APRIL 2017 | VOLUME 102 NUMBER 4 | AMERICAN COLLEGE of SURGEONS Bulletin Contents

APRIL 2017 | VOLUME 102 NUMBER 4 | AMERICAN COLLEGE OF SURGEONS Bulletin Contents

FEATURES COVER STORY: Using global surgical indicators to improve trauma care in Latin America 11 Gregory Peck, DO, FACS; Saurabh Saluja, MD, MPP; David N. Blitzer, MD; Deesha Sarma; Geoffrey A. Anderson, MD, MPH; Edgar Rodas, MD, FACS; Jorge Esteban Foianini, MD, FACS; Juan Carlos Puyana, MD, FACS; John Meara, MD, DMD, MBA, FACS; Carlos Morales, MD; Carlos Ordonez, MD, FACS; and Vicente Gracias, MD, FACS

UM Ryder Trauma Center/Israel fellowship program provides a model for global trauma training 17 Enrique Ginzburg, MD, FACS; Courtney Goodman; Gerald Sussman, PhD; and Yoram Klein, MD

QPP in 2017: Navigating the transition year 22 Matthew R. Coffron, MA, and Patrick V. Bailey, MD, MLS, FACS | 1 The future of trauma care on Capitol Hill: Implementing military-civilian trauma care and establishing a national trauma system 29 Carrie Zlatos and Justin Rosen

2016 ACS International Governors Survey: Membership benefits and challenges for International Fellows are revealed in first-time study 34 Mark W. Puls, MD, FACS; Juan C. Paramo, MD, FACS; David J. Welsh, MD, FACS; and Peter Andreone, MD, FACS

APR 2017 BULLETIN American College of Surgeons Contents continued

STATEMENT ACS Clinical Research Program: NEWS Junior investigators: Get engaged in Statement on the use of general the Alliance for Clinical Trials In memoriam: Denton A. Cooley, anesthetics and sedation drugs in in Oncology 62 MD, FACS, a fierce competitor 70 children and pregnant women 39 Geoffrey L. Uy, MD; Charles D. Fraser, Jr., MD, FACS COLUMNS Matthew H. G. Katz, MD, FACS; Chapter news 75 and Judy C. Boughey, MD, FACS Luke Moreau and Brian Frankel Looking forward 9 Your ACS benefits: ACS Case David B. Hoyt, MD, FACS Access new surgeon and resident Reviews in Surgery and AHRQ well-being resources 77 What surgeons should know Safety Program for ERAS: Associate Fellows: Apply now for about...Reporting global codes New ACS programs enhance ACS Fellowship 78 data in 2017 40 quality patient care 64 Capitol Hill lawmakers Vinita Ollapally, JD Whitney Greer and Stacey McSwine participate in bleeding control Coding and practice management A look at The Joint Commission: simulations 79 New resources for surgeons to corner: Hernia repair and complex Coming next month in JACS, obtain true informed consent 66 abdominal wall reconstruction 52 and online now 79 Christopher Senkowski, MD, FACS; Carlos A. Pellegrini, MD, 2 | Mark Savarise, MD, FACS; FACS, FRCSI(Hon), FRCS(Hon), MEETINGS CALENDAR John S. Roth, MD, FACS; and Jan FRCSEd(Hon) Calendar of events 80 Nagle, MS, RPh NTDB data points: No bones Dispatches from rural surgeons: about it 68 Diamonds in the rough— Richard J. Fantus, MD, FACS a case for rural surgery rotations 60 Edward Kreimier III, MD

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EDITOR-IN-CHIEF Letters to the Editor Diane Schneidman should be sent 2017 with the writer’s DIRECTOR, DIVISION OF name, address, INTEGRATED COMMUNICATIONS e-mail address, and OCTOBER 22–26 Lynn Kahn daytime telephone SAN DIEGO CONVENTION CENTER number via e-mail to SENIOR EDITOR SAN DIEGO, CA Tony Peregrin dschneidman@facs. org, or via mail to NEWS EDITOR Diane S. Schneidman, Matthew Fox Editor-in-Chief, Bulletin, American SENIOR GRAPHIC DESIGNER/ PRODUCTION MANAGER College of Surgeons, Tina Woelke 633 N. Saint Clair St., Chicago, IL 60611. EDITORIAL ADVISORS Letters may be edited Charles D. Mabry, MD, FACS for length or clarity. Leigh A. Neumayer, MD, FACS Permission to publish Marshall Z. Schwartz, MD, FACS letters is assumed Mark C. Weissler, MD, FACS unless the author indicates otherwise. 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. ©2017 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.

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Timothy J. Eberlein, MD, FACS Nicole S. Gibran, MD, FACS, Christian Shalgian Officers St. Louis, MO Seattle, WA Director James K. Elsey, MD, FACS S. Robert Todd, MD, FACS, FCCM AMERICAN COLLEGE OF Courtney M. Townsend, Atlanta, GA Houston, TX SURGEONS FOUNDATION Jr., MD, FACS Henri R. Ford, MD, FACS Shane Hollett Galveston, TX Executive Director PRESIDENT Los Angeles, CA Gerald M. Fried, MD, FACS, FRCSC Advisory Council ALLIANCE/AMERICAN J. David Richardson, MD, FACS COLLEGE OF SURGEONS Louisville, KY Montreal, QC to the Board CLINICAL RESEARCH PROGRAM IMMEDIATE PAST-PRESIDENT James W. Gigantelli, MD, FACS of Regents Kelly K. Hunt, MD, FACS Hilary A. Sanfey, MB, Omaha, NE (Past-Presidents) Chair BCh, MHPE, FACS B. J. Hancock, MD, FACS, FRCSC Springfield, IL CONVENTION AND MEETINGS Winnipeg, MB Kathryn D. Anderson, MD, FACS Robert Hope FIRST VICE-PRESIDENT Eastvale, CA Enrique Hernandez, MD, FACS Director Mary C. McCarthy, MD, FACS Philadelphia, PA W. Gerald Austen, MD, FACS DIVISION OF EDUCATION Dayton, OH Boston, MA SECOND VICE-PRESIDENT Lenworth M. Jacobs, Jr., MD, FACS Ajit K. Sachdeva, MD, Hartford, CT L. D. Britt, MD, MPH, FACS, FRCSC Edward E. Cornwell III, FACS, FCCM Director MD, FACS, FCCM L. Scott Levin, MD, FACS Norfolk, VA Washington, DC Philadelphia, PA EXECUTIVE SERVICES SECRETARY John L. Cameron, MD, FACS Maxine Rogers Mark A. Malangoni, MD, FACS Baltimore, MD William G. Cioffi, Jr., MD, FACS Philadelphia, PA Director, Leadership Operations Providence, RI Edward M. Copeland III, MD, FACS FINANCE AND FACILITIES TREASURER Fabrizio Michelassi, MD, FACS Gainesville, FL New York, NY Gay L. Vincent, CPA David B. Hoyt, MD, FACS A. Brent Eastman, MD, FACS Director Chicago, IL Valerie W. Rusch, MD, FACS Rancho Santa Fe, CA New York, NY HUMAN RESOURCES 4 | EXECUTIVE DIRECTOR Gerald B. Healy, MD, FACS AND OPERATIONS Gay L. Vincent, CPA Linda G. Phillips, MD, FACS Wellesley, MA Michelle McGovern Chicago, IL Galveston, TX Director CHIEF FINANCIAL OFFICER R. Scott Jones, MD, FACS Marshall Z. Schwartz, MD, FACS Charlottesville, VA INFORMATION TECHNOLOGY Philadelphia, PA Edward R. Laws, MD, FACS Brian Harper Anton N. Sidawy, MD, FACS Boston, MA Interim Director Officers-Elect Washington, DC LaSalle D. Leffall, Jr., MD, FACS DIVISION OF INTEGRATED (take office October 2017) Beth H. Sutton, MD, FACS Washington, DC COMMUNICATIONS Wichita Falls, TX Lynn Kahn Barbara L. Bass, MD, FACS LaMar S. McGinnis, Jr., MD, FACS Director Houston, TX Courtney M. Townsend, Jr., Atlanta, GA PRESIDENT-ELECT MD, FACS JOURNAL OF THE AMERICAN Galveston, TX David G. Murray, MD, FACS COLLEGE OF SURGEONS Charles D. Mabry, MD, FACS Syracuse, NY Timothy J. Eberlein, MD, FACS Pine Bluff, AR Steven D. Wexner, MD, FACS Editor-in-Chief FIRST VICE-PRESIDENT-ELECT Weston, FL Patricia J. Numann, MD, FACS Syracuse, NY Basil A. Pruitt, Jr., MD, DIVISION OF MEMBER SERVICES FACS, FCCM, MCCM Carlos A. Pellegrini, MD, FACS Patricia L. Turner, MD, FACS San Antonio, TX Board of Seattle, WA Director SECOND VICE-PRESIDENT-ELECT Richard R. Sabo, MD, FACS M. Margaret Knudson, MD, FACS Governors/ Bozeman, MT Medical Director, Military Health Systems Strategic Partnership Executive Seymour I. Schwartz, MD, FACS Board of Regents Rochester, NY Girma Tefera, MD, FACS Committee Director, Operation Giving Back Michael J. Zinner, MD, FACS Frank C. Spencer, MD, FACS Diana L. Farmer, MD, FACS PERFORMANCE IMPROVEMENT Boston, MA Sacramento, CA New York, NY CHAIR CHAIR Will Chapleau, RN, EMT-P Andrew L. Warshaw, MD, FACS Director Leigh A. Neumayer, MD, FACS, Steven C. Stain, MD, FACS Boston, MA Tucson, AZ Albany, NY DIVISION OF RESEARCH AND VICE-CHAIR VICE-CHAIR OPTIMAL PATIENT CARE Clifford Y. Ko, MD, Anthony Atala, MD, FACS Susan K. Mosier, MD, MBA, FACS, Executive Staff MS, MSHS, FACS Winston-Salem, NC Lawrence, KS EXECUTIVE DIRECTOR Director John L. D. Atkinson, MD, FACS SECRETARY David B. Hoyt, MD, FACS David P. Winchester, MD, FACS Rochester, MN Daniel L. Dent, MD, FACS DIVISION OF ADVOCACY Medical Director, Cancer James C. Denneny III, MD, FACS San Antonio, TX AND HEALTH POLICY Alexandria, VA Francis D. Ferdinand, MD, FACS Frank G. Opelka, MD, FACS Michael F. Rotondo, MD, FACS Medical Director, Trauma Margaret M. Dunn, MD, FACS Wynnewood, PA Medical Director, Quality Dayton, OH and Health Policy Patrick V. Bailey, MD, FACS Medical Director, Advocacy V102 No 4 BULLETIN American College of Surgeons Author bios*

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

a b c

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h i j

DR. ANDERSON (a) is a general DR. BOUGHEY (e) is professor of surgery DR. FOIANINI (h) is director, Clinica surgery resident, Massachusetts and vice-chair, research, department of Foianini, Santa Cruz, Bolivia. He is General Hospital, Boston. surgery, Mayo Clinic, Rochester, MN. secretary-treasurer, Panamerican Trauma She is Chair, ACS Clinical Research Society, Richmond, VA; ACS Governor, DR. ANDREONE (b) is a cardiac and thoracic Program (CRP) Education Committee. Bolivia Chapter of the ACS; and Vice-Chair, surgeon, Sioux Falls, SD, and a member of the International Workgroup of the ACS. American College of Surgeons (ACS) Board MR. COFFRON (f) is Manager, of Governors (B/G) Survey Workgroup. Policy Development, ACS Division MR. FRANKEL (i) is Manager, International of Advocacy and Health Policy. Chapter Services and Special Initiatives, ACS DR. BAILEY (c) is Medical Director, Division of Member Services, Chicago, IL. Advocacy, ACS Division of Advocacy DR. FANTUS (g) is vice-chairman, and Health Policy, Washington, DC. department of surgery; medical director, DR. FRASER (j) is surgeon-in-chief and trauma services; and chief, section of Donovan Chair in Congenital Heart DR. BLITZER (d) is a general surgery surgical critical care, Advocate Illinois Surgery, Texas Children’s Hospital; and resident, department of surgery, MedStar Masonic Medical Center. He is clinical Susan V. Clayton Chair in Surgery and Union Memorial Hospital, Baltimore, MD. professor of surgery, University of Illinois professor of surgery and pediatrics, Baylor College of Medicine, Chicago, and Past- College of Medicine, Houston, TX. Chair, ad hoc Trauma Registry Advisory Committee, ACS Committee on Trauma. continued on next page

APR 2017 BULLETIN American College of Surgeons Author bios continued

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DR. GINZBURG (k) is professor of DR. KATZ (o) is associate professor of DR. MEARA (s) is Kletjian Professor of surgery, DeWitt Daughtry Department surgical oncology, University of Texas Global Surgery, department of global health of Surgery, University of Miami Miller MD Anderson Cancer Center, Houston; and social medicine; professor of surgery; and School of Medicine; trauma medical Co-chair, Young Investigator Committee, director of the Program in Global Surgery director and vice-chair of surgery, Alliance for Clinical Trials in Oncology; and Social Change, Harvard Medical School; Jackson South Community Hospital; and Chair, ACS CRP Cancer Care plastic surgeon-in-chief, department of plastic and Chair, Florida Board of Medicine. Standards Development Committee. and oral surgery, Boston Children’s Hospital; co-director, the Paul Farmer Global Surgery MS. GOODMAN (l) is an undergraduate DR. KLEIN (p) is director, division of Fellowship Program; and chair, The Lancet student, Duke University, Durham, NC. trauma surgery, Sheba Medical Center, Commission on Global Surgery. He is Vice- Tel-Hashomer, Ramat-Gan, Israel. Chair, ACS Health Policy Advisory Group. DR. GRACIAS (m) is senior vice- chancellor, clinical affairs, Rutgers DR. KREIMIER (q) is a fourth-year DR. MORALES (t) is professor of surgery, Biomedical Health Sciences; chair, Rutgers general surgery resident at St. Joseph University of Antioquia, and an attending Health Group; and professor of surgery, Mercy Hospital, Ann Arbor, MI. surgeon, Hospital Universitario San Rutgers University Robert Wood Johnson Vicente Fundación, Medellín, Colombia. Medical School, New Brunswick, NJ. MS. McSWINE (r) is Enrollment Project Manager, Enhanced Recovery After continued on next page MS. GREER (n) is Managing Editor, Surgery, ACS Division of Research and Selected Readings in General Surgery Optimal Patient Care, Chicago, IL. and ACS Case Reviews in Surgery, ACS Division of Education, Chicago, IL.

