surgeons indicated that their hospital had new require- ments for plastic bags covering anything brought into • Prohibition of home-laundered scrubs (57 percent) the OR, including briefcases and loupe cases. The respondents were largely skeptical of the poten- • Requirement that bouffant hats be worn in the OR tial benefits of these requirements. In fact, 91 percent (37 percent) disagreed or strongly disagreed that “disallowing cloth caps will reduce wound infections.” Similarly, • Requirement that OR hats be pulled down to cover 91 percent of respondents disagreed or strongly dis- the ears such that sideburns and all facial hair are cov- agreed that “mandating complete coverage of ears ered (27 percent) and sideburns will reduce wound infections.” None

OCT 2016 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

FIGURE 2. YFA MEMBER PERCEPTIONS OF THE IMPACT OF OR ATTIRE ON OUTCOMES AND MORALE

14 |

of the respondents agreed that “recent changes in surgeons (71.2 percent), and the surgical team as a OR attire are based upon valid scientific evidence,” whole (67.1 percent). (See Figure 2, this page.) and 97 percent strongly disagreed or disagreed with In the comments section of the survey, respondents this statement. On the other hand, 79 percent of expressed gratitude that the YFA was conducting this the respondents agreed or strongly agreed that sur- study and a sense of frustration that the recent surge geon comfort is an important safety concern, and in policies related to OR attire is not evidence-based. 87.5 percent indicated that surgeon discomfort could Interestingly, one Fellow reported being involved in negatively affect patient outcomes. (See Figure 1, page a prospective study to investigate OR attire policies 13.) In all, 31.9 percent indicated that they have oper- that was halted because of fear of being “out of com- ated while uncomfortable because of recent changes pliance” with recommendations. in attire regulations, and 52.8 percent indicated that they have operated while uncomfortable because of changes in OR temperature. Guideline implementation Overall, most respondents said that the changes Another prominent theme suggested by the survey was in OR attire would not affect SSI rates (93 percent) that surgeons felt poorly positioned to influence the or overall outcomes (96 percent) in their hospi- creation and implementation of guidelines in the OR tals. Among those respondents who indicated that and that many of these policies were being developed changes in OR attire would influence wound infec- by nonphysicians. Moreover, respondents expressed tion rates and overall outcomes, more believed that concerns related to differential enforcement of attire infection rates and outcomes would worsen rather policies. One surgeon was concerned that in her hospi- than improve. Of the respondents, 69 percent said tal, patient care has been delayed because consultants that these changes lessen surgeon comfort, and most are forced to completely change into scrubs before indicated that these regulations lower morale among entering the OR suites (bunny suits have been disal- nurses (58.4 percent), anesthesiologists (52.8 percent), lowed), whereas noncompliant contractors and other

V101 No 10 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

FIGURE 3. YFA GC OPINIONS REGARDING AORN GUIDELINES

nonphysicians are routinely seen in the OR without factor in the creation of new policies by nearly all | 15 changing into scrubs attire. Another surgeon expressed respondents, but were considered “most important” outrage that, by policy, the infection control personnel by only five. who round through the OR at his hospital were exempt All members of the YFA GC carefully reviewed from the attire regulations to which all other person- the AORN guidelines document mentioned at the nel are required to adhere. Finally, several surgeons beginning of this article.1 The survey revealed that expressed concern regarding an increased risk of infec- 17 of the 18 GC members and Past-YFA Chairs dis- tion in their patients because of their own perspiration agreed (10) or strongly disagreed (seven) that “most dripping into the wound as a result of uncomfortably of the evidence cited in the AORN document is sci- warm room requirements. entifically valid,” and 16 of 18 disagreed or strongly We also compared the responses of the members disagreed that “the evidence in that document sup- of the YFA GC with those of the general YFA mem- ports the conclusions and recommendations that were bership. We found that the responses of the YFA GC made.” Likewise, 16 of 18 agreed (five) or strongly members closely approximated the responses of mem- agreed (11) that the AORN recommendations were bers of the YFA at large. published with insufficient consideration for the com- In interviews with perioperative services leaders, plex nature of wound infections. compliance with regulatory mandates (such as those issued by state health departments or The Joint Com- mission) emerged as the “most important” reason for Discussion instituting new OR attire policies. Of 16 hospitals, 14 In alignment with the College’s mission statement, the cited a visit from a regulatory agency as the “most YFA is “dedicated to improving the care of the surgical important” (10) or a “very important” (four) factor in patient and to safeguarding standards of care in an opti- establishing new policies on OR attire. A regulatory mal and ethical practice environment.”7 Because SSI is visit at a neighboring hospital was considered a “most the second most common hospital-acquired infection important” factor in the creation of new OR attire and associated with increased morbidity, length of stay, policy changes at four additional hospitals. Efforts and costs, prevention of SSI is an important goal for all to reduce infection rates were cited as a contributing ACS members.8 However, research shows that SSIs are

OCT 2016 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

complex in nature and arise from etiologies that are evidence lacks scientific validity in the first place. both intrinsic and extrinsic to the patient.9 Although (See Figure 3, page 15.) many SSIs are potentially preventable, nearly half are unavoidable using existing evidence-based strat- egies.10 It is noteworthy that participation in the ACS AORN guidelines: What is the evidence? National Surgical Quality Improvement Program We carefully reviewed the literature used to develop (ACS NSQIP®) is related to a significant decline in the AORN guidelines. As stated earlier in this article, SSI rates.11 much of the evidence that formed the basis for the Our study yielded several important findings. AORN recommendations is “quasi-scientific,” and is First, it is apparent that several changes in periop- founded on the premise that health care workers and erative services policies have been implemented in their apparel lead to bacterial contamination in the OR. many hospitals or health systems over the past year, It has been well documented that bacteria are found in but their enforcement varies greatly. Another impor- human hair, on surgical attire, and on shed skin cells tant finding in our study is that the overwhelming called squames.12-14 Many of the cited studies looked at majority of respondents (93 percent and 96 percent, colony-forming units (CFUs) produced by the dispersal 16 | respectively) thought that the recent policy changes of bacteria through the air and the number of bacte- would have no impact on wound infections or over- rial species that were found on scrubs, but to date, no all outcomes. More than 90 percent of respondents study has shown that the use of specific scrub type has either disagreed or strongly disagreed with specific a direct effect on SSI.15-17 statements in support of the implementation of spe- Recommendations also were made to completely cific new restrictions to attire in the OR. cover arms with a long-sleeved jacket. This guideline A majority of respondents believed that the new is also based on a theoretical risk of SSI due to squame changes in OR attire would either worsen (approx- production from exposed skin. Interestingly, in 2007, imately two-thirds of all respondents) or have no the U.K. Department of Health took the exact opposite effect (approximately one-third of all respondents) stance and implemented a “bare below the elbows” on morale among surgeons, nurses, anesthesiologists, policy, which was thought to reduce patient exposure and the team as a whole. In addition, 70 percent of to bacteria by promoting better hand hygiene prac- respondents reported that the comfort of the operat- tices.18 Again, none of the available evidence supports ing surgeon would be reduced—a significant finding, either policy. given that more than 80 percent indicated that sur- Other guidelines also lack supporting evidence. geon comfort is an important safety factor that could AORN recommends wearing street clothes when negatively affect patient outcomes. outside the hospital. This restriction emerged from a The survey suggests that the most common driv- study comparing bacterial contamination of clothing ing force in creating new OR attire policies are visits worn inside and outside the perioperative area, which by regulatory agencies. These agencies require OR showed no increased contamination levels.19 Although personnel to follow a nationally recognized set of that study did not address surgical attire worn outside guidelines. However, when our team of surgical of the hospital, AORN stated that this recommendation leaders reviewed the guidelines for perioperative was supported by “moderate evidence.” practice—standards that are the foundation of most The restriction of briefcases and backpacks in the new OR attire policy changes—we were nearly OR is based on data that demonstrated that those items unanimous that the evidence cited does not support can harbor bacteria despite the fact no data has shown the AORN’s recommendations and that much of the that these personal items contribute to the occurrence

V101 No 10 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

of SSI.20 The same is true of cell OTHER YFA GC AND ACS CONTRIBUTORS phones, which the AORN recom- TO OR ATTIRE STUDY mendations call for cleaning before Rebecca C. Britt, MD, FACS David B. Hoyt, MD, FACS being brought into the perioperative Associate professor of surgery, ACS Executive Director 21 setting. Finally, myriad guidelines department of surgery, Eastern Joshua M. V. Mammen, MD, PhD, Virginia Medical School, Norfolk call for eliminating cloth caps and FACS replacing them with bouffant-style Edie Y. Chan, MD, FACS Associate professor of surgery, coverings. Although hair is a carrier Associate professor of surgery, department of surgery, University of bacteria, no comparative studies department of general surgery, Rush of Kansas, Kansas City University Medical Center, Chicago, IL exist on head coverings and their Joseph Scharpf, MD, FACS impact on SSI.12,17 Ellen T. Derrick, MD, MPH, FACS Associate professor of surgery, Associate professor of surgery, Cleveland Clinic Lerner College We reviewed the relevant scien- department of surgery, Providence of Medicine, and staff, Head tific evidence related to OR masks Regional Medical Center, Everett, WA and Neck Institute, Cleveland and found that in the largest study, Cynthia D. Downard, MD, MMSc, Clinic Foundation, OH by Tunevall and colleagues, 3,088 FACS Shoaib Sheikh, MD, FACS patients undergoing general surgery Associate professor of surgery, Hiram Assistant professor of surgery, | 17 showed a slightly reduced rate (3.5 C. Polk, Jr., MD, Department of Memorial University of Newfoundland percent versus 4.7 percent; P>0.05) Surgery, University of Louisville, KY and Labrador, GB Cross Memorial Hospital, Clarenville, NL of wound infections and no change Joseph J. DuBose, MD, FACS in bacterial culture results from SSI Associate professor of surgery, S. Rob Todd, MD, FACS, FCCM when healthy surgeons operated University of California Davis, Fresno Associate professor of surgery, Baylor College of Medicine, and 22 John Elfar, MD, FACS without masks. chief, general surgery and trauma, Associate professor of orthopaedic Further, a Cochrane review, Ben Taub Hospital, Houston surgery, University of Rochester updated in 2014, found only three Medical Center, NY Ashley Vergis, MD, MMEd, FACS, studies of a total 2,106 patients who Paula Ferrada, MD, FACS FRCSC underwent clean surgery worthy of Associate professor of surgery, Assistant professor, section 23 inclusion. Interestingly, all three department of surgery, Virginia of general surgery, University studies showed a trend toward a Commonwealth University, Richmond of Manitoba, Winnipeg lower SSI rate in the unmasked Gerald R. Fortuna, Jr., MD, FACS Robert D. Winfield, MD, FACS versus the masked group. Associate professor of surgery, Associate professor of surgery, department of cardiothoracic and department of surgery, University of It is noteworthy that even in the Kansas Medical Center, Kansas City context of prosthetic joint implan- vascular surgery, University of Texas tation surgery, where extreme at Houston School of Medicine measures are taken to prevent infec- tious complications, supportive evidence is lacking. A recent review of nearly 90,000 joint replacements over 10 years found that the use of space suits and laminar airflow (LAF) systems in the OR was actu- ally associated with an increased infection rate and that the rate of

OCT 2016 BULLETIN American College of Surgeons OR ATTIRE RESTRICTIONS

REFERENCES revision surgery was not reduced in cases performed using either or both of these 1. Association of periOperative Registered Nurses. Guidelines for 24 Perioperative Practice. 2015 Edition. Available at: www.aorn.org/ interventions. In addition, a recent sys- guidelines/purchase-guidelines. Accessed August 18, 2016. tematic review included eight studies that 2. American College of Surgeons. General Surgery Community. OR evaluated the effect of LAF on SSI rates attire, hats, and so on. November 15, 2015. Password protected. in patients who underwent knee or hip Available at: acscommunities.facs.org/communities/community- replacement surgery. In that study, the home/digestviewer/viewthread?GroupId=13&MID=24889&tab=di gestviewer. Accessed August 18, 2016. preponderance of the evidence pointed 3. American College of Surgeons. General Surgery Community. toward an increased SSI rate with LAF, Surgical caps. May 15, 2015. Password protected. Available at: with summary odds ratios of 1.36 and acscommunities.facs.org/communities/community-home/ 1.71 for knee prosthesis and hip prosthe- digestviewer/viewthread?MID=38243&GroupId=13&tab=digestvie sis, respectively.25 wer&UserKey=a26b175f-d3f1-45eb-b1bd-369d8ccfa218&sKey=2434c 9aa02ab4016b0e1#bm0. Accessed August 18, 2016. 4. American College of Surgeons. Member Services. Young Fellows Association. Available at: facs.org/member-services/yfa. Accessed Comment August 18, 2016. Although our study demonstrated that 5. American College of Surgeons. Member Services. Young Fellows young surgeons oppose the recent surge Association. About YFA. Available at: facs.org/member-services/ yfa/leadership. Accessed August 18, 2016. of OR attire-related regulations (personal | 18 6. American College of Surgeons. Welcome to ACS Communities. communication with Sara Morse, Manager, Available at: acscommunities.facs.org/home. Accessed August 18, Legislative and Political Affairs, ACS Divi- 2016. sion of Advocacy and Health Policy, May 7. American College of Surgeons. About ACS. ACS mission statement. 2016), there remain important opportuni- Available at: facs.org/about-acs. Accessed August 18, 2016. 8. Scott RD. The direct medical costs of healthcare-associated ties for improved conduct in this regard. infections in U.S. hospitals and the benefits of prevention. Centers Unfortunately, it is fairly commonplace for Disease Control and Prevention. March 2009. Available at: to see surgeons and other members of the www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf. Accessed OR team wearing surgical scrubs outside August 18, 2016. the hospital and in public places.26-28 Such 9. Jenks PJ, Laurent M, McQuarry S, Watkins R. Clinical and economic burden of surgical site infection (SSI) and predicted conduct raises questions in the minds of financial consequences of elimination of SSI from an English patients as to the cleanliness of the attire hospital. J Hosp Infect. 2014;86(1):24-33. worn inside the OR. In addition, unclean 10. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, personal hospital garb, such as white coats, Brennan PJ. Estimating the proportion of healthcare-associated cloth scrub caps, and OR shoes, is often infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(02):101-114. observed throughout the hospital. Although 11. Cohen ME, Liu Y, Ko CY, Hall BL. Improved surgical outcomes for no studies to date prove that this practice is ACS NSQIP hospitals over time: Evaluation of hospital cohorts with detrimental to our patients, this behavior up to 8 years of participation. Ann Surg. 2016;263(2):267-273. fails the “sniff test” and is unprofessional. 12. Summers MM, Lynch P, Black T. Hair as a reservoir of Moreover, research clearly shows that staphylococci. J Clin Pathol. 1965;18(1):13-15. 13. Dankert J, Zijlstra J, Lubberding H. A garment for use in the patients’ perceptions of quality of care, and operating theatre: The effect upon bacterial shedding. J Hyg. their trust and confidence in their surgeon, 1979;82(1):7-14. is influenced by his or her appearance.29,30 14. Noble W. Dispersal of skin microorganisms. Br J Dermatol. Thus, while AORN’s guidelines are overly 1975;93(4):477-485. intrusive and unlikely to improve patient continued on next page safety, surgeons are encouraged to play a leadership role in restricting OR attire to the perioperative environment.

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Conclusion REFERENCES (CONTINUED) Our study suggests that the overwhelming 15. Tammelin A, Domicel P, Hambraeus A, Ståhle E. Dispersal of majority of young Fellows oppose the wave of methicillin-resistant Staphylococcus epidermidis by staff in an new and more restrictive policies related to OR operating suite for thoracic and cardiovascular surgery: Relation to attire. They believe that these guidelines will skin carriage and clothing. J Hosp Infect. 2000;44(2):119-226. not improve patient outcomes and may in fact 16. Krueger CA, Murray CK, Mende K, Guymon CH, Gerlinger TL. The bacterial contamination of surgical scrubs. Am J Orthop (Belle increase surgeon discomfort in the OR, and Mead NJ). 2012;41(5):E69-73. may demoralize all members of the OR team. 17. Salassa TE, Swiontkowski MF. Surgical attire and the operating Therefore, these policy changes violate both room: Role in infection prevention. J Bone Joint Surg Am. components of the ACS mission statement: 2014;96(17):1485-1492. “improving the care of the surgical patient” 18 Burger A, Wijewardena C, Clayson S, Greatorex R. Bare below elbows: Does this policy affect handwashing efficacy and reduce and maintaining an “optimal and ethical prac- bacterial colonisation? Ann R Coll Surg Engl. 2011;93(1):13-16. tice environment.” 19. Sivanandan I, Bowker KE, Bannister GC, Soar J. Reducing the risk Based on these findings, the YFA GC of surgical site infection: A case controlled study of contamination strongly urged the ACS to take a leader- of theatre clothing. J Perioper Pract. 2011;21(2):69-72. ship role in the creation of a comprehensive 20. Feldman J, Feldman M. Women doctors’ purses as an unrecognized fomite. Del Med J. 2012;84(9):277-280. evidence-based set of guidelines and rec- 21. Datta P, Rani H, Chander J, Gupta V. Bacterial contamination ommendations related to OR attire. The of mobile phones of health care workers. Indian J Med Microbiol. findings and literature review reported 2009;27(3):279-281. | 19 herein ultimately served as background 22. Tunevall TG. Postoperative wound infections and surgical face materials and a major stimulus for the ACS masks: A controlled study. World J Surg. 1991;15(3):383-387. 23. Lipp A, Edwards P. Disposable surgical face masks for preventing position statement, “Statement on operat- surgical wound infection in clean surgery. Cochrane Database Syst ing room attire” (see page 47 of this issue of Rev. 2002;(1):CD002929. the Bulletin). 24. Hooper G, Rothwell A, Frampton C, Wyatt M. Does the use of We encourage all surgeons to set a posi- laminar flow and space suits reduce early deep infection after total tive example by wearing nonsurgical attire hip and knee replacement? The ten-year results of the New Zealand Joint Registry. J Bone Joint Surg Br. 2011;93(1):85-90. outside of the hospital and to seek leadership 25. Gastmeier P, Breier AC, Brandt C. Influence of laminar airflow positions within their own departments of on prosthetic joint infections: A systematic review. J Hosp Infect. perioperative services so that they can more 2012;81(2):73-78. effectively advocate for their patients and 26. Tolkoff M. Could wearing scrubs prove dangerous? Medscape become engaged in the creation and imple- Business of Medicine. March 27, 2015. Available at: www.medscape. com/viewarticle/840854. Accessed August 18, 2016. mentation of policies that directly affect 27 Scott M. Should scrubs be worn only inside hospitals to limit the surgeons and their patients. ♦ spread of germs? NewsWorks. The Pulse. January 15, 2015. Available at: www.newsworks.org/index.php/local/the-pulse/77247-should- scrubs-be-worn-inside-hospitals-only-to-limit-the-spread-of-germs. Accessed August 18, 2016. 28. Chopra V, Saint S. Forget scrubs: Doctors need a dress code. Washington Post. July 7, 2015. Available at: www.washingtonpost. com/posteverything/wp/2015/07/07/forget-scrubs-doctors-need-a- dress-code/?utm_term=.0bd545c874ad. Accessed August 18, 2016. 29. Major K, Havase Y, Balderrama D, Lefor AT. Attitudes regarding surgeons’ attire. Am J Surg. 2005;190(1):103-106. 30. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005;118(11):1279-1286.

OCT 2016 BULLETIN American College of Surgeons BUILDING THE QPP

The new Medicare physician reimbursement system: Building the Quality Payment Program

by Christian Shalgian and Patrick V. Bailey, MD, FACS

or nearly 20 years, Medicare has paid physicians Pathways to participation in the same manner. The Medicare Access and Surgeons, and all physicians, have two pathways to 20 | FCHIP (Children’s Health Insurance Program) participate in the QPP—participate in the Merit-based Reauthorization Act (MACRA) of 2015 called for Incentive Payment System (MIPS) or in the advanced major changes in the physician payment system that Alternative Payment Models (APMs). At present, lim- will begin to take effect in 2017. This new payment ited options are available for surgeons to participate system—the Quality Payment Program (QPP)— in APMs; thus, most surgeons will be in the MIPS continues to advance a policy goal of basing payment program. on value rather than on volume. The specifics of how this new payment system will be implemented began to come to light on MIPS participation April 27, when the Centers for Medicare & Medic- The MIPS program consists of four components: qual- aid Services (CMS) released the proposed rule. The ity, resource use, advancing care information (ACI), American College of Surgeons (ACS) Division of and clinical practice improvement activities (CPIA). Advocacy and Health Policy staff carefully analyzed Each physician will receive a composite score, which the proposed regulation and provided detailed feed- will be a total of the scores from each of the four com- back to the CMS in late June.* Because the final ponents. This score will be benchmarked against or Medicare regulations will be issued in late October compared with other physicians’ scores to determine or early November, this article is intended to provide whether the individual physician receives a payment surgeons with the initial background on the QPP penalty of as much as 4 percent or payment increase and how it is likely to affect surgical practices and of up to 12 percent. (These percentages will change the business side of the surgeon’s office. after the first year.) Although the names of the programs have changed, most surgeons are familiar with three of the *Hoyt DB. Medicare Program; Merit-based Incentive Payment System components. (MIPS) and Alternative Payment Model (APM) Incentive Under the Phy- sician Fee Schedule, and Criteria for Physician-Focused Payment Mod- Quality component els. ACS comment letter. June 27, 2016. Available at: facs.org/~/media/ files/advocacy/regulatory/acs%20macra%20comment%20letter%20 The quality component of MIPS replaces the Physi- final.ashx. Accessed August 31, 2016. cian Quality Reporting System (PQRS). Fortunately,

V101 No 10 BULLETIN American College of Surgeons BUILDING THE QPP

FIGURE 1. MACRA AT A GLANCE QPP PROPOSED FOUR COMPONENTS REGULATION OF MIPS • 982-page regulation • Quality (formerly PQRS) • Published April 27, 2016 • Resource use (formerly VBM) • ACS feedback provided • ACI (formerly EHR to CMS June 27, 2016 meaningful use) • 2 tracks: • CPIA ȖȖ MIPS ȖȖ APMs

CMS is proposing some changes that surgeons will ACI component likely welcome. The ACI component modifies and replaces the Elec- In contrast to the previous PQRS requirement that tronic Health Record (EHR) Incentive Program. physicians report nine quality measures, the MIPS qual- The proposed overall score for this component is ity component requires providers to report only six derived from two separate scores: measures. One of these six measures must be an “out- come” measure and another must be a “cross-cutting” • Base score (50 percent) measure. Although the reporting threshold for the per- • Performance score (up to an additional 50 percent) centage of patients for which reports will be required is | 21 proposed to increase substantially, the ACS and other The threshold for achieving the base score continues physician organizations will be advocating that the to be defined as “all or nothing.” Only after meeting the required percentage published in the final rule be close requirements for the base score is a physician eligible to to the 50 percent level found in current programs. receive the additional performance score credit, which A surgeon who has been participating in the PQRS will be based on the level of performance on a subset of program is well positioned to successfully meet the the same measures required to achieve the base score. quality component requirements. A good first step ACI scores in 2017 are expected to be based on cri- for a surgeon who has not been participating in PQRS teria similar to those in the 2016 requirements for the is to start using the ACS Surgeon Specific Registry EHR Incentive Program. (SSR).† The SSR allows surgeons to more easily par- ticipate in the PQRS and the new quality component CPIA component of MIPS. The fourth component of MIPS is the CPIA component. This is a new component with no analogous previous Resource use component program requirement. As such, this facet of MIPS is The resource use component replaces the value-based continuously evolving. modifier (VBM). Surgeons will not have to fulfill any In the first year of MIPS assessment (2017), achiev- reporting requirements for the resource use compo- ing full credit for the CPIA component should pose a nent. Medicare will complete the calculations based nominal additional administrative burden, as report- on the claims submitted by surgeons. Beginning in ing will be by simple attestation. Physicians will choose 2018, CMS also plans to take into account such fac- from a list of activities (the proposed rule comprises tors as patient condition and attribution of costs as 94 possible activities) assigned two different weighted appropriate to the relationship of the physician to values. To receive full credit for the CPIA component, the patient. most providers will need to attest that they have par- ticipated in a minimum of three and a maximum of †American College of Surgeons. Quality Programs; Surgeon Specific Reg- six of the 94 activities, depending on the weight of the istry. Available at: facs.org/quality-programs/ssr. Accessed August 16, 2016. activities selected, for 90 days.

OCT 2016 BULLETIN American College of Surgeons BUILDING THE QPP

FIGURE 2. MIPS: COMPOSITE PERFORMANCE SCORE YEAR 1: WEIGHT BY CATEGORY

As noted earlier in this article, MIPS participants Nonparticipation in the QPP will be assigned a composite performance score based Physicians who choose not to participate in the QPP on their performance in all four components. For will receive a 4 percent cut in their Medicare payments 2017, the first year for assessment under the QPP, 50 in 2019. Note the 4 percent cut increases in subsequent percent of the score will be based on performance years, up to 9 percent in 2022. This maximum 4 per- in the quality component, 10 percent will be based cent cut in 2019 is less severe than the 10 percent cut on the resource use component, 25 percent will be that physicians were receiving for not participating in 22 | based on the ACI component, and 15 percent will be the PQRS, the EHR Incentive Program, and the VBM. based on CPIA. More to come Participation in alternative payment models Key points that health care professionals should bear As noted at the beginning of this article, surgeons in mind are as follows: have two options for participating in the QPP—the MIPS and the APMs. Physicians may participate in • The final regulation on the QPP is expected to be released an APM that provides greater flexibility in care deliv- in late October or early November. While the informa- ery but which carries a greater risk of financial loss tion outlined in this article is not expected to change, if care costs exceed what is expected. Both routes a substantial number of details will be included in the have advantages and risks, but over time, there will final regulation that surgeons will need to understand. be growing financial pressure for physicians to move to APMs. • The proposed regulations would have the data collec- To date, Medicare has released two APMs related to tion for 2017 begin on January 1. The College and other surgical care—a cardiac care bundle and a hip replace- physician organizations have urged CMS to begin the ment bundle. However, very few additional options 2017 data collection on July 1, 2017, to give physicians are available to surgeons who want to participate in more time to understand this complex new program approved Advanced APMs. MACRA encourages phy- before beginning active participation. sician-led development of new models and has created a new Physician-Focused Payment Model Technical As CMS rolls out the QPP, the ACS will be providing Advisory Committee tasked with providing feedback numerous resources to help Fellows understand and on APMs developed and submitted by stakeholders. participate in the Medicare payment program. These The ACS has contracted with Brandeis University, resources will be available on the College’s website, at Waltham, MA, and the Center for Surgery and Public the ACS Clinical Congress, at ACS chapter meetings, Health at the Brigham and Women’s Hospital, Boston, and elsewhere. ♦ MA, to develop surgical APMs.