V102 No 4 BULLETIN American College of Surgeons Author bios continued

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bb cc dd

MR. MOREAU (u) is Manager, DR. PARAMO (y) is a surgical oncologist, DR. PULS (bb) is a general surgeon in Domestic Chapter Services, ACS Mount Sinai Medical Center Comprehensive Alpena, MI; Immediate Past-Chair of the ACS Division of Member Services. Cancer Center, Miami Beach; associate B/G Survey Workgroup; and Vice-Chair, clinical professor of surgery, Florida ACS Advisory Council for Rural Surgery. MS. NAGLE (v) is an independent consultant International University, Miami; and in Chicago who assists the ACS with associate clinical professor of surgery, Nova DR. PUYANA (cc) is a member of the American Medical Association (AMA) Southeastern University, Ft. Lauderdale, FL. Committee on Global Health and the Current Procedural Technology (CPT) He is Chair, ACS B/G Survey Workgroup. Future of the United States, National coding education and health data analyses. Academies of Sciences, Engineering, and DR. PECK (z) is assistant professor of Medicine, Washington, DC; and professor of MS. OLLAPALLY (w) is Regulatory surgery, associate director of performance surgery, critical care medicine and clinical Affairs Manager, ACS Division of improvement, trauma, and acute care translational science and a trauma/acute Advocacy and Health Policy. surgery fellowship, Rutgers University, care surgeon, University of Pittsburgh, PA. Robert Wood Johnson Medical School. DR. ORDONEZ (x) is associate professor DR. RODAS (dd) is associate professor of general surgery, trauma and intensive DR. PELLEGRINI (aa) is chief medical of surgery, division of acute care surgery, care, and chief director, trauma and acute officer, UW Medicine, and vice-president for Virginia Commonwealth University care surgery, Universidad del Valle and medical affairs, University of Washington, School of Medicine, Richmond. Fundacion Valle del Lili, Cali, Colombia; and Seattle. He is a Past-President of the ACS. president, Panamerican Trauma Society. continued on next page

APR 2017 BULLETIN American College of Surgeons Author bios continued

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MR. ROSEN (ee) is Congressional Lobbyist, MS. SARMA (hh) is a second-year DR. SUSSMAN (kk) is director, Southwest ACS Division of Advocacy and Health Policy. medical student, Robert Wood Center for the Study of Hospital and Johnson Medical School. Health Care Systems, Coral Springs, FL. DR. ROTH (ff) is professor of surgery; chief, gastrointestinal, and minimally invasive DR. SAVARISE (ii) is associate clinical DR. UY (ll) is associate professor of surgery; director, minimally invasive surgery; professor of surgery, University of medicine, Washington University School and director, Center for Advanced Training Utah School of Medicine, Salt Lake of Medicine, St. Louis, MO, and co- and Simulation, University of Kentucky, City. He serves on the ACS Advisory chair, Young Investigators Committee, Lexington. He is the Society of American Council for Rural Surgery. Alliance for Clinical Trials in Oncology. Gastrointestinal Endoscopic Surgeons’ advisor to the AMA CPT Editorial Panel. DR. SENKOWSKI (jj) is professor and chair, DR. WELSH (mm) is a general surgeon department of surgery, Mercer University in Batesville, IN, and a member of DR. SALUJA (gg) is a general surgery School of Medicine, Savannah, GA. He is the ACS B/G Survey Workgroup. resident, department of surgery, Weill Vice-Chair of the ACS General Surgery Cornell Medicine, New York, NY. Coding and Reimbursement Committee MS. ZLATOS (nn) is Congressional Lobbyist, and a member of the AMA/Specialty Society ACS Division of Advocacy and Health Policy. Relative Value Scale Update Committee.

V102 No 4 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

s I was drafting this column, news of the death All of these problems were aggravated by the lack of Salome Karwah, a Liberian nurse who was of material and financial resources in the affected Aa 2014 Time Person of the Year, was topping countries. The White House and U.S. Department of the headlines. Ms. Karwah lost her parents to Ebola, State tried to intervene by establishing international survived the disease herself, and went on to provide priorities, including containing the outbreak through care to many patients who had fallen victim to the isolation of patients, mitigating economic instability West African epidemic. Ms. Karwah reportedly died by working with the International Monetary Fund, as a result of complications from childbirth, and the and coordinating efforts with other nations and non- lingering suspicions of some Liberians toward Ebola governmental organizations. survivors reportedly were partly to blame. What An International Command Center was established happened to this heroic health care professional in in Monrovia, Liberia. In the U.S., the Centers for Dis- February 2017 is the most recent example of the last- ease Control and Prevention (CDC), the Department ing effects of this epidemic. of Health and Human Services, and the Department At the height of the outbreak, which was first rec- of Defense sought to address epidemiology, infection ognized in March 2014, and in response to growing and disease control, emergency medical services and reports that health care professionals were becom- hospital readiness, and treatment guidelines for per- ing ill and dying from the disease, two Fellows of sonal protection. the American College of Surgeons (ACS)—Sherry M. | 9 Wren, MD, FACS, FCS(ECSA), and Adam L. Kushner, MD, MPH, FACS—sought to turn the situation around Guidelines for protective surgical attire and avert tragedies like this one. Their story and the Around this same time, Drs. Wren and Kushner recollections of other health care professionals who began taking action. Their work centered largely on were on the front lines during the Ebola crisis are told collaborating with health care professionals in West in a new book, Operation Ebola: Surgical Care during the Africa to create guidelines for personal protective West African Outbreak. equipment (PPE) for health care workers. Typical African operating room (OR) attire is cotton scrubs covered with a plastic butcher’s apron Responding to a crisis to prevent blood from soaking through to the chest A major side effect of the Ebola epidemic was that it and abdomen. Topping this gear is a cotton gown that reduced access to already limited surgical and medi- blood can easily penetrate. Recognizing the insuffi- cal services. As Ebola spread from Guinea to Liberia cient protection this attire provided and the impact and Sierra Leone in 2014, health care facilities in the it was having on the delivery of surgical care in the region closed, and some physicians, concerned for affected countries, Dr. Wren, a past-member of the their safety and the well-being of their families, ACS Board of Governors Executive Committee, and left or stopped operating. A number of those who Dr. Kushner, founder and director of Surgeons Over- stayed contracted the disease and died. As a result, Seas, searched the medical literature as well as the many patients with ordinarily treatable conditions World Health Organization (WHO) and the CDC went without proper care. websites for PPE guidelines. Health care workers who did remain often insisted After scores of e-mail exchanges with colleagues at that all patients be tested for Ebola, regardless of their U.S. institutions—the Center for Global Health whether they were showing symptoms. Waiting for and Innovation, Stanford University, CA, and the the results of these tests created unnecessary delays department of international health, Johns Hopkins in the delivery of surgical services, which inevitably Bloomberg School of Public Health, Baltimore, MD, led to the loss of more lives. respectively—Dr. Wren and Dr. Kushner eventually

APR 2017 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

At the height of the outbreak, which was first recognized in March 2014, and in response to growing reports that health care professionals were becoming ill and dying from the disease, two Fellows of the ACS—Sherry M. Wren, MD, FACS, FCS(ECSA), and Adam L. Kushner, MD, MPH, FACS—sought to turn the situation around and avert tragedies like this one.

learned that the Association for the Advancement of Africa, it can be applied to protect surgical team mem- Medical Instrumentation had gown and drape stan- bers the next time a virus ravages a region of the world. dards for virus and blood imperviousness. Using these We also learned a good bit about working with documents, guidelines on OR instruments and sharps nongovernment agencies such as Surgeons OverSeas management, and protocols for operating on patients and Partners in Health to ensure that adequate finan- 10 | with known blood-borne diseases, Drs. Wren and cial, material, and human resources are available. Kushner drafted recommendations and sent them to The College is committed to working with these and the ACS leadership for review and dissemination. other organizations through Operation Giving Back to The guidelines, posted at facs.org/surgeons/ebola/ stimulate international outreach to help nations facing surgical-protocol, contain recommendations on patient health care crises. selection, PPE, conduct of a surgical procedure, the Finally, the contributing authors to Operation Ebola OR checklist, and specimen handling. These standards teach us much about courage and the true meaning were readily and enthusiastically adopted by the Col- of humanitarianism. These exemplars of profession- lege of Surgeons of East, Central, and South Africa—a alism put themselves at great personal risk to provide 12-country consortium. care to patients in need. They inspire us to recommit to giving back to our fellow man and to averting the tragic deaths that Ms. Karwah and so many other West Timeless lessons learned African patients and providers experienced. ♦ On January 14, 2016, the World Health Organiza- tion declared the end of the West African Ebola outbreak. In all, the virus caused more than 11,300 deaths, including the deaths of more than 500 health care professionals. The nearly two-year plague taught us all some valuable lessons about how to handle the next epidemic—lessons that are both universal and timeless. The fact of the matter is that humankind has witnessed countless contagions throughout history, and undoubtedly will experience more in the future. Although the protocol that the ACS issued with the leadership of Dr. Wren and Dr. Kushner was created If you have comments or suggestions about this or other issues, please specifically in response to the Ebola epidemic in West send them to Dr. Hoyt at [email protected].

V102 No 4 BULLETIN American College of Surgeons GLOBAL SURGICAL INDICATORS IN LATIN AMERICA

| 11 Using global surgical indicators to improve trauma care in Latin America

by Gregory Peck, DO, FACS; Saurabh Saluja, MD, MPP; David N. Blitzer, MD; Deesha Sarma; Geoffrey A. Anderson, MD, MPH; Edgar Rodas, MD, FACS; Jorge Esteban Foianini, MD, FACS; Juan Carlos Puyana, MD, FACS; John Meara, MD, DMD, MBA, FACS; Carlos Morales, MD; Carlos Ordonez, MD, FACS; and Vicente Gracias, MD, FACS

APR 2017 BULLETIN American College of Surgeons GLOBAL SURGICAL INDICATORS IN LATIN AMERICA

HIGHLIGHTS • Summarizes strategies for data collection and analysis to enhance global surgical care • Describes how Latin American trauma program development may be improved by LCoGS indicator measurement • Identifies how surgical capacity within resource- poor settings is a multidisciplinary challenge

Editor’s note: This is the first in a series of articles that the and surgical systems overall. With this in mind, we Bulletin will be publishing on The Lancet Commission on have started a grassroots approach to integrate LCoGS Global Surgery’s (LCoGS) efforts to improve access to, and indicators as part of trauma system development, while quality of, surgical care starting in Latin America. Additional fostering collaborations between acute care surgery articles on this topic will be published in future issues of divisions in high-income countries (HICs) and LMICs the Bulletin. to narrow the gaps in education, training, research, and workforce in Latin America.6 eeting the global demand for surgical services The effective implementation of the LCoGS indica- has quickly escalated to become a top prior- tors measurement, specifically in trauma care settings, ity for both professional and public health can provide consistent mechanisms for collecting these M 1,2 organizations. During the last few years, attention data, while guiding multidisciplinary efforts to improve has focused specifically on the challenges that sur- Latin America’s trauma systems. We suggest that an gical systems face in addressing the growing global academic-based model geared toward simultaneous burden of surgical disease. In 2015, LCoGS published LCoGS indicators measurement and trauma system 12 | a report titled “Global Surgery 2030: Evidence and development can be effective, and this article demon- solutions for achieving health, welfare, and economic strates anecdotal support for this model based on our development,” which concluded that “surgery is an experience in Colombia.7-9 indivisible, indispensable part of health care.” Accord- This article highlights the confluence of trauma ingly, the development of integrated health systems system development with LCoGS indicators measure- capable of providing safe and affordable surgical care ment and suggests enhancing education and research would profoundly affect the health and socioeco- efforts within trauma systems to ensure successful nomic opportunities of much of the world.2 implementation of the recommendations that the The LCoGS report introduced six core surgical indi- LCoGS set forth. These observations serve as a call to cators to assess surgical systems, four of which have action for our partners in both HICs and LMICs in the since been published in the World Bank’s world devel- Americas to accurately evaluate trauma system development indicators (see Table 1, page 13).3 In the same opment as part of a collaborative process that improves year, the World Health Assembly (WHA) passed res- the provision of emergent and essential surgical care olution WHA 68.15, Strengthening Emergency and in LMICs. Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage.4 Now that the provision of global surgical care is a Measuring surgical indicators priority for many key stakeholders, the goal is to find in a trauma system an effective strategy for data collection, analysis, and As global surgery research expands, a fundamental interpretation that will lead to the establishment of component of the process is the implementation of a regional surgical systems tailored to address the health consistent set of goals to accurately gauge progress. care priorities of these environments. The LCoGS indicators can serve as a measuring tool The data suggest that trauma is one of the lead- to assess key elements of trauma program developing causes of preventable death around the world and ment. For example, a collaboration between both disproportionately affects low- and middle-income HIC and LMIC trauma surgeons aimed at regional- countries (LMICs).5. Therefore, trauma program devel- izing trauma care in Cali, Colombia, started in 2014. opment may play a crucial role in improving health It allowed development of a joint needs assessment

V102 No 4 BULLETIN American College of Surgeons GLOBAL SURGICAL INDICATORS IN LATIN AMERICA

TABLE 1. LCoGS CORE INDICATORS AND ASSOCIATED TRAUMA PROGRAM/SYSTEM ELEMENT LCoGS Proposed trauma program/ Category indicator Description system element focus The geographic accessibility Prehospital system 1 of surgical facilities and integration with hospital registry Preparedness The density of specialist Acute care surgeon/fellowships; trauma 2* surgical providers program manager The number of surgical procedures Trauma and emergent/essential hospital/ 3* provided per 100,000 population societal registries Delivery Trauma and emergent/essential hospital/ 30-day perioperative 4 societal registries, formal trauma PIPS, and mortality rates trauma morbidity/mortality review process The risk of impoverishing Future work—ministries of health/ 5* expenditure when education/finance and trauma/acute care surgery is required surgery divisional business administration Impact The risk of catastrophic Future work—ministries of health/ 6* expenditure when education/finance and trauma/acute care surgery is required surgery divisional business administration *World development indicators for Colombia intended to develop core elements TABLE 2. KEY ELEMENTS OF ACS COT of trauma programs highlighted by the American RESOURCES FOR OPTIMAL CARE College of Surgeons Committee on Trauma (ACS OF THE INJURED PATIENT COT).10 (See Table 2, this page.) Our initial efforts • Regional trauma systems; optimal elements, focused on four of the core elements—prehospital integration, and assessment trauma care; trauma education (trauma nurse man- • Description of trauma center levels and | 13 ager and acute care surgeon training and workforce); their roles in a trauma system trauma registry; and performance improvement • Prehospital trauma care and patient safety (PIPS)—and provided an opportunity for exploration into indicators 1, 2, 3, and 4. • Trauma registry Because proven metrics that assessed and predicted • Performance improvement and patient safety the needs of designated trauma programs in Colom- • Education and outreach bia had never been developed, we proposed using the • Injury prevention LCoGS indicators for trauma program and system development. An acute care surgery team of stu- • Trauma research and scholarship dents, surgical residents, acute care surgery faculty, • Disaster planning and management and nursing leadership from both HICs and LMICs • Interhospital transfer obtained baseline data of LCoGS core surgical indicators 1, 2, 3, and 4 through retrospective review • Hospital organization and the trauma program of available hospital data. Using LCoGS indicators, • Collaborative clinical services we learned a great deal regarding trauma program • Rural trauma care evaluation during this pilot project. • Clinical functions: general surgery, emergency Assessment of each of the core trauma program medicine, orthopaedics, neurosurgery elements mentioned previously revealed notable overlap with surgical systems development and • Pediatric trauma care the LCoGS indicators 1, 2, 3, and 4 (see Table 3, • Rehabilitation page 14). Specifically, prehospital trauma care is • Guidelines for trauma centers caring for burn patients closely related to the geographic accessibility of surgical facilities (indicator 1) and the golden hour • Solid organ procurement of trauma care.11 The acute care surgery profession • Verification, review, and consultation program and practice in Latin America, along with the development of acute care surgery fellowships, augments

APR 2017 BULLETIN American College of Surgeons GLOBAL SURGICAL INDICATORS IN LATIN AMERICA

surgical workforce density (indicator 2) and promulgates emergent TABLE 3. LCoGS INDICATORS 9 AND TRAUMA PROGRAM and essential surgery education and training regionally. Trauma DEVELOPMENT registries provide data regarding number of procedures per 100,000 population (indicator 3) for trauma, and emergent and essential sur- Indicator 1: Improve data collection geries. Finally, a formal trauma PIPS program and trauma morbidity and analysis of prehospital care and mortality (M&M) process provides mortality data in order to to merge prehospital and trauma generate corrective action plans regarding intraoperative and post- registries and outcome operative mortality rate (indicator 4). Indicator 2: Depend on local and Single-month summer research experiences conducted over a national societies; improve surgeon three-month period by medical students during the third year of workforce via acute care surgery global surgery program implementation revealed a few key suc- education and training fellowships cesses. Internationally, measurement of indicator 1—two-hour Indicator 3: Identify country-specific geographical access to surgical facilities—has proven difficult to assess and is the least reported indicator.3,12 By focusing on pro- 14 | care settings/recordkeeping and provider workforce to assess total cess improvement and data collected from prehospital care, we surgical volume; integrate with have identified a new approach to measuring indicator 1, and more trauma registry; combine public importantly, to assess prehospital care quality improvement. The and private sectors; utilize TNM development of standardized service intake forms and enhanced communication between the field, the emergency department, and Indicator 4: Build performance surgical/trauma personnel—along with the Panamerican Trauma improvement and quality improvement Society trauma registry expansion, which now includes prehospital to assess trauma and essential and care—all contribute to the generation of prospective data that can emergent surgery M&M; integrate estimate two-hour access while also improving the prehospital care with trauma registry; combine public system. A data collection mechanism is proposed among private and and private sectors; utlize TNM public acute care facilities, including the following: The Hospital de Fundación del Valle de Lilli and Hospital de Universidad del Valle in Cali, Colombia; several private and public acute care facilities in Medellin, Colombia; and private, public, or professional emergency medical service (EMS) providers in both cities. The data collection mechanisms in these facilities include the duration of prehospital delay in reaching a hospital, surgical system readiness at the hospital, and the time to definitive surgical care. Most early LCoGS indicator implementation has occurred in low-income countries with fragmented prehospital care. However, middle-income cities, such as Cali and Medellin, Colombia, which have multisectoral and geopolitical limitations but more mature health systems, have provided some background information in urban prehospital care capacity. Our preliminary findings indicate that insurance contracts between hospitals and EMS often supersede surgical and trauma facility triage. The result often is additional costly time delays due to unnecessary interfacility transfers.

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The data suggest that trauma is one of the leading causes of preventable death around the world and disproportionately affects LMICs. Therefore, trauma program development may play a crucial role in improving health and surgical systems overall.

Furthermore, a quality improvement study will make it REFERENCES feasible to transfer data from independent prehospital data 1. Rose J, Chang DC, Weiser TG, Kassebaum NJ, systems to trauma hospital registries. This study provides Bickler SW. The role of surgery in global health: the ability to assess prehospital care as a factor in trauma out- Analysis of United States inpatient procedure comes and integrates prehospital with hospital data collection frequency by condition using the global in trauma registries, providing an opportunity for individual burden of disease 2010 framework. PLoS One. 2014;9(2):e89693. patient and systems of care evaluation and improvement. 2. Meara JG, Leather AJM, Hagander L, et al. Certain aspects of indicator data collection proved challeng- Global Surgery 2030: Evidence and solutions ing. It was difficult to locate hospital data that were consistently for achieving health, welfare, and economic collected and that accurately reflected the LCoGS indicator development. Lancet. 2015;6736(15):1-56. being measured. For example, indicator 2 (surgical workforce 3. The World Bank. World development indicators. Available at: data.worldbank.org/data-catalog/ density) was conflated on both ends of the spectrum. We found world-development-indicators. Accessed that surgeons tend to have multiple independent hospital con- February 17, 2017. tracts, potentially inflating reported workforce density. In 4. World Health Organization. Strengthening addition, other credentialed health care professionals are per- Emergency and Essential Surgical Care and | 15 mitted to perform surgical procedures in Colombia as surgeon Anaesthesia as a Component of Universal Health Coverage Report by the Secretariat. May 16, 2014. assistants. As a result, the data is skewed in the opposite direc- Available at: apps.who.int/gb/ebwha/pdf_files/ tion. Indicator 3 (volume of surgical procedures) was affected EB135/B135_3-en.pdf. Accessed February 17, 2017. by the underrecording of operations that occur outside of the 5. World Health Organization. Department operating theater (for example, procedures that trauma or of Violence and Injury Prevention and acute care surgeons perform in the emergency room), amount- Disability. Injuries and Violence: The Facts. 2010. Available at: apps.who.int/iris/ ing to the exclusion of approximately 40 percent of surgical bitstream/10665/44288/1/9789241599375_eng. cases at an academic hospital. Furthermore, because only pdf. Accessed February 17, 2017. public sector records were readily accessible, operations per- 6. Ng-Kamstra JS, Greenberg SLM, Abdullah formed in the private sector were excluded. F, et al. Global Surgery 2030: A roadmap for It is also important to note that in the U.S., the trauma nurse high income country actors. BMJ Glob Heal. 2016;1(1):1-12. manager (TNM) plays a key role in trauma programs and sys- 7. Riviello R, Ozgediz D, Hsia RY, Azzie G, tems (see Table 3). Our experience with domestic stakeholders Newton M, Tarpley J. Role of collaborative from the nursing profession and the Ministry of Health has academic partnerships in surgical training, shown that TNMs are grossly underrepresented in Colom- education, and provision. World J Surg. bia. Support of nursing education and training in the region 2010;34(3):459-465. 8. Peck GL, Paula F, Hanna J, et al. Can we could augment the capacity for a national trauma system while augment the U.S. trauma fellow’s operative also promoting gender-balanced leadership in the health and training? The PTS fellowship: A U.S. surgical surgical care workforce. The Especializacion en Enfermeria en critical care fellow’s experience in Colombia. Trauma, Emergencia Quirurgica y Cuidado Critico del Trauma (The Panam J Trauma, Crit Care Emerg Surg. 2014;3(1):1-7. Specialization of Trauma, Emergency Surgery, and Surgical 9. Blitzer D, Gupta R, Peck G. Extending the acute care surgery paradigm to global surgery. JAMA Critical Care Nursing) is an initiative in Colombia that seeks Surg. 2016;151(6):586-587. to expand the domestic nursing leadership. Although the pro- liferation of TNMs would not change the value of indicator continued on next page 2 under its current definition, which focuses on the physician workforce, the development of a regionally appropriate

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REFERENCES (CONTINUED) indicator of surgeons, anesthesia providers, obstetricians, and 10. American College of Surgeons Committee on nurses would be affected. Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2014. Call to action 11. Cowley RA. A total emergency medical system for the State of Maryland. Md State Med J. Achieving adequate surgical capacity within resource-poor 1975;24(7):37-45. settings is a multidisciplinary challenge. Research efforts 12. The Lancet Commission on Global Surgery. have focused on surveying the scope of the issue, and the Global indicator initiative. Surgical indicators next step is to explore effective methods to meet these capac- report. December 2015. Available at: www. ity issues. Our early work, and the existing literature on the lancetglobalsurgery.org/indicators. Accessed February 27, 2017. global burden of surgical disease, prompts a call to action for 13. Peden M, McGee K, Krug E, eds. Injury: A Latin America with a particular focus on trauma programs leading cause of the global burden of disease, and systems development. We assert that a focus on trauma 2000. World Health Organization. 2002. is relevant in light of the strength of regional relationships 16 | Available at: www.who.int/violence_injury_ between the trauma and surgical societies and the extent to prevention/publications/other_injury/injury/ en/. February 27, 2017. which trauma accounts for the burden of surgical disease in 13-16 14. Pan American Health Organization. Statistics the region. The development of trauma systems regionally on homicides, suicides, accidents, injuries, and will not only strengthen education, training, and the surgi- attitudes towards violence. Available at: www1. cal workforce, but also will improve the global health care paho.org/English/AD/DPC/NC/violence- community’s ability to collect data on surgical indicators, graphs.htm. Accessed March 1, 2017. 15. Krug EG, Dahlberg LL, Mercy JA, et thereby improving quality, value, and outcomes. al, eds. World report on violence and Given some of the challenges to reliable data collection, we health. World Health Organization. recommend the LCoGS core indicators be addressed through 2002. Available at: whqlibdoc.who.int/ a Latin America Surgical and Trauma Indicators Working publications/2002/9241545615_eng.pdf. Accessed Group within existing organizations such as the Panamerican March 1, 2017. 16. U.S. Centers for Disease Control and Prevention. Trauma Society. This group would be charged with identify- Web-based injury statistics query and reporting ing mechanisms that allow trauma and surgical systems to system. Fatal injury data. Available at: www. implement measurement of indicators, and properly assess cdc.gov/injury/wisqars/fatal.html. Accessed strengths and weaknesses of regional and national surgical February 27, 2017. planning efforts. Ultimately, this call to action will help strengthen comprehensive national surgical plans in countries where surgical and trauma care improvement is interdependent. Given the enormity of the challenge at hand—that is, building and strengthening surgical systems globally—we recognize the need for innovative mechanisms to evaluate, standardize, and improve critical information, such as core surgical indicators, across Latin America. The integration of an enhanced surgical system with trauma system development may be a particularly effective approach.7 ♦

V102 No 4 BULLETIN American College of Surgeons UM/ISRAEL TRAUMA FELLOWSHIP PROGRAM

UM Ryder Trauma Center/ Israel fellowship program provides a model for global trauma training

by Enrique Ginzburg, MD, FACS; Courtney Goodman; Gerald Sussman, PhD; and Yoram Klein, MD

t was 9:00 pm, and Israeli surgeon Ilan Schrier, MD, and his trauma team HIGHLIGHTS sprang into action to save a woman who had been stabbed in the heart | 17 by a mugger. Her systolic blood pressure read 60 (mm Hg). She was on • Describes UM Ryder I Trauma Center’s ongoing the verge of death. Within seven minutes of arrival, Dr. Schrier and his efforts to assist in the trauma team opened her chest. Her pericardial sac was brimming with development of sustainable blood. She was going through cardiac tamponade. They found a puncture global trauma systems in her left ventricle and quickly stitched it up. This lifesaving procedure was not performed in Israel—it happened at the University of Miami (UM) • Summarizes UM Ryder Ryder Trauma Center, FL. Trauma Center’s training Dr. Schrier is training to become an expert trauma surgeon with a fellow- initiative for Israeli ship at the UM Ryder Trauma Center. Later this year, he will have completed trauma surgeons a one-year fellowship and returned to the Rabin Medical Center in Petah- • Identifies the challenges of Tikva, one of six Level I trauma centers in Israel, and will work alongside developing a continuous the facility’s director, Michael Stein, MD, FACS. trauma system in Israel Israel does not have the same rate of continuous penetrating trauma as • Offers recommendations for the U.S., despite the violence associated with the Israel-Palestine conflict. other institutions interested “In Israel, we barely see gunshot wounds,” Dr. Schrier said. “In Miami, we in training international see them every day.” Because penetrating trauma is uncommon outside trauma surgeons of the U.S., aspiring trauma surgeons in Israel and other countries must train in high-volume centers abroad to acquire the skills needed to perform trauma surgery. This article focuses on Ryder’s efforts to contribute to global trauma care training. Ryder, one of several U.S. health care facilities that train trauma surgeons from around the world, has been particularly involved in training trauma surgeons from Israel through an initiative proposed by Kenneth L. Mattox, MD, FACS, an active member of the American College of Surgeons (ACS) Committee on Trauma (COT) and Past First Vice-President of the College. The development of the Ryder program is described, which offers a

APR 2017 BULLETIN American College of Surgeons UM/ISRAEL TRAUMA FELLOWSHIP PROGRAM

blueprint for other academic medical institutions inter- in the launch of an organized trauma system, includ- ested in training surgeons to provide specialized care ing the development of the first electronic trauma outside of the U.S. registry for the region. This registry contains data on nine trauma centers that serve a population of more than 12 million Argentinians. This registry is compli- Trauma and disaster relief ant with the International Classification of Diseases, The UM Ryder Trauma Center has an active interna- 10th Revision, and has been used in multiple aca- tional trauma training program, and the institution’s demic research projects and by the ministry of health trauma surgeons and residents have been involved in in the development of health policy. The Argentine disaster response and trauma system development government has since signed a memorandum of under- efforts in Haiti, Brazil, and Argentina. standing to work with Fundación Trauma to expand Dr. Ginzburg, a co-author of this article, was the national use of the database. international director of Project Medishare in 2010 In addition, UM Ryder Trauma Center organized when a catastrophic earthquake struck Haiti, killing and continues to host the Panamerican Trauma Soci- more than 160,000 and displacing close to 1.5 million ety weekly telemedicine grand rounds. Each Friday, 18 | people. In this role, he served as the informal field hos- up to 20 different international centers participate in pital coordinator for the World Health Organization a trauma case presentation. the first 72 hours after the catastrophe took place. An affiliate of the UM Medical School, Project Medishare used four large event tents to establish one of the early Launch of Israel initiative field hospitals for trauma care after the earthquake. We were honored in 1992 when Dr. Mattox contacted This tent-turned-critical-care-hospital was established Robert Zeppa, MD, FACS, then-chair of surgery at UM, at the Port-au-Prince airport with 250 to 300 beds. to see if Ryder Trauma Center would assist in train- Dr. Ginzburg subsequently transferred to the ing an Israeli trauma surgeon. Considering UM Ryder 80-bed Hospital Bernard Mevs in Port-au-Prince— Trauma Center’s experience helping countries build one of the two current Haitian-run trauma centers in and sustain trauma systems, we felt well-equipped the city. The facility provides care to trauma patients to develop this program, which formally launched in Haiti to this day. two years after the first Israeli fellow, Mauricio Lynn, The UM Ryder Trauma Center also assisted the MD, returned home in 1998. This initiative has proven Brazilian government in establishing two new trauma invaluable in enabling Ryder to conduct the outreach centers in Rio de Janeiro. The centers were established programs described previously. to provide care at the 2014 FIFA World Cup and emer- Since the program’s inception, 16 Israeli surgeons gency services at the 2016 Summer Olympics. This have completed trauma fellowships in the U.S., includ- latter effort was led by Antonio C. Marttos, Jr., MD, ing one at Ben Taub Hospital, Houston, TX, where associate professor of surgery and co-director, Wil- Dr. Mattox is chief of staff and surgeon-in-chief; two liam Lehman Injury Research Center, UM. The two at the University of Pittsburgh, PA; two at the Mary- hospitals continue to function as trauma centers, one land Institute for Emergency Medical Services Systems, of which, Hospital Estadual Alberto Torres, is a stand- Baltimore; and 11 at the UM Ryder Trauma Center. alone facility. Of these 16 Israeli trauma surgeons, nine practice in The UM’s global trauma relief efforts in Argen- Israel. Dr. Schrier will be the 10th surgeon to return tina include a partnership with Fundación Trauma in to Israel after he completes the program this year. Of Buenos Aires that, over the last six years, has resulted the remaining six surgeons, one chose to remain in the

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U.S., and the other five have focused on their general to co-author Yoram Klein, MD, former chairman of surgery practices. the Israeli Trauma Society and head of Sheba Medical The Israeli fellows have no impact on the number of Center, Tel-Hashomer, Ramat-Gan. fellowships available to U.S. surgeons through Ryder’s The challenges facing Israel’s trauma care system formal trauma training program. However, they do are better understood with the realization that the rotate on the same services, receiving the same caliber system is in its early stages of development. Even of training as UM’s formal Residency Review Commit- though Israel has experience with trauma that covers tee fellows. The Israeli fellows participate in the same eight wars, two Palestinian intifadas, and thousands of critical care, acute care surgery, and trauma service internecine attacks, an organized trauma system was lines, and conduct research alongside our U.S. fellows. nonexistent until the early 1990s.1 Therefore, Israeli fellows are required to pass the U.S. National recognition of the need for a continuous Medical License Examination (USMLE) before they trauma system by the Revach Committee in the late can practice and provide clinical care in our program. 1980s propelled the Ministry of Health to implement Because these are formal fellowship positions, the major organizational changes, equipment updates, hospital regards these fellows as residents and provides and staff training.1,2 The new system was modeled them with a sixth- and seventh-year salary line. More on the U.S. trauma system but was adapted to meet | 19 than 90 percent of the Israeli trainees have successfully Israel’s needs.1 Six Level I trauma centers were desig- completed the two-year surgical critical care/trauma nated according to ACS COT standards, centralizing fellowship. severe trauma patients.3 A national trauma registry that included injury severity score was assembled.3 All medical personnel in trauma and emergency services were Why Israel? required to take the Advanced Trauma Life Support® To assess the present trauma care system in Israel (ATLS®) course.4 Amidst these changes, top general sur- and determine the ongoing need for the training pro- geons volunteered to complete U.S. trauma fellowships.5 gram, in 2015 the members of the UM Ryder Trauma These surgeons serve as the current trauma directors. Center team interviewed the directors at the six Level I The trauma directors we interviewed, however, trauma centers in the country. All of the directors indi- fear that the momentum of the 1990s has subsided and cated that the greatest need was for more surgeons that recruitment of new surgeons to train outside of formally trained in trauma care. Most Level I hospi- Israel is unsustainable. “There is no new generation tals in Israel have just one dedicated trauma surgeon ready to replace the aging trauma surgeon generation, on staff; the exceptions are Rambam Medical Center which is alarming,” said Hany Bahouth, MD, director in Haifa and Tel Aviv Medical Center, both of which of Rambam Medical Center and chairman of the Israeli have two trauma surgeons on staff. Trauma Society. “It is a one-man show,” said Prof. Gadi Shaked, direc- While U.S. Level I hospitals are open to training tor of Soroka Medical Center in Be’er Sheva, the only Israeli fellows, the directors said that there are no incen- Level I trauma center that serves Israel’s southern popu- tives for formal trauma training. In Israel, the salary of a lations. Trauma directors are on-call around the clock, dedicated trauma surgeon or director is the same as the but are rarely available 24/7 a week due to other pro- salary of a general attending surgeon, but, unlike other fessional time commitments, including teaching. The senior surgeons, trauma surgeons are unable to supple- limited availability of trauma directors puts patients ment their income with private practice. In addition, who require immediate complex operations at risk. the lifestyle is less than ideal because they are on-call Israel needs at least 10 more trauma experts, according 24/7. The time spent training and the requirement to