V101 No 10 BULLETIN American College of Surgeons PREVENTABLE DEATHS

ACS Committee on Trauma pledges to make zero preventable deaths a reality

by Ronald M. Stewart, MD, FACS; Donald H. Jenkins, MD, FACS; Robert J. Winchell, MD, FACS; and Michael F. Rotondo, MD, FACS

HIGHLIGHTS he National Academy of Science released the seminal report, Accidental Death and Disability: The Neglected • Describes the College’s ongoing Disease of Modern Society, 50 years ago.1 Three Fellows involvement in national efforts T of the American College of Surgeons (ACS)—Sam Seeley, to improve trauma care MD, FACS; Alan Thal, MD, FACS; and John Howard, MD, | 23 • Outlines recommendations in the FACS—played a critical role in the development of this docu- NASEM’s latest report on translating ment.2 The report was, in large measure, stimulated by and experience gained in military based on the experiences of these surgeons during their mili- medicine to civilian trauma tary deployment in the Korean War. The authors took what • Summarizes the COT’s mission they learned in the military and translated those lessons into and pathways to improving care a list of recommendations to improve trauma care for injured for the trauma patient U.S. civilians. The findings and recommendations described • Discusses collaborative efforts in the in Accidental Death and Disability were pivotal in the early trauma community to avert patient development of emergency medical services (EMS), emer- deaths from traumatic injury gency medicine, trauma centers, and trauma care systems across the nation. Today, however, the U.S. trauma system remains an incomplete patchwork. Many of the gaps identified in Acci- dental Death and Disability remain, and summary paragraphs describing areas in need of improvement in the report are as applicable today as they were when the report was written. In an effort to develop strategies for improving the U.S. trauma system, the National Academies of Sciences, Engi- neering, and Medicine (NASEM) Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector released a report this spring, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury.3 The report was sponsored by the ACS, the U.S. Department of Defense, and other leading health care organizations dedi- cated to improving outcomes after injury. This new report

OCT 2016 BULLETIN American College of Surgeons PREVENTABLE DEATHS

A report sponsored by the ACS, the U.S. Department of Defense, and other leading health care organizations calls for eliminating all preventable trauma-related deaths in both military and civilian trauma patients.

calls for eliminating all preventable trauma-related tank of senior civilian consultants to take on the deaths in both military and civilian trauma patients. larger and more difficult issues for the readiness and The leadership of the ACS Committee on Trauma surgical mission of the Defense Health Authority and (COT) is grateful for the contributions of the the Department of Defense.” He went on to state National Academies and our dedicated Fellows of the that “these subject content experts should be struc- College, specifically those who produced both the tured to assure relevance, impact, and value. This original white paper and this latest comprehensive think tank should be composed of the best thinkers report. In the tradition of the original contributors in academic surgery and medicine, health adminis- from 50 years ago, six Fellows of the College served tration, finance, and economics.”4 24 | on the most recent committee (all MD, FACS): Adil In line with this vision, other key sponsors of the Haider; John B. Holcomb; Cato T. Laurencin; the NASEM report included the American College of late Norman E. McSwain, Jr.; Thomas M. Scalea; Emergency Physicians, the National Association of and C. William Schwab. The Academies dedicated EMS Physicians, the National Association of Emer- the report to Dr. McSwain, who died during pro- gency Medical Technicians, the Trauma Center duction of the current report. Association of America, the U.S. Department of This latest document outlines important oppor- Defense, the U.S. Department of Homeland Secu- tunities for strengthening the relationship between rity, and the U.S. Department of Transportation. the ACS and the U.S. military. Moreover, the efforts Although sponsored by the ACS and these other of the Academies committee provide a roadmap for leading organizations, one of the strengths of the improving the trauma care of U.S. citizens and of our Academies’ report is that the recommendations were troops in times of war. derived independently from a group of experts con- This article outlines the events leading up to the vened by NASEM. release of the report, summarizes its 11 recommenda- Donald Berwick, MD, chair of the NASEM tions, and describes how the ACS and other trauma Committee on Military Trauma Care’s Learning leaders have collaborated to promote optimal care of Health System and Its Translation to the Civilian the injured patient and to advance the agenda estab- Sector, noted, “Both the military and civilian sec- lished by the NASEM. tors have made impressive progress and important innovations in trauma care, but there are serious limitations in the diffusion of those gains from loca- Events leading up to the report tion to location…the successes have saved many Dr. Schwab set the stage for developing A National lives; the disparities have cost many lives. With the Trauma Care System: Integrating Military and Civilian decrease in combat and the need to maintain readi- Trauma Systems to Achieve Zero Preventable Deaths after ness for trauma care between wars, a window of Injury in the Scudder Oration, which he delivered at opportunity now exists to integrate military and the ACS Clinical Congress 2014. In his presentation, civilian trauma systems and view them not sepa- Dr. Schwab called for the establishment of “…a think rately, but as one.”5

V101 No 10 BULLETIN American College of Surgeons PREVENTABLE DEATHS

Report recommendations mands, giving players in the system access to timely The report is comprehensive and broad in scope, call- evidence, data, educational opportunities, research, ing for the development of a national trauma care and performance improvement activities. system and highlighting 11 specific recommenda- tions. These recommendations can be summarized • The Secretary of the U.S. Department of Health and as follows: Human Services (HHS) should designate and fully support a locus of responsibility and authority within • The White House should set a national aim of the department for leading a sustained effort to achieve achieving zero preventable deaths after injury and the national aim of zero preventable deaths after injury minimizing trauma-related disability. and minimizing disability. This leadership role should include coordination with governmental (federal, state, • The White House should lead the integration of mili- and local), academic, and private-sector partners and tary and civilian trauma care to establish a national should address care from the point of injury to rehabili- trauma care system. This initiative would include tation and post-acute care. assigning a locus of accountability and responsibil- ity that would ensure the development of common • The Secretary of HHS and the Secretary of Defense, best practices, data standards, research, and workflow together with their governmental, private, and academic | 25 across the continuum of trauma care. partners, should work jointly to ensure that military and civilian trauma systems collect and share common data • The Secretary of Defense should ensure combatant spanning the continuum of care. Within that integrated commanders and the Defense Health Agency (DHA) data network, measures related to prevention, mortality, Director are responsible and held accountable for the disability, mental health, patient experience, and other integrity and quality of the execution of the trauma intermediate and final clinical and cost outcomes should care system in support of the aim of zero prevent- be made readily accessible and useful to all relevant pro- able deaths after injury and minimizing disability. viders and agencies. To this end: • To support the development, continuous refinement, and ȖȖThe Secretary of Defense also should ensure the dissemination of best practices, the designated leaders of DHA Director has the responsibility and authority the recommended national trauma care system should and is held accountable for defining the capabili- establish processes for real-time access to patient-level ties necessary to meet the requirements specified by data from across the continuum of care and just-in-time the combatant commanders with regard to expert access to high-quality knowledge for trauma care teams combat casualty care personnel and system support and those who support them. infrastructure. • To strengthen trauma research and ensure that the ȖȖThe Secretary of Defense should hold the Secretar- resources available for this research are commensu- ies of the military departments accountable for fully rate with the importance of injury and the potential for supporting the DHA in that mission. improvement in patient outcomes, the White House should issue an Executive Order mandating the estab- ȖȖThe Secretary of Defense should direct the DHA lishment of a National Trauma Research Action Plan Director to expand and stabilize long-term support requiring a resourced, coordinated, joint approach to for the Joint Trauma System so its functionality can trauma care research across the Department of Defense be improved and used across all combatant com- (DoD), HHS (including the National Institutes of

OCT 2016 BULLETIN American College of Surgeons PREVENTABLE DEATHS

Health, Agency for Healthcare Research and Quality, the report. In an invited commentary published in Centers for Disease Control and Prevention, Food and 2015 in the Journal of the American College of Surgeons, Drug Administration, and Patient-Centered Outcomes Margaret “Peggy” Knudson, MD, FACS, Director of Research Institute), the Department of Transporta- MHSSPACS, noted, “Dr. (Col.) Edward D. Churchill tion, the Department of Veterans Affairs, and others is quoted as saying, ‘Surgeons in a current war never (academic institutions, professional societies, and begin where the surgeons in the previous war left off; foundations). they always go through another long learning period.’ Dr. Churchill, we will do our best to not let that be the • To accelerate progress toward the aim of zero prevent- case going forward.”6 The ACS—through the COT, able deaths after injury and minimizing disability, the MHSSPACS, the ACS Division of Advocacy and regulatory agencies should revise research regulations Health Policy, and the Coalition for National Trauma and reduce misinterpretation of the regulations through Research (CNTR)—is committed to effective imple- policy statements—that is, guidance documents. mentation of the NASEM recommendations as a means of responding to Dr. Churchill’s concerns. • All military and civilian trauma systems should par- The ACS COT’s activities are administered through ticipate in a structured trauma quality improvement an 85-member national committee that oversees a 26 | process. field force of more than 3,500 trauma care profession- als nationwide. These individuals work together to • Congress, in consultation with HHS, should identify, develop and implement meaningful trauma care pro- evaluate, and implement mechanisms that ensure the grams in local, regional, national, and international inclusion of prehospital care (for example, emergency arenas. The COT was established in 1922 and has medical services) as a seamless component of health care worked to continuously improve the care of injured delivery, rather than merely a transport mechanism. patients. The COT is dedicated to preventing inju- ries, improving all phases and systems of care that • To ensure readiness and to save lives through the deliv- are important to the injured patient, and to actively ery of optimal combat casualty care, the Secretary of cooperating with other national organizations that Defense should direct the development of career paths have similar strategic goals.7 for trauma care—for example, foster leadership devel- Since its founding, the ACS has been dedicated opment, create joint clinical and senior leadership to promoting the highest standards of surgical care positions, remove any relevant career barriers, and through the pillars of education, quality, and advo- attract and retain a cadre of military trauma experts cacy.7 The ACS COT has formally adopted this pillar with financial incentives for trauma-relevant special- approach to national leadership in trauma and has ties. Furthermore, the Secretary of Defense should championed trauma systems strength, as depicted in direct the Military Health System to pursue the devel- Table 1, page 27. opment of integrated, permanent joint civilian and military trauma system training platforms to create Education and sustain an expert trauma workforce. To advance trauma education with respect to A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Commitment to better trauma care Injury, the ACS COT’s Trauma Systems Committee has The ACS COT and the Military Health System Stra- partnered with NHTSA to convene the Innovations in tegic Partnership ACS (MHSSPACS) strongly support Trauma Care Conference, which is scheduled to take and endorse the findings and recommendations in place in spring 2017. The conference will highlight the

V101 No 10 BULLETIN American College of Surgeons PREVENTABLE DEATHS

TABLE 1. NATIONAL TRAUMA LEADERSHIP PILLARS ADVANCE TRAUMA ENSURE QUALITY CHAMPION TRAUMA DRIVE EDUCATION PATIENT CARE SYSTEMS STRENGTH ADVOCACY Accredited continuing A verification program helps Comprehensive expert Advocacy activities at the education programs trauma centers confirm that assessment and consultative federal and state level that support medical they have adequate resources, guidance for the improvement focused on prevention as professionals across the ensures readiness, and improves or development of state and well as socioeconomic, continuum of trauma care: trauma care. The quality cycle regional trauma systems legislative, and regulatory issues that • Advanced Trauma Life continues with TQIP, a risk- Integrates and partners with affect trauma care Support® Course adjusted local and national multidisciplinary teams in each benchmarking program to • Trauma Evaluation and locality or region Develop and advocate measure and inform the health care policies that Management Trauma Systems Consultation improvement of outcomes, are in the best interests • Advanced Trauma for counties, regions, states, or and a PIPS program that of trauma patients, such Operative Management systems continuously measures and as the Stop the Bleed • Rural Trauma Team evaluates in order to improve Benchmarks, indicators, and campaign (bleeding Development Course care. scoring facilitations control or BCon) • Disaster Management and Resources for Optimal Care of the Emergency Preparedness Promote injury Injured Patient prevention and control • Advanced Surgical Skills VRC programs aimed at for Exposure in Trauma reducing needless injury, TQIP • “Stop the Bleed” campaign death, and suffering • Basic Endovascular Skills PIPS for Trauma (BEST)

| 27 findings of the NASEM report, generate information quality goals a reality. The Trauma Quality Improve- and knowledge aimed at implementation of the report’s ment Program (TQIP®), the Verification, Review, and recommendations, and stimulate further innovation Consultation Program (VRC), and the Performance in trauma systems. Improvement and Patient Safety (PIPS) programs pro- vide an integrated comprehensive approach to quality Advocacy improvement, as called for in the report. The COT’s Working with the American Association for the Sur- Trauma System Committee is currently partnering gery of Trauma (AAST), the National Trauma Institute with the Department of Defense and the MHSSPACS (NTI), the Eastern Association for the Surgery of to comprehensively address the goals outlined in the Trauma (EAST), the Western Trauma Association latest Academies’ report. (WTA), and their respective memberships, the ACS COT helped establish the CNTR. Bill Cioffi, Jerry Jurkovich, Tim Fabian, Thomas Scalea, Don Jenkins, Moving forward together with key partners Chris Cocanour, and Kim Davis (all MD, FACS) played Along these lines of partnership and to advance the crucial early roles in the establishment of the coali- goals of a national trauma system described in the tion. As a result of the joint advocacy efforts of CNTR report, the ACS COT, MHSSPACS, and CNTR are members, Congress appropriated $10 million in 2016 moving forward together to further coordinate and for the development of a national trauma clinical trials integrate civilian and military trauma systems and network and has authorized an additional $10 million to improve the quality and impact of trauma-related for the 2017 budget to further support that initiative.8 research. The CNTR is developing the National Trauma Quality Research Repository and recently received its first Three key programs form the foundation of the COT’s major project aimed directly at reducing prehospi- Quality Pillar, which is poised to help make the NASEM tal deaths in a manner recommended in the NASEM

OCT 2016 BULLETIN American College of Surgeons PREVENTABLE DEATHS

report. The ACS COT has committed to assist CNTR by REFERENCES ® ® using the National Trauma Data Bank and the TQIP 1. National Research Council. Accidental Death and systems to enhance the efficacy of clinical trials in these Disability: The Neglected Disease of Modern Society. networks. Making the report’s research agenda a reality Washington, DC: The National Academies Press; 1966. remains the top goal of the CNTR. The AAST, NTI, EAST, 2. Howard JM. Historical background to Accidental Death and Disability: The Neglected Disease Of Modern Society. and WTA have been great partners to the ACS COT in Prehosp Emerg Care. 2000;4(4):285-289. advancing our combined efforts to improve the care of 3. National Academies of Sciences, Engineering, and the injured patient. Medicine. A National Trauma Care System: Integrating The ACS COT and CNTR have both created position Military and Civilian Trauma Systems to Achieve Zero statements outlining support for specific implementation Preventable Deaths after Injury. Washington, DC: The National Academies Press; 2016. strategies aligned with the NASEM guidelines. These state- 4. Schwab CW. Scudder Oration on Trauma. Winds of ments are scheduled to be published in the October issue of war: Enhancing civilian and military partnerships the Journal of Trauma and Acute Care Surgery.9-10 Creating this to assure readiness. White paper. J Am Coll Surg. implementation strategy is vital, as the charge of the Acad- 2015;221(2):254-255. emies’ committee is essentially complete once the report 5. National Academies of Sciences, Engineering, and Medicine. Up to 20 percent of U.S. trauma deaths is fully released in November. This is a critical project for could be prevented with better care. June 17, 2016. | 28 the ACS, CNTR, and other partner organizations. This past Press release. Available at: www8.nationalacademies. August, the American College of Emergency Physicians org/onpinews/newsitem.aspx?RecordID=23511. and the COT collaborated on the development of a national Accessed August 18, 2016. database that would enable an immediate preventable death 6. Knudson MM. Scudder Oration on Trauma. Invited Commentary. J Am Coll Surg. 2015;221(2):254-255. analysis following active mass casualty incidents. A com- 7. American College of Surgeons. About ACS. mitment to working together is at the heart of the COT’s Committee on Trauma. Available at: facs.org/about- approach to making zero preventable deaths a reality. acs/governance/acs-committees/committee-on- trauma. Accessed August 18, 2016. 8. Stewart RM. $10 million closer to meeting the trauma challenge. ACS Surgery News. February Conclusion 17, 2016. Available at: www.acssurgerynews. We believe the NASEM report will have a tremendous com/?id=14883&tx_ttnews[tt_news]=482625&cH impact on the care of the injured patient, and the ACS COT ash=641c0f8bc7ab81c94b2eb3584c771f9d. Accessed is committed to making this belief a reality. August 18, 2016. Grace Rozycki, MD, FACS, AAST President, com- 9. Jenkins DH, Winchell R, Rotondo MF, et al. Position statement of the American College of Surgeons mented: “The AAST has a long history of promoting, Committee on Trauma on the National Academies of evaluating, and leading innovation in trauma systems. Sciences, Engineering and Medicine report, A National We are committed to dissemination, implementation, and Trauma Care System: Integrating Military and Civilian working with our CNTR partners to create the research Trauma Systems to Achieve Zero Preventable Deaths after agenda called for in this latest report.” And, as Dr. Scalea, Injury. J Trauma Acute Care Surg. August 16, 2016. [Epub ahead of print]. a founding member of CNTR and a contributor to the 10. Jenkins DH, Cioffi WG, Cocanour CS. Position current recommendations, added, “It was a pleasure and Statement of the Coalition for National Trauma an honor to serve on the Military Trauma Care’s Learning Research (CNTR) on the National Academies of Health System and its Translation to the Civilian Sector Sciences, Engineering and Medicine (NASEM) Report: Committee. I am confident that, working together, we A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable can meet the goal of zero preventable deaths called for Deaths after Injury. J Trauma Acute Care Surg. August 16, in our report.” ♦ 2016. [Epub ahead of print].

V101 No 10 BULLETIN American College of Surgeons GET OUT THE VOTE

Get out the vote: Make a difference on issues of critical concern to surgery

by Michael Carmody egislative and regulatory policies can directly affect and Katie Oehmen surgeons and patients. Fellows who take action and Lleverage their voices through political advocacy help to demonstrate the profession of surgery’s position and allow the American College of Surgeons (ACS) to serve as a valuable resource to policymakers while helping to effect real change in health policy. The 2015–2016 election cycle is proving to be one of the most unpredictable, yet critical, U.S. elections in recent years, which is why it’s so important to get out the vote. Candidate platforms include proposals pertaining to Medicaid and Medi- care, health information technology, research, funding, and many more health care-related issues that have the potential to affect the future of surgery and the surgical patient. Both inside the halls of Congress and locally back home, it is crucial that | 29 the College’s surgeon advocates engage with their representa- tives, educate them about issues affecting their patients and practice, and provide feedback to the ACS Division of Advocacy and Health Policy’s federal legislative team.

Make your voice heard The ACS and the ACS Professional Association (ACSPA) work to ensure that issues of concern to surgery remain top pri- orities on Capitol Hill. To uphold the College’s stance on promoting and protecting the future of surgical practice, members are encouraged to register to vote prior to Elec- tion Day. According to the National Conference of State Legislatures (NCSL), more than two-thirds of the states (37), plus the District of Columbia, offer some form of early voting. Many proponents argue that early voting makes the process easier, and, as a result, increases turnout, which may be significant come November. Additionally, the Pew Research Center’s July and August 2016 studies examining this year’s presidential election suggest that while many voters appear conflicted about this election pro- cess—with respondents’ views ranging from more interested in politics than they were four years ago to completely turned off by this year’s campaigns—it appears that turnout can be rela- tively high even when voter satisfaction with the candidates is low, and vice versa.1

OCT 2016 BULLETIN American College of Surgeons GET OUT THE VOTE

Before you cast your vote, visit SurgeonsVoice.org, the legislation forward and influence his or her party’s posi- College’s nationwide, interactive advocacy program, to tion on the issues. get up to speed with the lawmakers in your state and district. SurgeonsVoice has several resources to assist you, • Committee assignment. Candidates who serve on key including an interactive map and toolkit. The interac- committees are better positioned to advance health tive map allows you to learn about the key players from policy legislation in support of surgeons and the sur- your state on Capitol Hill and important legislation in gical patient. your state legislature. The SurgeonsVoice toolkit is the College’s most • Record on issues. ACSPA-SurgeonsPAC evaluates candi- comprehensive pre-election education resource. Issue dates’ service as champions for surgery and the surgical briefs, talking points, and PowerPoint presentations are patient. available to assist you in evaluating where your candi- dates stand in terms of the ACS legislative priorities. • Medical professional. Candidates with medical degrees, For an insider’s perspective on races within your especially surgeons who are Fellows of the ACS, are 30 | congressional district, contact the ACS Washington recognized leaders in health policy. office staff at [email protected] or 202-337-2701. • Political viability. The candidate should have an orga- nized campaign with demonstrated potential to win. Surgery’s success starts with ACSPA-SurgeonsPAC Although the ACSPA’s political action committee Candidates and incumbents (ACSPA-SurgeonsPAC) does not participate in presiden- supported by ACSPA-SurgeonsPAC tial elections, gauging how it and other health care To enhance the probability of electing and re-electing PACs disburse contributions to candidates can be help- candidates who are sympathetic to the concerns of ful in benchmarking which members of Congress are surgeons and their patients, the ACSPA-SurgeonsPAC advocating for the future of health care. has contributed more than $900,000 to key U.S. House Standing together as surgeons allows surgeons to and Senate races across the country. In addition to make a difference when it comes to the issues they supporting 14 physician incumbents, ACSPA-Surgeon- care about most. ACSPA-SurgeonsPAC, in conjunc- sPAC has contributed to seven physician and dentist tion with the College’s federal legislative team and candidates’ campaigns, including two Fellows of the surgeon advocates, works to establish relationships College. The following are a few examples of candi- with surgical champions on Capitol Hill. The more dates and incumbents whose races ACSPA-SurgeonsPAC champions we have in Congress, the greater success has supported to date: we will have leveraging our issues and establishing surgeons as leaders and partners in finding legislative • Rep. Ami Bera, MD (D-CA). Representative Bera is one solutions to complex issues. The following guidelines of the few Democratic incumbents facing a tougher shape the ACSPA-SurgeonsPAC disbursement strategy race than expected this year. Since being elected for candidates: to California’s Seventh Congressional District in 2012, he has worked his way up the ladder, gaining • Leadership position. Candidates who serve as ranking respect and support from key Democratic leadership members of their parties have a greater ability to move and is one of the few Democratic liability reform

V101 No 10 BULLETIN American College of Surgeons GET OUT THE VOTE

TOSS UP SEATS IN THE SENATE TOSS UP SEATS IN THE HOUSE • Open seat, NV, Harry Reid (D-NV) • Open seat, AZ-01, Ann Kirkpatrick (D) • Mike Coffman (R-CO-06) • Kelly Ayotte (R-NH) • Open seat, FL-18, Patrick Murphy (D) • Carlos Curbelo (R-FL-26) • Michael Bennett (D-CO) • Open seat, PA-8, Mike Fitzpatrick (R) • Bob Dold (R-IL-10) • Dan Coats (R-IN) • Open seat, NV-03, Joe Heck (R) • Frank Guinta (R-NH-01) • Ron Johnson (R-WI) • Open seat, NY-03, Steve Israel (D) • Will Hurd (R-TX-23) • Mark Kirk (R-IL) • Open seat, NY-19, Chris Gibson (R) • Mia Love (R-UT-04) • Rob Portman (R-OH) • Open seat, NY-22, Richard Hanna (R) • John Katko (R-NY-24) • Marco Rubio (R-FL) • Open seat, WI-08, Reid Ribble (R) • Steve Knight (R-CA-25) • Pat Toomey (R-PA) • Bruce Poliquin (R-ME-02) • David Young (R-IA-03) • Lee Zeldin (R-NY-01)

champions in Congress. Representative Bera’s first and more than 20 other members of Congress, includ- political event was held in the ACS Washington, DC, ing Sen. Dick Durbin (D-IL), House Democratic Leader Office board room, and he has championed many Nancy Pelosi (D-CA), and Rep. Jan Schakowsky (D-IL). efforts important to members of the College. • Roger Marshall, MD (R-KS). Dr. Marshall, an obstetrician- • Neal Dunn, MD, FACS (R-FL). Dr. Dunn is on the National gynecologist from Great Bend, won the August 2 Republican Congressional Committee (NRCC) “young Kansas First Congressional District Republican pri- guns” list, which means he is running for one of the mary with 57 percent of the vote against incumbent most competitive congressional seats in the 2016 elec- Rep. Tim Huelskamp. This win is significant, as Rep- | 31 tion cycle. Dr. Dunn is a urologist and Fellow of the resentative Huelskamp is the first House Republican in College who is running in Florida’s Second Congressio- this election cycle to lose a primary for reasons unre- nal District. This is an open seat vacated by Rep. Gwen lated to redistricting. Whereas this district is solidly Graham (D-FL). Dr. Dunn has support from former Republican, Dr. Marshall is the projected winner for Florida House Speaker Allan Bense (R), the Florida the general election. Medical Association, and several physician groups in Washington, DC. • Rep. Tom Price, MD, FACS (R-GA). Representative Price is an ACS Fellow who has risen through the congressional • Drew Ferguson, DMD (R-GA). Dr. Ferguson is a den- ranks. Serving on the advisory group to House Speaker tist running for Rep. Lynn Westmoreland’s (R) seat in Paul Ryan (R-WI), Rep. Price is typically in the room Georgia’s Third Congressional District. In Georgia, the when key decisions are made. He played a critical role winner of the primary (held this year on May 24) must in inserting the global codes provision in the sustainable take 50 percent plus one. If this goal is not accomplished, growth rate formula, as well as advocating that future the top two candidates—in this case, Dr. Ferguson and payment models should be physician-centric. state Sen. Mike Crane (R)—enter a runoff, which Dr. Ferguson won July 26 with 54 percent of the vote. Dr. To view a complete list of candidates supported by Ferguson is strongly favored to win the general election ACSPA-SurgeonsPAC in your state, visit SurgeonsVoice. in this heavily Republican district. org. To learn more about ACSPA-SurgeonsPAC’s dis- bursement process, contact ACSPA-SurgeonsPAC sta ff • Raja Krishnamoorthi (D-IL). Mr. Krishnamoorthi, con- at [email protected] or 202-672-1520. sidered to be one of the Democratic Party’s emerging leaders, is running in Illinois’ Eighth Congressional District as Representative Tammy Duckworth (D-IL) Election update vies for the Senate seat. Mr. Krishnamoorthi is still the Many of this year’s congressional races have proven clear frontrunner, receiving critical endorsements from competitive, and the November election results may President Barack Obama, Representative Duckworth, change the political climate of the U.S.