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To assess the present trauma care system in Israel and determine the ongoing need for the training program, in 2015 the members of the UM Ryder Trauma Center team interviewed the directors at the six Level I trauma centers in the country. All of the directors indicated that the greatest need was for more surgeons formally trained in trauma care.

pass the USMLE inhibit formal trauma training for functioning of a trauma care system would be the many surgeons. Essentially, many Israeli surgeons feel equivalent of denying the best treatment possible for that a trauma fellowship in the U.S. is arduous work emergency cases to both Israelis and Palestinians. for the same pay. With the recent escalation of terrorist attacks and To incentivize recruitment, one solution would be to rising tensions in Gulf states, a need for a trauma raise the salary of expert trauma surgeons. Drs. Klein care system is critical for Israel and its neighbors. As and Bahouth, however, described trauma care as one relations with surrounding territories and countries of the least recognized divisions of medicine in Israel. hopefully improve, a well-established Israeli trauma Only two Level I hospitals have dedicated trauma beds. system can further foster cooperation and sustained Expert trauma surgeons even provide specialty services peace through collaborative training programs. Dr. on the side because they are paid four to five times more Schrier’s training in the UM Ryder Trauma Center for private practice. More recognition, according to is a step in the right direction, but a national push to Drs. Klein and Bahouth, would allow trauma care to maintain the efficacy of Israel’s daily trauma system become more organized, raise salaries, and attract resi- needs to be ensured. dents. A fellowship does exist in Israel, but the current 20 | program does not expose fellows to enough penetrating and operative cases. A call for action Dr. Klein believes that adding a three-month oper- The authors are sharing these experiences as an exam- ative experience in the U.S. would correct this gap. ple of the opportunity that academic programs have This proposal, however, lacks funding. The health care to help develop trauma systems globally. We believe system in Israel provides a low volume of trauma ser- our partnership with Israeli trauma centers can serve vices on an everyday basis, which hinders obtaining as a model for other academic institutions that are additional financial support. In fact, some directors interested in helping other countries to develop sus- have stated that too many centers have the potential tainable trauma care systems. It is interesting to note to take trauma cases, which dilutes staff opportunities that the UM tented hospital worked collaboratively to train with significant numbers of cases. the first days of the Haitian earthquake with the Israeli Tel Aviv has a population of 3 million, yet has three military rescue team. One of the graduated Israeli UM Level I trauma centers. A potential solution to the lack fellows, Guy Lin, MD, was in the Israeli military team of expert trauma surgeons would be to concentrate the that participated in the relief effort. trauma surgeons into two centers in Tel Aviv rather Based on UM Ryder Trauma Center’s more than than three to further consolidate severe trauma patients 20 years of experience in offering a successful inter- and increase direct resources, including staff. Forcing national trauma training program, the authors offer a Level I unit to step down, however, is a controversial the following suggestions to academic medical cen- proposition. Nonetheless, concentration of expertise ters interested in establishing a similar opportunity would not solve the problem of developing a new gen- for trainees from other countries: eration of expert trauma surgeons. While Israel’s newly established trauma system • Establish a sustainable funding source, either through significantly reduced inhospital patient mortality by salary support from the U.S. hospital or through the 33 percent between 2000 and 2010, steps need to be ministry of health for the country sending the trainee. taken to ensure that the system remains fully opera- tional.1 Because the Israeli medical system is a hub for • Locate a champion at your institution who has a pas- Western medicine in the Middle East, to deny optimal sionate interest in promoting better access to and quality

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of surgical care in a particular region or country and has the energy REFERENCES and connections needed to get the project started. 1. Siman-Tov M, Radomislensy I, Peleg K. Reduction in trauma mortality in Israel • Develop a sustained group of candidates once the program has been during the last decade (2000-2010): The formed, as identified by surgeons in the country of origin. impact of changes in the trauma system. Injury. 2013;44(11):1448-1452. • Promote the program through media outlets in the trainee’s coun- 2. Soffer D, Klausner JM. Trauma system configurations in other countries: try of origin. The Israeli model. Surg Clin North Am. 2012;92(4):1025-1040. UM continues to reach out to other countries to help them 3. Aharonson-Daniel L, Avitzour M, Giveon establish sustainable trauma systems. For example, UM has reached A, Peleg K. A decade to the Israel National out to Palestine and has trained one fellow from Jordan and one Trauma Registry. IMAJ. 2007;9(5):347-351. 4. Peleg K, Aharonson-Daniel L, Stein M, et from Saudi Arabia. At press time, the university also is in discus- al. Increased survival among severe trauma sions with the United Arab Emirates to determine the feasibility patients. Arch Surg. 2004;139(11):1231-1236. of developing a trauma training partnership. 5. Goldman S, Siman-Tov M, Bahouth H, et In November 2016, Marc De Moya, MD, FACS, director, sur- al. The contribution of the Israel trauma | 21 gical clerkship, Harvard Medical School, and medical director, system to the survival of road traffic casualties. Traffic Inj Prev. 2015;16(4):368-373. trauma nurse practitioner program, Massachusetts General Hos- pital, Boston, organized a group of Harvard and UM physicians that traveled to Cuba to assist in the presentation of the first operative trauma training course and participate in the second Cuban Sur- gical Congress. Dr. De Moya is a graduate of the UM trauma and critical care fellowship program. The trauma surgeons at UM Ryder Trauma Center look forward to continuing to support efforts to improve trauma surgery around the world, and we encourage other academic medical centers to explore similar opportunities. ♦

Acknowledgments The authors want to thank Hany Bahouth, MD; Miklosh Bala, MD; Gadi Shaked, MD; Dror Soffer, MD; and Michael Stein, MD, FACS, for sharing their views on the status of Israel’s trauma system. We also want to recognize Matthew Patton for his support in writing this article, as well as Nicholas Namias, MD, FACS; Louis Pizano, MD, FACS; Daniel Pust, MD; Carl Schulman, MD, FACS; Tanya Zakrison, MD, FACS; and the UM division of trauma and critical care, all of whom actively participated in the programs described in this article.

APR 2017 BULLETIN American College of Surgeons QPP IN 2017

QPP in 2017: Navigating the transition year

by Matthew R. Coffron, MA, and Patrick V. Bailey, MD, MLS, FACS

he Medicare Access and CHIP (Children’s reporting requirements for individuals and groups, 22 | Health Insurance Program) Reauthorization summarizes the transition to MIPS in 2017, describes TAct (MACRA) of 2015 repealed the flawed sus- how surgeons and groups can set their own pace for tainable growth rate formula used to adjust physician participation, and highlights how MIPS will evolve reimbursements for services provided to Medicare in the coming years. It also looks at accommodations beneficiaries and called for establishment of a new that are being made for small, rural practices, and payment system that emphasizes value over volume. describes the resources that the American College of In response to this charge, the Centers for Medicare Surgeons (ACS) has developed to help Fellows suc- & Medicaid Services (CMS) developed the Quality ceed under MIPS. Payment Program (QPP). Central to the QPP is the new Merit-based Incentive Payment System (MIPS). In addition, the QPP seeks to encourage surgeons and MIPS and its components other physicians to participate in Advanced Alterna- MIPS began measuring performance in January. The tive Payment Models (APMs) and other options under data reported in 2017 will be used to adjust payments development that may become available to surgeons in 2019. in future years. MIPS consists of four components. Three of these The 2017 transition year to MIPS began in January. are analogous to previous Medicare quality improve- As part of this transition year, CMS has taken a number ment programs, and include Quality, formerly the of steps to streamline reporting and make it easier for Physician Quality Reporting System (PQRS); Cost, surgeons and other physicians to avoid penalties and formerly the Value-Based Payment Modifier (VM); achieve positive updates. However, over time, penalties and Advancing Care Information (ACI), formerly for nonparticipation or poor performance will grow, the Electronic Health Record (EHR) Incentive Pro- as will payment increases for successful participation gram, commonly referred to as meaningful use and improved performance. (EHR-MU). MIPS also added a new component, It is critically important that all surgeons make a Improvement Activities (IA). During the first year, plan for how they can best participate and succeed in three components—Quality, ACI, and IA—will be the new program. This article provides background used to derive a composite MIPS final score. The on MIPS and its components, offers a discussion of weights for the individual components of the final

V102 No 4 BULLETIN American College of Surgeons QPP IN 2017

FIGURE 1. 2017 PERFORMANCE CATEGORY WEIGHTS

score for the first year of the MIPS program are rep- physicians who performed well in PQRS and EHR-MU resented in Figure 1, this page. are more likely to be successful in MIPS. Accordingly, Although CMS has chosen not to provide any the ACS recommends that all Fellows take a few weight to the Cost component during the first year simple steps to ensure successful participation in MIPS of the program, those physicians who report Quality reporting. First, verify that the certified EHR technol- data will receive feedback reports on their perfor- ogy (CEHRT) you are using is either a 2014 or 2015 mance in the Cost component. edition. Use of one of these two editions is required | 23 to participate in ACI. In addition, it is critically important to become familiar with the available Quality Reporting options measures and the data submission methods available The payment adjustment for surgeons who submit to your practice, including consideration of the use MIPS data as individuals will be based on their indi- of a registry or a QCDR. The ACS recommends that vidual performance. A final score is calculated using Fellows review the Quality measure benchmarks the data submitted for Quality, ACI, and IA. Data for available at qpp.cms.gov/resources/education to opti- each of these three MIPS categories may be submit- mize their quality score. ted through an EHR, a registry, or a qualified clinical data registry (QCDR). Quality data also may be submitted through the routine Medicare claims process, Pick Your Pace and data for ACI and IA may be submitted through CMS has designated 2017 as a transition year and the CMS web portal. has provided a clear pathway to avoid penalties. In Surgeons who submit MIPS data as part of a group addition, CMS has reduced the reporting require- practice under a single taxpayer identification number ments in 2017 for those physicians who wish to will receive the MIPS final score and corresponding fully participate in preparation for the future or payment adjustment in accordance with the assess- for those practices aiming for a positive payment ment made for their group practice (a single MIPS update. It is important to note that the funds avail- final score and corresponding payment adjustment able for positive payment updates are derived from is made for all individuals within the group). Those the penalties assessed on physicians who choose not practices that choose to report as a group for any one to participate. Accordingly, by making it easier to of the reporting requirements also must report as a avoid penalties in the first year, CMS has reduced group for all of the remaining components of MIPS. the amount of funds available for positive incen- It is important to have an idea of one’s current tives. Surgeons should bear this adjustment in mind preparedness and previous status with the Medi- when planning their course of action and attendant care programs that form the basis for MIPS, as those resource requirements for 2017.

APR 2017 BULLETIN American College of Surgeons QPP IN 2017

Participating to avoid penalties Option 1: Test the MIPS program For 2017, CMS instituted a Pick Your Pace approach, Submit a minimum amount of 2017 data (for example, which gives surgeons options for participation in one Quality measure or one IA for any point in 2017) MIPS. Those physicians who opt out of participa- to Medicare to avoid a 4 percent Medicare Part B pen- tion at any level will receive the full negative 4 alty in 2019. This option is for surgeons who may be percent payment adjustment in 2019. However, it unfamiliar with quality reporting and want to test it is worth noting that a negative 4 percent payment out or for those who only want to do the minimum adjustment is less than half of the negative adjust- amount of reporting required to avoid the penalty. ments associated with the PQRS, VM, and EHR-MU Again, CMS defines the minimum data submission programs in 2016. necessary to avoid a penalty as one of the following: To avoid the 4 percent penalty, CMS only requires that surgeons test their ability to report • One Quality measure data in any one of three reporting components, 24 | namely Quality, ACI, or IA. Information for the • One IA Cost component is derived automatically and has no reporting requirement. To avoid a penalty, • The required base score ACI measures surgeons must complete just one of the following tasks: Option 2: Participate in MIPS for part of the year Surgeons may submit data to Medicare for a continuous • Report one Quality measure for a single patient 90-day period in 2017 to avoid the penalty and possibly earn a small incentive payment. Surgeons who were • Attest to participating in a designated IA for at least not ready to start reporting on January 1 may start any 90 consecutive days time through October 2. This option adds flexibility for those surgeons who want to participate in the pro- • Complete the base score requirements for ACI gram but prefer to report for a shorter period of time. By reporting for a 90-day minimum, surgeons will Participating to prepare for future success be eligible for at least a neutral adjustment, if not a Surgeons seeking to achieve a higher score must small positive adjustment. Positive adjustments are report data for 50 percent of all patients seen (for based on performance, not the amount of information all payors) for any period of 90 consecutive days. or length of time reported. However, reporting for a Accordingly, one could begin as late as October 2; longer period of time is the best way to earn the maxi- however, CMS encourages reporting for the full mum positive adjustment because surgeons can track year. How data are reported depends upon the cir- their performance and thereby have the opportunity cumstances of an individual’s practice, as there are to improve. multiple methods (EHR, registry, or QCDR) of sub- Partial participation in MIPS means that surgeons mitting data to CMS. It should be noted that data should meet at least the following three criteria: can also be submitted either on an individual basis or as a group. • Six Quality measures for 90 or more consecutive days In the 2017 transition year to QPP, surgeons may on 50 percent of all-payor applicable patients (50 percent use one of the following four options to participate: of applicable Medicare patients for claims reporting)

V102 No 4 BULLETIN American College of Surgeons QPP IN 2017

CMS has designated 2017 as a transition year and has provided a clear pathway to avoid penalties. In addition, CMS has reduced the reporting requirements in 2017 for those physicians who wish to fully participate in preparation for the future or for those practices aiming for a positive payment update.

• Four medium-weighted or two high-weighted IA for 90 Surgeons who receive 25 percent of Medicare pay- consecutive days ments or see 20 percent of Medicare patients through an Advanced APM in 2017 could earn a 5 percent • Report ACI measures for 90 or more consecutive days incentive payment in 2019. The ACS is working to expand the Advanced Surgeons may choose different 90-day reporting APM options for surgeons in the future. To view periods for each performance category, including Qual- an Advanced APM proposal that the ACS submitted ity, IA, and ACI. in December 2016, visit the “For Public Comment” section of the Physician-Focused Payment Model Option 3: Fully participate in MIPS Technical Advisory Committee web page at aspe. Surgeons may submit up to a full year of data to hhs.gov/documents-public-comment-physician-focused- Medicare in 2017 to be eligible for a positive payment payment-model-technical-advisory-committee. adjustment in 2019. Full participation in MIPS means that surgeons report all of the following: Option 5: Do not participate | 25 Nonparticipation in the QPP in 2017 will result in a • Six Quality measures for up to a full year on 50 percent 4 percent Medicare Part B payment penalty in 2019. of all-payor applicable patients (50 percent of applicable Medicare patients for claims reporting) Pathway to a positive payment update • Four medium-weighted or two high-weighted IA for 90 To compete for a positive payment update, surgeons consecutive days and surgical practices will need to report specific information for each component of MIPS. Follow- • ACI measures for up to a full year ing is a summary of the reporting requirements by component. Reporting for up to a full year is the best way to get the maximum positive payment adjustment. Not Reporting for Quality only does full participation allow surgeons to track To be eligible to receive the full potential Quality their performance over a longer period of time, it also score, data must be submitted for 50 percent of all expands the number of available measures while better patients seen (for all payors, except those who report preparing them for future years of the QPP, which will by claims) for at least a 90-consecutive-day period likely require full-year participation. on a minimum of six measures, including one outcome measure. Another high-priority measure may Option 4: Participate in an Advanced APM be substituted if an outcome measure is unavailable. An APM is a payment approach that provides incen- Measures can be chosen from the MIPS measures tive payments for the provision of high-quality and list, a MIPS specialty-specific measure set, or QCDR cost-efficient care. APMs can apply to a specific measures. clinical condition, a care episode, or a population. Those surgeons who do meet the reporting Advanced APMs are a subset of APMs that meet addi- requirement and perform well on the measures can tional requirements, including use of CEHRT, use of receive up to 60 points toward their MIPS final score. evidence-based quality measures, and financial risk. For those surgeons simply seeking to avoid penalties

APR 2017 BULLETIN American College of Surgeons QPP IN 2017

for the first year of the MIPS program, reporting a Reporting for IA single measure for a single patient will yield the While IA is a new category, surgeons are familiar three points necessary to meet the threshold that with many of the activities it encompasses, such as CMS has prescribed for avoiding a penalty in this Maintenance of Certification, use of the ACS National transition year. Bonus points also are available by Surgical Quality Improvement Program Surgical Risk reporting on additional outcome measures, high-pri- Calculator, participation in a QCDR, and registration ority measures, and end-to-end reporting measures with their state’s prescription drug monitoring pro- using CEHRT. gram. Each activity is assigned a value of either 20 points (high value) or 10 points (medium value). The Reporting for ACI reporting requirement for the IA is fulfilled through The ACI component is worth 25 percent of the MIPS simple attestation via a registry, a QCDR, or a portal final score. The assessment for ACI is a composite on the CMS website. To receive full credit, most sur- score composed of two parts: a base score and a geons must select and attest to having completed 26 | performance score. As stated previously, to receive two to four activities for a total of 40 points. For credit for the ACI component in 2017, one must use small practices, which CMS defines as those with 2014 or 2015 edition CEHRT. According to current fewer than 15 providers or those in rural practices, regulations, only those providers with 2015 edition the agency has said that to achieve full credit only technology will qualify for ACI beginning in 2018. one high-value or two medium-value activities are The base score is an all-or-nothing threshold and required. Those who fulfill the requirement will accounts for 50 percent of the total score for the receive 15 points toward the MIPS final score. Sur- ACI component. Achievement of the base score is geons who simply want to avoid a penalty in the first required before any score can be accrued for the reporting year of MIPS may do so by attesting that performance portion. Achieving the base score they have completed a single activity for 90 days. also is one of the options prescribed by CMS sufficient to avoid any MIPS penalties in 2017. If the base score is achieved, no penalty will be imposed, The MIPS final score and payment updates even if no Quality, IA, or additional ACI data are To review, performance in the four MIPS categories submitted. The ACI measures are intended to ensure (Quality, ACI, IA, and Cost) will be combined into a that CEHRT is being used for core tasks, such as single MIPS final score, which will be benchmarked providing patients with online access to their medi- against a threshold to determine each provider’s pay- cal records, exchanging health information with ment update. The maximum payment updates, the patients and other providers, electronic prescribing, category weights (see Figure 1), and the threshold and protecting sensitive patient health information will all vary over time. through a security risk analysis. Once all of the measures for the base score have Component weights been met, clinicians are eligible to receive credit for For the 2017 performance year, Quality, ACI, and performance on both a subset of the base score mea- IA performance will account for 60, 25, and 15 per- sures and on a set of additional optional measures. cent of the total MIPS score, respectively. For the Bonus points are also available by reporting certain first year, the Cost category carries no weight, IA via CEHRT. although providers still will receive information on

V102 No 4 BULLETIN American College of Surgeons QPP IN 2017

FIGURE 2. MIPS YEARLY PAYMENT ADJUSTMENTS

Source: Centers for Medicare & Medicaid Services

their resource use relative to other providers. By 2019, in setting the threshold for the first two years. For the Quality and Cost are set to be equally weighted at 30 2017 performance year, the threshold is set at 3, which percent, with ACI and IA continuing to account for 25 means that any provider who reports a single Quality and 15 percent, respectively. Also of note, once 75 per- measure for a single patient, participates in a single cent of physicians are classified as meaningful users of IA for 90 consecutive days, or completes the ACI base EHR technology, the ACI component weight can be score requirements will be at or above the threshold reduced to as low as 15 percent, with the remainder and, therefore, avoid penalties. As previously men- | 27 distributed among the other categories. tioned, this flexibility means that most providers will Provider performance in the four categories will be be exempt from penalties in the 2019 payment year, adjusted annually based upon that category’s weight, and positive updates for eligible providers are likely and combined into a MIPS final score between 0 and to be modest. 100 (see Figure 2, this page). This score will then be compared against a performance threshold. If the score Single update versus multiple penalty programs is above the threshold, the provider will be eligible for The MIPS program’s scoring system may seem com- a positive update; if the score is equal to the threshold, plex, but it effectively replaces multiple programs the update will be neutral; and if the score is below (PQRS, EHR-MU, and VM), which had the combined the threshold, payments will be reduced. potential to impose penalties totaling 10 percent in 2016. In general, the maximum positive and negative MIPS, in contrast, has a single update mechanism and updates are 4 percent for the 2019 payment year (based provides much greater opportunity for positive pay- on 2017 performance) and will grow annually until ment adjustments while reducing the downside risk. they reach plus or minus 9 percent for 2022 and future years. For the first six years of the program, MIPS providers with the highest performance scores (typically Support for individual, small those in the top three quartiles above the performance group, and rural practices threshold) will be eligible for an additional positive Solo practitioners and small group practices of 15 or update of up to 10 percent. Up to $500 million per year fewer physicians, particularly those in rural or health is available for these additional updates. professional shortage areas (HPSAs), may be eligible for technical assistance or subject to reduced requirements The performance threshold designed to help them succeed in the QPP. HHS will The performance threshold will typically be the aver- award $20 million for each of the first five years of the age of a prior performance period, but because of the QPP to organizations tasked with helping these prac- lack of historical data, the Secretary of the Department tices, as well as those in medically underserved areas, of Health and Human Services (HHS) has discretion succeed. This money will be allocated to provide

APR 2017 BULLETIN American College of Surgeons QPP IN 2017

direct outreach and technical assistance, such as penalties in the 2017 transition year, CMS has decided helping practices decide which Quality measures to not to implement this option for at least the first year report, offering advice on EHR selection and imple- of the QPP. mentation, and discussing how to improve the MIPS final score by receiving credit for IAs. Help also will be provided to those individuals and practices inter- Resources for ACS members ested in exploring participation in APMs. To assist Fellows in the transition to QPP, the ACS has Certain scoring advantages for small practices created a variety of resources that explain the pur- are built into the MIPS scoring criteria. Specifically, pose and structure of the MIPS program and help to small practices, rural practices, or practices located guide Fellows in choosing the level of participation in geographic HPSAs can receive full credit in the that is right for their individual practice. Knowing IA component of MIPS by attesting to a single high- what options are available is vital to navigating the weighted or two medium-weighted activities (half new reporting requirements, making an informed 28 | the requirement of larger practices). value judgment, and ultimately achieving the best In addition, practices may be excluded from MIPS possible financial outcomes. altogether if they do not see many Medicare patients The ACS has created a set of tools to facilitate Fel- or if they receive a low amount of Medicare Part B lows’ understanding of MACRA and the QPP. These payments. Specifically, a low-volume threshold has tools can be found at facs.org/qpp and include a series been established such that if providers see fewer of short videos providing a historical background of than 100 Medicare patients annually or submit less MACRA, an overview of the MIPS program, more than $30,000 in Medicare claims, they are exempt detailed explanations of the components making from MIPS participation. For the 2019 MIPS pay- up the assessment for the final score in 2017, as well ment adjustment, CMS will initially identify the as a guide to choosing your level of participation. low-volume status of individual eligible clinicians This site is reviewed and updated as new informa- based on 12 months of data starting September 1, tion becomes available. The College urges Fellows 2015, to August 31, 2016. The second determination to use these resources and to contact the Division period will be based on data starting September 1, of Advocacy and Health Policy at [email protected] 2016, to August 31, 2017. CMS will notify provid- with questions. ♦ ers who meet this criteria by mail based on their address listed in the Provider Enrollment, Chain, and Ownership System. CMS also intends to provide a National Provider Identifier level lookup feature that will allow clinicians to determine if they are within the low-volume threshold. In the future, small practices with 10 or fewer clinicians will be allowed to form virtual groups to streamline and increase the efficiency of the MIPS reporting requirements. Due to technological barriers associated with this new reporting method and the steps CMS has taken to shelter practices from

V102 No 4 BULLETIN American College of Surgeons THE FUTURE OF TRAUMA CARE ON CAPITOL HILL

HIGHLIGHTS • Summarizes the NASEM report’s role in trauma-focused legislation • Describes the goals of military- civilian trauma partnerships as outlined in the NDAA The future • Outlines how the Mission Zero Act will enhance military-civilian partnerships of trauma care • Explains the goals of the Congressional on Capitol Hill: Pediatric Trauma Caucus

Implementing military-civilian | 29 trauma care and establishing he American College of Surgeons a national trauma system (ACS) Division of Advocacy and THealth Policy (DAHP) and the Com- mittee on Trauma (COT) continue to by work closely to craft and implement a Carrie Zlatos trauma-focused agenda to take to Capitol and Hill. While federal government budget Justin Rosen debates and partisan politics have been an impediment to passing trauma-related legislation, within the last several months the momentum has shifted. This change is perhaps attributable to the publication of the National Academy of Sciences, Engi- neering, and Medicine (NASEM) report, A National Trauma Care System: Integrat- ing Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. The report, released in June 2016, outlines 11 recommendations that would help achieve the goal of zero preventable deaths after injury through the establishment of a nationwide trauma system that incor- porates elements of trauma care in both the military and civilian sectors. Since the release of the NASEM report, several pieces of trauma-focused legislation have

APR 2017 BULLETIN American College of Surgeons THE FUTURE OF TRAUMA CARE ON CAPITOL HILL

In February 2017, the ACS and the COT hosted a congressional briefing on Capitol Hill to highlight the Stop the Bleed program, which trains civilian bystanders in the basics of hemorrhage control.

been introduced in Congress, and the House Energy system. Building on this momentum, the ACS is and Commerce Committee held a hearing on the revamping its trauma priorities and advocacy strat- establishment of a national trauma system. The ACS egies for today and beyond. In February 2017, the COT issued a statement in support of the NASEM ACS and the COT hosted a congressional briefing on report in October 2016.* Capitol Hill to highlight the Stop the Bleed program, which trains civilian bystanders in the basics of hemorrhage control. The briefing featured an overview Previous barriers of Stop the Bleed® and the Hartford Consensus—the Until this year, Congress’ focus was on two pieces of mass casualty and active shooter response commit- trauma legislation that would have funded trauma tee led by ACS Regent Lenworth M. Jacobs, Jr., MD, systems and centers. However, these bills faced mul- MPH, FACS—and provided an opportunity for con- tiple obstacles, including congressional leaders who gressional legislators and staff to engage in a hands-on were hesitant to appropriate funding to implement bleeding control simulation (BCon) led by COT lead- the legislation without finding a revenue stream to ers (see related article, page 79). pay for these bills, or an equal number of budget cuts 30 | that would cover the cost. Congressional inaction has stalled the bills, but some progress has occurred Legislative first steps: with the emergence of trauma champions, includ- National Defense Authorization Act ing Reps. Michael Burgess, MD (R-TX), Gene Green As trauma care leaders were developing the NASEM (D-TX), and Larry Bucshon, MD, FACS (R-IN), and report, congressional leaders working with DAHP staff Sens. Patty Murray (D-WA), Jack Reed (D-RI), and were focused on addressing improvements to the mili- Mark Kirk (R-IL), who retired in January 2017. With tary health system. In the 114th Congress (2015–2016), their support, trauma legislation remains on the con- the ACS worked with Rep. Joe Heck, DO (R-NV), gressional radar, and the ACS will work with these then-Chair of the House Armed Services Subcommit- legislators and their colleagues to identify alternate tee on Military Personnel, to include a provision in the funding mechanisms. National Defense Authorization Act (NDAA), which The NASEM report helped bring new policy calls for the establishment of a Joint Trauma System ideas to the forefront and elevate trauma as an (JTS) within the U.S. Department of Defense (DoD). issue on Capitol Hill. As a result, several legisla- Under the NDAA, enacted in December 2016, the JTS tors have redoubled their efforts to pass legislation will add uniformity to trauma care for the U.S. Armed that addresses the concerns outlined in the NASEM Forces by aligning all military medical treatment facili- report. Some recommendations highlight the need ties under the same set of trauma standards. In the for greater cooperation between military and civil- past, each medical corps (Army, Navy, and Air Force) ian trauma care, increased research for trauma care, had its own protocols, including requirements for pre- expanded participation in trauma quality improve- deployment training. The JTS also will be responsible ment programs, and inclusion of prehospital care as for coordinating the translation of research from DoD a seamless component of the health care delivery centers of excellence into standards of clinical trauma care, as well as incorporating lessons learned from *Stewart R, Jenkins D, Winchell R, Rotondo M. ACS Committee on trauma education and training partnerships into clin- Trauma pledges to make zero preventable deaths a reality. Bull Am ical practice. Coll Surg. 2016;101(10):23-28. Available at: bulletin.facs.org/2016/10/acs- committee-on-trauma-pledges-to-make-zero-preventable-deaths-a-reality/. Rep. Brad Wenstrup, DPM (R-OH), helped to Accessed January 31, 2017. secure language in the NDAA that calls for a review

V102 No 4 BULLETIN American College of Surgeons THE FUTURE OF TRAUMA CARE ON CAPITOL HILL

of the military trauma system by a nongovernment casualty care instruction for all members of the entity with subject matter experts. The ACS COT U.S. Armed Forces, including the use of standard- Trauma Systems Consultation Program regularly ized trauma training platforms. The Military Health conducts such reviews. The comprehensive review System Strategic Partnership American College of will look at combat casualty care and wartime trauma Surgeons (MHSSPACS) is developing a blueprint for systems from January 1, 2001, through the date of testing and maintaining currency and competency the review. It will include an assessment of lessons in combat casualty care. learned to improve combat casualty care in future Central to the mission of improving military conflicts. The reviewer will be required to make trauma care, the directorate will be responsible for this report publicly available. The report will con- the creation of a comprehensive trauma care registry tain findings from the review and recommendations to compile relevant data from point of injury through to establish a comprehensive trauma system for the rehabilitation of military service members. The direc- U.S. Armed Forces. torate also will be charged with the development of The NDAA also contains a provision that estab- quality of care outcome measures for combat casu- lishes a Joint Trauma Education and Training alty care. Aligning military trauma care and creating Directorate, which is charged with ensuring that military-civilian trauma partnerships is expected to | 31 trauma providers in the Armed Forces maintain a have a profound impact on the U.S. military and state of readiness. Maintaining this capability will be civilian trauma systems. These initiatives provide accomplished, in part, by entering into partnerships the opportunity not only to save lives and prevent with civilian academic medical centers and large met- disabilities domestically, but also globally for those ropolitan teaching hospitals that have Level I civilian serving in the U.S. Armed Forces. trauma centers, providing trauma teams—including military surgeons—with continuous exposure to critically injured patients. Facilities eligible for these Congressional action: partnerships will be selected by the U.S. Secretary of Zero preventable deaths Defense based on patient volume, acuity, and other On July 12, 2016, the U.S. House of Representatives factors deemed necessary to support the goal of readi- Committee on Energy and Commerce Subcommit- ness. Additionally, major military treatment facilities tee on Health held a hearing on Strengthening Our will be required to participate as trauma centers in National Trauma System. This hearing focused on their region in areas of need. implementing the parameters of the NASEM report The directorate’s role is to improve military to establish a nationwide trauma system that would trauma care and increase readiness for the rapid achieve zero preventable deaths after injury. The deployment of integrated military trauma teams, ACS provided testimony for this hearing and echoed including forward surgical teams (mobile surgical the view of the NASEM report, which noted that units in the field). For example, the directorate will accomplishing this goal will depend on supporting establish goals and metrics for the partnerships to civilian and military trauma center partnerships, ensure that providers maintain professional com- ensuring that lessons learned from combat are petency in trauma care. The directorate also will implemented in civilian trauma care. C. William be responsible for the communication and coordi- Schwab, MD, FACS, testified about his contribu- nation of lessons learned from such partnerships to tion to the NASEM report and his experiences in the JTS. Additionally, chief among the directorate’s a military-civilian partnership project during the duties is the development of standardized combat Vietnam War. Dr. Schwab highlighted the limited