OCT 2016 BULLETIN American College of Surgeons GET OUT THE VOTE

Approximately one-third (34) of U.S. senators are up for re-election REFERENCES in November. Members of Congress within both parties are concerned that the current political climate may cause a shift in power. At pres- 1. The Pew Research Center. 2016 ent, the Senate is composed of 44 Democrats, 54 Republicans, and two campaign: Strong interest, widespread dissatisfaction for July 7, 2016. Independents. According to recent polls and race ratings, including Available at www.people-press. The Cook Political Report, a nonpartisan online analysis of electoral org/2016/07/07/2016-campaign-strong- politics, the U.S. Senate has several vulnerable “toss-up” seats; two are interest-widespread-dissatisfaction/. held by Democrats and seven by Republicans.2,3 (See sidebar, page 31.) Accessed August 25, 2016. At present, Republicans have a 54–46 majority in the Senate. To 2. The Cook Political Report. 2016 Senate race ratings for August 19, 2016. Available gain a majority in the Senate, Democrats would need a net gain of at: www.cookpolitical.com/senate/ five seats. Sources such as The Rothenberg and Gonzales Political Report charts/race-ratings. Accessed August 25, indicate that Democrats are likely to gain 3–6 seats.4 2016. In terms of the House, although Republicans have a 247–188 major- 3. The Pew Research Center. U.S. voter ity, recent polling analyses predict Democrats are likely to pick up turnout trails most developed countries 32 | 5 for August 2, 2016. Available at: www. at least 10 seats, but larger numbers are conceivable. The possibility pewresearch.org/fact-tank/2016/08/02/ of Democrats gaining control of the House also continues to grow u-s-voter-turnout-trails-most-developed- as Democrats only need to win 15 races to obtain majority status. countries/. Accessed August 25, 2016. Some of the most contested House races nationwide include three 4. The Rothenberg and Gonzales Democratic and 16 Republican seats. Toss up seats in the House appear Report. Senate ratings. Available at rothenberggonzales.com/ratings/senate. in the sidebar on page 31. Accessed August 25, 2016. To influence election outcomes, many political groups have recently 5. The Rothenberg and Gonzales increased their presence in some of these contentious races, including Report. House ratings. Available at the National Republican Senatorial Committee and the Democratic rothenberggonzales.com/ratings/house. Senatorial Campaign Committee, both of which are investing staff, Accessed August 25, 2016. time, and money in Arizona, Colorado, Florida, Illinois, Iowa, Maryland, Missouri, Nevada, New Hampshire, North Carolina, Ohio, Pennsylva- nia, and Wisconsin. Similarly, the Democratic Congressional Campaign Committee and the NRCC are promoting their respective “emerging races,” “red-to-blue” candidates, and “young guns” to increase contribu- tions. From investing in ads in battleground states to adopting the use of Snapchat to expand their demographic reach via custom filters and videos, party committee tactics are proving to be almost as competi- tive as some of the races themselves.

ACS continues to fight for surgery In this unpredictable election year, one fact is certain: the ACS con- tinues to have strong working relationships with both Democrat and Republican members of Congress and will continue to success- fully advocate on behalf of all of surgery during the remainder of the 114th Congress and beyond. ♦

V101 No 10 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

The city of Duhok

Two decades of humanitarian surgical outreach | 33 and capacity building in Kurdistan

by Quyen D. Chu, MD, MBA, FACS; Gazi B. Zibari, MD, FACS; and A. Anand Annamalai, MD, FACS

A local urologist from Duhok performing the first successful laparoscopic nephrectomy

OCT 2016 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

HIGHLIGHTS • Describes the health care issues that affected the people of Kurdistan after decades of Iraqi dictatorship • Illustrates the role ACS Fellows played in developing a sustainable health care system in Kurdistan • Offers advice to surgeons who are interested in leading similar efforts in war-torn nations

pproximately 5 billion people, or two-thirds Mesopotamia) in the fourth century BC. An estimated of the world’s population, lack access to safe, 45 million Kurds live in Kurdistan, an area that is spread Aaffordable surgical and anesthesia care; and of throughout the bordering states. Approximately 6.5 the 313 million procedures that are performed glob- to 7 million Kurds reside in northern Iraq (Kurdistan ally each year, only 6 percent are done in the poorest of Iraq), comprising about 17 percent of the popula- countries.1 These staggering statistics speak volumes tion of Iraq.4 The Kurds have their own culture and to the need for intensive capacity building in many language; very few self-identify as Arabs. In fact, their parts of the world. history demonstrated fierce resistance against Arab After decades of oppression, the people of Kurdistan, expansion in the sixth century. The Kurds may be the Republic of Iraq, have sought to build an independent largest ethnic group in the world that does not have nation—one with a self-sustaining health care system. its own nation. This article describes how several Fellows of the Ameri- In June 1992, Kurdistan formed its own parliament can College of Surgeons (ACS) provided care to the for the first time in its history. Members of parliament 34 | victims of the malevolent regime led by Saddam Hus- are freely elected, and the government has an appointed sein and assisted in the establishment of a sustainable cabinet and functions under a ratified regional consti- health care system. tution. From our multiple trips to Kurdistan, we have found the Kurds to be extremely gracious people. They were quick to embrace and thank the U.S. for liberat- Background on Kurdistan ing them from Saddam Hussein’s regime. The Republic of Iraq borders six countries in the Middle East—Jordan, Syria, Turkey, Iran, Kuwait, and Saudi Arabia. Iraq encompasses approximately 168,753 square Early trips to Kurdistan miles (437,072 square kilometers), which is three-fifths Dr. Zibari, a co-author of this article, was one of the the size of Texas. In 2015, the population was 36,575,000, fortunate Kurds who survived Mr. Hussein’s atrocities; making it the fourth-most populated country in the more than 50 percent of his high school classmates Middle East.2 were murdered during the Iraq/Iran war and the Iraqi/ Iraq’s current borders were drawn in 1920 under the Kurdish war. On May 1, 1976, Dr. Zibari immigrated to Treaty of Sèvres, which allowed the League of Nations the U.S. after graduating from high school in an Iraqi to partition the collapsed Ottoman Empire.3 For Iraq, Kurdish refugee camp in Kurdistan of Iran. the treaty had essentially amalgamated three different Like many other exiled Kurds, Dr. Zibari was forbid- groups of people—the Arab Shi’ites and Sunnis and the den from returning to Iraq, with a threat of immediate non-Arab Kurds—into one nation. A plethora of other execution by Mr. Hussein. However, after 16 years in minority groups, such as the Assyrians, Turks, and absentia and immediately after the first Gulf War, he Kurdish Yazidis, also inhabit the country. The Yazidi returned to his native land in June 1992 after complet- Kurds practice their ancient religion, Zoroastrianism, ing a solid abdominal organ transplant fellowship at and have been persecuted by the Islamic State in Iraq the Johns Hopkins University School of Medicine, Bal- and Syria (ISIS), also known as the Islamic State in Iraq timore, MD. His return was possible due to the no-fly and the Levant (ISIL), since June 2014. zone over Kurdistan, which the North Atlantic Treaty The Kurds are descendants of the Indo-European Organization (NATO) established to protect the mass tribes who resided in Iraq (Ararat Mountains of exodus of Kurdish refugees who had fled Mr. Hussein’s

V101 No 10 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

U.S. and Kurdish physicians at the Governor of Duhok’s guest house on Lake Duhok.

brutality following their uprising in northern Iraq, by Mr. Hussein at that time, had refused to pay sala- and the Shi’ite uprising in southern and central Iraq. ries to any employees who lived in the no-fly zone. Dr. Zibari’s initial visit to Kurdistan in 1992 was Compounding these adverse conditions, the a fact-finding mission. It was a historic time for the Kurds also had to endure a double embargo—one | 35 region, as 1992 represented the first year that the from the UN against Iraq and the other imposed by Kurds were allowed to vote freely and elect a Kurd- Mr. Hussein—which resulted in further isolating the ish Parliament. The parliament met for the first time Kurdish medical community. Despite these adver- in June 1992 under NATO and United Nations (UN) sities, the Kurdistan/Duhok medical community protection. At that time, Dr. Zibari visited the only approached the development of a revitalized health public hospital in Duhok, a city 50 miles from Mosul, care system with dedication, energy, and optimism. which, at present, is under ISIL control. The hospital, With the assistance of U.S. volunteers, they were Azadi Hospital of Duhok/Freedom Hospital, which able to make great strides in rebuilding their medi- had replaced Saddam Hussein Hospital, became the cal infrastructures. main center of Dr. Zibari’s humanitarian medical outreach program for nearly 25 years. As would be expected following decades of war, Building the foundation for future trips Dr. Zibari discovered that the Kurdish medical com- Most of the earlier trips to Kurdistan were spent meet- munity had a severe lack of resources and feeble ing and achieving buy-in from major stakeholders, system infrastructure. By his estimate, the Kurds’ such as the local health care leaders, the mayor of the medical system was at least two to three decades town, the Kurdish political leadership, and the Kurd- behind the American health care system. Exam- ish Regional Government (KRG). Dr. Zibari sought ples of the multiple challenges that needed to be advice from these parties, supported the founding addressed included filling empty pharmacy shelves; committee for the creation of Duhok Medical School, updating antiquated ultrasound and X-ray machines; and was instrumental in creating plans for the new supplementing the shortage of allied health care per- medical school. The governor of Duhok and the sonnel and physicians; establishing Internet service; prime minister of the Kurdish regional government replacing obsolete medical texts and journals; and donated a significant portion of land to the Azadi compensating for a dearth of medical, dental, nursing, Hospital of Duhok to build the medical school and and allied health schools. Furthermore, the central for future medical center expansion. Six years later, government in Baghdad, which was still maintained Dr. Zibari attended the first graduation ceremony for

OCT 2016 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

Post-perfusion of living-related renal transplantation.

the medical school in June 1998. These successes led to laparoscopy, HPB, and transplant. We treated a large the establishment of the University of Duhok, which number of cases that varied in complexity. Between now comprises 12 colleges. cases, the teams saw patients and performed pre- and 36 | Before each trip, we assembled a cadre of volun- postoperative evaluations. teers from different disciplines. This team included Like many regions of the developing world, patients general surgeons, ophthalmologists, surgical oncolo- would come to see us with folders containing their gists, transplant surgeons, hepato-pancreato-biliary medical records and images. Unlike U.S. health care (HPB) surgeons, laparoscopic surgeons, traumatolo- facilities, a centralized area dedicated to maintaining gists, otolaryngology–head and neck (ENT) surgeons, medical records does not exist in Kurdistan. Because neurosurgeons, emergency physicians, medical oncol- on some missions we did not have a particular spe- ogists, nephrologists, surgical residents and fellows, cialty surgeon with a certain area of expertise, we had and nurses. On each trip, we also organized an aca- to turn away some patients—specifically those with demic surgical symposium where each volunteer gave major orthopaedic and gynecologic disorders, as well a formal presentation on a specific topic lasting at least as other patients whose medical diseases exceeded our half an hour. We also invited local surgeons to speak on level of expertise. Even then, the patients were grateful a topic of their choice. One such presentation was titled that we had taken the time to see them. Many patients Review of Renal Transplantation at Azadi Hospital of had traveled on foot for days to come and see the “sur- Duhok and Abdominal Cocoon: A Cause of Intestinal geons from the U.S.” Obstruction. The symposium was well attended and After each exhausting day, we would head back to stimulated interesting discussion. our hotel to share a nice dinner with our Kurdish col- The total length of each trip to Kurdistan was a leagues. This was probably one of our favorite times little more than a week. The first day began with the because we all had a chance to unwind, get to know team arriving at the hospital and being greeted by hos- each other better, and share war stories. On each trip, pital administration and heads of the different medical our Kurdish colleagues would reserve a day for us to and surgical departments. A camera crew videotaped go sightseeing and visit Dr. Zibari’s brother, General this event and broadcast it to the people in Kurdistan. Babakir Zebari. After the introduction and discussion with the lead- On our more recent trips in 2014 and 2015, we visited ers of Duhok Hospital, the physicians split into three refugee camps to care for the people who had escaped groups: neurosurgery; trauma/emergency care, oto- ISIS’ atrocities. We employed the VSee system— laryngology, and ophthalmology; and general surgery, a Health Insurance Portability and Accountability

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| 37

Bottom left, from left: Dr. Chu, Dr. Zibari, and a pediatric surgeon from Erbil, Iraqi Kurdistan, care for a four-year-old child who required a right hepatectomy for liver cancer.

Act-compliant telehealth platform—to consult with could provide the support needed to launch a capacity- our colleagues in the U.S. building effort. For more than a decade, Dr. Zibari has consistently brought a dedicated and committed team of eight to 12 clinicians to assist with capacity building. Capacity building These teams have been cosponsored by the Americas- For many years, Dr. Zibari has spent his vacation months Hepato-Pancreato-Biliary Association (AHPBA), the traveling to Duhok to assist the medical community International Hepato-Pancreato-Biliary Association with capacity building. It was not until Mr. Hussein’s (IHPBA), Operation Hope, the World Surgical Founda- toppling that he felt comfortable enough traveling to tion (WSF), the American Kurdish Medical Group, the the country to solicit help from medical colleagues who Kurdish Regional Government, the Barzani Foundation,

OCT 2016 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

38 |

Dr. Zibari and Dr. Chu (left and right, respectively, upper left photo) operate on a young man with a painful extremity sarcoma that did not respond to neoadjuvant chemotherapy. He underwent a successful quarter amputation.

and other organizations. Through the years, the team June 2004. Today, an average of two renal transplants has been able to achieve a number of notable accomplish- are done weekly in Duhok, and four are done in Erbil. ments, including the following: • Trained local surgeons to perform complex neuro- • Developed the resources, personnel, and facilities needed surgical procedures such as craniotomy for temporal to offer basic and advanced laparoscopic operations. lobe tumor, resection of sphenoid wing meningioma, The first laparoscopic cholecystectomy was performed and spinal decompression/stabilization for traumatic in Duhok in 2005. Laparoscopic cholecystectomies fracture/dislocation. are performed more than 80 percent of the time over open cholecystectomies. Other advanced laparoscopic • Trained local surgeons to perform complex HPB and operations now include adrenalectomy, splenectomy, oncologic operations such as the Whipple procedure, nephrectomy, Nissen fundoplication, gastric sleeve resec- major liver resections (central hepatectomy, formal tion, and gynecologic procedures. lobectomy), radical cholecystectomy, esophagectomy, and gastrectomy with lymphadenectomy; and the team • Established a living-related renal transplantation pro- introduced them to modern technology and surgical gram. More than 1,500 renal transplantations have been devices such as the Ligasure, staplers, and modern lapa- performed since Dr. Zibari established the program in roscopic instruments.

V101 No 10 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

A man who presented with a locally advanced squamous cell carcinoma. He underwent a successful resection and adjacent tissue flaps.

• Supported the first medical journal in Duhok, Duhok surgical care to patients in underdeveloped countries, Medical Journal. including the following:

• Engaged surgeons in the global surgical commu- • Plan far in advance (at least nine months to a year). nity by assisting them with obtaining membership to professional organization such as the ACS and • Start with a fact-finding mission to assess patient needs AHPBA. to determine the specialties that are in greatest demand. | 39

• Established an annual Joint Operation Hope, AHPBA, • Have a reliable contact person at the host institution. and World Surgical Foundation Surgical Symposium to update the medical community on innovations • Travel with the support of a recognized health care out- and technologies. reach organization, such as the ACS Operation Giving Back Program, AHPBA, Operation Hope, or World Sur- • Established a trauma team—composed of trauma sur- gical Operation. geons, critical care clinicians, a neurosurgeon, and an emergency medicine clinician—who taught the • Do your homework, and contact the state department local surgeons prehospital patient care, mass casualty and the embassy. Make sure to inform the U.S. embassy triage, and management of patients exposed to chemi- once you arrive at your destination. cal weapons. • Obtain adequate vaccinations and go to the state depart- At present, efforts are under way to establish tele- ment Web page to learn more about the host country. medicine and tele-fellowship programs. The purpose of this endeavor is to train clinicians to use telemedicine • Obtain medical/airlift insurance in case of an emergency as a means to remotely evaluate patients. A memoran- medical evacuation. dum of understanding was signed between the Duhok University president, the director of the health system • Learn as much as possible about the culture and cus- of Duhok, and the surgical team. toms of the country where you will be providing care. The last thing you want to do is to offend the patients whom you are trying to help. Lessons learned through the decades In the course of our efforts in Kurdistan, we have • Ship supplies ahead of your scheduled arrival, and make learned several lessons that may be of value to other sure a contact person in the host country can verify that health care professionals interested in providing necessary equipment clears customs and is available for

OCT 2016 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

With proper help, time, dedication, and, most importantly, good intentions and perseverance, health care providers can help build advanced surgical programs, such as renal transplantation, advanced laparoscopy, HPB surgery, and esophageal surgery, in a developing nation.

VOLUNTEER HEALTH CARE PROFESSIONALS use. Carry any must-have devices (such as reuse- able instruments, Bovie devices, and retractors) The following health care volunteers have donated their talents to bringing surgical care to the people of Kurdistan: and keep a list of supplies/equipment to bring on subsequent trips. • Patricia Arledge, MD • P. Kirk Labor, MD, FACS Plastic surgery Ophthalmology Lubbock, TX Grapevine, TX • Know the host institution’s infrastructure and • Gene Bolles, MD • Thomas R. McCune, MD resource capacity before tackling big cases. Neurosurgery Colonel, U.S. Military Boulder, CO Transplant nephrologist • Start with straightforward, low-risk cases ini- • Christine Butts, MD • Michael Moore, MD tially to build confidence and trust among your Emergency medicine Hematology hosts. Houma, LA Shreveport • Horacio D’Agostino, MD • Lisa Moreno-Walton, MD • Seek help and advice from local government, as 40 | Interventional radiologist Emergency medicine well as from the health care system leadership. Shreveport, LA New Orleans, LA • Bill Day, MD, FACS • Ashor Odisho • Empower the local medical team, and get its General surgeon Family medicine members involved from the start. This effort Florence, OR Shreveport, LA will ensure the establishment of great relations • Marc Dean, MD • Chris Porter, MD with your counterpart health care community. Otolaryngology General surgeon Fort Worth, TX Phoenix, AZ • Prepare to revisit the same destination multiple • Blaine Enderson, MD, FACS • Lou Smith, MD, FACS times to have a meaningful impact on capacity Critical care surgery Trauma/critical care Knoxville, TN Knoxville building. • Shawn Gibbs, PA • Byron Turkett, PA • Be ready to improvise. The host country may Orem, UT Trauma/critical care Knoxville not have all of the equipment and support to • Bharat Guthikonda, MD which you have grown accustomed in the U.S. Neurosurgery • John Thomas, MD, FACS Shreveport Minimally invasive surgery Lubbock • If possible, arrange for a host surgeon to visit • Jamal J. Hoballah, MD, FACS Vascular • Susan Shattuck, MD, FACOG your medical center, so he or she can see how Beirut, Lebanon Obstetrics/gynecology surgery is practiced in the U.S. Shreveport • Monirul Islam, MD Critical care medicine • Deborah Ross • Help host surgeons become members of U.S. Danville, PA Operating room nurse surgical societies. supervisor • Andrew J. Kosmowski, MD Shreveport Colonel, U.S. Military • Plan at least a day for an academic symposium Emergency medicine during your visit.

• Encourage host physicians to publish clinical papers and assist them in establishing their own

V101 No 10 BULLETIN American College of Surgeons OUTREACH IN KURDISTAN, IRAQ

Syrian refugee camp in Kurdistan (photos courtesy of VSee).

surgical journal if one is not available, so they can better share their REFERENCES research and best practices. 1. Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030: Evidence and solutions for achieving health, welfare, | 41 Conclusion and economic development. Lancet. With proper help, time, dedication, and, most importantly, good 2016;386(9993):569-624. 2. Wikipedia. List of Middle East countries by intentions and perseverance, health care providers can help build population. Available at: en.wikipedia.org/ advanced surgical programs, such as renal transplantation, advanced wiki/List_of_Middle_East_countries_by_ laparoscopy, HPB surgery, and esophageal surgery, in a developing population. Accessed April 5, 2016. nation. It is important to keep in mind that the care of the patients 3. Lawrence Q. Invisible Nation. How the of the host country should be no different than that in the U.S. It is Kurds’ Quest for Statehood Is Shaping Iraq and the Middle East. New York, NY: Walker & advisable to provide care only for those cases with which the surgeon Company, 2008. is comfortable, and it is also important to ensure that patients can be 4. Izady MR. The Kurds: A Concise History and cared for by the local clinicians when a surgical team, like the one Fact Book. New York, NY: Taylor & Francis; described in this article, has departed the country. The work that we 1992. have accomplished in Kurdistan is a testament of the effective and meaningful effect that can be achieved through collaboration with major stakeholders. ♦

Acknowledgements The authors would like to acknowledge the AHPBA and its Foundation, IHPBA, Operation Hope, the World Surgical Foundation, the Kurdish Regional Government, Willis-Knighton Medical Center, Louisiana State University Health Sciences Center-Shreveport, Vsee, Eye Consultants of Texas, and our countless host colleagues. We also want to acknowledge the assistance and support of the following individuals: the late U.S. Army Lieu- tenant Colonel Mark Weber; Roger Lindley, cinematographer and director; and Nicolas Thompson; Thai LaGraff; Monirul Islam, MD; Yvette Sanchez; Beverly Wright; and Shelly Humphrey, who provided technical assistance.

OCT 2016 BULLETIN American College of Surgeons STATEMENT

Statement on distractions in the operating room

This statement was developed by the American College of Surgeons (ACS) Committee on Perioperative Care and approved by the ACS Board of Regents at its June 2016 meeting.

here are many opportunities for distraction in the a structured communication protocol should be Toperating room (OR). Some can be attributed to implemented to reduce the risk of distraction and mis- the introduction of new technology, such as smart- communication. The identification of critical phases phone and mobile technology, and some are a func- of surgery has been shown not only to reduce mis- tion of noise levels, unnecessary conversation, and communication and distraction, but also operating other variables that dilute the focus of perioperative time and costs.5 team members because their attention is drawn “to… different object[s] or different directions at the same time.”1,2 Because of the deleterious effects of distrac- Distractions arising from technology tion on cognitive processing and the performance of Newer technologies, including smartphones and complex tasks and because of the potential impact of other handheld electronic devices, have become ubiq- distraction on patient safety, it is important to recog- uitous. In many hospitals, they have been integrated nize and mitigate the risks of distraction in the OR. into routine hospital communications and serve as 42 | Distraction can result from both intrinsic sources, access points to patient data and images. As useful including alarms, noise from surgical devices, shift and as important as they may be when used correctly, changes, and necessary communications, as well as the undisciplined use of these devices may enhance extrinsic sources such as cell phones, beepers, comput- distractions such as social media, e-mail, and other ers and personal electronic devices, calls from outside forms of electronic communication for health care the OR, communication that is not relevant to the personnel. case, visitors, and traffic in and throughout the OR. As a practical matter, many surgeons have come All members of the surgical team may be affected. to rely on digital devices, including smartphones, The surgical checklist was developed as an anal- for voice and data communication outside the office. ogy to flight crew checklists, which is a series of Some institutions have established restrictive policies procedures performed preliminary to takeoff that are regarding the use of digital devices whereas others intended to ensure safety during flight operations. have not. By extension, the concept of the “sterile cockpit” has Therefore the ACS recommends that the use of been introduced to describe protocols intended to smartphones in the OR be guided by the following limit distraction during critical periods in the OR. The considerations: sterile cockpit protocol is designed to limit activities that might “distract any flight crew member from • The undisciplined use of smartphones in the OR— the performance of his or her duties or which could whether for voice, e-mail, or data communication, interfere in any way with the proper conduct of those and whether by the surgeon or by other members of duties.”3,4 One important difference between the OR the surgical team—may pose a distraction and may and the cockpit, however, lies in the timing of criti- compromise patient care. cal events. They are much more tightly concentrated during flight. In the OR, critical events can and do • Surgeons should be considerate of the duties of person- occur throughout the operation. nel in the OR suite and refrain from engaging them When the timing of critical events, such as the unnecessarily in activities, including assistance in cel- clipping of an intracranial aneurysm or the initia- lular communication, that might divert attention from tion of a cardiopulmonary bypass, can be predicted, the patient or the conduct of the procedure.

V101 No 10 BULLETIN American College of Surgeons STATEMENT

The surgical checklist was developed as an analogy to flight crew checklists.... One important difference between the OR and the cockpit, however, lies in the timing of critical events. They are much more tightly concentrated during flight. In the OR, critical events can and do occur throughout the operation.

• Smartphones must not interfere with patient moni- government regulations pertaining to patient privacy toring devices or with other technologies required and confidentiality. for patient care.

• Whenever possible, members of the OR team, includ- Distractions due to noise ing the operating surgeon, should only engage in There are many sources of noise in the OR. Some, like urgent or emergent outside communication during music, may be relaxing or distracting, depending on an operation. Personal and routine calls should be the circumstances. minimized. All phone calls should be kept as brief Critical alarms are distracting but crucial. They as possible. are meant to focus attention, rather than to distract attention, even though they do both. False alarms • Whenever possible, incoming calls should be for- are problematic.6 The reduction of harm associated warded to the OR desk or to the hardwired telephone with clinical alarms was identified as a 2014 National in the OR to minimize the potential distraction of Patient Safety Goal by The Joint Commission.7 The | 43 smartphones. introduction of “smart alarms,” which are individual- ized to each patient’s needs, has been recommended • Whenever possible, incoming calls and data transmis- as one solution.8 sions should be forwarded to voice mail or to memory. Surgical equipment noise, noise from visitors enter- The ring tone should be silenced. An inaudible signal ing the OR from corridors, and noise transmitted may be employed. into the OR from other areas may be more difficult to control. The problem of transmitted noise is an • Whenever possible, a distinct signal for urgent or architecture-based issue and must be addressed when emergent calls should be enabled. This signal may be ORs are designed and maintained. Surgical equipment implemented via a “page” option in most smartphones. noise cannot be controlled easily once a piece of equip- Callers should be advised to use this function only for ment has been installed but should be a consideration urgent and emergent calls if the phone is unanswered. when equipment is selected. Therefore the ACS recommends the following pro- • The use of electronic and mobile devices or their tocols to reduce noise: accessories (such as earphones or keyboards) must not compromise the integrity of the sterile field. Special • Surgeons should be sensitive to all members of the OR care should be taken to avoid sensitive communica- team when selecting the music played during an opera- tion within the hearing of awake or sedated patients. tion (volume, genre, lyrics).

• Communication using hardwired phones in the OR is • Tools to assist in establishing alarm safety protocols are subject to the same discipline as communication using widely available and should be implemented institution- electronic device technology. wide, not just in the OR or perioperative areas.9

• The use of electronic mobile devices to take and • Traffic in and out of the OR should be controlled both transmit photographs should be governed by hos- because of the potential for distraction and for pur- pital policy on photography of patients and by poses of infection control.

OCT 2016 BULLETIN American College of Surgeons STATEMENT

The importance of designing health care facilities to reduce transmitted noise into the OR should be emphasized when facilities are being conceived and maintained.