APR 2017 BULLETIN American College of Surgeons THE FUTURE OF TRAUMA CARE ON CAPITOL HILL

Not only would these efforts improve sustained readiness among military providers, but they would allow for a smooth transition of trauma lessons learned from the military to the civilian setting, and may assist in alleviating staffing demands at civilian centers.

opportunities for military trauma training and how BCon these partnerships will increase military readiness, In 2016, the American Medical Association House of skills, and competency. Delegates (AMA-HOD) endorsed the ACS-led resolu- As a result of the hearing, the Mission Zero Act tion to support the Stop the Bleed program, which (S. 3407 and H.R. 6229) was introduced in the Senate encourages educating first responders and immedi- by Sens. Mark Kirk, Johnny Isakson (R-GA), and John ate first responders (bystanders) in bleeding control Cornyn (R-TX), and in the House by Reps. Michael techniques, including the use of holding pressure, Burgess, Kathy Castor (D-FL), Gene Green, and Rich- tourniquets and gauze dressings, and creative use ard Hudson (R-NC). The Mission Zero Act, which of nontraditional materials such as clothing or belts. did not pass, would have assisted military health care This initiative represents a revolutionary step in providers in maintaining a state of readiness by pro- saving lives and turning bystanders of traumatic viding grants for military trauma teams and providers events into lifesaving heroes. to embed in civilian trauma centers. Building on this momentum, the ACS is working The Mission Zero Act would have specifically with congressional trauma champions to introduce provided $40 million in grant funding from the legislation that would assist in bringing BCon train- 32 | Department of Health and Human Services to facil- ing to the general public. The overarching goal is itate partnerships between military trauma care to ensure that the ability to control bleeding is as teams/providers and high-volume civilian Level I commonplace as the ability to perform the Heim- trauma centers. These partnerships would allow mili- lich maneuver or administer cardiopulmonary tary trauma care teams/providers to gain exposure resuscitation. by treating critically injured patients and increase As a leader in BCon training and trauma care, the readiness for when these units are deployed. College will have unique opportunities to advocate Not only would these efforts improve sustained for the advancement of BCon and trauma priorities readiness among military providers, but they would during the ACS Leadership & Advocacy Summit in allow for a smooth transition of trauma lessons Washington, DC, May 6–9. learned from the military to the civilian setting, and may assist in alleviating staffing demands at civilian centers. In February 2017, the Mission Zero Act was Congressional Pediatric Trauma Caucus reintroduced in the House of Representatives (H.R. The ACS is supportive of the congressional Pediatric 880) by the same sponsors from the 114th version. Trauma Caucus, created in 2016 by Reps. Richard At press time, Senate reintroduction is forthcoming. Hudson (R-NC) and G.K. Butterfield (D-NC), to In addition to the Mission Zero Act, the ACS is ensure that all children have access to a properly inclined to support legislation that improves the U.S. resourced trauma facility within the golden hour. trauma system and supports a sufficient number of The goal of the caucus is to reduce the number of trauma centers and trauma personnel to meet both pediatric trauma fatalities in the U.S. Both Represen- civilian and military needs. The message of several tatives Hudson and Butterfield serve on the House NASEM recommendations clearly indicates that Committee on Energy and Commerce, one of the without a nationwide system, the goal of zero pre- main committees with jurisdiction over health care ventable trauma deaths is not obtainable. The COT, legislation. the MHSSPACS, and the DAHP will continue to The caucus has hosted two congressional advocate for a trauma system that will cover injured briefings—one on overall pediatric trauma, and the patients, regardless of their location. other on youth sports injuries in May and September

V102 No 4 BULLETIN American College of Surgeons THE FUTURE OF TRAUMA CARE ON CAPITOL HILL

of 2016, respectively. The ACS played an active role How to help in both briefings. The involvement of surgeon-advocates is paramount The pediatric trauma briefing focused on pediat- to establishing an active relationship with federal and ric trauma as the number one cause of death among state legislators. The key to successful advocacy is an children in the U.S., and on what can be done to engaged membership, and the ACS suggests the fol- prevent injuries and improve access to appropriate lowing activities to support this work: pediatric trauma care. David Adelson, MD, FACS; Barbara Gaines, MD, FACS; and John Petty, MD, • Attend the Leadership & Advocacy Summit, May 6–9 FACS, served on the panel and offered their expert in Washington, DC input. The youth sports injury briefing focused on the • Host your federal/state legislators for a trauma center importance of concussion diagnosis, treatment, and or facility tour access to follow-up care post injury. Shelly Tim- mons, MD, FACS, and Brendan Campbell, MD, • Meet with your member of Congress in your home FACS, served on this panel and offered their per- district or in Washington, DC spectives on youth injury diagnosis and treatment. | 33 Drs. Timmons and Campbell emphasized the impor- The DAHP is available to help with these efforts, tance of funding for concussion research to further and can assist with preparations for a congressional identify prognostic tools, diagnostic testing modali- meeting or facility tour. ties, and the efficacy of treatment modalities for For questions about military-civilian trauma post-concussion symptoms. policy, e-mail [email protected]. For questions about trauma policy, e-mail [email protected]. ♦ Looking ahead The College will continue to make strengthening the nation’s trauma system a high priority in the 115th Congress, while elevating the goal of zero preventable deaths and ensuring all trauma patients receive appropriate care within the golden hour. On a daily basis, Congress, government regula- tors, and state legislatures are making decisions that could have drastic effects on the health care profession. As trauma research struggles to receive adequate federal funding relative to the number of injuries per year, the ACS and COT, along with trauma partners who represent the full spectrum of trauma care, will continue to join together to engage congressional leaders and public officials with a unified voice.†

†Gillum LA, Gouveia C, Dorsey ER, et al. NIH disease funding levels and burden of disease. PLoS ONE. 2011;6(2):e16837. Available at: journals.plos. org/plosone/article?id=10.1371/journal.pone.0016837/. Accessed Febru- ary 16, 2017.

APR 2017 BULLETIN American College of Surgeons 2016 ACS GOVERNORS SURVEY

2016 ACS International Governors Survey: Membership benefits and challenges for International Fellows are revealed in first-time study

by Mark W. Puls, MD, FACS; Juan C. Paramo, MD, FACS; David J. Welsh, MD, FACS; and Peter Andreone, s ACS Executive Director David B. Hoyt, MD, FACS, MD, FACS reported in his February “Looking forward” column, Athe College is making a heightened effort to respond to the needs of International Fellows and the global surgery community. International Fellows and their local chapters 34 | Editor’s note: The American College of Surgeons are important to the continued growth of the organization and to the College’s mission of ensuring that all surgical (ACS) Board of Governors (B/G) has conducted an patients have access to quality surgical care. annual survey of its members for more than 20 Unquestionably, issues and concerns vary from region to years. The purpose of the survey is to provide a region and country to country. In an effort to learn more means of communicating between the Governors about these issues and concerns, the ACS B/G conducted the first survey of International Governors in 2016. and the ACS Board of Regents, Officers, and Exec- The survey consisted of a series of demographic questions, utive Staff. This year, the B/G also conducted a followed by a series of in-depth questions on the following survey of the International Governors, in addition topics: surgical education conferences, chapter issues, ACS to the traditional survey of domestic Governors. benefits to International Fellows, national surgical societies, and financial barriers to participation in ACS activities. Some of the highlights of the survey are described in this The following article focuses on the survey of article. The complete results of the survey can be viewed International Governors and is the first in a series online at facs.org/~/media/files/about acs/governors/2016_intl_ of four articles highlighting key issues addressed gov_survey.ashx. in both the domestic and international surveys. Future articles in this series will center on issues Demographics of concern to domestic surgeons, including acute The response rate to the International Governors survey was care surgery, firearm injury prevention, and pay- 82 percent, with 36 of 44 ACS Governors from 33 different countries participating in the survey. Most of the Interna- ment reform under the Medicare Access and CHIP tional Governors (72 percent) are 56 to 70 years old; more (Children’s Health Insurance Program) Reautho- specifically, 41 percent are 61 to 65 years old (see Figure 1, rization Act (MACRA). page 35). Most International Governors practice in large cities, with 74 percent of the respondents indicating that they

V102 No 4 BULLETIN American College of Surgeons 2016 ACS GOVERNORS SURVEY

FIGURE 1. AGE OF INTERNATIONAL GOVERNORS

practice in cities with populations of more than 1 million people (see Figure FIGURE 2. POPULATION OF THE CITY 2, this page). WHERE YOU PRACTICE When asked to describe their practice setting, 52 percent of the respondents said they are at university-based practices, and 29 percent said they are in private practice (see Figure 3, this page).

Surgical education conferences | 35 The survey included a series of questions aimed at learning more about the educational needs of International Governors. When asked to rank their preferred type of surgical education conference, the most popular response was the ACS Clinical Congress (80 percent). The second most FIGURE 3. SURGICAL PRACTICE SETTING popular response (77 percent) was a large international conference in another country (see Figure 4, page 36). The study results suggest that the ACS Clinical Congress is the preferred surgical education conference among International Governors. However, the International Governors who responded to the survey also indicated that they would like to see more international participants in Clinical Congress programs. In fact, all of the respondents said they would like to see more international speakers featured at the annual meeting. They particularly expressed interest in more international participation in Clini- cal Congress Panel Sessions (80 percent) and Named Lectures (46 percent). (See Figure 5, page 36.)

APR 2017 BULLETIN American College of Surgeons 2016 ACS GOVERNORS SURVEY

FIGURE 4. PREFERRED EDUCATIONAL CONFERENCE

International ACS chapters FIGURE 5. WHICH CLINICAL CONGRESS The ACS recognizes the importance of PROGRAMS WOULD BENEFIT FROM INCREASED having strong and active international PARTICIPATION OF INTERNATIONAL FELLOWS? chapters that can respond to Fellows’ local needs. With that perspective in mind, International Governors were asked a series of questions regarding chapter issues. The survey, which asked participants to rank their preferences on a scale of 1 (most important) to 6 (least 36 | important), revealed that International Governors ranked “educational activities” as the greatest benefit of chapter membership (with an average score of 1.85), followed by “improving the surgical training of residents/medical students” (2.55). (See Table 1, this page.) To determine how the ACS can help TABLE 1. RANKING OF BENEFITS TO international chapters become more ACS INTERNATIONAL CHAPTERS* robust, International Governors were asked to rank barriers impeding chapter Benefit Average score growth. The most common response was Educational activities 1.85 “chapter members are not active in chapter activities” followed by concerns that Improving the surgical training 2.55 of residents/medical students there are “too many competing interests with the national surgical society or soci- Advancement of surgical care 3.42 for patients in our nation eties” (see Table 2, page 37). Camaraderie with surgical peers 3.47 Social activities 4.21 ACS benefits for Advocacy issues 5.04 International Governors *Scoring is recorded as: 1 = most important and 6 = least important International Governors were asked to rank the ACS benefits of most importance to International Fellows. The highest ranking benefits were all education- based, with the Clinical Congress as the top-rated benefit, followed by the Journal

V102 No 4 BULLETIN American College of Surgeons 2016 ACS GOVERNORS SURVEY

TABLE 2. BARRIERS IMPEDING INTERNATIONAL CHAPTER GROWTH*

Category Average score Our chapter members are not 2.92 active in chapter activities Too many competing interests with the national 3.24 surgical society (or societies) Too many competing interests with 3.41 specialty surgical societies Surgeons are not willing to participate 4.30 in leadership positions There are not enough chapter members 4.35 Surgeons will not join our chapter 4.50 because of financial barriers It is difficult to find good administrative staff 5.55

*Scoring is recorded as: 1 = largest barrier and 7 = smallest barrier of the American College of Surgeons, the Bul- TABLE 3. RANKING OF ACS BENEFITS letin of the American College of Surgeons, and TO INTERNATIONAL GOVERNORS participation in Advanced Trauma Life Support® courses. The ACS Communities Number were rated as a midline benefit, suggest- ACS benefit of times ing an opportunity for increased use of the selected ACS Communities among International Clinical Congress 32 | 37 Governors (see Table 3, this page). Journal of the American College of Surgeons 28 Bulletin of the American College of Surgeons 25 Interactions between national Advanced Trauma Life Support courses 24 surgical societies and the ACS International Guest Scholarships 17 All of the International Governors who FACS designation 16 participated in the study indicated that their country has at least one national sur- Opportunities for networking 15 gical society. When asked if their national Local ACS chapter membership 12 surgical society and the ACS engaged in ACS NewsScope 11 any organized interactions, 71 percent ACS Surgery News 11 responded “yes,” and 29 percent responded “no.” When asked if enhanced interaction Selected Readings in General Surgery 10 between their national surgical society and ACS National Surgical Quality Improvement Program 10 the College would be beneficial, 85 percent ACS Communities 9 said it would be helpful, and 15 percent said it would not. Suggestions for addi- Surgical Education Self-Assessment Program 8 tional interactions included “ACS Clinical Surgical Risk Calculator 8 Congress/educational help,” and “Educa- Commission on Cancer accreditation program 5 tional collaboration” (see Figure 6, page 38). Community surgeons travel awards 3 National Accreditation Program for Breast Centers 3 Financial barriers Surgeon Specific Registry 1 ACS Fellowship requires a certain financial commitment. The International Gover- nors were asked how much of a financial

APR 2017 BULLETIN American College of Surgeons 2016 ACS GOVERNORS SURVEY

FIGURE 6. WOULD YOU LIKE TO SEE ENHANCED ORGANIZED INTERACTION BETWEEN YOUR NATIONAL SURGICAL SOCIETY AND THE ACS?

FIGURE 7. FINANCIAL BARRIERS FOR barrier it is for a surgeon to join their local INTERNATIONAL SURGEONS ACS chapter, join the College, or attend the ACS Clinical Congress. As Figure 7, this page, indicates, chapter membership does not pose a large financial barrier, accord- 38 | ing to survey respondents. The financial burden is greater for joining the ACS, with the highest cost related to Interna- tional Fellows attending the ACS Clinical Congress.

Conclusion International Fellows and their local ACS Chapters are important to the success of the College overall. This survey provided the B/G with a better understanding of the specific issues and concerns facing international Fellows. The B/G is considering conducting future surveys of the Inter- national Governors to learn more about the challenges these members encounter, as well as to give international Fellows an opportunity to make their opinions known to ACS leadership. ♦

V102 No 4 BULLETIN American College of Surgeons STATEMENT

Statement on the use of general anesthetics and sedation drugs in children and pregnant women

The American College of Surgeons (ACS) Advisory Council for Pediatric Surgery developed the following statement, which the ACS Board of Regents approved at its February 2017 meeting in Chicago, IL.

n December 2016, the U.S. Food and Drug Admin- communication be discussed with patients and their Iistration (FDA) released a Drug Safety Communica- families. Health care professionals also need to remind tion warning that stated repeated or lengthy (greater patients and their families that the timing of surgery is than three hours) use of general anesthetic or seda- critical to an outcome in many instances. Examples of tion drugs during operations or procedures in chil- when timing plays a critical role in surgical outcomes dren younger than three years of age or in pregnant include cleft palate surgery, cranial vault surgery, and women during the final trimester may affect neuro- orchiopexy for undescended testes. logic development.* Historically, pediatric surgeons have been at the The potential adverse effects of anesthesia have forefront of practice changes leading to the safe delay been studied for years, and to date, no human data or avoidance of surgery and general anesthesia, and support this conclusion. The FDA’s communication is the management of solid organ injury and repair of based solely upon animal data, which may or may not umbilical hernia are two prime examples of this prac- pertain to humans.* Some epidemiologic studies have tice. It is assumed that our professional awareness of | 39 suggested an association between childhood anesthe- the theoretical risks associated with general anesthesia sia exposure, particularly longer duration or repeated will invoke a thoughtful professional debate on other exposure, and adverse neurodevelopmental outcomes; elective surgical procedures that might reasonably be however, it remains unclear whether these associations delayed. represent an effect of the anesthetic drugs as opposed The ACS recommends that although an informed to the operation itself, underlying patient medical con- discussion based on existing and emerging evidence of ditions, or other factors. the potential adverse effects of repeated general anes- The ACS would like to remind the public that when thesia in children younger than three years old on a pediatric surgical subspecialist recommends an opera- neurologic development should take place—and may, tion for a child, the preservation of a child’s short- and in some instances, lead to a decision to delay surgery— long-term health and well-being are foundational to it is our responsibility to encourage shared decision this recommendation. Pediatric surgeons understand making that equally considers the consequences of that when parents are engaged in an informed consent delaying a time-sensitive operation. ♦ discussion for urgent and emergent procedures, the focus of the discussion will include the known risks of surgery and anesthesia but will necessarily emphasize the need for surgery (and therefore general anesthesia) in the absence of a safe alternative therapy. However, this FDA communication provides a different perspective for elective procedures. It is the recommendation of the advisory council that the FDA

*U.S. Food & Drug Administration (FDA). FDA Drug Safety Commu- nication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. December 14, 2016. Available at: www.fda.gov/Drugs/DrugSafety/ ucm532356.htm. Accessed February 22, 2017.