• Reduced surgical equipment noise should be REFERENCES conveyed as a critical design factor to surgical 1. Feil M. Distractions in the operating room. Patient Safety instrument and device manufacturers. Advisory. June 2014. Available at: patientsafetyauthority.org/ ADVISORIES/AdvisoryLibrary/2014/jun;11(2)/Pages/45.aspx. Accessed August 15, 2016. Conclusion 2. Magrabi F, Li SY, Dunn AG, et al. Challenges in measuring the impact of interruption on patient safety and workflow outcomes. The risks of distraction in the OR and the tools to Methods Inf Med. 2011;50(5):447-453. overcome distraction should be incorporated in 3. Sumwalt R. Sterile cockpit rules: FAR 121.542/FAR 135.100. training programs for surgeons and for periopera- National Aeronautics and Space Administration. ASRS Directline. tive personnel. The importance of designing health Available at: asrs.arc.nasa.gov/publications/directline/dl4_ care facilities to reduce transmitted noise into the sterile.htm#anchor524636. Accessed August 15, 2016. 4. U.S. Department of Transportation. Federal Aviation OR should be emphasized when facilities are being Administration. Cockpit distractions. April 26, 2010. Available at: conceived and maintained. Noise levels should be www.faa.gov/other_visit/aviation_industry/airline_operators/ 44 | considered when surgical and anesthetic devices airline_safety/info/all_infos/media/2010/InFO10003.pdf. and instrumentation are selected. ♦ Accessed August 15, 2016. 5. Lee BT, Tobias AM, Yeuh JH, et al. Design and impact of an intraoperative pathway: A new operating room model for team- based practice. J Am Coll Surg. 2008;207(6):865-873. Disclaimer 6. Wyatt RM. The Joint Commission. The alarming world. The The ACS offers this statement for consideration by sur- Leadership Blog. July 17, 2013. Available at: www.jointcommission. geons, their hospitals, and health care organizations. org/jc_physician_blog/the_alarming_world/. Accessed August This statement is provided as general guidance. It does 15, 2016. 7. The Joint Commission. The R3 report: Requirement, rational, not constitute a standard of care and is not intended reference: Alarm system safety. December 11, 2013. Available at: to replace the professional judgment of the surgeon or www.jointcommission.org/r3_report_issue5/. Accessed August health care administrator. The statement may be re- 15, 2016. viewed and modified as necessary to conform with the 8. Agency for Healthcare Research and Quality. Alarm safety laws of the applicable jurisdiction, the circumstances resource site. Available at: innovations.ahrq.gov/qualitytools/ alarm-safety-resource-site. Accessed August 15, 2016. of the individual hospital and health care organiza- 9. The Joint Commission. Sound the alarm: Managing physiologic tion, and requirements of other allied health care or- monitoring systems. The Joint Commission Perspectives on Patient ganizations. Safety. December 2011. Available at: www.jointcommission.org/ assets/1/6/perspectives_alarm.pdf. Accessed August 15, 2016.

V101 No 10 BULLETIN American College of Surgeons STATEMENT

Statement on documentation and reporting of accidental punctures and lacerations during surgery

The following statement was developed by the American College of Surgeons (ACS) Committee on Perioperative Care and approved by the ACS Board of Regents at its June 2016 meeting.

he Agency for Healthcare Research and Quality Revision, Clinical Modification (ICD-10-CM) codes T(AHRQ) patient safety indicator (PSI) for acci- that are covered under PSI #15.* Determination should dental puncture or laceration (PSI #15) is a quality be based upon the nature of the operative field and measure that reports the rate of inadvertent cuts, operation performed. punctures, perforations, and lacerations to a patient during a procedure. This quality measure is intend- • Although an injury, tear, or repair that was reason- ed to capture a patient injury that was entirely un- ably necessary to perform an operation may not meet intended and caused by medical management rather the criteria for PSI #15, surgeons should document all than by the underlying disease or condition of the intraoperative events. The College encourages sur- | 45 patient. These injuries have adverse consequences geons to carefully word operative reports to make it for patients and are often preventable. Although the clear whether a puncture or incision is accidental or indicator has been externally validated, it has been expected. shown to be less predictive of injuries that could be considered clinically important. As a provider-lev- • Regardless of whether codes that are covered under el measure, it is important that surgeons as well as PSI #15 are used, the surgeon should document whether hospital and office coding staff understand how to the tear or laceration was significant, whether it required correctly report this quality measure. repair, and whether it affected patient care or the patient’s Therefore the ACS recommends the following course of treatment or recovery. Documentation in the guidelines for documenting and reporting accidental operative report of tears and lacerations should contain punctures and lacerations: clear, detailed, and specific terminology to communi- cate the circumstances under which the injury occurred, • By definition, PSI #15 is limited to accidental punctures including the following: and lacerations that are not intrinsic or inherent to a major procedure. Punctures or lacerations that occur ȖȖ A description of the consequences of the laceration in surgical procedures often are incorrectly coded as or injury “accidental” when the puncture or laceration was, in fact, a natural consequence or part of the operation. ȖȖDocumentation of increased operating time and Injuries inherent to a procedure or that are unavoid- changes to the intended procedure(s) able due to the structure of the patient’s anatomy or underlying disease process should not be coded with ȖȖDocumentation of potential increased length of the International Classification of Diseases, Tenth stay due to the complication

*To view a complete list of codes encompassing PSI #15 under ICD-10, ȖȖIf an injury was present prior to an operation, that go to www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50- ICD10/TechSpecs/PSI%2025%20Accidental%20Puncture%20or%20 information should be clearly stated in the medi- Laceration%20Rate.pdf. cal record

OCT 2016 BULLETIN American College of Surgeons STATEMENT

This quality measure is intended to capture a patient injury that was entirely unintended and caused by medical management rather than by the underlying disease or condition of the patient. These injuries have adverse consequences for patients, and are often preventable.

• Surgeons should be available to coding professionals for BIBLIOGRAPHY clarification of the medical record. If the postoperative doc- Agency for Healthcare Research and Quality. umentation conflicts with the procedure report, the attending Patient safety indicators: PSI #15, Accidental surgeon who performed the procedure must be queried for puncture or laceration. Available at: www. clarification. Accurate coding is ultimately the responsibility qualityindicators.ahrq.gov/Downloads/Modules/ PSI/V41/TechSpecs/PSI%2015%20Accidental%20 of the surgeon of record. Puncture%20or%20Laceration.pdf. Accessed September 13, 2016. • ICD-10-CM has 21 codes indicating accidental puncture and Agency for Healthcare Research and Quality. laceration specifying organ or body system and will require AHRQ quality indicators toolkit. Available at: increased levels of documentation. As such, surgeons are www.ahrq.gov/sites/default/files/wysiwyg/ professionals/systems/hospital/qitoolkit/b4- strongly encouraged to work with hospital staff to ensure documentationcoding.pdf. Accessed August 30, proper documentation and coding. 2016. 46 | Barney L, Mabry C, Ollapally V, Savarise M, Senkowski • Educating surgeons and others to code accurately will result C. Reporting patient safety indicator-15. Bull Am in improved accuracy and enhanced value of this important Coll Surg. 2014;99(5):39-42. Available at: bulletin.facs. org/2014/05/reporting-patient-safety-indicator-15/. quality measure. It is highly recommended that coding of Accessed September 13, 2016. this measure by institutions be done in consultation with Centers for Disease Control and Prevention. National the primary surgeon to ensure accurate documentation. ♦ Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification. Available at: www.cdc.gov/nchs/icd/ icd9cm.htm. Accessed September 13, 2016. Disclaimer Centers for Medicare & Medicaid Services. Medicare The ACS offers this statement for consideration by surgeons, program; Hospital inpatient prospective payment their hospitals, and health care organizations. This statement is systems for acute care hospitals and the long provided as general guidance. It does not constitute a standard of term care; Hospital prospective payment system care and is not intended to replace the professional judgment of and fiscal year 2014 rates; Quality reporting requirements for specific providers; Hospital the surgeon or health care administrator. The statement may be conditions of participation; Payment policies reviewed and modified as necessary to conform with the laws of related to patient status; Final rule. Federal Register. the applicable jurisdiction, the circumstances of the individual Available at: www.gpo.gov/fdsys/pkg/FR-2013- hospital and health care organization, and requirements of other 08-19/pdf/2013-18956.pdf. Accessed September 13, allied and health care organizations. 2016.

V101 No 10 BULLETIN American College of Surgeons STATEMENT

Statement on operating room attire

The following statement was developed by an American College of Surgeons (ACS) task force on operating room (OR) attire and approved by the ACS Board of Regents in July 2016.

he values of the ACS include professionalism, ex- the nape of the neck, or modest sideburns uncovered Tcellence, inclusion, innovation, and introspec- contributes to wound infections. tion. Appropriate attire is a reflection of professional- ism and is integral to establishing and maintaining a • Earrings and other jewelry worn on the head or neck patient-physician rapport based on trust and respect. where they might fall into or contaminate the sterile In addition, insofar as clean and properly worn attire field should all be removed or appropriately covered may decrease the incidence of health care-associated during procedures. infections, it also speaks to a desire and drive for ex- cellence in clinical outcomes and a commitment to • The ACS encourages clean, appropriate, professional patient safety. attire (not scrubs) to be worn during all patient encoun- The ACS guidelines for appropriate attire are based ters outside of the OR. on professionalism, common sense, decorum, and the available evidence on this topic. Specific guidelines are The skull cap is symbolic of the surgical profession. as follows: The skull cap may be worn when close to the total- | 47 ity of hair is covered by it and when only a limited • Soiled scrubs and hats should be changed as soon as fea- amount of hair on the nape of the neck or modest side- sible, particularly before speaking with family members burns remains uncovered. Like OR scrubs, cloth skull after a surgical procedure. caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every • Scrubs and hats worn during dirty or contaminated cases dirty or contaminated case. Religious beliefs regarding should be changed prior to subsequent cases, even if not head wear should be respected without compromising visibly soiled. patient safety. Many different health care providers (surgeons, • Masks should not be allowed to hang or dangle around anesthesiologists, certified registered nurse anesthe- the neck at any time. tists, laboratory technicians, aides, and so on) wear scrubs in the OR setting. The ACS strongly suggests • OR scrubs should not be worn in the hospital facility that scrubs should not be worn outside the perimeter outside of the OR area without a clean lab coat or appro- of the hospital by any health care provider. To facili- priate cover-up worn over them. tate enforcement of this guideline, the ACS suggests the adoption of distinctive, colored scrub suits for OR • OR scrubs should not be worn at any time outside of the personnel. hospital perimeter. The ACS emphasizes patient safety and quality of care and prides itself on leadership in an ever-changing • OR scrubs should be changed at least daily. and increasingly complex health care environment. As stewards of our profession, we must retain an empha- • During invasive procedures, the mouth, nose, and hair sis on key principles of our culture, including proper (skull and face) should be covered to avoid potential attire, since attention to what we wear inside and out- wound contamination. Large sideburns and ponytails side the OR helps to uphold the public’s perception of should be covered or contained. There is no evidence surgeons as highly trustworthy, attentive, professional, to suggest that leaving ears, a limited amount of hair at and compassionate. ♦

OCT 2016 BULLETIN American College of Surgeons STATEMENT

Revised statement on health care industry representatives in the operating room

The following statement was revised by the American College of Surgeons (ACS) Committee on Perioperative Care and was reviewed and approved by the ACS Board of Regents at its June 2016 meeting.

he ACS recognizes the need for a structured sys- • Facility requirements and procedures for manufac- Ttem within the perioperative setting to allow turers’ representatives to be present in the OR are as for education, training, and introduction of proce- follows: dures, techniques, technology, and equipment to the surgical health care team. Health care industry ȖȖThe institution should designate an authority for representatives (HCIR), by virtue of their training, approving an HCIR’s presence in the OR. A time knowledge, and expertise, often can provide techni- frame for securing this approval should be estab- cal assistance to the surgical team. Such assistance lished. Among other responsibilities, the authority may expedite the procedure and may facilitate the should do the following: safe and effective application of surgical products and technologies. ƑƑ Implement measures to ensure that the The purpose of this statement is to supply health of the HCIR is comparable to that of guidelines to health care facilities and members other personnel in the institution who are in 48 | of the perioperative care team to ensure optimal contact with patients and should apply the surgical outcomes, to ensure patient safety, and same standards for assessing the health status to protect patients’ rights to privacy and confiden- of the HCIR as they do other personnel. tiality when an HCIR is present during a surgical procedure. ƑƑ Establish a time limit and appropriate Therefore the ACS recommends the following: identification (to be worn at all times) for the HCIR.

Institutional policies ƑƑ Ensure orientation to the facility is provided. Surgical department administrators in all facili- ties, including the acute care hospital, ambulatory ƑƑ Verify the education and training of surgery facility, and office-based operating room the HCIR in the following areas: (OR) settings should be aware of all relevant insti- tutional policies and incorporate them into specific Health Insurance Portability and written policies governing the presence of HCIRs Accountability Act (HIPAA) compliance in the OR. and all other matters related to These policies should define the requirements patients’ rights and confidentiality and procedures for manufacturer representatives to be present in the OR and the role and limitations of Appropriate conduct and attire the HCIR in the perioperative setting. in the OR environment These policies should comply with applicable state laws and regulations and be consistent with Aseptic principles and sterile technique the institution’s existing policies, those promulgated by the OR, and those established by credentialing Infectious disease and blood-borne pathogens and privileging committees. Institutional policies should include but not be Occupational safety standards for limited to the following elements: biohazardous waste, fire risk and

V101 No 10 BULLETIN American College of Surgeons STATEMENT

The purpose of this statement is to supply guidelines to health care facilities and members of the perioperative care team to ensure optimal surgical outcomes, to ensure patient safety, and to protect patients’ rights to privacy and confidentiality when an HCIR is present during a surgical procedure.

prevention, electrical safety, radiation, laser technology) to the surgeons’ and manufacturers’ and other safety protocols specifications

All other applicable practices that • Should have his or her activities monitored and sup- may be related to the operation ported by the surgeon or at the surgeon’s discretion by the perioperative nurse responsible for the patient’s care ȖȖThe presence of the HCIR is at the discretion of the operating surgeon. The HCIR should be A clearly defined institutional mechanism should introduced to the entire OR team and the purpose exist to address any departures from these established of the visit should be explained. The surgeon may policies. ♦ initiate the request. If not, the surgeon should be notified and approve the visit in advance of the operation. Disclaimer The ACS offers this statement for consideration by surgeons, | 49 ȖȖThe patient should be informed of the presence their hospitals, and health care organizations. This state- and purpose of the HCIR in the OR and consent ment is provided as general guidance. It does not constitute in accordance with institutional policy and state a standard of care and is not intended to replace the profes- law. Documentation should also be provided in sional judgment of the surgeon or health care administrator. accordance with institutional policy and state law. This statement may be reviewed and modified as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the individual hospital and health care Roles and limitations of the HCIR in the OR: organization, and the requirements of other allied and health The HCIR is present as an advisor to the perioperative care organizations. team. The presence of the HCIR in the OR cannot sub- stitute for preoperative training of the surgical team. The surgical team should have received training and demonstrated competence in the application of surgi- cal devices and technologies used in the OR before the procedure. The HCIR serves as an educator and facilitator. In this role, the HCIR:

• Should not engage in the practice of surgery, nursing, or medical decision making

• Should not scrub in or be involved in direct patient contact

• May be involved in the remote calibration or adjust- ment of medical devices (for example, pacemakers,

OCT 2016 BULLETIN American College of Surgeons STATEMENT

Revised statement on the prevention of unintentionally retained surgical items after surgery

The following statement was revised by the American College of Surgeons (ACS) Committee on Perioperative Care and was reviewed and approved by the ACS Board of Regents at its June 2016 meeting.

he ACS recognizes patient safety as an issue of ȖȖMaintenance of an optimal OR environment to Tthe highest priority and strongly urges individ- allow focused performance of operative tasks ual hospitals and health care organizations to take all reasonable measures to prevent the unintended ȖȖUse of X ray or other technology (such as retention of surgical items in the surgical wound. radiofrequency detection and bar coding) as Surgical procedures take place within a system indicated to ensure that no unintended item of perioperative care composed of surgeons, periop- remains in the operative field erative registered nurses, surgical technologists, and 50 | anesthesia professionals. These health care providers ȖȖSuspension of these measures may be necessary in share a common ethical, legal, and moral responsi- certain life-threatening situations bility to promote an optimal patient outcome. Prevention of unintentionally retained surgical • Documentation should include, but not be limited to, items after surgery requires good communication results of surgical item counts, notification of the surgi- among perioperative personnel and the consistent cal team members, instruments or items intentionally application of reliable and standardized processes left as packing, and actions taken if count discrepan- of care. cies occur. Therefore the ACS recommends the following guidelines that can be adapted to various practice • Surgical facilities must provide resources to ensure that settings, including traditional operating rooms (OR), necessary equipment and personnel are available to ambulatory surgery centers, surgeons’ offices, and support these perioperative surgical safety measures. other areas where operative and invasive procedures are performed: • Policies and procedures for the prevention of retained foreign bodies should be developed, reviewed periodi- • Recommendations to prevent the retention of sponges, cally, revised as necessary, and available in the practice sharps, instruments, and other designated miscella- setting. neous items include: • Disclosure of the event to patients and family members ȖȖConsistent application and adherence to should follow the institution’s adverse event policy. standardized counting procedures The ACS also endorses the National Quality ȖȖPerformance of a methodical wound exploration Forum’s definition of “end of surgery” as the moment before closure of the surgical site “…after all incisions or procedural access routes have been closed in their entirety, device(s) such as probes ȖȖUse of X ray-detectable items in the surgical or instruments have been removed, and, if relevant, wound final surgical counts confirming accuracy of counts

V101 No 10 BULLETIN American College of Surgeons STATEMENT

Prevention of unintentionally retained surgical items after surgery requires good communication among perioperative personnel and the consistent application of reliable and standardized processes of care.

and resolving any discrepancies have concluded and the BIBLIOGRAPHY patient has been taken from the operating/procedure Cima RR, Kollengode A, Storsveen AS, et al. A room,” where applicable. ♦ multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf. 2009;35(3):123-132. National Quality Forum. Serious Reportable Events in Healthcare–2011 Update: A Consensus Report. Disclaimer Washington, DC. Available at: www.qualityforum. The ACS offers this statement for consideration by surgeons, org/Publications/2011/12/SRE_2011_Final_Report. their hospitals, and health care organizations. This statement is aspx. Accessed August 15, 2016. provided as general guidance. It does not constitute a standard Recommended practices for prevention of retained of care and is not intended to replace the professional judgment surgical items. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; of the surgeon or health care administrator. This statement 2013:305-321. may be reviewed and modified as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the | 51 individual hospital and health care organization, and require- ments of other allied and health care organizations.

OCT 2016 BULLETIN American College of Surgeons STATEMENT

Revised statement on safe surgery checklists, and ensuring correct patient, correct site, and correct procedure surgery

The following statement was revised by the American College of Surgeons (ACS) Committee on Perioperative Care and the revision was reviewed and approved by the ACS Board of Regents at its June 2016 meeting.

he ACS recognizes patient safety as an item of BIBLIOGRAPHY Tthe highest priority and strongly urges individu- The Joint Commission. Universal protocol for preventing al hospitals and health care organizations to develop wrong site, wrong procedure and wrong person surgery. guidelines and checklists to ensure correct patient, Available at: www.jointcommission.org/standards_ information/up.aspx Accessed August 8, 2016. correct site, and correct procedure surgery. World Health Organization. WHO Safe Surgery Checklist. Therefore, the ACS recommends the following Available at: www.who.int/patientsafety/safesurgery/ guidelines to eliminate wrong site surgery: ss_checklist/en/. Accessed August 8, 2016.

• Verify that the correct patient is taken to the operat- 52 | ing room (OR). This verification can be made with the • Conduct a briefing prior to administering anesthesia and patient or the patient’s designated representative if the call for a final time out before skin incision. These two patient is underage or unable to answer for him/herself. steps should include verification with members of the surgical team to confirm the correct patient, site, and • Verify that the correct procedure is on the OR schedule. procedure. If any verification process fails to confirm the correct site, all activities should be halted until verifica- • Verify with the patient or the patient’s designated repre- tion is confirmed to be accurate by the surgeon and team. sentative the procedure that is expected to be performed, as well as the anatomic location of the procedure. • Conduct a debriefing prior to the patient leaving the OR; the debriefing should include verbal discussion of • Confirm the submission of a consent form with the sponge and needle counts. patient or the patient’s designated representative. • In the event of an emergency, these steps may be modi- • In the case of a bilateral organ, limb, or anatomic site fied according to local hospital guidelines. ♦ (for example, hernia location of melanoma), the surgeon and patient should be in agreement and the operating surgeon should mark the site before giving the patient Disclaimer narcotics, sedatives, or anesthesia. For spine cases, level The ACS offers this statement for consideration by sur- should be verified. geons, their hospitals, and health care organizations. This statement is provided as general guidance. It does not con- • If the patient is scheduled for multiple procedures that stitute a standard of care and is not intended to replace the will be performed by multiple surgeons, all the items professional judgment of the surgeon or health care ad- on the surgical checklist must be verified for each ministrator. This statement may be reviewed and modi- procedure. fied as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the individual hospital • Ensure that all relevant records, imaging studies, equip- and health care organization, and requirements of other ment, and implants are available as needed. allied and health care organizations.

V101 No 10 BULLETIN American College of Surgeons STATEMENT

Revised statement on sharps safety

The following statement was revised by the American College of Surgeons (ACS) Committee on Perioperative Care and was reviewed and approved by the ACS Board of Regents at its June 2016 meeting.

harps injuries and surgical glove tears continue OR work practices Sto expose surgeons and operating room (OR) Glove barrier failure is common, with reported perfo- personnel to the risk of infection. Patients’ blood ration rates as high as 61 percent for surgeons and 40 makes contact with the skin or mucous mem- percent for scrub personnel. Double gloving reduces branes of OR personnel in as many as 50 percent the risk of exposure to patient blood by as much as 87 of operations, with cuts or needlesticks occur- percent when the outer glove is punctured. However, ring in as many as 15 percent of operations. Sur- double gloving has certain disadvantages, such as geons and first assistants are at highest risk for in- decreased tactile sensation. In certain types of oper- jury, sustaining up to 59 percent of the injuries in ations (such as neurosurgery procedures), where the OR. Scrub personnel have the second highest delicate manipulation of instruments and tissues is frequency of injuries in the OR (19 percent), fol- required, double gloving may impair the surgeon’s lowed by anesthesiologists (6 percent), and circu- ability to optimally perform the procedures. Despite a lating nurses (6 percent). Of the estimated 384,000 large body of data documenting the benefits of double needlestick injuries that occur in hospitals each gloving, this technique has not received wide accep- | 53 year, 23 percent occur in surgical settings. tance among surgeons. In many cases, a period of Published literature indicates that while needle- adaptation and “retraining” appears to be necessary stick injury rates have been decreasing among before practitioners feel comfortable with the tech- nonsurgical health care providers, they have not nique. Specially designed undergloves are available declined among health care professionals who work to make the process of double gloving more accept- in surgical settings. According to a 2010 article able to surgeons. published in the Journal of the American College of Sur- Therefore the ACS recommends: geons and citing data from a 1998 study, more than half of needlestick injuries involving suture nee- • The universal adoption of the double glove (or under- dles occur during the suturing of fascia or muscle. glove) technique to reduce exposure to body fluids For surgeons, suture needles are the most frequent resulting from glove tears and sharps injuries. In cer- source of sharps injuries. tain delicate operations, and in situations where it may The ACS supports work practices that are compromise the safe conduct of the operation or safety designed to eliminate, protect, or standardize the of the patient, the surgeon may decide to forgo this use of sharp instruments in the OR. The ACS also safety measure. recommends the use of structured evaluations and user-based criteria that include performance standards, task analysis, simulation, and training Blunt tip suture needles programs for devices intended to reduce sharps inju- Suture needle injuries pose the greatest risk of sharps ries in the OR. injury to the surgeon and scrub personnel. The effec- A team approach is critical to reduce the risk of tiveness of the use of blunt-tip suture needles in blood-borne infections resulting from sharps inju- reducing sharps injuries is supported by a number of ries in the OR. Hospitals and health care facilities randomized studies and case series that demonstrate a should make sharps injury reduction techniques decrease in the rate of glove puncture from 38 percent and instruments available to surgeons and OR down to 6 percent—and down to zero in some cases— personnel. following the adoption of blunt-tip suture needles.

OCT 2016 BULLETIN American College of Surgeons STATEMENT

ADDITIONAL RESOURCES • Food and Drug Administration, • International Sharps Injury • Davis MS. Advanced Precautions National Institute for Prevention Society: Education, for Today’s O.R. In: The Occupational Safety and Health, information and product Operating Room Professional’s and Occupational Safety and knowledge to help reduce Handbook for the Prevention Health Administration Joint the number of sharps of Sharps Injuries and Safety Communication. Blunt- injuries. www.isips.org Bloodborne Pathogen Exposures. Tip Surgical Suture Needles • International Healthcare Worker Atlanta, GA: Sweinbinder Reduce Needlestick Injuries Safety Center EPInet—Exposure Publications LLC; 2001. and the Risk of Subsequent Prevention Information • Training for the Development Bloodborne Pathogen Network. www.healthsystem. of Innovative Control Transmission to Surgical med.virginia.edu/internet/ Technologies Project (TDICT) Personnel, May 30, 2012. www. epinet/about_epinet.cfm Project. www.tdict.org fda.gov/MedicalDevices/Safety/ AlertsandNotices/ucm305757.htm • The Joint Commission Sentinel Alert. Preventing needlestick and sharps injuries. August 2001. www.jointcommission.org/sentinel_ event_alert_issue_22_preventing_ needlestick_and_sharps_injuries/

Recently published studies show that using blunt-tip • The universal adoption of blunt-tip suture needles for 54 | suture needles reduces the risk of needlestick injuries the closure of fascia and muscle in order to reduce from suture needles by 69 percent. Although blunt- needlestick injuries in surgeons and OR personnel. tip suture needles cost approximately 70 cents more than their standard suture needle counterparts, the benefits of reducing the risk of serious and potentially The neutral zone fatal blood-borne infections for health care personnel The hands-free technique (HFT) requires the surgical support their use when clinically appropriate. team to designate a sharps neutral zone (for example, A 2007 report suggests that the slight difference in a towel, Mayo stand, magnetic pad) for the pickup and costs of blunt- and sharp-tip suture needles is balanced release of surgical sharps such as needle-holders, scal- by the economic savings associated with needlestick pels, and syringes with needles. With this technique, injury prevention. This report, which assessed the there is no direct handing of instruments from scrub costs of managing occupational exposures to blood person to surgeon and back. If the surgeon must not and body fluids, concluded that the cost of managing break eye contact with the surgical field during critical a needlestick injury can range from $376 to $2,456 parts of the operation where patient safety or workflow per reported incident. In addition, personnel who might be compromised, a partial HFT may be used receive needlestick injuries may experience anxiety whereby sharps are directly handed from the scrub and a loss of productivity as they await the results person to the surgeon but then returned to the scrub of blood tests. person via a neutral zone. The use of blunt-tip suture needles does not The use of the neutral zone to transfer sharps is require the surgeon to change their work practices. supported by the Occupational Safety and Health In fact, a new generation of blunt-tip suture needles Administration and the Association of periOperative is now on the market with a slightly more tapered tip Registered Nurses as a method to reduce health care profile that may provide for easier suturing compared workers’ risk of sharps injury during surgery. The data with the earlier needles used in the referenced studies. supporting the use of HFT are inconclusive at pres- The College recognizes that specific procedures may ent, with one large study reporting lower needlestick preclude the use of blunt-tip suture needles. rates more than 75 percent of the time when the HFT Therefore the ACS recommends: technique was used, and another, smaller randomized

V101 No 10 BULLETIN American College of Surgeons STATEMENT

The use of blunt-tip suture needles does not require the surgeon to change their work practices.... The College recognizes that specific procedures may preclude the use of blunt-tip suture needles.

controlled trial reporting no difference in needlestick rates BIBLIOGRAPHY with HFT use. Aarnio P, Laine T. Glove perforation rate in vascular Therefore the ACS recommends: surgery—A comparison between single and double gloving. Vasa. 2001;30(2):122-124. • The use of HFT as an adjunctive safety measure to reduce Berguer R, Heller PJ. Strategies for preventing sharps injuries in the operating room. Surg Clin North Am. sharps injuries during a surgical procedure except in situ- 2005;85(6):1288-305. ations where it may compromise the safe conduct of the Eggleston MK Jr, Wax JR., Philput C, et al. Use of operation, in which case a partial HFT may be used. surgical pass trays to reduce intraoperative glove perforations. J Matern Fetal Med. 1997;6(4):245-247. Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. Engineered sharps injury prevention devices AORN J. 1998;67(5):979-981, 983-974, 986-977. Engineered sharps injury prevention (ESIP) mechanical Jagger J, Berguer R, Phillips EK, Parker G, Gomaa AE. devices may provide varying degrees of mechanical pro- Increase in sharps injuries in surgical settings tection from sharps injuries involving suture needles and versus nonsurgical settings after passage of scalpel blades. Manufacturers of ESIP devices approved by national needlestick legislation. J Am Coll Surg. 2010;210(4):496-502. the U.S. Food and Drug Administration have been permit- Jensen SL. Double gloving—Electrical resistance and ted to claim prevention of sharps injury as a feature of their surgeons’ resistance. Lancet. 2000;355(9203):514-515. use. No study published to date demonstrates the clinical Laine T, Aarnio P. How often does glove perforation | 55 effectiveness of ESIP devices. The design and quality of occur in surgery? Comparison between single these devices has been variable and their acceptance among gloves and a double-gloving system. Am J Surg. 2001;181(6):564-566. surgeons limited. Nevertheless, these devices may contrib- Naver LP, Gottrup F. Incidence of glove perforations in ute to minimizing sharps injuries in the OR. gastrointestinal surgery and the protective effect of Therefore the ACS recommends: double gloves: A prospective, randomised controlled study. Eur J Surg. 2000;166(4):293-295. • The use of ESIP devices as an adjunctive safety measure to O’Malley EM, Scott RDII, Gayle J, et al. Costs of management of occupational exposures to blood reduce sharps injuries during surgery except in situations and body fluids. Infect Control Hosp Epidemiol. where it may compromise the safe conduct of the operation 2007;28(7):774-782. or safety of the patient. ♦ Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff. Cochrane Database of Systemic Reviews. 2011; Issue 11, Disclaimer Art. No.: CD009170. DOI: 10. 1002/14651858. The ACS offers this statement for consideration by surgeons, CD009170.pub2. their hospitals, and health care organizations. This statement is Stringer B, Infante-Rivard C, Hanley JA. Effectiveness provided as general guidance. It does not constitute a standard of the hands-free technique in reducing of care and is not intended to replace the professional judgment operating theatre injuries. Occup Environ Med. 2002;59(10):703-707. of the surgeon or health care administrator. This statement may be reviewed and modified as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the individual hospital and health care organization, and requirements of other allied and health care organizations.

OCT 2016 BULLETIN American College of Surgeons STATEMENT

Revised statement on surgical technology training and certification

The following statement was revised by the American College of Surgeons (ACS) Committee on Perioperative Care and the revision was reviewed and approved by the ACS Board of Regents at its June 2016 meeting.

urgical technologists are individuals with spe- ministrator. The statement may be reviewed and modified Scialized education who function as members of as necessary to conform with the laws of the applicable ju- the surgical team in the role of a scrub person. With risdiction, the circumstances of the individual hospital and additional education and training, some surgical health care organization, and requirements of other allied technologists function in the role of surgical first as- and health care organizations. sistant. Surgical technology programs are accredited by the Accreditation Review Council on Education in Surgical Technology and Surgical Assisting—a col- laborative effort between the Association of Surgical Technologists and the ACS, under the auspices of 56 | the Commission on Accreditation of Allied Health Education Programs. Accredited programs provide both didactic education and supervised clinical experience based on a core curriculum for surgi- cal technology. Graduates of accredited surgical technol- ogy programs are eligible for certification by the National Board of Surgical Technology and Surgical Assisting—a collaborative effort between the Associa- tion of Surgical Technologists and the ACS composed of representatives including certified surgical tech- nologists, a surgeon, and a member of the public. Therefore the ACS strongly supports the following:

• Adequate education and training of all surgical tech- nologists, the accreditation of all surgical technology educational programs, and the examination for certifi- cation of all graduates of accredited surgical technology educational programs ♦

Disclaimer The ACS offers this statement for consideration by sur- geons, their hospitals, and health care organizations. This statement is provided as general guidance. It does not con- stitute a standard of care and is not intended to replace the professional judgment of the surgeon or health care ad-

V101 No 10 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

Rural surgery and the volume dilemma

by Patrick L. Molt, MD, FACS

nother 3:00 am phone call In light of the decline in overall number of cases is rarely left me struggling toward general surgeons practicing in an issue for rural surgeons. Awakefulness. This time it rural areas (an estimated 8.1 Unfortunately, outcomes was the obstetrician. He went per 100,000 population in 1981, research evaluating a variety of on too long, explaining how he declining to 5 per 100,000 in medical diagnoses has shown had produced a large laceration 2005, and likely even fewer poorer results in CAHs than in | 57 in a patient’s bladder in the today), there is no shortage larger hospitals. Surgical services course of performing a cesarean of patients in need of surgical suffer from guilt by association. delivery. Finally awake enough services.1 In comparison with Several recent publications have to interrupt, I said, “Whatever their urban counterparts, of confirmed that as rural surgeons, it is, I’ll take care of it.” For whom there are approximately we do well those procedures general surgeons in small rural 7.7 per 100,000 patients, rural we do regularly. Gadzinski and hospitals, this is what we do— surgeons take responsibility colleagues, in a 2013 publication we take care of it, whatever it is. for 50 percent more lives.1 Case from the University of Michigan loads are higher for surgeons Center for Healthcare Outcomes practicing in both small and and Policy, Ann Arbor, compared Growing demand for large rural hospitals by a similar results using administrative data rural surgeons proportion, as documented by sets from 1,283 CAHs and 3,612 In the approximately two- analysis of the American Board non-CAHs for eight common thirds of the 1,300 critical access of Surgery (ABS) recertification procedures in general surgery, hospitals (CAH) located across case logs.2 Analysis of the Dakota obstetrics and gynecology, the U.S. where general surgeons Database for Rural Surgery and orthopaedics, including still operate, we engage in a yielded an average of 1,071 the following: appendectomy, scope of practice that has largely surgical procedures annually cholecystectomy, colorectal disappeared in metropolitan among the 43 rural surgeons cancer resection, cesarean areas. As one contributor to the participating. Case distribution delivery, hysterectomy, knee American College of Surgeons included 48 percent of cases replacement, hip replacement, rural listserv wrote, “You know considered general surgery, and hip fracture repair.4 you are a rural surgeon when 40 percent endoscopy, and Length of stay was statistically your OR [operating room] list 12 percent subspecialty.3 When significantly shorter at CAHs for the day would require five it comes to the volume part of for four procedures and risk- subspecialists in a larger hospital.” the volume/outcome equation, adjusted mortality rates were

OCT 2016 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

As one contributor to the American College of Surgeons rural listserv wrote, “You know you are a rural surgeon when your OR list for the day would require five subspecialists in a larger hospital.”

equivalent, with the exception Medicare expenditures, but inferior results. The factors of hip fracture in Medicare were less medically complex.”6 leading to better outcomes are beneficiaries. The 2015 report more nuanced than surgeon of the Rural Health Research and institutional volumes and Center at the University of Higher risk, more diverse cases include training, specialization, Washington, Seattle, showed The debate over the relationship cumulative experience, and that for a variety of common between volume and outcomes technical surgical skill.10,11 general surgery, obstetrics and is certainly much older than In another study, a 2.5-fold gynecology, and orthopaedic the modern era of research, difference in risk-adjusted procedures, patients treated in which dates to the seminal mortality rates between rural hospitals had fewer serious article of health care economist institutions for six high-risk 58 | complications than their urban Harold Luft, published in procedures was explained on counterparts, although the the New England Journal of the basis of failure to rescue; rural hospital cohort appeared Medicine in 1979.7 The list of that is, lack of recognition to have a lower risk profile.5 procedures across multiple or optimal management of Most recently, Ibrahim surgical specialties where a surgical complications.12 When and colleagues published an relationship between volume I relocated to a CAH 17 years analysis of surgical outcomes and outcomes has been ago, I decided the days of and expenditures among documented in the surgical performing high-complexity Medicare beneficiaries treated literature is much larger than oncology procedures were over in 828 CAHs and 3,676 non- the eight complex procedures for me. This realization was CAHs in a retrospective review listed in the “Volume Pledge.”8 not because I had developed of 1,631,904 admissions. Four Few common procedures selective amnesia after common general surgery have escaped such analysis; crossing the Hudson River, procedures were included: from inguinal herniorraphy to but because a 25-bed hospital appendectomy, cholecystectomy, open heart surgery, the nearly with no full-time medical colectomy, and hernia repair. universal result has been the or surgical subspecialists The investigators concluded, documentation of a correlation. cannot provide the level of “Among Medicare beneficiaries Luft recognized that “practice support necessary to provide undergoing common surgical makes perfect” was only one the postoperative care that procedures, patients admitted possible explanation.9 Another patients need when undergoing to critical access hospitals would be “selective referral”; that high-morbidity procedures. compared with noncritical is, patients are more likely to be The trip to a staffed surgical access hospitals had no referred to surgeons and facilities intensive care unit with a full significant difference in 30-day with a good reputation for a complement of subspecialty mortality rates, decreased risk- particular procedure and that consultants is not an elevator adjusted serious complication low-volume providers are low ride for CAH patients, but rates, and lower adjusted volume because they produce often a helicopter ride.

V101 No 10 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

Rural surgical practices CAH would require six years by widespread restriction tend to generate diverse case of cumulative data without a of surgical privileges on the loads, unlike the niche practices mortality to come down to the basis of numerical quotas or common in major metropolitan 3.3 percent reported in Ibrahim’s mandated regionalization, fewer areas. Looking over the case study. We will not be much general surgeons would find log I submitted last year for helped by individual scorecards. rural practice attractive, further ABS recertification, few of the Some health care limiting access to emergency procedures listed would pass policymakers would have and elective surgical care. muster individually by volume rural surgeons give up doing metrics. As individuals, it is all but the most basic of rarely possible to accumulate surgical procedures in favor Suggestions for rural surgeons sufficient data to prove that we of regionalization. However, What, then, ought we do as | 59 are producing excellent results. this situation would present rural surgeons to overcome In an analysis of 5,033 a number of problems for these challenges? Here’s what colectomies performed over patients, hospitals, and surgeons. I do. First, I try to “color three years by 345 surgeons Rural patients on average inside the lines.” That is, I in the Michigan Surgical are older, poorer, and less try to manage my patients Quality Collaborative (MSQC) mobile than patients in larger according to accepted guidelines Colectomy Quality Improvement metropolitan areas. Lack of and the current literature. Intervention Project, a valid mobility, whether as a result Clinical practice guidelines risk-adjusted surgeon-specific of economic, psychological, or are available online from a complication rate could be physical limitations, represents variety of sources, including the calculated for only one surgeon.13 a real barrier for poor and American College of Surgeons, A caseload of 168 colectomies elderly patients. Some patients National Comprehensive Cancer over three years was required to have such a strong preference Network, American Society calculate a reliable result. The for local care that they will of Breast Surgeons, Society of average number of cases per opt for a local provider American Gastrointestinal and surgeon annually calculates to even in the face of greatly Endoscopic Surgeons, American 4.86. In the Ibrahim study cited increased risk of mortality.14 Society of Colon and Rectal earlier, average annual Medicare At the hospital level, CAHs Surgeons, American College colectomies per CAH were 2.46.6 are dependent on the revenue of Obstetrics and Gynecology, If one assumes an equal number generated by surgical services to and others. These professional of colectomies in non-Medicare sustain their financial viability. guidelines serve as “guardrails” beneficiaries (extrapolating Recruitment and retention to keep me on track. from the MSQC data), the of general surgeons in rural Second, I try to maintain same number results. A single areas is difficult already. Were currency of knowledge and mortality after a colectomy the scope of practice of rural technical skills appropriate to by the average surgeon in a surgeons to be constrained my scope of practice. When

OCT 2016 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

The trip to a staffed surgical intensive care unit with a full complement of subspecialty consultants is not an elevator ride for CAH patients, but often a helicopter ride.

your OR schedule on any REFERENCES given day might include a total 1. Cogbill TH, Cofer JB, Jarman BT. Contemporary issues in rural surgery. Curr Probl thyroidectomy, an ultrasound- Surg. 2012;49(5):263-318. guided partial mastectomy 2. Valentine RJ, Jones A, Biester TW, Cogbill TH, Borman KR, Rhodes RS. General surgery workloads and practice patterns in the United States, 2007 to 2009: A 10- with sentinel node biopsy, a year update from the American Board of Surgery. Ann Surg. 2011;254(3):520-526. laparoscopic cholecystectomy 3. Sticca RP, Mullin BC, Harris JD, Hosford CC. Surgical specialty procedures with common bile duct in rural surgery practices: Implications for rural surgery training. Am J Surg. exploration, a components 2012;204(6):1007-1013. separation incisional hernia 4. Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States. JAMA Surg. repair, or a laparoscopic 2013;148(7):589-596. hysterectomy, staying current 5. Doescher MP, Jackson JE, Fordyce MA, Lynge DC. Variability in general surgical 60 | can be daunting. Without the procedures in rural and urban U.S. hospital inpatient settings. Final Report #142. Internet, I could never manage. WWAMI Rural Health Research Center, University of Washington, 2015. I limit the patients I treat and 6. Ibrahim AM, Hughes TG, Thumma JR, Dimick JB. Association of hospital critical access status with surgical outcomes and expenditures among Medicare the procedures I perform to beneficiaries.JAMA . 2016;315(19):2095-2103. those I believe are within my 7. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The areas of competence and the empirical relation between surgical volume and mortality. New Eng J Med. capabilities of my facility. 1979;301(25):1364-1369. When complications occur, 8. Sternberg S. Hospitals move to limit low-volume surgeries. U.S. News & World Report. Available at: www.usnews.com/news/articles/2015/05/19/hospitals-move- I try to recognize and admit to-limit-low-volume-surgeries. May 19, 2015. Accessed August 17, 2016. them and arrange for transfer 9. Luft HS, Hunt SS, Maerki SC. The volume-outcome relationship: Practice-makes- to an appropriate level of care, perfect or selective-referral patterns? Health Serv Res. 1987;22(2):157-182. whether across the hall to our 10. Bilimoria KY, Phillips JD, Rock CE, Hayman A, Prystowsky JB, Bentrem DJ. Effect intensive care unit or across the of surgeon training, specialization, and experience on outcomes for cancer surgery: A systematic review of the literature. Ann Surg Onc. 2009;16(7):1799-1808. state to a tertiary care facility. 11. Birkmeyer JD, Finks FF, O’Reilly A, et al. Surgical skill and complication rates after Finally, we have begun to bariatric surgery. New Eng J Med. 2013;369(15):1434-1442. expand the measurement of 12. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, outcomes and to participate and mortality with major inpatient surgery in medicare patients. Ann Surg. in collaborative quality 2009;250(6):1029-1034. 13. Shih T, Cole A, Al-Attar PM, et al. Reliability of surgeon-specific reporting of improvement projects complications after colectomy. Ann of Surg. 2015;261(5):920-925. through the Illinois Surgical 14. Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF Jr. Patient preferences for Quality Improvement location of care: Implications for regionalization. Med Care. 1999;37(2):204-209. Collaborative, a major new initiative for my facility. To paraphrase Vince Lombardi, perhaps perfect practices will make perfect. ♦

V101 No 10 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

NRG GI002: Moving the needle toward TNT in locally advanced rectal cancer

by Thomas J. George, Jr., MD, FACP; Christina Wu, MD; and Y. Nancy You, MD, MHSc, FACS

olorectal cancer remains three months from the time of emerging that uses total a leading cause of cancer- initial diagnosis. However, little neoadjuvant therapy (TNT), Cassociated deaths in the data are available to show that which typically includes four U.S., and rectal cancer represents adjuvant systemic chemotherapy months of FOLFOX systemic nearly one-third of this burden. reduces the risk of distant failure chemotherapy, followed by For patients with stage II or III in rectal cancer, as opposed chemoRT, and ending with rectal cancer, the paradigm of to colon cancer. Interestingly, surgical resection (see Figure 1, preoperative chemoradiotherapy most contemporary randomized page 62). In a randomized phase (chemoRT), followed by complete controlled trials show that 25 II study, this approach has surgical resection (ideally in the percent to 70 percent of rectal demonstrated a significant setting of sphincter preservation), cancer patients never receive improvement in compliance followed by adjuvant or complete their intended with delivery of all therapy | 61 chemotherapy, represents the adjuvant systemic chemotherapy. and no untoward surgical current standard of care in the This statistic is in contrast to complications.6 Postoperative U.S.1-3 This paradigm is supported most adjuvant colon cancer recovery is thus unabated by national consensus guidelines clinical trials, in which more by the need to continue and major cancer professional than 75 percent of patients anti-cancer treatments. societies.4 Through the use of routinely receive the intended quality controlled external beam therapy. Even at NCCN centers radiotherapy and subsequent total (a network of regional centers Study approach and aims mesorectal resection, local control with the capacity to provide The NRG Oncology TNT rates remain consistently greater comprehensive multimodality clinical trial (NRG-GI002) is a than 90 percent. Today, most cancer therapy), nearly 20 randomized phase II platform patients who succumb to rectal percent of patients do not receive study with parallel, non- cancer do so through distant their intended rectal cancer comparative experimental failure and systemic metastases. adjuvant chemotherapy.5 It is arms with a single comparative It is plausible to speculate thus likely that, for a variety control arm of neoadjuvant that a treatment regimen that of reasons, the rate of adjuvant chemotherapy and chemoRT in ensures all patients with high- therapy administration is locally advanced and high-risk risk rectal cancers receive optimal similarly suboptimal among rectal cancer (see Figure 1, page systemic therapy could lead to patients treated off trial 62). Additional arms testing novel meaningful improvements in and in general practice. agents and unique hypotheses survival. Furthermore, for most One way to effectively ensure will be added through protocol patients today, systemic therapy that all patients receive intended amendments and compared (and thus potential eradication and earlier systemic therapy with the continuously running of occult micro-metastatic is induction or neoadjuvant control arm. Any novel arm disease) does not begin until after chemotherapy. Thus, a new demonstrating success against recovery from surgery—close to clinical trial paradigm is the control arm will be further

OCT 2016 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

FIGURE 1. NRG ONCOLOGY NRG-GI002 SCHEMA

FOLFOX × 8 XRT + capecitabine Surgery

FOLFOX × 8 XRT + capecitabine + veliparib Surgery Locally advanced R rectal cancer

FOLFOX + ? XRT + capecitabine + Surgery × 8 ? ?

tested in larger and more • Distal location: cT3-4 ≤ 5 cm from REFERENCES: definitive randomized controlled the anal verge, any N 1. Sauer R, Becker H, Hohenberger trials. The primary endpoint is W, et al. Preoperative versus postoperative chemoradiotherapy a novel pathologic endpoint of • Bulky: Any cT4 with the majority for rectal cancer. N Engl J Med. the neoadjuvant rectal (NAR) of tumor < 12cm from the anal 2004;351(17):1731-1740. score,which measures pathologic verge or evidence that the tumor 2. Sauer R, Liersch T, Merkel S, et al. response to TNT and has been is adjacent to (defined as within Preoperative versus postoperative shown to predict long-term 3 mm of) the mesorectal fascia chemoradiotherapy for locally 7 advanced rectal cancer: Results of survival endpoints. Such a t he Ger ma n C AO/A RO/A IO -94 pathologic endpoint allows trial • High risk for metastatic disease randomized phase III trial after a 62 | outcomes to be assessed rapidly. with four or more regional lymph median follow-up of 11 years. J Clin The platform design of the trial nodes (cN2) Oncol. 2012;30(16):1926-1933. allows for a systematic approach 3. Roh MS, Colangelo LH, O’Connell MJ, et al. Preoperative multimodality to study novel radiosensitizers, • Not a candidate for sphincter- therapy improves disease-free survival such as the poly(ADP-ribose) sparing surgical resection prior to in patients with carcinoma of the polymerase inhibitor veliparib; neoadjuvant therapy (as planned rectum: NSABP R-03. J Clin Oncol. personalized treatment selection by the primary surgeon) 2009;27(31):5124-5130. using novel targeted systemic 4. NCCN Guidelines. Available at: www. nccn.org/professionals/physician_ therapeutics; and identification of Associated translational studies gls/f_guidelines.asp. Accessed August patients at exceptionally high risk will correlate clinical outcomes 23, 2016. for recurrence. Hence, the TNT with molecular, biomarker, 5. Khrizman P, Niland JC, ter Veer A, et al. protocol will provide a clinical and imaging interrogation. Postoperative adjuvant chemotherapy trial to support the testing of use in patients with stage II/III rectal cancer treated with neoadjuvant multiple parallel hypotheses therapy: A national comprehensive and help justify more definitive Study status cancer network analysis. J Clin Oncol. randomized controlled studies The study is currently undergoing 2013;31(1):30-38. only after the demonstration the pre-activation phase at 6. Fernandez-Martos C, Garcia-Albeniz of substantive activity. the National Cancer Institute X, Pericay C, et al. Chemoradiation, surgery and adjuvant chemotherapy Cancer Trials Support Unit. It is versus induction chemotherapy expected to be available for all followed by chemoradiation and Eligibility criteria sites to open in October 2016. surgery: Long-term results of the Patients must have biopsy- The study is endorsed by all Spanish GCR-3 phase II randomized proven clinical stage II/III rectal cooperative groups, including trial. Ann Oncol. 2015;26(8):1722-1728. 7. George TJ Jr, Allegra CJ, Yothers G. adenocarcinoma. The disease the Alliance for Clinical Trials in Neoadjuvant rectal (NAR) score: A must be clinically determined Oncology. For more information, new surrogate endpoint in rectal as “locally advanced” by any contact thom.george@ cancer clinical trials. Curr Colorectal one of the following criteria: medicine.ufl.edu. ♦ Cancer Rep. 2015;11(5):275-280.

V101 No 10 BULLETIN American College of Surgeons YOUR ACS BENEFITS

Maximize your visibility and the benefits of Fellowship with the My Profile Web page

by Elizabeth McAllister

he online gateway to all of SAMPLE “MY PROFILE” WEB PAGE your American College of TSurgeons (ACS) benefits is your online ACS Member Profile.

Maximum visibility You can maximize your Web presence by regularly updating your Member Profile. The information is automatically formatted to serve as your personal ACS Web page. You have the option of including a photo, describing your | 63 practice, specifying your areas of concentration, and highlighting your training, board certifications, society memberships, and academic and hospital appointments. You can customize your privacy settings to determine what information remains confidential, is viewable only by other ACS members, or may be viewed by the public through the ACS ONLINE COMMUNITIES Find A Surgeon site. On average, more than 10,000 individuals visit the Find A Surgeon page each month. Maintaining a complete profile increases your visibility when patients are searching by specialty, procedure, or location, or are validating your credentials and looking for a second opinion. It also allows colleagues to easily connect with you, as your page can be linked to your practice website and to social media.

OCT 2016 BULLETIN American College of Surgeons YOUR ACS BENEFITS

MYCME SITE

Medicaid Services Physician Communicate Quality Reporting System You also may use your online mandates and Maintenance Member Profile to link to the of Certification requirements ACS Communities that are of issued by the surgery boards. interest to you. At present, the ACS has more than 100 members- only Communities. The ACS Take advantage of QUICK LINKS Communities have multiple layers ACS programs of security to allow members to From your profile page, you may freely discuss cases and issues. contact your ACS representatives, Visit the ACS Communities including the Board of Governors, 64 | to participate in discussions your Advisory Council Chair, relevant to your specific interests, join your state or local chapter, engage with experts, and share print your ACS membership ID documents, photos, and videos. card, pay your membership dues, and sign up for the wide variety of ACS Insurance Programs Comply with regulatory and other discount programs. requirements Fellows also may download FACS Your profile includes a link that artwork for use on their website, allows users to manage and letterhead, lab coat, and more. track their continuing medical Visit your ACS Member Profile education (CME) credits. You page and make sure you are can track both ACS and non- taking advantage of everything ACS CME credits, print CME your ACS membership has certificates, and transfer your to offer. You may access your CME credits directly to the profile page by logging into American Board of Surgery the facs.org website using your through the MyCME site. member login information. Members also may access Once you have logged into the the ACS Surgeon Specific site, select “My Profile” from the Registry (SSR). The SSR online menu bar, and then “My Profile software application and Overview.” If you do not know database allows you to track your member login information, your cases and outcomes, as well you can retrieve it securely as meet a number of regulatory through the facs.org login page. requirements, including Contact [email protected] or call the Centers for Medicare & 1-800-621-4111 for assistance. ♦

V101 No 10 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Workplace bullying is a real problem in health care

by Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)

ullying and workplace bullying as “repeated, health- instrumentation; and changes violence, in any setting, harming mistreatment of one in the patient care plan. are unacceptable. These or more persons by one or more Bullying under these B 3 behaviors are of particular perpetrators.” This bullying circumstances poses an concern in the health care may manifest as verbal abuse, immediate and direct threat to setting, as they pose a risk not threats, intimidation, humiliation, the safety of the patient, as those only to our colleagues and peers, or even work interference. who are bullied are nervous and but also to patient safety. The institute estimates 65.6 will most likely underperform million workers in the U.S. either because of their anxiety. In have been bullied in the workplace the long term, the impact on Too common a problem or have witnessed bullying. A 2014 bullied employees can include According to an article in survey showed that 69 percent of lower morale, productivity, and The International Journal of bullies were men, and 57 percent attendance. This, in turn, can lead Environmental Research and Public of targets were women; it also to more organizational turnover, Health, “Workplace bullying showed that 68 percent of women causing talented workers to among healthcare workers” by bullies targeted other women.3 leave the profession—which can | 65 Antonio Ariza-Montes and co- directly affect patient safety. authors, the most frequent victims The Journal of Community of violent events in the health care Effects on patient care & Applied Social Psychology sector are 40 years old or younger. In the health care arena, categorizes workplace The article also states that women bullying occurs most frequently violence as the following:4 physicians and unmarried women in behavioral health units, employees with less education emergency departments, and • Threat to professional status and with children at home are intensive care units. Bullying also • Threat to personal standing more likely to endure bullying.1 is fairly common in perioperative • Isolation In addition, a recent areas, including the pre-anesthesia • Overwork Occupational Safety and Health room, the operating room, and • Destabilization Administration (OSHA) report the recovery room. Whether it is indicates that 21 percent of exercising the power of authority Workplace bullying—which registered nurses or nursing or misusing the hierarchical is more common than sexual students said they have been structure, some surgeons have harassment—tends to happen physically assaulted, and more been known to intimidate other to employees who don’t have than 50 percent said they have coworkers, sometimes with the good support systems or who been verbally abused—a form excuse of doing so “on behalf of are unable to defend themselves of workplace violence that their patients.” Circumstances from their aggressors. Factors includes bullying.2 Meanwhile, that are particularly suited to that contribute to workplace 12 percent of emergency nurses spurring this type of behavior bullying include the following: reported physical violence and include emergencies, which are 59 percent experienced verbal common in surgery; difficult • A bullying culture abuse during a one-week period. situations faced during the • Poor staffing levels The Workplace Bullying course of an operation that • Excessive workloads Institute defines workplace require prompt attention; new • Power imbalances

OCT 2016 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Health care organization leaders also can play a role in battling bullying by creating a safety culture that doesn’t tolerate bullying behaviors, confronts bullies, and supports their victims.