APR 2017 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

Reporting global codes data in 2017

by Vinita Ollapally, JD

tarting July 1, the Centers CMS has determined that for Medicare & Medicaid Which providers are required the 293 services on this list SServices (CMS) will require to report global codes data? of global codes are provided practitioners in nine states who The claims-based data collection to Medicare patients by more are part of groups of 10 or more requirements will apply to than 100 practitioners per to report data on the services health care practitioners who year and are either furnished that they provide for select are part of practices with 10 or more than 10,000 times or 10- and 90-day global surgical more practitioners and located have allowed charges of more codes. The data collected will be in one of nine specified states: than $10 million annually.† used to improve the accuracy of Florida, Kentucky, Louisiana, The agency estimates that global codes starting in 2019. Nevada, New Jersey, North these 293 codes describe CMS has set forth Dakota, Ohio, Oregon, and approximately 87 percent of all requirements for global codes Rhode Island. These states were furnished 10- and 90-day global 40 | data collection via claims, but selected because they offer a services, and approximately the agency also has indicated representative sample in terms 77 percent of all Medicare that it will collect additional of geography and Medicare expenditures for 10- and 90- data using a survey and other beneficiary distribution. day global services under methods such as data collection the physician fee schedule. targeting Accountable Care Organizations (ACOs) and What data must be direct observation studies. reported and how? Is claims-based data reporting At press time, details of the Health care practitioners mandatory? Is there a penalty additional data collection who meet claims-based data for failure to report? had not been released. collection requirements will be Yes, reporting is mandatory so This column describes the required to report American that CMS can gather enough information CMS has released Medical Association Current data on postoperative visits regarding the claims-based Procedure Terminology (CPT)* to improve the accuracy of global codes data collection. code 99024, Postoperative follow- global code values starting in up visit, normally included 2019. CMS has the authority *All specific references to CPT codes and in the surgical package, to to implement a 5 percent descriptions are © 2016 American Medical indicate that an evaluation withhold in payment for Association. All rights reserved. CPT and and management service was global services for health care CodeManager are registered trademarks of the American Medical Association. performed during a postoperative professionals who fail to report; †Foe L, Nagle J, Ollapally V. The 2017 period for a reason(s) related to however, the agency has not Medicare physician fee schedule: An the original procedure, for every implemented the withhold at overview of provisions that will affect surgical practice. Bull Am Coll Surg. postoperative visit they provide this time. Although a penalty 2017;102(1):11-15. Available at: bulletin. within the global period of or withholding of payment for facs.org/2017/01/the-2017-medicare- a select list of 10- or 90-day failure to report has not been physician-fee-schedule-an-overview- of-provisions-that-will-affect-surgical- global codes. See Table 1, pages practice/. Accessed February 23, 2017. 41–50, for the list of codes. continued on page 51

V102 No 4 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS CPT Global code Descripton period 10040 Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) 010 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous 10060 010 or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or 10061 010 subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple 10120 Incision and removal of foreign body, subcutaneous tissues; simple 010 10140 Incision and drainage of hematoma, seroma or fluid collection 010 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst 010 10180 Incision and drainage, complex, postoperative wound infection 010 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions 010 Excision, benign lesion including margins, except skin tag (unless listed 11400 010 elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less 11401 excised diameter 0.6 to 1.0 cm 010 11402 excised diameter 1.1 to 2.0 cm 010 11403 excised diameter 2.1 to 3.0 cm 010

11404 excised diameter 3.1 to 4.0 cm 010 | 41 11406 excised diameter over 4.0 cm 010 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), 11420 010 scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less 11421 excised diameter 0.6 to 1.0 cm 010 11422 excised diameter 1.1 to 2.0 cm 010 11423 excised diameter 2.1 to 3.0 cm 010 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), 11440 010 face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less 11441 excised diameter 0.6 to 1.0 cm 010 11442 excised diameter 1.1 to 2.0 cm 010 11443 excised diameter 2.1 to 3.0 cm 010 11601 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm 010 11602 excised diameter 1.1 to 2.0 cm 010 11603 excised diameter 2.1 to 3.0 cm 010 11604 excised diameter 3.1 to 4.0 cm 010 11606 excised diameter over 4.0 cm 010 Excision, malignant lesion including margins, scalp, neck, hands, 11621 010 feet, genitalia; excised diameter 0.6 to 1.0 cm 11622 excised diameter 1.1 to 2.0 cm 010 11623 excised diameter 2.1 to 3.0 cm 010 11640 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less 010 11641 excised diameter 0.6 to 1.0 cm 010 continued on next page

APR 2017 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period 11642 excised diameter 1.1 to 2.0 cm 010 11643 excised diameter 2.1 to 3.0 cm 010 11644 excised diameter 3.1 to 4.0 cm 010 11646 excised diameter over 4.0 cm 010 Excision of nail and nail matrix, partial or complete (eg, ingrown 11750 010 or deformed nail), for permanent removal 11765 Wedge excision of skin of nail fold (eg, for ingrown toenail) 010 Repair, intermediate, wounds of scalp, axillae, trunk and/or 12031 010 extremities (excluding hands and feet); 2.5 cm or less 12032 2.6 cm to 7.5 cm 010 12034 7.6 cm to 12.5 cm 010 12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 010 12042 2.6 cm to 7.5 cm 010 12051 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 010 12052 2.6 cm to 5.0 cm 010 42 | 13101 Repair, complex, trunk; 2.6 cm to 7.5 cm 010 13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm 010 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, 13131 010 genitalia, hands and/or feet; 1.1 cm to 2.5 cm 13132 2.6 cm to 7.5 cm 010 13151 Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm 010 13152 2.6 cm to 7.5 cm 010 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated 090 14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less 090 14021 defect 10.1 sq cm to 30.0 sq cm 090 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, 14040 090 neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less 14041 defect 10.1 sq cm to 30.0 sq cm 090 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 090 14061 defect 10.1 sq cm to 30.0 sq cm 090 14301 defect 30.1 sq cm to 60.0 sq cm 090 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 15100 090 1% of body area of infants and children (except 15050) Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or 15120 090 multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) Full thickness graft, free, including direct closure of donor site, forehead, cheeks, 15240 090 chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, 15260 090 nose, ears, eyelids, and/or lips; 20 sq cm or less continued on next page

V102 No 4 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, 15732 090 masseter muscle, sternocleidomastoid, levator scapulae) 15734 trunk 090 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid 090 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 17000 010 curettement), premalignant lesions (eg, actinic keratoses); first lesion 17004 15 or more lesions 010 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of 17110 010 benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 17111 15 or more lesions 010 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17260 010 surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less 17261 lesion diameter 0.6 to 1.0 cm 010 17262 lesion diameter 1.1 to 2.0 cm 010 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17263 010 surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, | 43 17270 010 surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less 17271 lesion diameter 0.6 to 1.0 cm 010 17272 lesion diameter 1.1 to 2.0 cm 010 17273 lesion diameter 2.1 to 3.0 cm 010 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 17280 010 curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less 17281 lesion diameter 0.6 to 1.0 cm 010 17282 lesion diameter 1.1 to 2.0 cm 010 17283 lesion diameter 2.1 to 3.0 cm 010 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, 19120 090 duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions 19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion 090 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) 090 19303 Mastectomy, simple, complete 090 Mastectomy, modified radical, including axillary lymph nodes, with or without 19307 090 pectoralis minor muscle, but excluding pectoralis major muscle 19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 090 20670 Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) 010 20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 090 20926 Tissue grafts, other (eg, paratenon, fat, dermis) 090 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone 22513 biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral 010 body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic continued on next page

APR 2017 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period 22514 lumbar 010 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy 22551 090 and decompression of spinal cord and/or nerve roots; cervical below C2 Arthrodesis, anterior interbody technique, including minimal discectomy 22558 090 to prepare interspace (other than for decompression); lumbar 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 090 22612 lumbar (with lateral transverse technique, when performed) 090 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy 22630 090 to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody 22633 technique including laminectomy and/or discectomy sufficient to prepare interspace 090 (other than for decompression), single interspace and segment; lumbar 22830 Exploration of spinal fusion 090 23120 Claviculectomy; partial 090 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic 090 23430 Tenodesis of long tendon of biceps 090 44 | Arthroplasty, glenohumeral joint; total shoulder (glenoid and 23472 090 proximal humeral replacement [eg, total shoulder]) 23500 Closed treatment of clavicular fracture; without manipulation 090 23600 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation 090 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes 23615 090 internal fixation, when performed, includes repair of tuberosity(s), when performed 23650 Closed treatment of shoulder dislocation, with manipulation; without anesthesia 090 25447 Arthroplasty, interposition, intercarpal or carpometacarpal joints 090 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, 25600 090 includes closed treatment of fracture of ulnar styloid, when performed; without manipulation 25605 with manipulation 090 25607 Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation 090 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation 25609 090 of 3 or more fragments 26055 Tendon sheath incision (eg, for trigger finger) 090 26160 Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger 090 26600 Closed treatment of metacarpal fracture, single; without manipulation, each bone 090 Closed treatment of phalangeal shaft fracture, proximal or middle 26720 090 phalanx, finger or thumb; without manipulation, each 27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) 090 Arthroplasty, acetabular and proximal femoral prosthetic replacement 27130 090 (total hip arthroplasty), with or without autograft or allograft 27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft 090 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft 090 continued on next page

V102 No 4 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period 27235 Percutaneous skeletal fixation of femoral fracture, proximal end, neck 090 27236 Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement 090 Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral 27244 090 fracture; with plate/screw type implant, with or without cerclage 27245 with intramedullary implant, with or without interlocking screws and/or cerclage 090 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment 090 27447 medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) 090 27486 Revision of total knee arthroplasty, with or without allograft; 1 component 090 27487 femoral and entire tibial component 090 Open treatment of femoral shaft fracture, with or without external fixation, with insertion 27506 090 of intramedullary implant, with or without cerclage and/or locking screws 27590 Amputation, thigh, through femur, any level 090 27786 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation 090 Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and 27814 090 posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed

27880 Amputation, leg, through tibia and fibula 090 | 45 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone 28122 090 (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus 28124 phalanx of toe 090 28232 Tenotomy, open, tendon flexor; toe, single tendon (separate procedure) 090 28270 Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) 090 28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) 090 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when 28296 090 performed; with distal metatarsal osteotomy, any method Osteotomy, with or without lengthening, shortening or angular 28308 090 correction, metatarsal; other than first metatarsal, each 28470 Closed treatment of metatarsal fracture; without manipulation, each 090 28510 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each 090 28810 Amputation, metatarsal, with toe, single 090 28820 Amputation, toe; metatarsophalangeal joint 090 28825 interphalangeal joint 090 29822 Arthroscopy, shoulder, surgical; debridement, limited 090 29823 debridement, extensive 090 29824 distal claviculectomy including distal articular surface (Mumford procedure) 090 29827 with rotator cuff repair 090 29828 biceps tenodesis 090 29848 Endoscopy, wrist, surgical, with release of transverse carpal ligament 090 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) 090 continued on next page

APR 2017 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or 29879 090 microfracture with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/ 29880 090 shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/ 29881 090 shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed 30140 Submucous resection inferior turbinate, partial or complete, any method 090 Septoplasty or submucous resection, with or without cartilage 30520 090 scoring, contouring or replacement with graft 32480 Removal of lung, other than pneumonectomy; single lobe (lobectomy) 090 32663 Thoracoscopy, surgical; with lobectomy (single lobe) 090 33207 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular 090 33208 atrial and ventricular 090 Removal of permanent pacemaker pulse generator with replacement 33228 090 of pacemaker pulse generator; dual lead system Insertion or replacement of permanent implantable defibrillator 33249 090 system, with transvenous lead(s), single or dual chamber 46 | Removal of implantable defibrillator pulse generator with replacement of 33263 090 implantable defibrillator pulse generator; dual lead system 33264 multiple lead system 090 33282 Implantation of patient-activated cardiac event recorder 090 Replacement, aortic valve, open, with cardiopulmonary bypass; with 33405 090 prosthetic valve other than homograft or stentless valve 33426 Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring 090 33430 Replacement, mitral valve, with cardiopulmonary bypass 090 33533 Coronary artery bypass, using arterial graft(s); single arterial graft 090 33860 Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when performed 090 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; 34802 090 using modular bifurcated prosthesis (1 docking limb) Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal 34825 090 aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel Thromboendarterectomy, including patch graft, if performed; 35301 090 carotid, vertebral, subclavian, by neck incision 36470 Injection of sclerosing solution; single vein 010 36471 multiple veins, same leg 010 Insertion of tunneled centrally inserted central venous catheter, 36558 010 without subcutaneous port or pump; age 5 years or older Insertion of tunneled centrally inserted central venous access 36561 010 device, with subcutaneous port; age 5 years or older Replacement, complete, of a tunneled centrally inserted central venous catheter, 36581 010 without subcutaneous port or pump, through same venous access continued on next page

V102 No 4 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period 36589 Removal of tunneled central venous catheter, without subcutaneous port or pump 010 Removal of tunneled central venous access device, with subcutaneous 36590 010 port or pump, central or peripheral insertion 36819 Arteriovenous anastomosis, open; by upper arm basilic vein transposition 090 36821 direct, any site (eg, Cimino type) (separate procedure) 090 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate 36830 090 procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft) Revision, open, arteriovenous fistula; without thrombectomy, autogenous 36832 090 or nonautogenous dialysis graft (separate procedure) 37607 Ligation or banding of angioaccess arteriovenous fistula 090 37609 Ligation or biopsy, temporal artery 010 37765 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions 090 37766 more than 20 incisions 090 38500 Biopsy or excision of lymph node(s); open, superficial 010 38525 open, deep axillary node(s) 090

38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy 010 | 47 38724 Cervical lymphadenectomy (modified radical neck dissection) 090 40808 Biopsy, vestibule of mouth 010 Laparoscopy, surgical, repair of paraesophageal hernia, includes 43281 090 fundoplasty, when performed; without implantation of mesh Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass 43644 090 and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) 44005 Enterolysis (freeing of intestinal adhesion) (separate procedure) 090 44120 Enterectomy, resection of small intestine; single resection and anastomosis 090 44140 Colectomy, partial; with anastomosis 090 44143 with end colostomy and closure of distal segment (Hartmann type procedure) 090 44145 with coloproctostomy (low pelvic anastomosis) 090 44160 with removal of terminal ileum with ileocolostomy 090 44204 Laparoscopy, surgical; colectomy, partial, with anastomosis 090 44205 colectomy, partial, with removal of terminal ileum with ileocolostomy 090 44207 colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) 090 44970 Laparoscopy, surgical, appendectomy 090 46221 Hemorrhoidectomy, internal, by rubber band ligation(s) 010 46500 Injection of sclerosing solution, hemorrhoids 010 Destruction of internal hemorrhoid(s) by thermal energy (eg, 46930 090 infrared coagulation, cautery, radiofrequency) 47562 Laparoscopy, surgical; cholecystectomy 090 47563 cholecystectomy with cholangiography 090 continued on next page