• Poor management skills REFERENCES • Role conflict or ambiguity Surgeons must lead 1. Ariza-Montes A, Muniz NM, • Stress I believe that surgeons can Montero-Simo MJ, Araque-Padilla • Lack of autonomy play a substantial role in the RA. Workplace bullying among fight against bullying in the healthcare workers. Int J Environ Res Public Health. 2013;10(8):3121-3139. Gerry Hickson, MD, and health care field. Not only do I 2. Occupational Safety and Health colleagues at Vanderbilt believe that we should always Administration. Workplace violence University Medical Center, self-monitor to ensure that our in health care: Understanding the Nashville, TN, determined statements, our actions, and our challenge. OSHA 3826, 12/2105. that a common barrier in the attitudes are not interpreted as Available at: www.osha.gov/ Publications/OSHA3826.pdf. fight against bullying was bullying, but that we also have Accessed May 18, 2016. underreporting of the issue. an obligation to observe and 3. Workplace Bullying Institute. The In response, they created counsel our colleagues who Healthy Workplace Campaign. a Co-Worker Observation may exhibit those behaviors. Healthy Workplace Bill website. Reporting System to encourage Surgeons should leverage Available at: healthyworkplacebill. accountability and respect among their visibility, their position in org/problem/. Accessed May 14, 2016. 5 4. Rayner C, Hoel H. A summary coworkers. This reporting system the hierarchy of an organization, review of literature relating to 66 | allows coworkers to document the way that other health care workplace bullying. J Comm Applied observed acts of bullying, which providers perceive the role of Social Psych. 1997;7:181-191. provides an inventory of such surgeons, and their capacity to 5. Webb LE, Dmochowski RR, Moore IN, et al. Using coworker events and an opportunity for influence institutional policies observations to promote administrators to address these and procedures to create and accountability for disrespectful and issues through education and maintain an environment that unsafe behaviors by physicians and compliance-related initiatives. is positive—for the health care advanced practice professionals. Health care organization workers, the surgeons and, most Jt Comm J Qual Patient Saf. 2016;42(4):149-161. leaders also can play a role in importantly, the patients. 6. The Joint Commission. Issue 40: battling bullying by creating For more, read a Quick Behaviors that undermine a culture of a safety culture that doesn’t Safety report on workplace safety. Sentinel Event Alert. July 9, 2008. tolerate bullying behaviors, bullying at bit.ly/28KusuG. ♦ Available at: www.jointcommission. confronts bullies, and org/sentinel_event_alert_issue_40_ behaviors_that_undermine_a_ supports their victims. culture_of_safety/. Accessed August The Joint Commission Disclaimer 24, 2016. also highlighted some safety The thoughts and opinions actions to consider in Sentinel expressed in this column are Event Alert, Issue 40, which solely those of Dr. Pellegrini and include the following:6 do not necessarily represent those of The Joint Commission or the • Educating team members on American College of Surgeons. appropriate behaviors

• Holding team members accountable

• Developing anti-bullying policies

V101 No 10 BULLETIN American College of Surgeons NTDB DATA POINTS

Stairway to heaven

by Richard J. Fantus, MD, FACS

tairway to Heaven,” Elevator Company introduced collect data on all injuries seen a song by the British the first working escalator. in emergency departments, an rock band Led Zeppelin The word escalator is derived estimated 12,774 patients were “S 4 and composed by guitarist from the Latin word “scala,” injured using escalators in 2014. Jimmy Page and vocalist Robert meaning steps, and the word To examine the occurrence Plant, was released in 1971 elevator, coined by Otis for the of escalator injuries contained and became one of the most name of their moving lift. A in the National Trauma Data popular rock songs of all time. Frenchman in 1898 invented Bank® (NTDB®) research The lyrics describe a mythical a “step-less” escalator for the dataset for admission year “lady” buying a stairway to Harrods department store 2014, medical records were | 67 heaven to ascend on a spiritual in London, England, using searched using the International quest. In the last two decades, a continuous leather belt. Classification of Diseases, this fascination with heavenly Customers that were shaken by Ninth Revision, Clinical stairways has spilled over to the the experience were revived with Modification codes. Specifically real world. The world’s highest free smelling salts and cognac.2 searched were records that escalators are 39 stories tall (one Today, escalators are included the diagnosis code takes passengers up and the ubiquitous. It would be difficult E880.0 (Accidental Fall on or other takes them down) and to go to any urban area, from Escalator). A total of 431 are located in Osaka, Japan, in a shopping mall, transportation records were found, of which glass-enclosed structure at the facility, airport, or large 363 contained a discharge Floating Garden Observatory convention center and not find status, including 234 patients in the Umeda Sky Building.1 moving stairs that will take discharged to home, 56 to acute you from one floor to the next. care/rehab, and 57 sent to skilled The U.S. has an estimated nursing facilities; 16 died. Half An escalating problem 35,000 escalators that serve an of these patients (50 percent) The concept of the escalator average of 12,000 people per were women, on average 63.9 dates back to 1859, when escalator, amounting to 105 years of age, had an average Nathan Ames of Massachusetts billion passenger trips annually.3 hospital length of stay of 5.8 patented his idea of a moving However, use of this days, an intensive care unit staircase; however, Mr. Ames conveyance convenience length of stay of 4.1 days, an did not successfully build a carries with it potential harm. average injury severity score of working model. At the end of According to the U.S. Consumer 9.5, and were on the ventilator the 19th century, several other Product Safety Commission’s for an average of 4.7 days. Of inventors patented similar (CPSC) National Electronic those tested for alcohol, almost ideas but never actually built a Injury Surveillance System one-third (56 out of 180) tested working model. In 1899, Otis (NEISS), a system designed to positive (see Figure 1, page 68).

OCT 2016 BULLETIN American College of Surgeons NTDB DATA POINTS

FIGURE 1. HOSPITAL DISCHARGE STATUS

68 | more detailed study. If you are REFERENCES Watch your step interested in submitting your 1. Wilson M. World’s tallest Escalator injuries can be averted trauma center’s data, contact escalator, another day at the mall. by taking a few simple steps. Melanie L. Neal, Manager, Gizmodo.com. August 17, 2007. Avoid carrying heavy packages, NTDB, at [email protected]. Available at: gizmodo.com/290625/ worlds-tallest-escalator-another-day- hold the handrail, stay away at-the-mall. Accessed August 29, 2016. from the lines at the edge 2. The history of the escalator. Elevator of each step that identify an Acknowledgment design info. Available at: www. entrapment risk, do not take Statistical support for this article elevatordesigninfo.com/the-history- strollers or wheelchairs onto was provided by Chrystal Caden- of-the-escalator. Accessed August 1, 2016. the steps, and be aware of other Price, Data Analyst, NTDB. ♦ 3. Consumerwatch.com. Escalators. riders in case someone ahead Available at: www.consumerwatch. of you falls. Next time you get com/workplacepublic/escalators/. on an escalator and think that Accessed August 1, 2016. it is a stairway to heaven, make 4. U.S. Consumer Product Safety Commission. National Electronic sure you heed these safety Injury Surveillance System query measures—or it just may be. builder. Available at: www. Throughout the year, we will cpsc.gov/cgibin/NEISSQuery/ highlight these data through PerformEstimates.aspx. Accessed brief monthly reports found in September 2, 2016. the Bulletin. The NTDB Annual Report 2015 is available on the ACS website as a PDF file at facs. org/quality-programs/trauma/ ntdb. In addition, information is available on our website about how to obtain NTDB data for

V101 No 10 BULLETIN American College of Surgeons NEWS

In memoriam: Barrett G. Haik, MD, FACS

by James W. Gigantelli, MD, FACS Dr. Haik

Barrett George Haik, MD, FACS, we traveled with my father to oncology and orbital disease Hamilton Professor of visit colleagues in other cities.” service at Tulane University. Ophthalmology and director, To Barrett, medicine was not He was soon program and the University of Tennessee a career; it was woven into the medical director of the Eye, Health Science Center Hamilton fabric of his life. He obtained Ear, Nose and Throat Hospital, Eye Institute (HEI), Memphis, his undergraduate degree at and was appointed to serve as | 69 unexpectedly died in his sleep on Centenary College, Shreveport, Tulane’s first endowed chair July 22 while visiting his much- LA, and worked as a research in ophthalmology, the George loved family and friends in his fellow at the Oak Ridge National M. Haik, Sr., MD–St. Giles hometown of New Orleans, LA. Research Laboratory, TN, before Foundation Professor of Pediatric He was 64 years old. A dedicated earning his medical degree and and Adult Ophthalmic Oncology. teacher, insightful researcher, master’s degree in anatomy from skilled surgeon, and proven the Louisiana State University cultivator of philanthropy, (LSU) Medical School, New Passion for teaching, Dr. Haik leaves a legacy to his Orleans. He moved to New York, humanitarianism students, colleagues, and patients NY, to complete his residency in Barrett was a natural mentor, to live by his example: to treat ophthalmology at the Edward supervising resident physicians all with kindness, warmth, and S. Harkness Eye Institute at from programs at Tulane, respect, and to continue to believe Columbia-Presbyterian Medical Louisiana State University, and the that any vision can be achieved. Center. Thereafter, he joined Oschner Foundation. He not only the faculty of Cornell University taught residents how to practice Medical College and staff of medicine, but also nurtured them Born into ophthalmology Memorial Sloan Kettering Cancer into compassionate caregivers. Dr. Haik was born into Center, New York, soon becoming Caring for others was Barrett’s life ophthalmology. The son of the associate director of its mission, and he found dignity and George M. Haik, Sr., MD, and ophthalmic oncology service. worth in every person. At Tulane, Isabelle Saloom Haik, Barrett To Barrett, family and Barrett would take his pediatric could count 14 ophthalmologists friendships were deep-rooted, cancer patients to the Audubon in his extended family. When so it came as no surprise that in Zoo as part of the healing process. reminiscing about his childhood, 1986, he returned to New Orleans To his students or colleagues, he once recalled jokingly, “We as a professor of ophthalmology he was generous with his time didn’t go on family vacations; and director of the ophthalmic and advice. You left a coaching

OCT 2016 BULLETIN American College of Surgeons NEWS

Dr. Haik leaves a legacy to his students, colleagues, and patients to live by his example: to treat all with kindness, warmth, and respect, and to continue to believe that any vision can be achieved.

session with Barrett with renewed Martinelli bestowing Barrett the Program Committee appreciation of your abilities with the National Award of the (2007−2011), the Committee and a confidence to pursue what Grand Officer in the Order Vasco on Education (2007−2013), had seemed unattainable. Núñez de Balboa in 2012. He the Member Services Liaison In 1995 the University of also was presented with the Keys Committee (Chair, 2012−2013), Tennessee Health Science Center to Panama City by its mayor. the Committee on Research and recruited Dr. Haik to lead its In 2012, Dr. Haik stepped Optimal Patient Care (2004−2012), department of ophthalmology. down as chair of HEI to serve and the Health Policy Steering During his extraordinary 17-year as director and chair emeritus. Committee (2006−2009). span as department chair, A prolific fundraiser, Dr. Haik Dr. Haik also served as an Dr. Haik transformed the small raised more than $100 million officer or board member of department with four faculty for HEI’s research and global numerous other medical and members into the HEI, a world- eye care programs. His success scientific societies, including class eye center that is home to was due to a rare combination of the American Academy of more than 40 faculty members, tremendous intellect, unclouded Ophthalmology (AAO), acclaimed clinical programs, and vision, a gentleman’s demeanor, Association of University a strong core of basic scientists. and unfailing kindness. He Professors of Ophthalmology, 70 | He also built the ophthalmic exhibited the same warmth and American Eye Study Club, oncology service at St. Jude appreciation for everyone— American Society of Ophthalmic Children’s Research Hospital, janitors and plumbers, professors Ultrasound, and New York Memphis, saving the lives of and businessmen, students Academy of Medicine. He children, both at home and and residents. He led not only received a Lifetime Achievement abroad, with ophthalmic through genius and vision, but Award from the Memphis tumors. Retinoblastoma is a through the day-to-day example Business Journal and the AAO. pediatric eye cancer that once set by how he treated others. A prolific author and editor, had a mortality rate of 90 percent Dr. Haik was also a highly in low-resource nations, but sought-after lecturer in national through Dr. Haik’s outreach Committed surgeon volunteer and international forums. initiatives to establish centers Dr. Haik was a tireless advocate Barrett loved caring for of excellence throughout the of the American College of patients and teaching others, but developing world, that mortality Surgeons (ACS) and its mission, he also enjoyed the company rate is now less than 10 percent voluntarily contributing to a of friends and his bloodhound in many countries. He equated range of ACS committees and Maddie. Recreationally, he identifying retinoblastoma in governing bodies. Dr. Haik was enjoyed golfing and fishing the children to saving their lives. a leading member of the Board waters of the Louisiana delta Dr. Haik’s true passion was of Regents (2004−2013), the and gulf. He is survived by his helping people. For the better Board of Governors (2000−2005), companion, Bianca Phillips; son, part of his career, Barrett traveled and the ACS Committee on Christopher Barrett Haik of semiannually to Panama with Emerging Surgical Technology Quito, Ecuador; daughter, Claire colleagues to operate field clinics and Education (member, 2006– Marie Haik of Philadelphia, PA; serving local residents. His 2007, Chair 2007−2013). He two brothers, George M. Haik, commitment to the Panamanian also served on the Advisory Jr., MD, and Kenneth Haik, MD, patients and physicians resulted Council for Ophthalmic Surgery both of New Orleans; and a in First Lady Marta Linares de (1998−2013, Chair, 2002–2004), sister, Suzanne Haik Terrell. ♦

V101 No 10 BULLETIN American College of Surgeons NEWS

Mary H. McGrath, MD, MPH, FACS, to be honored with Distinguished Philanthropist Award

Dr. McGrath

The American College of and workforce issues. Her She served on the Board of Surgeons (ACS) Foundation Board career as an academic surgeon Governors Executive Committee of Directors will present the 2016 started at Yale in 1978 with a and as a Governor-at-Large Distinguished Philanthropist position as assistant professor representing the District of Award to Mary H. McGrath, MD, of surgery in the school of Columbia and is a member of the MPH, FACS, professor of surgery, medicine’s division of plastic and ACS Foundation Board. In 2009 University of California, San reconstructive surgery. In 1980, the ACS appointed her to serve Francisco (UCSF), at its annual she became assistant professor on the Board of Commissioners Donor Recognition Luncheon of surgery, division of plastic and of The Joint Commission; she Monday, October 17, at Clinical reconstructive surgery, Columbia is currently serving her third Congress 2016 in Washington, University College of Physicians term in this capacity. For this DC. Dr. McGrath will be and Surgeons, New York, NY. In remarkable service, Dr. McGrath | 71 recognized for her generous 1984, she moved to the George received the College’s highest contributions to the College, her Washington University Medical honor, the Distinguished service to the larger philanthropic Center, Washington, DC, where Service Award, in 2011. community, her longstanding she began as chief, division record of ACS volunteerism, and of plastic and reconstructive a career-long dedication to the surgery, and director, residency Generous philanthropist quality of surgical patient care. training program, and ultimately As an ACS donor since 1994, A graduate of St. Louis ascended to professor of surgery. Dr. McGrath’s generous University School of Medicine, She has held her current position philanthropy has elevated her to MO (1970), she completed her at UCSF since 2003. She has the Fellows Leadership Society general surgery residency at the held many national positions in Legacy Circle, one of the top University of Colorado Medical plastic surgery and is currently giving tiers that ACS Foundation Center, Denver (1976), and trained president-elect of the American donors may achieve. Remarking in plastic surgery at the Yale Association of Plastic Surgeons. on her reasons for supporting University School of Medicine A Fellow of the College since the ACS, she said, “The surgical (1976–1978), New Haven, CT. 1983, Dr. McGrath has provided profession and other surgeons exceptional service to the ACS have enabled me to be personally and has served for 25 years in and financially successful, Contributions to the profession leadership roles, including First for which I am tremendously Since then, Dr. McGrath has Vice-President (2007–2008); grateful. I encourage other made outstanding clinical and Vice-Chair, Board of Regents Fellows to consider making academic contributions to the (2005–2006); member, Executive their own contributions and join field of plastic surgery, especially Committee, Board of Regents the community of colleagues in the areas of breast and (2002–2006); Regent (1997– planning to see surgery survive hand surgery, wound healing, 2006); and Chair, Committee successfully in the future.” ♦ introduction of new technology, on Ethics (2003–2006).

OCT 2016 BULLETIN American College of Surgeons You would expect nothing less from the Bulletin.

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ACS NSQIP National Conference inspires participants to innovate to make a difference

by Jeannie Glickson and Diane Schneidman

The pursuit of quality when she called ACS NSQIP Dr. Freischlag oversees the improvement (QI) is what “a better way to keep patients University of California (UC) drives surgeons and other safe.” Speakers throughout the Davis Health System’s academic, health care professionals to conference described steps they research, and clinical programs, attend the American College take to ensure patient safety. including the School of Medicine, of Surgeons Annual Surgical The conference offered a variety the Betty Irene Moore School Quality Improvement Program of sessions aimed at reducing of Nursing, the 1,000-member (ACS NSQIP®) conference, said surgical complications, applying physician practice group, and Clifford Y. Ko, MD, MS, MSHS, FACS, QI concepts to difficult surgical UC Davis Medical Center. Director, ACS NSQIP and ACS problems, and maximizing “Surgeons fret and we worry Division of Research and Optimal efficiency and resource use in because we care,” Dr. Freischlag Patient Care, in his welcoming health care. Many sessions also said. “Despite our best efforts, | 73 remarks at the 11th annual ACS offered strategies for adapting someone’s going to return to the NSQIP Annual Conference. The to a changing health care hospital, and as a surgeon, you theme of this year’s conference, environment and using evidence- need to generate ways to bounce July 16−19 at the San Diego based tools and case studies to up.” Lack of resilience often leads Bayfront Hilton, CA, was improve organizational culture. to burnout, which manifests Innovate to Make a Difference. This year’s meeting was itself as anxiety, depression, “Everybody wants to innovate, co-chaired by E. Patchen broken marriages/relationships, but few want to change,” Dellinger, MD, FACS, professor alcoholism, substance abuse, Dr. Ko told the gathering of and vice-chairman, and chief, and suicide. “Surgeons have nearly 1,500 surgeon champions division of general surgery, to learn how to reboot, so (SCs), surgical clinical reviewers University of Washington they don’t drive the people (SCRs), and other QI leaders. Medical Center, Seattle; and around them crazy,” she said. “What we’re fighting is the Molly Clopp, RN, MS, strategic She offered suggestions for attitude that, ‘We’ve always leader, patient safety, Kaiser avoiding burnout, including done it this way.’ Our goal is to Permanente, San Francisco, CA. staying connected to other people. find better ways to do things “When things are not going well, and to make changes in the take the time to see a friend,” way we approach standards Keynote address: Resilience she said. “People are what will of care,” he said. Comparing Surgery is all-consuming—from get you through the toughest the QI task to moving an training to practice—but it also times.” Find mentors and be a immense boulder, Dr. Ko said, can be highly rewarding, said mentor, she advised. Be a good “Every day, we’re working to Julie A. Freischlag, MD, FACS, Past- colleague, and try to help your move that boulder uphill.” Chair, ACS Board of Regents, colleagues who are experiencing Dr. Ko said that New York in her keynote address, Career burnout. “Do not hesitate to have Times blogger Pauline Chen, Satisfaction by Way of Resilience. those difficult conversations,” MD, FACS, got it right years ago An academic health care leader, Dr. Freischlag said.

OCT 2016 BULLETIN American College of Surgeons NEWS

“What we’re fighting is the attitude that, ‘We’ve always done it this way.’ Our goal is to find better ways to do things and to make changes in the way we approach standards of care,” Dr. Ko said.

Dr. Ko

Dr. Freischlag noted that to understand your culture in Payment Program (QPP). the health care paradigm order to change it,” she said. Physicians have two pathways has changed, with patients “Learn to be resilient. When to participation in the QPP: the driving quality improvement, they tell you that you can’t, Merit-based Incentive Payment and surgeons need to be tell them that you can, and System (MIPS) or advanced resilient in response to make sure you’re right.” Alternative Payment Models these changes, as well. (APMs). (See related story, page “As surgeons, we’ve got 20 of this issue.) Surgeons who to move forward,” she said. Town Hall put the patient at the center Earlier in her career, when New at this year’s conference was of care should do well under she worked for the Veterans a Town Hall with ACS Executive MACRA, Dr. Hoyt said. 74 | Health Administration (VHA), Director David B. Hoyt, MD, FACS, Surgeons are well-positioned Dr. Freischlag recalls that moderated by Bruce L. Hall, MD, to lead QPP implementation, members of the operating room PhD, MBA, FACS, professor of as they have been leading the (OR) team worried that if they surgery, Washington University; charge toward patient-centered, reported their complications vice-president of quality, Barnes evidence-based care for more they would create problems for Jewish Hospital, St. Louis, MO; than a century. “Surgeons have the VHA and their colleagues. and ACS NSQIP Consulting been the most aggressive among Today, reporting problems Director. Dr. Hoyt reviewed health care professionals in and understanding why legislative and regulatory issues engaging quality improvement,” they occur are considered affecting surgery and the role Dr. Hoyt said. “We now have to part of the solution. of ACS Quality Programs in be accountable to our patients, ACS NSQIP is based on the influencing these initiatives and surgeons are as ready as premise that members of the and their implementation. anyone for this challenge.” surgical team can learn from A key factor driving health Performance is going to their mistakes—that they can be care reform in the U.S. is cost, be measured, and without in a state of continuous quality according to Dr. Hoyt. “The cost valid, robust data that flow improvement. According to of health care has woken us up,” from QI initiatives, hospitals Dr. Freischlag, surgeons should he said, and there is pressure to cannot accurately compare be judged not by their mistakes, lower it. Many of the legislative their performance with other but by their resilience—how well and regulatory responses to rising hospitals or between patients. they recover from an error. “I health care spending have focused “We’ve got to create the don’t measure success by how on physician payment reform. intellectual trust, because high a surgeon climbs, but how Most recently, the Medicare if we do, important people that surgeon bounces back from Access and CHIP (Children’s will follow,” Dr. Hoyt said. rock bottom,” Dr. Freischlag said. Health Insurance Program) Other ACS quality-related Culture trumps everything, Reauthorization Act (MACRA) activities that Dr. Hoyt discussed Dr. Freischlag added. “You have of 2015 established a new Quality included the development

V101 No 10 BULLETIN American College of Surgeons NEWS

Dr. Dellinger and release of statements on unresolved without a change more change, and hardwire perioperative care and OR attire; in the institutional culture. the changes into the culture. efforts to ensure that general “Leading and managing surgery residents are adequately change is a lot harder than it prepared for surgical practice looks,” according to session Surgeon champions when they finish training, moderator Nestor F. Esnaola, MD, In a breakout session for new including the ACS Transition MPH, MBA. Surgical leaders must SCs, Charles A. Lane, MD, FACS, to Practice program; and the guide the change management a general and laparoscopic changing surgical culture. process, said Dr. Esnaola, surgeon, Maryville, IL, urged “I think it’s an exciting time associate director, cancer health SCs not to “criticize, condemn, to be a surgeon,” Dr. Hoyt disparities and community or complain. The challenge said. “We’ve got to change engagement; attending surgeon, is to engage and influence | 75 the culture, and we’ve got gastrointestinal oncology, your colleagues,” he said. to have the right tools.” hepatopancreaticobiliary “You will become the face surgery; and sarcoma professor, of [your institution’s] quality department of surgical oncology, improvement program, and Managing change Fox Chase Cancer Center, Temple they’ll be counting on you to be In a preconference session, University, Philadelphia, PA. the change agent.” He advised: SCs, SCRs, and other attendees “Change is not an event,” he Take the softer approach. reviewed a case study involving said. It’s a planned and structured Always ask them to consider a hospital that had received an process, and it only can occur something. Don’t show anger ACS NSQIP report showing that when change champions get or frustration. Good opening its surgical site infection (SSI) buy-in across the department phrases include “Tell me more rates were increasing. Session and institution, preferably from about it,” and “What are your participants determined that people who are in high-power/ thoughts?” Show humility, he this problem could be attributed high-influence positions initially. said. Listen more, and talk less. to a range of factors, including To motivate health care Pierre F. Saldinger, MD, miscommunication during professionals to accept change, FACS, chairman, department of patient handoffs, conflicts you have to “shock them out surgery, surgeon-in-chief, New between the surgical staff of the status quo.” Show them York-Presbyterian, Queens, and the circulating nurses, high-quality data that point discussed local organizational administrative pressures to a real problem, Dr. Esnaola culture. “Culture is what people to cut costs, a shortage of said. Communicate a vision and do when no one is looking,” he intensive care beds, and strategy for change, and empower said. A cynical attitude toward changes in leadership in broad-based action. Start with change and a lack of faith in anesthesiology. The group small improvements that people the organization’s ability to determined that many of can see and appreciate. Then, transform itself are examples these issues would remain explain the gains to drive of barriers to change.

OCT 2016 BULLETIN American College of Surgeons NEWS

“Despite our best efforts, someone’s going to return to the hospital, and as a surgeon you need to generate ways to bounce up,” said Dr. Freischlag.

Dr. Freischlag

In another session for SCs, be passionate about surgery and Permanente, Oakland, CA. “The Robert E. Glasgow, MD, FACS, surgical outcomes, and you have leaders are very interested in the professor of surgery, University to be willing to try to change the return on their investment, so I of Utah School of Medicine; culture [in your institution].” keep them continually informed section chief, gastrointestinal SCs also need to have some about how much money we’ve and general surgery, division standing within the institution saved the hospital over time.” of general surgery; and vice- and have demonstrable chairman, clinical operations leadership skills, Dr. Cofer said. and quality and chief value They need to be magnanimous Learning from mistakes officer, department of surgery, and effective communicators, Panelists at a general session University of Utah, Salt and they need the support of described what they learned 76 | Lake City, emphasized the an effective infrastructure. from projects that did not importance of actively using go according to plan. ACS NSQIP reports to drive Saulat S. Sheikh, MB, BS, general change. Allan Siperstein, MD, Collaboratives must collaborate surgery resident, York Hospital, chair of endocrine surgery; Many successful ACS NSQIP PA, noted that SSIs account for program director, general participants are part of approximately $8.6 billion in surgery residency program and collaboratives. Karl Y. Bilimoria, health care spending, according endocrine surgery fellowship; MD, FACS, led a pre-conference to a report from The Joint and SC, Cleveland Clinic, OH, workshop on the growing Commission Center for noted that his institution sought number of ACS NSQIP Transforming Health Care.* The to reduce SSIs. They succeeded collaboratives. Dr. Bilimoria goal at York Hospital was to bring in this effort by implementing is a surgical oncologist and the colorectal infection rate in standardized steps in the OR. director, Surgical Outcomes line with the national average. Joseph B. Cofer, MD, FACS, and Quality Improvement The hospital implemented professor of surgery and surgery Center, Feinberg School of an SSI prevention bundle and residency program director at the Medicine, Northwestern monitored the change in SSI rate. University of Tennessee College University, Chicago, IL. After initial success, the hospital of Medicine, Chattanooga, has Participants gathered at witnessed a substantial jump in been involved in ACS NSQIP roundtables and provided SSIs. According to Dr. Sheikh, and an SC for 11 years. To be an overviews of their collaboratives, the lessons learned are that effective SC, he said, “You have to sharing stories about their success does not always occur successes and challenges. continuously, and failure can lead *Joint Commission Center for Transforming Buy-in from the collaborative’s SCs to ask the right questions. All Health Care. Reducing Colorectal Surgical institutional leadership will stakeholders must be involved, Site Infections December 2014. Available largely determine the group’s and a clear implementation plan at: www.centerfortransforminghealthcare. org/assets/4/6/SSI_storyboard. success, said Olakunle Ajayi, MD, and measures for compliance pdf. Accessed July 27, 2016. a colon-rectal surgeon, Kaiser must be in place, he added.

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“Surgeons have been the most aggressive among health care professionals in engaging quality improvement,” Dr. Hoyt said. “We now have to be accountable to our patients, and surgeons are as ready as anyone for this challenge.”

Dr. Hoyt

Other speakers included operations and OR, Kaiser ERAS in small and community the following: Permanente San Jose Medical hospitals. Rural and small Center, CA, and Paul Preston, hospitals serve approximately • Elizabeth C. Wick, MD, FACS, a MD, anesthesiologist, Kaiser 23 percent of the U.S. population, colorectal surgeon and assistant Permanente, San Jose, and 20 percent of their patient professor of surgery, Johns offered a view of enhanced population is age 65 and older, Hopkins University Medicine, recovery after surgery (ERAS) Dr. Ahuja said. The challenges of Baltimore, MD, who discussed programs at Kaiser. providing quality care to these readmissions after complex The Kaiser team promoted patients include remote location, abdominal operations the ERAS tagline, “Get up, which can make it difficult to get moving, get better,” and recruit skilled staff; surgeons • Jyotirmay Sharma, MD, FACS, developed a detailed plan for each with less experience than their | 77 director, thyroid and endocrine patient, including specific pre- counterparts in larger hospitals surgery, Emory University and postoperative instructions for because of the low volume of Hospital; associate professor pain control, diet, exercise, and certain procedures done; and of general and endocrine other factors that affect recovery. distance to tertiary centers. surgery, division of general Kaiser targeted colorectal and hip and gastrointestinal surgery, fracture patients for the ERAS department of surgery, Emory program and used ACS NSQIP Improving pediatric and University School of Medicine; data to evaluate outcomes. The geriatric surgical care and SC, Emory University protocol included preoperative The ACS has developed two Hospital, Atlanta, GA, who counseling, nutritional programs to address the unique discussed his institution’s guidance, and administration of needs of pediatric surgical efforts to prevent hypothermia prescription painkillers. Kaiser patients: the Children’s Surgery during complex procedures found that ERAS reduced the Verification™ (CSV) Quality length of stay for patients with Improvement Program and • Ryan D. Macht, MD, a general hip fractures by 39 percent ACS NSQIP Pediatric. surgery resident at Boston and for colorectal patients by Keith T. Oldham, MD, FACS, University Medical Center, MA, 19 percent. Patient care improved professor and chief, division of who spoke on patterns of failure based on multiple metrics, pediatric surgery, Medical College identified in a standardized including pain management; of Wisconsin, Milwaukee, and venous thromboembolism occurrence of transfusion, Chair, CSV program, noted prophylaxis protocol urinary tract infection, and that pediatric surgery patients venous thromboembolism; require different resources and patient satisfaction. than their adult counterparts. ERAS Vanita Ahuja, MD, FACS, However, “even today, a large Efren E. Rosas, MD, assistant WellSpan York Hospital, PA, segment of children receive care physician-in-chief, hospital spoke on barriers to implementing in nonspecialized environments,”

OCT 2016 BULLETIN American College of Surgeons NEWS

Dr. Oldham said. These general said. Specific changes included hospitals often lack the proper implementation of standards instrumentation and specialists defining who can operate on needed to provide effective children without the supervision pediatric care. The CSV program of a pediatric specialist, adverse seeks to ensure that all hospitals event analysis, and increased are equipped to address the needs pediatric on-call care. of pediatric patients and that These changes happened “every child in need of surgical through the work and guidance care in North America today of a multidisciplinary children’s will receive care in an optimal surgical performance and 78 | environment,” Dr. Oldham said. patient safety committee, That vision culminated earlier Dr. Farmer said, allowing this year with the release of multiple departments and Optimal Resources for Children’s key personnel within the Surgical Care—the nation’s first hospital at-large to collaborate, Dr. Hall and only multispecialty standards which was paramount to for children’s surgical care. The the program’s success. ACS developed the standards Similarly, Texas Children’s with the Task Force for Children’s Hospital, Houston, another Surgical Care with an eye toward pilot site, established a ensuring hospitals follow the multidisciplinary surgical College’s four guiding principles quality committee (SQC), of QI—set the standards; build according to director of the right infrastructure; use the strategic projects Laura Higgins, right data; and don’t trust, verify. Esq. The SQC provides the Diana L. Farmer, MD, FACS, infrastructure necessary FRCS, pediatric surgeon and to support QI initiatives, chair, department of surgery, UC Ms. Higgins said. It has helped to Davis, and a member of the ACS improve accountability, prevent Board of Governors Executive duplication of efforts, and ensure Committee, said her institution availability of optimal resources. Dr. Ahuja served as a pilot site for the CSV Jacqueline M. Saito, MD, FACS, program. Participation in the pilot assistant professor of surgery, created early quality benefits for division of pediatric surgery, pediatric patients at UC Davis, Washington University School including enhanced efficiency, of Medicine, and a pediatric safety, and performance, she surgeon at St. Louis Children’s

V101 No 10 BULLETIN American College of Surgeons NEWS

“What makes surgery unique is that it requires harm in order to heal,” Dr. Angelos said. “Healing cannot occur without actions that would be illegal in any other context. It is an intensely physical relationship.”

Hospital, MO, described how Surgery and Outcomes. The BEST PRACTICES that institution used ACS NSQIP session examined gauging Pediatric data reports as a patient frailty and other signs Each year, ACS NSQIP issues a “prompt for a deeper dive” into of readiness for surgery. call for abstracts to participating adverse outcomes. This in-depth “Despite recent hospitals to submit presentation analysis was carried out through improvements in surgical topics on how they have used a multidisciplinary performance technique, patient selection, and improvement and patient safety perioperative care pathways, ACS NSQIP to improve patient (PIPS) program. The PIPS 25 percent to 40 percent of care. Awards honored authors group reviewed surgical deaths, patients undergoing liver in three abstract areas: complications, and other adverse resection develop a postoperative events and compared quality complication,” partly because • Clinical Abstract Competition: | 79 performance metrics to national they are too frail to withstand David D. Odell, MD, MMSc, benchmarks. These findings the procedure and recovery, said assistant professor of surgery, were used to address outliers. Timothy M. Pawlik, MD, MPH, PhD, Northwestern University Feinberg In addition, R. Lawrence FACS, a colon and rectal surgeon, School of Medicine, Chicago. Moss, MD, FACS, surgeon-in- Johns Hopkins University The Impact of Hospital Safety chief, Nationwide Children’s School of Medicine. Dr. Pawlik Culture on Surgical Outcomes Hospital, Columbus, OH, and his colleagues at Hopkins spoke on the importance of developed a frailty index based • Resident Abstract Competition rare patient safety events as a on routine preoperative clinical Winner: Mary M. Mrdutt, measure of performance. In characteristics to predict MD, Texas A&M College of fact, analysis of such events led postoperative complications Medicine, Temple. Where Are to the development of a Wake and postoperative mortality We Now? Two-Year Review of Up Safe anesthesia program. following liver surgery. a Single-Institution Experience Several sessions examined Blair C. Baldwin, DO, a general Implementing a Pilot Quality geriatric surgery. Thomas N. surgery resident at Berkshire In-Training Initiative Curriculum Robinson, MD, FACS, a member Medical Center, Pittsfield, of the ACS Task Force on MA, and colleagues sought to • Surgical Clinical Review Abstract Geriatric Surgery and associate determine whether inguinal Competition Winner: Lori E. professor of surgery, University hernia repair can be performed Abel, RN, ONC. MEd, surgical of Colorado, Aurora, and effectively in elderly patients. quality expert, Lancaster General Ronnie A. Rosenthal, MD, FACS, Their research shows that Health System/Penn Medicine, Chair, Task Force on Geriatric surgeons should offer elective PA. Post-Operative Pneumonia Surgery, and professor of inguinal hernia repair to their Reduction in Surgical Patients surgery, Yale University School elderly patients, although they of Medicine, New Haven, endorsed further study of CT, led a session on Elderly whether watchful waiting or

OCT 2016 BULLETIN American College of Surgeons NEWS

Dr. Aloia

elective surgery is more effective Jonathan S. Abelson, MD, a School of Medicine; and co- in patients ages 80 and older. general surgery resident at New director, Huntsman Cancer Jennifer Dwyer, MD, Nebraska York Presbyterian Hospital, Institute’s thoracic oncology Medical Center, Omaha, New York, described a study of program, Salt Lake City. reported on a study designed his institution’s use of the ACS According to Dr. Varghese, under to determine whether the risk NSQIP Surgical Risk Calculator the ACS Strong for Surgery analysis index score—a measure in weekly morbidity and model, health care providers of frailty—correlates with mortality conferences. The study use a series of checklists and complications after urologic showed that the risk calculator tools first developed at the operations. The study indicated can be particularly effective in University of Washington, that frailty affects both primary predicting patients with “above Seattle, in four modifiable areas 80 | (mortality and pulmonary, average” risk of complications. to ensure the patient’s optimal cardiac, and infectious Julia Berian, MD, an ACS readiness for operative care: complications) and secondary Clinical Scholar in Residence nutrition, blood sugar, smoking (length of stay, readmission, who has played a significant status, and medication use. return to the OR, discharge role in the ACS and the John A. destination) outcomes. Hartford-supported Coalition Luis A. de la Cruz, MD, MBA, for Quality in Geriatric Surgery, Surgical ethics Baptist Hospital of Miami, also spoke, offering insights Peter Angelos, MD, PhD, FACS, described how a strategy into future directions in this Linda Kohler Anderson Professor combining risk stratification, growing surgical arena. of Surgery, chief, endocrine protective intraoperative surgery, and associate director, interventions, and postoperative MacLean Center for Clinical renal function monitoring ACS Strong for Surgery Medical Ethics, University of significantly reduced the To ensure that all patients Chicago Medicine, explored incidence of acute renal failure are in optimal condition for the concept of professionalism. in noncardiac surgery patients. operative care, the College Surgical professional ethics Beth Turrentine, PhD, RN, will be leading a national ACS centers on three factors: the trauma care coordinator, Strong for Surgery initiative. surgeon-patient relationship, the acute care nurse practitioner Each year, approximately 210,000 invasive nature of surgery, and instructor, University of preventable deaths occur in U.S. informed consent for surgery. Virginia, Charlottesville, offered hospitals—half during some “What makes surgery unique insights into a study that tested phase of surgical care, according is that it requires harm in order the hypothesis that sarcopenia, to Thomas K. Varghese, Jr., MD, to heal,” Dr. Angelos said. as measured by preoperative MS, FACS, head, general thoracic “Healing cannot occur without computed tomography scans, surgery, University of Utah; actions that would be illegal predicts morbidity and mortality associate professor, department in any other context. It is an in emergent laparotomy. of surgery, University of Utah intensely physical relationship.”

V101 No 10 BULLETIN American College of Surgeons NEWS

Dr. Kelz (left) and Dr. Guillamondegui

Informed consent in surgery is not a workable concept residency program, University allows patients to actively in surgery. If it were, high- of Pennsylvania, Philadelphia, participate in the medical risk patients would never spoke on the privilege of being decision-making process and receive surgical care. a surgeon and of forming is rooted in respect for patient “The surgeon has to balance relationships with patients autonomy, Dr. Angelos said. issues of safety and quality,” he when they often are at their Informed consent involves said. Safety has to do with the most vulnerable. Dr. Kelz noted more than ticking off the risks, absence of harm to the patient, that she has the privilege of benefits, and alternatives to the whereas quality has to do with being able to reassure them patient; it also involves building efficient, effective, purposeful that they will be okay, and trust. “Good data are essential care that gets the job done at that they are not alone. for informed consent, but that the right time for the right “All of us in this room | 81 is not enough,” Dr. Angelos cost. Safety focuses on avoiding have the potential to said. “People don’t want to be bad events. Quality focuses on lead extraordinary lives,” operated on by people who can’t doing things well. “Safety can Dr. Kelz said. By providing talk to them. The responsibility drain a provider’s morale, but compassionate, quality care of surgeons goes beyond what quality builds provider morale,” to surgical patients, she said, happens in the OR.” It is the he said. “That’s why enhanced “we have the opportunity surgeon’s job to educate the recovery has taken off.” to extend our lives. We patient about the condition, to Kimberly McKinley, BSN, have the opportunity to clarify the goals of the operation, RN, quality leader, BC [British be extraordinary.” and to ensure that the patient Columbia] Patient Safety and Offering advice for the is aware of risks, he added. Quality Council, Penticton, modern surgeon was Oscar D. BC, spoke about physician- Guillamondegui, MD, MPH, FACS, patient communication. “We’ve professor of surgery medical Personal perspectives all heard the expression, ‘It’s director, trauma intensive Several presenters at this year’s not what you say—it’s how care unit; director, Vanderbilt conference focused on personal you say it,’” she said. “But I Multidisciplinary Traumatic stories, which they offered in truly believe that what we Brain Injury Clinic; and vice- a more conversational style. say matters. Nothing can chairman, surgical quality, Thomas A. Aloia, MD, FACS, override the power of a few safety, and professionalism, asked, “Should zero [errors] poorly chosen words. Think of Vanderbilt University School be the goal?” According to the power of your language, of Medicine, Nashville, Dr. Aloia, SC and associate and take ownership of it.” TN. “Surgeons graduate professor of surgical oncology, Rachel R. Kelz, MD, MSCE, from the school of anxiety,” division of surgery, University FACS, an endocrine and oncologic Dr. Guillamondegui said, of Texas MD Anderson Cancer surgeon and associate program pointing to the high rates of Center, Houston, perfection director of the general surgery depression and suicide among

OCT 2016 BULLETIN American College of Surgeons NEWS

surgeons. “Stop comparing touchdown,” he added. “Just associate professor of surgery, yourself to other surgeons. We’re score the touchdown.” division of general surgery, all good, but learn from your Lillian Kao, MD, FACS, professor, Medical University of South mistakes,” he said. Vulnerability is department of surgery, division Carolina, Charleston, said what allows surgeons to do that. of acute care surgery, Lyndon his experience as a firefighter Baines Johnson General Hospital taught him the importance and Clinic, University of Texas, of camaraderie. Dr. Sakran Residents as leaders Houston, explained what she defines organizational culture as The conference closed with a learned about “cultivating “civilization in the workplace.” session aimed at the future of culture” as president of the Each organization’s culture is surgical innovation—surgical Association for Academic Surgery: unique. “Anyone can copy a residents—which Dr. Kelz company’s strategies, but you moderated. In this session, young • Diagnose the current state can’t copy its culture,” he said. surgeons described how their roles of the team culture. Dr. Sakran outlined the in other arenas have prepared following core concepts that he 82 | them for surgical leadership. • Discuss results and brainstorm promotes in his organization: John F. Sweeney, MD, FACS, for possible improvements. chair, department of surgery, • Engage your patients. Emory University, described • Create a staff compact. the lessons he learned as a • Communicate effectively and high school and collegiate • Create opportunities “listen with intent to understand.” football player as follows: for interaction. • Encourage camaraderie building • Culture begins at the top. • Meet regularly. by having team huddles and debriefings and spending time • Know and understand the • Strengthen the team by focusing with the team outside of the OR. legacy of your organization; on individual development. an institution’s legacy • Move away from informs its culture. • Get to know team members. management structures.

• If you prepare and work hard, • Teach leaders to be mentors, • Demonstrate humility. opportunity will present itself. not just managers. • Coach with clarity. • Celebrate success, but • Create an environment that don’t get cocky. encourages learning. • Provide flexibility.

• Be confident in your • Find a way to foster • Offer real-time feedback. abilities and be optimistic new membership. about the outcome. The next ACS NSQIP Annual Joseph V. Sakran, MD, Conference will take place July Importantly, “Don’t be MPH, MPA, FACS, who at the 21–24, in New York, NY. ♦ concerned who scores the time of the conference was

V101 No 10 BULLETIN American College of Surgeons INTRODUCING A Mirror Reflecting Surgery, Surgeons, and their College: The Bulletin of the American College of Surgeons

Copies of this recently published book will be for sale during Clinical Congress 2016 in Washington, DC. Please visit the Logo Shop, which will be located in the ACS Resource Center in the Exhibit Hall. The book is also available for purchase from amazon.com. The first 100 people to purchase a book from the Logo Shop will receive a signed copy.

David L. Nahrwold, MD, FACS, wrote this engaging account of the rich history of the Bulletin of the American College of Surgeons. Dr. Nahrwold served as a Regent, Chairman of the Board of Governors, First Vice-President, and Interim Director of the American College of Surgeons, and received its Distinguished Service Award. He is co-author, with Peter J. Kernahan, MD, PhD, FACS, of A Century of Surgeons and Surgery: The American College of Surgeons 1913–2012.

Price: $15.95

Published by the American College of Surgeons. NEWS

Ethics Committee Town Hall on industry representatives in the OR highlights issues outlined in ACS statement

by Enrique Hernandez, MD, FACS; and Mark C. Weissler, MD, FACS

The American College of open avenues of communication Surgeons (ACS) recently Role of industry in patient care would help define the optimal issued an updated Statement The Town Hall participants relationship between the two. on health care industry agreed that relationships Participants concluded that representatives in the operating between surgeons and industry industry representatives fall room (OR) (see page 48, this representatives are beneficial into one of two categories: 84 | issue), the purpose of which for both parties. Industry technical and sales. Some is to “supply guidelines to representatives can provide surgical specialties rely on health care facilities and surgeons with important the presence of the industry members of the perioperative technical information and technical representative in care team to ensure optimal assistance. Furthermore, the OR; vascular surgery is surgical outcomes, to ensure at a time when funding for an example. When a graft is patient safety, and to protect continuing medical education needed, the caliber and length patients’ rights to privacy and medical research is of the graft selected before and confidentiality when decreasing, the pharmaceutical surgery can change based on [a health care industry and device industry should intraoperative findings. The OR representative] is present be a transparent partner with may stock only a limited number during a surgical procedure.” the medical and scientific of grafts because it is financially The College has had an community. Conflicts of prohibitive for the OR to stock active interest in this matter interest need to be avoided, or a large selection. The industry for some time. At Clinical at least identified and managed representative has access to and Congress 2015, the ACS appropriately. Guidelines can supply a selection of grafts Committee on Ethics hosted governing how to structure and that will accommodate the needs a Town Hall meeting that operationalize the relationship of the patient. Similar examples brought together roughly 30 also need to be established. of this symbiotic relationship surgeons and representatives of The conversation at the Town between the surgeon and the the pharmaceutical and device Hall meeting highlighted some industry technical representative industries in a session titled, Do of the realities, ethical issues, and can be found in other surgical You Want (or Need) the Sales best practices that can guide the specialties, such as orthopaedics. Rep in Your OR? In light of the interaction between the surgeon This relationship benefits updated statement, this article and the industry representative all involved parties, including reviews some of the issues in the OR. Participants the patient. However, the discussed at that meeting. generally agreed that more patient has the right to self-

V101 No 10 BULLETIN American College of Surgeons NEWS

The College recognizes the importance of the health care industry representative and the benefits that the relationship between these individuals and the surgeon can provide patients.

determination and therefore between industry and the CME- their equipment and devices should be informed if an industry sponsoring organization onerous, in an area outside the OR. representative will be in the OR. which has caused both parties to One of the challenges is timing. shy away from such interaction. • Surgeons who participated in Informing the patient on the day It has been suggested that the the Town Hall meeting were of surgery in the preparation ACS and other professional of the opinion that industry area may make it difficult for the education organizations look representatives should not have patient to refuse. In addition, to for mechanisms that will access to the surgeons’ lounge. preserve the patient’s privacy, avoid conflict of interest, real the industry representative or perceived, which would • Industry representatives should should not enter the OR until allow industry to support CME be registered, verified, and the patient is fully draped. activities for the advancement distinctively identifiable. In The introduction of new of surgical care. It also was many hospitals, the industry surgical equipment and suggested that the industry representatives wear different | 85 technology also can benefit breakfast that brought industry colored caps or scrubs. the patient. Surgeons usually representatives and surgical are introduced to new devices leadership together at the • Some hospitals include in and technology by industry annual Clinical Congress in their informed consent sales representatives. Even the past be reinstituted. forms for surgery that an when the surgeon has become industry representative may proficient in the use of the be present in the OR at the new equipment or technology, Recommendations surgeon’s discretion. the industry representative Some of the suggestions and/or may be needed in the OR to guidelines discussed at the Town The College recognizes the help troubleshoot unexpected Hall meeting and incorporated importance of the health care difficulties. The policies or into the College’s policy statement industry representative and the guidelines of each hospital include the following: benefits that the relationship will facilitate the interaction between these individuals and between the surgeon and the • Industry representatives should the surgeon can provide patients, industry representative without not have access to private patient and the revised statement on this disrupting patient privacy and or surgeon information (such as topic provides guidelines on how safety. This interaction should access to the full OR schedule). to structure the relationship. ♦ be transparent and organized. Another mechanism by which • Invited industry representatives surgeons become familiar with should make an appointment new equipment and technology and not just show up in the OR. is through Continuing Medical Education (CME) programs. • Many hospitals have “industry However, some of the current fairs,” where industry regulations have made contacts representatives can demonstrate

OCT 2016 BULLETIN American College of Surgeons ACS Practice Management Course for R ES I D E N T S and YO U N G S U R G EO N S Now Available Online.

The ACS Practice Management Course for Residents and Young Surgeons, Volumes I, II, and III are designed to educate and equip participants with basic practice management skills and the knowledge to manage a surgical practice.

Using an interactive/lecture format, NEW topic in each volume: the three separate courses cover a variety of topics, including: zzVolume 1: Interpersonal and Communication Skills—An Important Competency for zzPros and cons of a career Risk Management in private practice zzVolume 2: Professionalism—A Critical Risk zzSurgical practice organization Management Tool zzCoding for surgical residents zzVolume 3: Postadverse Event Communication— The Key! zzSurgical financial management reports zzInsurance processing To access the ACS Practice Management Course today, visit www.facs.org/education/ zzAccumulation planning resources/elearning. zzGoal planning and risk management For more information, contact Olivier Petinaux, zzNegotiation Senior Manager, Distance Education and zzLiability equation changes E-Learning, at [email protected] or 866-475-4696.

AMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION Blended Surgical Education and Training for Life NEWS

Dr. Ajit Sachdeva takes helm of the Society for Academic Continuing Medical Education

Dr. Sachdeva addresses the World Congress on Continuing Professional Development shortly after his induction as president of SACME

Ajit K. Sachdeva, MD, FACS, FRCSC, of a broad spectrum of standard- associate dean for medical Director of the American College setting education, training, education and director of the of Surgeons (ACS) Division of verification, validation, and Academic Center for Educational Education, was inducted earlier accreditation programs that are Excellence at that institution. In this year as president of the aimed at promoting excellence addition, Dr. Sachdeva served Society for Academic Continuing and expertise in surgery. He as chief of surgical services Medical Education (SACME) at the is currently pursuing the at the Philadelphia Veterans World Congress on Continuing development of a national system Affairs Medical Center (dually Professional Development in to address the training and affiliated with the University San Diego, CA. Dr. Sachdeva retraining needs of surgeons of Pennsylvania and MCP previously served as SACME at various stages of their Hahnemann School of Medicine) | 87 president-elect and vice-president. professional careers. Dr. Sachdeva for 10 years. Dr. Sachdeva has SACME plays a key national also is adjunct professor of served as chair of the Committee and international leadership surgery at the Feinberg School on Surgical Education of the role in advancing Continuing of Medicine, Northwestern Society of University Surgeons Medical Education (CME) University, Chicago, IL. and as chair of the Education through research and scholarship. Dr. Sachdeva received his Subcommittee (Study Section) Membership in SACME includes medical training at the All-India of the National Cancer Institute. deans of CME from medical Institute of Medical Sciences, New Dr. Sachdeva has received schools throughout the U.S. and Delhi. He completed a surgery many prestigious awards for Canada, CME directors from residency at the Hospital of the his contributions to surgical academic health centers, doctoral- Medical College of Pennsylvania and medical education. He has level professional educators, (MCP), Philadelphia, and has published widely in eminent vice-presidents and directors held specialty certification in peer-reviewed journals on of education from medical and surgery since 1981. Dr. Sachdeva educational topics and has surgical specialty societies, and has participated in the Harvard delivered invited presentations other stakeholders involved Macy Institute Program for across the U.S. and in Canada, with the fields of CME, quality Leaders in Medical Education. Europe, Australia, and Japan. improvement, and patient safety. Before joining the College, Dr. Sachdeva has served as Dr. Sachdeva has made Dr. Sachdeva was the Leon C. president of several national landmark contributions to Sunstein, Jr., Professor of Medical professional organizations, the evolving field of CME and and Health Science Education and including the Association for has focused specifically on the professor and vice-chairman for Surgical Education, American education and training needs educational affairs, department Association for Cancer of surgeons in practice. His of surgery, at the MCP Education, Alliance for Clinical vision and work have led to the Hahnemann School of Medicine, Education, and Council of development and dissemination Philadelphia, PA. He also was Medical Specialty Societies. ♦

OCT 2016 BULLETIN American College of Surgeons NEWS

National Medical Association honors Dr. Turner with Service Award

Patricia L. Turner, MD, FACS, Director of the American College of Surgeons Division of Member Services, received the 2016 National Medical Association (NMA) Council on Concerns of Women Physicians (CCWP) Service Award. Dr. Turner received the award July 31 at the CCWP Annual Muriel Petioni, MD, Awards Luncheon, which took place at the NMA’s 114th Dr. Turner (second from left) with (from left) Rachel Villanueva, MD, secretary, NMA house of delegates; Garfield A. D. Clunie, MD, NMA Annual Convention and Scientific chairman of the board; and Camille A. Clare, MD, chair, CCWP Assembly in Los Angeles, CA. This award honors women physicians who, through research, community service, and activism, strive to eliminate health care disparities, provide people of color with quality health care, and address women’s health and professional issues. The awards program, the most highly attended event of the convention, continues to grow in popularity. This year’s program featured award-winning actress and television director Regina 88 | King. Read more about the NMA and the award at www.afassanoco.com/nma/ccwpprogram.html. ♦

TQIP now in all 50 states and Washington, DC

The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP®) is now in all 50 states and Washington, DC. The ACS TQIP program reached this milestone August 2 with the addition of Meritus Medical Center in Hagerstown, MD, a Level III TQIP Site. The TQIP pilot program began in 2009 with 23 centers, and the full TQIP program launched in 2010 with 65 centers. In 2014, Pediatric TQIP was added, and on July 1 of this year, Level III TQIP was launched. As of September 20, TQIP has 602 enrolled sites (434 Level I and II Adult Sites, 59 Level III Sites, and 109 Pediatric Sites) and anticipates continued growth this year. TQIP standardizes the collection and measurement of trauma data to generate quality improvement strategies and reduce disparities in trauma care nationwide. TQIP collects data from trauma centers, provides feedback about center performance, and identifies institutional improvements for better patient outcomes. TQIP provides hospitals with risk-adjusted benchmarking for accurate national comparisons. In addition, TQIP provides education and training to help trauma center staff improve the quality of their data and accurately interpret their benchmark reports. The program fosters clinical improvements with tools such as the Patient Listing Application, the TQIP Driller, and the expert- generated Best Practice Guidelines. TQIP provides opportunities for networking and sharing of best practices at the TQIP annual meeting, in Web conferences, and through the TQIP Google Group. For more information, visit the TQIP website at acstqip.org. ♦

V101 No 10 BULLETIN American College of Surgeons NEWS

Associate Fellows: Apply now for ACS Fellowship

Associate Fellows of the American The following is a brief your current practice location, College of Surgeons (ACS) who summary of the qualifications to serve as references for your are interested in pursuing the for Fellowship and the steps application. Applicants do not next level of membership—full necessary to apply: need to request letters; just list Fellowship—are encouraged to the names on your application apply by December 1, 2016. The • Certification by an appropriate and the College staff will ACS admits into its Fellowship American Board of Medical contact your references. only those physicians who Specialties surgical specialty If you need assistance finding devote their practice entirely board, an American Osteopathic ACS Fellows in your area, view a to surgical services and who surgical specialty board, or the list on our website at facs.org (click agree to practice in accordance Royal College of Physicians on the “Find a Surgeon” button). with the professional and ethical and Surgeons in Canada Applications must be submitted standards of the College. by the December 1 deadline The College’s standards • One year of surgical practice to be considered for induction of practice are outlined in after the completion of all formal at Clinical Congress 2017 in the Fellowship Pledge and training (including fellowships) San Diego, CA. When your the Statements on Principles application is processed, you will found on the ACS website • A current appointment at receive an e-mail notification at facs.org. All Fellows of the a primary hospital with no providing details about the | 89 College and applicants for reportable action pending application timeline along with Fellowship are expected to a request for your surgical case adhere to these standards. A full list of the requirements list. The College provides several Surgeons request and can be accessed at facs.org/ options for the submission voluntarily submit applications member-services/join/fellows. of your surgical case list. for Fellowship. In so doing, Associate Fellows who are U.S. and Canadian Fellowship they are inviting an evaluation current with their membership applicants are required to attend of their practice by their peers. dues may submit a waived-fee a personal interview by an ACS In evaluating the eligibility application online by visiting committee in their local area. of applicants for Fellowship, facs.org/member-services/join Exceptions are made for military the College investigates each and clicking on the link for applicants and in certain rural applicant’s entire surgical practice. either Fellow or International areas. You will receive notification Applicants for Fellowship Fellow. You will need your by July 15 of the action taken must provide to the appointed log-in information to access on your application. Approved committees all information the application. If you do not applicants are designated as deemed necessary for the have your log-in, contact the Initiates to be inducted as Fellows investigation and evaluation College staff at 800-293-9623 or during the Convocation Ceremony of their surgical practice. via e-mail at facsapplications@ at the Clinical Congress. It is the College’s intention facs.org for assistance. Contact Member Services that all Associate Fellows consider The application requests basic with questions at any time applying for Fellowship within information regarding licensure, throughout the application the first six years of their surgical certification, education, and process. We look forward to practice. To encourage that current hospital affiliations. having you become a Fellow of the transition, Associate Fellowship Applicants also are asked to American College of Surgeons. ♦ is limited to surgeons who have provide the names of five Fellows been in practice less than six years. of the College, preferably from

OCT 2016 BULLETIN American College of Surgeons Purchase the ACS Pearls in General Surgery 2016 Audio Package today!

Enjoy 45 audio recordings of expert summaries based on the Meet-the-Expert Luncheons at Clinical Congress. Each audio recording provides an introduction, summary of the discussion, and a conclusion. Each session runs approximately 15 minutes.

Pricing Fellows $150, Non-Fellows $225 Resident and Associate Members $75 Surgical Residents, Non-RAS Members $100 Affilliate MD/DO Members $200 For more information and to find a full listing of audio recordings, visit facs.org/education/resources/elearning. Click on “Pearls in General Surgery Audio Package” under Programs for Purchase. Questions? Please contact us at [email protected] or call us at 312-202-5400.

AMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION Blended Surgical Education and Training for Life®

16-1955-ED-Pearls SGRS Ad-Bulletin-v01.indd 1 8/19/2016 12:01:12 PM NEWS

ACS joins effort to increase colorectal screening rates to 80 percent by 2018

A total of 1,000 health care organizations in the U.S., including the American College of Surgeons (ACS) and the Commission on Cancer, are joining a National Colorectal Cancer Roundtable effort to reach “80% by 2018.” The goal of the campaign is to reduce colorectal cancer as a major public health problem and, to this end, promote the screening of 80 percent of adults ages 50 and older for colorectal cancer by 2018. The ACS joined with the American Cancer Society, the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy in developing an online brochure titled What Can Gastroenterologists and Endoscopists Do to Advance 80% by 2018? available at nccrt.org/wp-content/uploads/IssueBrief_ GIs_WebFinal7.pdf. The detailed brochure provides information on joining the effort.♦

Apply now for 2017 ACS-UW Surgical Education Research Fellowship The American College of Surgeons (ACS) Division of Education and the department of surgery at the University of Wisconsin (UW), Madison, are seeking applicants for a two-year fellowship in surgical education. The fellowship begins July 1, 2017, and is designed so that surgery residents who have completed two or three years of postgraduate training can attain leadership skills | 91 in surgical education. Fellowship recipients also have the option of participating in the UW School of Education master’s degree program. Faculty from the ACS and UW will guide the participants through the completion of a mentored surgical education research project. Applications for the UW fellowship will be accepted until the positions are filled. Find additional details and contact information online at www.surgery.wisc.edu/uw-acs. ♦

Coming in November in JACS, and online now

Development and Evaluation of the American College of Surgeons NSQIP Pediatric Surgical Risk Calculator

Yaoming Liu, PhD; Mark E. Cohen, PhD; Bruce L. Hall, MD, PhD, MBA, FACS; and colleagues write in the November issue of the Journal of the American College of Surgeons (JACS) about a quick and easy way to provide patients and families with individualized information on surgical risk during consultations in the office and hospital settings. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP®) pediatric surgical risk calculator can be used as a tool in the shared decision-making process by providing clinicians, families, and patients with useful information about common operations. This article and all other JACS content is available at www.journalacs.org. ♦

OCT 2016 BULLETIN American College of Surgeons NEWS

National Surgical Patient Safety Summit participants stress teamwork, communication, and standards More than 100 representatives of medical professional associations, insurers, health care systems, payors, and government agencies convened August 4−5 in Rosemont, IL, for the inaugural National Surgical Patient Safety Summit sponsored by the American College of Surgeons (ACS) and the American Academy of Orthopaedic Surgeons (AAOS). Patient safety before, during, and after a surgical procedure requires an appropriately educated, committed, and empowered health care team, according to recommendations presented at the conference. Summit participants agreed that both technical and nontechnical skills are important for successful and safe surgical procedures. Program organizers sought to develop surgical care and surgical education curricula standards and to prioritize safety research. The surgeon, anesthesiologist, nurses, and supporting staff must ensure consistent use of surgical safety strategies and tools throughout surgical care, including patient-centered, shared decision making and timely informed consent; standardized surgical site marking procedures; accurate surgical information transfer; integrated electronic medical records; and effective team communication and coordination. Workgroups met before the summit to draft recommendations to be adopted by surgical team members, surgical institutions, medical and nursing schools, surgical residency and fellowship programs, and surgical credentialing organizations. Read the joint ACS-AAOS press release for a full list of the recommendations at facs.org/media/press-releases/2016/skills-080516. The recommendations will be used to finalize national surgical patient safety standards, develop surgical safety education curriculum proposals, and identify surgical safety knowledge gaps and research priorities. ♦

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V101 No 10 BULLETIN American College of Surgeons NEWS

Chapter news

| 93

Metropolitan Washington, DC, Chapter: Dr. Smalls-Mantey (left), and chapter Past-President Dr. Maniscalco-Theberge

FRCSEng(Hon), FRCSEd(Hon), The Metropolitan Washington, Inaugural combined FWACS(Hon), FRCSI(Hon), DC, Chapter of the Association symposium held in FCS(SA)(Hon), FRCSGlasg(Hon), of Women Surgeons held its Washington, DC ACS Past-President, and Henry 8th Annual Resident Research The Metropolitan Washington, Ford Professor and surgeon-in- Poster Competition, under the DC, Chapter of the American chief, Eastern Virginia Medical direction of Mary Maniscalco- College of Surgeons (ACS) held the School, Norfolk, also was a Theberge, MD, FACS, Deputy inaugural combined symposium keynote speaker, highlighting Medical Inspector, Office of the with the Virginia Chapter and the research and recent initiatives by Medical Inspector, Department Virginia Surgical Society April the ACS in addressing disparities of Veterans Affairs, and associate 30–May 1 at the Liaison Capitol in health care in his speech, professor of surgery, Uniformed Hill Hotel, Washington, DC. What Are the Real Challenges Services University of Health J. David Richardson, MD, and Threats in Healthcare? Sciences (USUHS), Bethesda, MD. FACS, 2015–2016 ACS President Legislative updates were A poster session highlighting and surgeon-in-chief, University given by Sara Morse, Manager, the research of residents from a of Louisville School of Medicine, Legislative and Political Affairs, number of training programs also KY, was the keynote speaker. ACS Division of Advocacy and took place at the meeting, as well He delivered an update on Health Policy (DAHP); Justin as several resident-delivered talks. the current state of care of the Rosen, Congressional Lobbyist, The Virginia Surgical Society surgical patient in the U.S. DAHP; and Leonard Weireter, also contributed significantly L.D. Britt, MD, MPH, MD, FACS, Vice-Chair, ACS to the program, with speakers DSc(Hon), FACS, FCCM, Committee on Trauma. addressing such issues as obesity

OCT 2016 BULLETIN American College of Surgeons NEWS

Jordan Chapter: Attendees included (from left) Mohammad Al Shobaki, Chapter Officer; Wael Al Na’san; Maha Qubain; Prof. Mahmoud Abu Khalaf, Chapter President; Prof. Abdalla Bashir, Chapter Governor; Dr. Townsend; Osama H. Hamed, Chapter Secretary; Hanan Rihani, Chapter Officer; Said Al Natour; Zaki Qulaghassi, Chapter Officer; Mohammad Al Zittawi, Chapter Officer; Khaled Ajarmeh, Chapter Vice-President; Ala’a Al Zuabi (all MD, FACS); and Mohannad Qulaghassi, MD, RAS representative, Jordan Chapter

and foregut diseases, evaluation of FCCM, assistant professor of the ACS to improve the Jordanian adrenal incidentalomas, enhanced surgery, Howard University surgical education system. recovery programs, the correlation Hospital, Washington, DC The scientific meeting of venous thromboembolism included three concurrent prophylaxis and electronic health • President-Elect: Jonathan Dort, sessions that covered a range records, and morbidity and MD, FACS, general surgeon, Inova of general surgery and surgical mortality after gastrectomy. Medical Group, Fairfax, VA subspecialty topics. In addition, Annesely Copeland, MD, concurrent sessions were held for FACS, associate professor of • Treasurer: Sharon Bachman, MD, residents and medical students, surgery, USUHS, spoke on FACS, general surgeon, Inova including the following: 94 | the topic of The Opportunity Medical Group, Falls Church, VA of Adversity: Reflections on a • Advanced Trauma Life Support® Surgical Career. A highlight • Governor: H. David Reines, MD, (ATLS®) in collaboration with of the two-day conference FACS, general surgeon, surgical the ATLS Jordan Chapter, Royal was the Resident Jeopardy critical care, Inova Fairfax Hospital Medical Services, and the Jordan Competition, which was both National Emergency Medical entertaining and educational. Services Educational Center The chapter continues its Jordan Chapter holds tradition of offering mock orals first annual meeting • Inaugural ACS Comprehensive to postgraduate year (PGY)-5 The Jordan Chapter of the ACS General Surgery Review residents who are preparing held its first annual meeting Course with support from the for board certification. In May 5–8 at the Le Royal Hotel ACS Division of Education; addition, a series of educational Amman under the patronage Patricia L. Turner, MD, FACS, sessions to prepare residents of the Minister of Health in Director, ACS Division of for the administrative aspects Jordan, Ali Al Hyasat, MD, Member Services; and Prof. of clinical practice, Business of FACS. Courtney M. Townsend, Jamal Hoballah, MD, FACS, Surgery Series, is in its third Jr., MD, FACS, ACS President- in collaboration with the year under the leadership of Elect, attended the meeting. Lebanon Chapter of the ACS Amy Vertrees, MD, FACS, The theme of the conference associate program director, was Optimal Surgical Education • Trauma Evaluation and Walter Reed National Military for Better Care and was chosen Management Course for Medical Center, Bethesda. based on the needs of the Medical Students The incoming 2016–2017 Jordanian surgical community. chapter officers are as follows: Before the official start of the • Inaugural Surgical Jeopardy meeting, Dr. Townsend met with competition with assistance • President: Norma Smalls- Jordanian officials, focusing the from the ACS Resident and Mantey, MD, MBA, FACS, discussion on collaboration with Associate Society (RAS-ACS)

V101 No 10 BULLETIN American College of Surgeons NEWS

• Inaugural Women in Will We Measure Performance? Update presented by current Surgery Session Dr. Opelka is Medical Director, Chapter Governor Emmanuel Quality and Health Policy, ACS A. Ameh, MB, BS, FACS, on There was a strong social DAHP, Washington, DC. behalf of Dr. Richardson. In media presence, and the A total of 14 residents addition, the chapter hosted its Communications Committee presented posters to attendees. first Comprehensive General was live tweeting via the official Laura Stafman, MD, a PGY- Surgery Review Course ACS Jordan Chapter Twitter 3 resident at the University with a focus on preoperative account @ACSJordan and the of Alabama at Birmingham, care, surgical practice issues, hashtag #ACSJO2016 and posting received the top award for her and oncology. More than 65 on the chapter’s official Facebook presentation on UAB30, A Novel senior residents and fellows page. Visit the Jordan Chapter Proprietary Retinoid, Decreases attended the course. Twitter and Facebook pages Viability and Tumor Initiating for details on the live coverage Cell Maintenance in Human that took place during the Neuroblastoma Patient-Derived Italy Chapter holds competition | 95 meeting at twitter.com/acsJordan Xenografts. William O. Richards, and training project and www.facebook.com/Jordan- MD, FACS, was recognized for his The second edition of Italian Chapter-of-the-American-College- year of service as President of the Surgical Jeopardy was offered of-Surgeons-940107526074681/, Alabama Chapter. E. Shields Frey, in Naples, Italy, June 11 under respectively. MD, FACS, was installed as 2016– the auspices of the ACS Italy 2017 Alabama Chapter President. Chapter. The event was organized The 2017 joint meeting is in collaboration with the Alabama and Mississippi scheduled for June 8–10, 2017, European Society of Surgery and Chapters hold joint meeting at The Grand Hotel Marriott the European Meeting of the The Alabama and Mississippi Resort in Point Clear. Residents and PhDs in Surgery. Chapters of the ACS held Prof. Antonio di Cataldo, their annual joint conference MD, FACS, Governor, ACS Italy June 9–11 at The Grand Nigeria Chapter holds Chapter, and Prof. Giuseppe Hotel Marriott Resort in inaugural annual meeting Nigri, MD, FACS, Treasurer Point Clear, AL. Surgeons The Nigeria Chapter of the ACS and Chapter Administrator, from both states gathered to held a successful meeting and chaired the conference, and listen to panel discussions Comprehensive General Surgery two general surgery residents on topics such as Acute Care Review Course July 4–8 at the moderated: Paolo Magistri, Surgery, Adopting New Nnamdi Azikiwe University MD, and Giammauro Berardi, Technologies, Cancer Updates, Teaching Hospital in Nnewi. MD, Sapienza University of Colorectal Carcinoma, and Hot The meeting took place in Rome. Judges of the competition Topics in General Surgery. conjunction with the Nigerian were Gabriele De Sena, MD, The chapters welcomed Surgical Research Society and FACS, from Naples, and Antoni Frank G. Opelka, MD, FACS, the Association of Surgeons of Szczepanic, MD, president- whose presentation was titled Nigeria. The highlight of the Welcome to the Future: How opening ceremony was the ACS continued on page 97

OCT 2016 BULLETIN American College of Surgeons NEWS

Alabama and Mississippi Chapters: Dr. Shields Frey (left) Nigeria Chapter: Stanley N. C. Anyanwu, MB, BS, FACS, presents Dr. Richards with plaque of appreciation for his year President, ACS Nigeria Chapter (left), and Dr. Ameh of service as President of the Alabama Chapter

96 |

Nigeria Chapter: Participants of the ACS Nigeria Chapter General Surgery Review Course

Italy Chapter: Attendees at the meeting included (from left) Dr. Magistri; Lorenzo Scardina, MD, FACS; Fabio Longo; Alessandro Mazzotta; Antonio Di Cataldo, MD, FACS, Governor, ACS Italy Chapter; Antoni Szczepanic, MD, president-elect of the European Society for Surgery; Dr. Nigri; Alfonso Barbarisi, MD, President, European Society for Surgery; and Dr. Berardi

V101 No 10 BULLETIN American College of Surgeons NEWS

TNACS: Attendees included (from left) Norma Edwards, MD, FACS, TNACS Chapter President; Dr. Richardson; Ms. Browning; and R. Phillip Burns, MD, FACS, Past First Vice-President of the ACS elect of the European Society Society of Lymphangiology, Greco, MD, FACS, Women of Surgery from Poland. the Italian Society of University Surgeons Committee, Milan. Residents from across Italy, Surgeons (including the College Dr. Nigri played an integral role Poland, and Moldavia attended of Professors of General Surgery), in contributing to the event the meeting. The team from the Italian Society of Surgical organization, along with the SIC. Modena and Reggio Emilia won Pathophysiology, the Italian Held in the historic and the competition. They were Society of Digestive System architecturally significant setting awarded with an invitation Pathology, the Polyspecialist of Genoa’s monumental Palazzo to attend the September Italian Society of Young Surgeons, della Borsa, the conference 2017 XXI Annual Meeting the Italian Society of Surgical mainly focused on the leading | 97 of the European Society of Research, the Triveneto’s Society role of prevention techniques Surgery in Krakow, Poland. of Surgery, and the Coordination and early treatment of lymphatic At press time, the next Committee Associazione complications in different fields annual meeting of the ACS Chirurghi Ospedalieri of oncological surgery. Much Italy Chapter was scheduled for Italiani—Regione Liguria. attention was paid to lymph September 25–29 in Rome. Corradino Campisi, MD, vessel-sparing techniques, More than 300 health care FACS, Chapter President; and to clinical applications of professionals attended a meeting Ferdinando Cafiero, MD, FACS, lymphatic microsurgery. on Lymph, Lymphatics, and president, Società Ligure di Lymph Nodes in Surgery Chirurgia; Stefano Puleo, MD, Best Practice: State-of-the-Art FACS, president, Società Siciliana Tennessee Chapter May 27 in Genoa under the di Chirurgia and of the Italian holds 2016 meeting aegis of the ACS Italy Chapter. Society of Surgical Research; and The Tennessee Chapter of the The event, recognized as Giovanni Sgroi, MD, president, ACS (TNACS) 2016 Annual a “training project” of the Italian Società Lombarda di Chirurgia, Meeting took place July 22–24 Society of Surgery (SIC), was chaired the conference. in Memphis. Approximately 100 organized in collaboration with Many ACS Fellows attended surgeons and other health care the regional Societies of Surgery the event, among them Prof. professionals gathered for the Società Ligure di Chirurgia, Antonio Di Cataldo, MD, FACS, event. The chapter welcomed Società Siciliana di Chirurgia, and Governor, Catania; Prof. Achille ACS President Dr. Richardson and Società Lombarda di Chirurgia, Lucio Gaspari, MD, FACS, Past- Georgia ACS Chapter Executive and with the participation of the Governor, Rome; Prof. Francesco Director Kathy Browning as Latin-Mediterranean Chapter Puccio, MD, FACS, Past-President, two of the guest speakers for of the International Society of Brescia; Prof. Biagio Ravo, MD, the event. Plans are already Lymphology, the European FACS, Second Vice-President, under way for the August Society of Lymphology, the Italian Rome; and Prof. Dalila Patrizia 2017 meeting in Nashville.

OCT 2016 BULLETIN American College of Surgeons NEWS

The Tennessee Surgical roundtable discussions, and unique partnership with industry, Quality Collaborative provided paper and poster presentations. the competition provides an a report on ongoing quality The chapter organized a basic interactive, game theory-based, improvement initiatives with science paper competition, and educational experience for our surgeons from the state. the winning article was titled Is residents. Each program fields Surgical Jeopardy was Concomitant Cholecystectomy a team comprising an intern, a a highlight of the event, with Bariatric Surgery in mid-level resident, and a chief with the team from the Asymptomatic Patient Necessary? to compete head-to-head with University of Tennessee by Narong Boonyagard, MD, other programs in challenges that College of Medicine, Memphis, general surgeon, department help to reinforce the skills they winning the competition. of medicine, faculty of are learning in their programs. medicine, Chulalongkorn The October chapter meeting University, Bangkok. is a joint annual meeting of Thailand Chapter supports The chapter also supported the the Connecticut Chapter, the academic organizations Second International Symposium Connecticut Surgical Quality The Thailand Chapter of the in Colorectal Disease, which took Collaborative (CtSQC) and the ACS continues to support place at the Hilton Phuket Arcadia Connecticut Chapter of the 98 | postgraduate surgical education Resort & Spa, December 5–7, American Society of Metabolic through a variety of national 2015. This subspecialty academic and Bariatric Surgery. and international organizations, activity involved many world- The CtSQC, an ACS National including the Royal College of renowned colorectal surgeons and Surgical Quality Improvement Surgeons Thailand, International included a comprehensive hands- Program (ACS NSQIP®)-based Society of Surgery, International on workshop, live operations, collaborative, incorporated College of Surgeons, Cleveland interactive lectures, panel in March 2016. Collaborative Clinic Florida, Bangkok Phuket discussions, and multidisciplinary members presented several talks Hospital, Prince of Songkla symposia covering state-of-the- and posters at the ACS NSQIP University, and Mae Fah Luang art technology, knowledge, Conference in July in San Diego, University. The spectrum of controversies, innovations, CA. The CtSQC has reached academic activities has been and new surgical techniques critical mass, with all hospitals designed to enhance the learning in colorectal surgery. ACS in Connecticut agreeing to experience in surgery not only for Regent Steven D. Wexner, participate in its educational young surgeons, but also for those MD, FACS, from Cleveland programs. The collaborative’s in the surgical subspecialties. Clinic Florida, Weston served new website, www.ctsqc.org, In the last year, the chapter as the ACS visiting professor. should be up and running by supported the World Congress the end of the third quarter. ♦ of Surgery, which took place at the Bangkok Convention Centre Connecticut Chapter develops at Central World, and included Skills Competition the involvement of the Royal The Connecticut Chapter College of Surgeons Thailand has been preparing for its and the International Society of Eighth Annual Surgical Skills Surgery. The scientific program Competition at the October 28 featured state-of-the-art lectures, chapter meeting at the Marriott live operations, plenary sessions, Hotel in Farmington, CT. In this

V101 No 10 BULLETIN American College of Surgeons ® SELECTED READINGS in GENERAL SURGERY

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AMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION Blended Surgical Education and Training for Life® MEETINGS CALENDAR

Calendar of events*

*Dates and locations subject to change. For more information on College events, visit www.facs.org/events or http://web2.facs.org/ChapterMeetings.cfm.

Wisconsin Surgical Society New Jersey Chapter OCTOBER November 4–5 December 3 Kohler, WS Iselin, NJ Rhode Island Chapter Contact: Terry Estness, Contact: Andrea Donelan, October 20 [email protected], [email protected], Providence, RI www.wisurgicalsociety.com www.nj-acs.org/ Contact: Megan Turcotte, [email protected], www.riacs.org Argentina Chapter Philippines Chapter November 14–17 December 6 Italy Chapter Buenos Aires, Argentina Manila, Phillipines October 21–24 Contact: Raul Ferreres, Contact: Vicky Pamintuan, Rome, Italy [email protected], Dial: 011-63-632-7432119 Contact: Giuseppe Nigri, www.facs.org.ar [email protected], Brooklyn-Long Island Chapter www.facsitaly.org Patient-Reported Outcomes December 7 in Surgery Conference Uniondale, NY Connecticut Chapter November 17 Contact: Teresa Barzyz, October 28 Washington, DC [email protected], 100 | Farmington, CT Contact: Katie Sommers, www.bliacs.org/ Contact: Christopher Tasik, [email protected], [email protected], bit.ly/2bkEFjI www.ctacs.org FUTURE CLINICAL Keystone Chapter Arkansas Chapter November 18 CONGRESSES October 29 Danville, PA 2016 Little Rock, AR Contact: Lauren Newmaster, October 16–20 Contact: Linda Gist, [email protected], Washington, DC [email protected] www.keystonesurgeons.org 2017 Arizona Chapter October 22–26 November 19–20 San Diego, CA NOVEMBER Tuscon, AZ Contact: Joni Bowers, 2018 San Diego Chapter [email protected], October 21–25 November 1 www.azacs.org Boston, MA San Diego, CA Contact: Jim Cox, [email protected], www.sdcacs.org DECEMBER Massachusetts Chapter South Korea Chapter December 3 November 3–5 Boston, MA Seoul, Korea Contact: Amy Nolfi, Contact: Sun-Whe Kim, [email protected], [email protected] www.mcacs.org/

V101 No 10 BULLETIN American College of Surgeons