APR 2017 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period 47600 Cholecystectomy 090 49422 Removal of tunneled intraperitoneal catheter 010 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance 49440 010 including contrast injection(s), image documentation and report 49505 Repair initial inguinal hernia, age 5 years or older; reducible 090 49507 incarcerated or strangulated 090 49560 Repair initial incisional or ventral hernia; reducible 090 49561 incarcerated or strangulated 090 49585 Repair umbilical hernia, age 5 years or older; reducible 090 49650 Laparoscopy, surgical; repair initial inguinal hernia 090 50360 Renal allotransplantation, implantation of graft; without recipient nephrectomy 090 50590 Lithotripsy, extracorporeal shock wave 090 Transurethral electrosurgical resection of prostate, including control of postoperative 52601 bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral 090 calibration and/or dilation, and internal urethrotomy are included)

48 | Laser vaporization of prostate, including control of postoperative bleeding, complete 52648 (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal 090 urethrotomy and transurethral resection of prostate are included if performed) 53850 Transurethral destruction of prostate tissue; by microwave thermotherapy 090 54161 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age 010 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve 55866 090 sparing, includes robotic assistance, when performed 57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele 090 57288 Sling operation for stress incontinence (eg, fascia or synthetic) 090 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; 58571 090 with removal of tube(s) and/or ovary(s) 58661 with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 010 60240 Thyroidectomy, total or complete 090 60500 Parathyroidectomy or exploration of parathyroid(s) 090 61312 Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural 090 Craniectomy, trephination, bone flap craniotomy; 61510 090 for excision of brain tumor, supratentorial, except meningioma Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic 62264 saline, enzyme) or mechanical means (eg, catheter) including radiologic localization 010 (includes contrast when administered), multiple adhesiolysis sessions; 1 day Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 63030 090 foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 63042 090 foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar

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V102 No 4 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 63045 decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal 090 or lateral recess stenosis]), single vertebral segment; cervical 63047 lumbar 090 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) 63056 (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or 090 lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach 63081 090 with decompression of spinal cord and/or nerve root(s); cervical, single segment 63650 Percutaneous implantation of neurostimulator electrode array, epidural 010 Insertion or replacement of spinal neurostimulator pulse 63685 010 generator or receiver, direct or inductive coupling 64555 Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) 010 Percutaneous implantation of neurostimulator electrode array; sacral nerve 64561 010 (transforaminal placement) including image guidance, if performed 64581 Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) 090 Insertion or replacement of peripheral or gastric neurostimulator 64590 010 pulse generator or receiver, direct or inductive coupling | 49 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, 64612 010 unilateral (eg, for blepharospasm, hemifacial spasm) Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, 64615 010 cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the 64616 010 larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic 64617 010 dysphonia), includes guidance by needle electromyography, when performed 64632 Destruction by neurolytic agent; plantar common digital nerve 010 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 64633 010 guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64635 lumbar or sacral, single facet joint 010 64640 Destruction by neurolytic agent; other peripheral nerve or branch 010 64718 Neuroplasty and/or transposition; ulnar nerve at elbow 090 64721 median nerve at carpal tunnel 090 65756 Keratoplasty (corneal transplant); endothelial 090 65855 Trabeculoplasty by laser surgery 010 66170 Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery 090 66179 Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft 090 66180 with graft 090 66711 Ciliary body destruction; cyclophotocoagulation, endoscopic 090 66761 Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) 010

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APR 2017 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. CPT CODES FOR REQUIRED GLOBAL SURGICAL REPORTING OF 99024 FOR POSTOPERATIVE VISITS (CONTINUED) CPT Global code Descripton period Discission of secondary membranous cataract (opacified posterior lens capsule and/ 66821 090 or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages) Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), 66982 complex, requiring devices or techniques not generally used in routine cataract surgery 090 (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), 66984 090 manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) 67036 Vitrectomy, mechanical, pars plana approach 090 67040 with endolaser panretinal photocoagulation 090 67041 with removal of preretinal cellular membrane (eg, macular pucker) 090 with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic 67042 090 macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) Repair of retinal detachment; with vitrectomy, any method, including, when performed, 67108 air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of 090 subretinal fluid, scleral buckling, and/or removal of lens by same technique Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or 50 | greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear 67113 of greater than 90 degrees), with vitrectomy and membrane peeling, including, when 090 performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without 67145 090 drainage, 1 or more sessions; photocoagulation (laser or xenon arc) Destruction of localized lesion of retina (eg, macular edema, 67210 090 tumors), 1 or more sessions; photocoagulation 67228 Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation 010 67255 Scleral reinforcement (separate procedure); with graft 090 67800 Excision of chalazion; single 010 67840 Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure 010 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) 090 67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach 090 67917 Repair of ectropion; extensive (eg, tarsal strip operations) 090 67924 extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) 090 68760 Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery 010 68761 by plug, each 010 68801 Dilation of lacrimal punctum, with or without irrigation 010 68810 Probing of nasolacrimal duct, with or without irrigation 010 68840 Probing of lacrimal canaliculi, with or without irrigation 010 69420 Myringotomy including aspiration and/or eustachian tube inflation 010 69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia 010 69436 general anesthesia 010

V102 No 4 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

implemented yet, the American CMS announced in the 2017 College of Surgeons (ACS) urges Why is CMS requiring the Medicare Physician Fee Schedule all surgeons who are required reporting of global codes data? final rule that the agency would to report to comply. Failure to For several years, CMS has not implement the G-code policy report will result in incomplete communicated its concerns for all practitioners who report data, which may affect the about the accuracy of the 10- and 90-day global codes. revaluation of global codes in values assigned to 10- and 90- Instead, CMS indicated that 2019. Should data analysis of day global codes. In 2014, CMS it would require practitioners both inpatient and outpatient proposed to transition all 10- in groups of 10 or more who postsurgical visits not reflect and 90-day global codes to are located in nine selected existing global code definitions, 0-day, with the requirement that states to report postoperative new assumptions may be created postoperative visits would be visit information on the list of to redefine postoperative care. reported separately. The ACS specified codes. Refer to the In addition, failure to report successfully argued against ACS web page dedicated to data could result in the 5 percent this transition because it would this issue at facs.org/advocacy/ | 51 withhold in payment for global have resulted in a reduction in regulatory/medicare-a-b/global- services in future years. surgeons’ reimbursement for codes; more information will be 10- and 90-day global services. posted as it becomes available. The Medicare Access What other forms of reporting and CHIP (Children’s on global codes could Health Insurance Program) I am a surgeon who is be required in 2017? Reauthorization Act (MACRA) required to report—where In addition to claims-based data of 2015 prevented the transition can I get more information? collection, CMS plans to conduct of all 10- and 90-day global If you have questions regarding a survey of practitioners to gain codes to 0-day global codes but the reporting of global codes information on postoperative required CMS to collect data, data, contact the ACS Division of activities to supplement the starting in 2017, to ensure the Advocacy and Health Policy at claims-based data collection. accuracy of the value for global [email protected]. For more CMS has not finalized the design codes starting in 2019. CMS information about global codes, of the survey, but intends to then proposed that, starting visit the ACS website at facs.org/ begin surveying mid-year. This January 1, all practitioners advocacy/regulatory/medicare-a-b/ survey could affect health care nationwide would be required to global-codes or the CMS website professionals in all states, not use G-codes to collect data from at www.cms.gov/Medicare/ just the nine states selected for all 10- and 90-day global code Medicare-Fee-for-Service-Payment/ claims-based data reporting. claims. This policy would have PhysicianFeeSched/Global-Surgery- CMS also has indicated that been extremely burdensome for Data-Collection-.html. ♦ it plans to collect global code practitioners, and the likelihood data from ACOs, but has not of gathering accurate, usable described how it plans to collect data was low. As a result of those data or when the ACO aggressive ACS legislative and data collection will start. regulatory advocacy efforts,

APR 2017 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

Hernia repair and complex abdominal wall reconstruction

by Christopher Senkowski, MD, FACS; Mark Savarise, MD, FACS; John S. Roth, MD, FACS; and Jan Nagle, MS, RPh

he American College American Medical Association to report different approaches of Surgeons (ACS) CPT Editorial Panel to to hernia repair, such as an TCoding Hotline receives revise hernia coding in 1994 inguinal approach versus numerous queries about Current based on several variables, an anterior extraperitoneal Procedural Terminology including the following: approach (Henry) for a femoral (CPT) coding for hernia repair hernia repair. Beginning in 1994, and complex abdominal wall • Type of hernia (inguinal, lumbar, all open hernia repair codes reconstruction.* Similarly, femoral, incisional, ventral, were categorized as reducible 52 | participants at ACS Surgical epigastric, umbilical, spigelian) or incarcerated/strangulated, Coding Workshops have except for the rare lumbar expressed confusion regarding • Patient age (infant, child, adult) hernia repair (49540) or rare coding for these procedures. spigelian hernia repair (49590). This column provides an update • Patient presentation (initial A hernia should be considered to a coding column published in versus recurrent) incarcerated if, at the time of the September 2011 issue of the the operation, it contains viscera Bulletin1 in an effort to educate • Clinical presentation (reducible that the surgeon must manually health care professionals and versus incarcerated or reduce. It should be considered coding staff on proper coding strangulated) strangulated if the incarcerated for hernia repair and complex contents have evidence of abdominal wall reconstruction. • Method of repair (open versus ischemia due to compression laparoscopic) of the vascular supply. The 1994 CPT code set added Hernia repair As identified in Table 1, page only two codes for laparoscopic Hernia repair includes 53, only the codes for open repair hernia repair (49650 and 49651). isolation and dissection of of inguinal hernias (49491–49525) Laparoscopic hernia repair the hernia sac, reduction of or umbilical hernias (49580– was developed as a technique intraperitoneal contents, fascial 49587) have distinct codes based long after open hernia repair. repair, and soft tissue closure. on the age of the patient. Until In 1994, when codes 49650 and In 1993, the ACS submitted a 1994, separate repair codes were 49651 were created, very few code change proposal to the used to report incarcerated laparoscopic inguinal hernia hernias and strangulated repairs were performed for *All specific references to CPT codes and hernias. These two patient incarcerated hernias. Therefore, descriptions are ©2016 American Medical presentations were combined separate codes to report this Association. All rights reserved. CPT and CodeManager are registered trademarks in the 1994 CPT revision. Until of the American Medical Association. 1994, separate codes were used continued on page 54

V102 No 4 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

TABLE 1. HERNIA REPAIR CODES AND 2017 MEDICARE RELATIVE VALUE UNITS (RVU)

CPT 2017 2017 code Descriptor work RVU total RVU Open hernia repair Repair, initial inguinal hernia, preterm infant (younger than 37 49491 weeks gestation at birth), performed from birth up to 50 weeks 12.53 22.65 postconception age, with or without hydrocelectomy; reducible Repair, initial inguinal hernia, preterm infant (younger than 37 weeks 49492 gestation at birth), performed from birth up to 50 weeks postconception 15.43 27.70 age, with or without hydrocelectomy; incarcerated or strangulated Repair, initial inguinal hernia, full term infant younger than age 6 months, or 49495 preterm infant older than 50 weeks postconception age and younger than age 6.20 10.93 6 months at the time of surgery, with or without hydrocelectomy; reducible Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm 49496 infant older than 50 weeks postconception age and younger than age 6 months at the 9.42 15.67 time of surgery, with or without hydrocelectomy; incarcerated or strangulated Repair initial inguinal hernia, age 6 months to younger than 49500 5.84 11.38 5 years, with or without hydrocelectomy; reducible Repair initial inguinal hernia, age 6 months to younger than 5 years, 49501 9.36 17.51 with or without hydrocelectomy; incarcerated or strangulated | 53 49505 Repair initial inguinal hernia, age 5 years or older; reducible 7.96 15.04 49507 Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated 9.09 16.91 49520 Repair recurrent inguinal hernia, any age; reducible 9.99 18.27 49521 Repair recurrent inguinal hernia, any age; incarcerated or strangulated 11.48 20.72 49525 Repair inguinal hernia, sliding, any age 8.93 16.56 49540 Repair lumbar hernia 10.74 19.47 49550 Repair initial femoral hernia, any age; reducible 8.99 16.63 49553 Repair initial femoral hernia, any age; incarcerated or strangulated 9.92 18.23 49555 Repair recurrent femoral hernia; reducible 9.39 17.28 49557 Repair recurrent femoral hernia; incarcerated or strangulated 11.62 20.95 49560 Repair initial incisional or ventral hernia; reducible 11.92 21.34 49561 Repair initial incisional or ventral hernia; incarcerated or strangulated 15.38 26.91 49565 Repair recurrent incisional or ventral hernia; reducible 12.37 22.22 49566 Repair recurrent incisional or ventral hernia; incarcerated or strangulated 15.53 27.15 49570 Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) 6.05 12.03 49572 Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated 7.87 14.91 49580 Repair umbilical hernia, younger than age 5 years; reducible 4.47 9.46 49582 Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated 7.13 13.34 49585 Repair umbilical hernia, age 5 years or older; reducible 6.59 12.85 49587 Repair umbilical hernia, age 5 years or older; incarcerated or strangulated 7.08 13.72

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APR 2017 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

TABLE 1. HERNIA REPAIR CODES AND 2017 MEDICARE RVU (CONTINUED)

CPT 2017 2017 code Descriptor work RVU total RVU 49590 Repair spigelian hernia 8.90 16.55 Laparoscopic hernia repair 49650 Laparoscopy, surgical; repair initial inguinal hernia 6.36 12.37 49651 Laparoscopy, surgical; repair recurrent inguinal hernia 8.38 16.08 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric 49652 11.92 21.51 hernia (includes mesh insertion, when performed); reducible Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia 49653 14.94 26.84 (includes mesh insertion, when performed); incarcerated or strangulated Laparoscopy, surgical, repair, incisional hernia (includes 49654 13.76 24.47 mesh insertion, when performed); reducible Laparoscopy, surgical, repair, incisional hernia (includes mesh 49655 16.84 29.86 insertion, when performed); incarcerated or strangulated Laparoscopy, surgical, repair, recurrent incisional hernia 49656 15.08 26.55 (includes mesh insertion, when performed); reducible Laparoscopy, surgical, repair, recurrent incisional hernia (includes 49657 22.11 38.24 54 | mesh insertion, when performed); incarcerated or strangulated Additional codes related to hernia repair 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk 19.86 37.95 20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 5.96 12.16 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue +49568 4.88 7.76 infection (List separately in addition to code for the incisional or ventral hernia repair) (Use 49568 in conjunction with 11004–11006, 49560–49566) 49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy 0.00* 0.00* 49999 Unlisted procedure, abdomen, peritoneum and omentum 0.00* 0.00*

*Contractor priced codes do not have assigned RVUs.

work were not included in new laparoscopic hernia repair the difference in operative the ACS 1994 code change codes for ventral and incisional time and effort. In addition, proposal. Also, no coding hernia repair (49652–49657) were multiple hernias repaired in the distinction was made regarding added to the CPT code set. same operative session through whether a laparoscopic inguinal Hernia repair codes are not the same incision cannot be hernia repair was performed size-dependent. A 1 centimeter coded separately. Multiple transabdominal preperitoneally incarcerated initial incisional holes in a “Swiss cheese” (commonly known as “TAPP”) hernia is repaired with the same abdominal wall count as a or totally extraperitoneally code (49561) as a 25 centimeter single incisional hernia repair.2 (commonly known as “TEP”).2 In incarcerated initial incisional All open and laparoscopic 2009, after sufficient supporting hernia, and both receive the hernia repairs are unilateral, literature was published, six same payment regardless of with the exception of umbilical

V102 No 4 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

CODING TIP: ROBOTIC HERNIA REPAIR Robotic hernia repair is reported with a laparoscopic hernia repair code. It is incorrect to report modifier 22, Increased procedural services, for robotic assistance. It is also incorrect to report an unlisted laparoscopic procedure code unless no existing laparoscopic code describes the procedure. Although laparoscopic surgery is typically covered by third-party payors, including Medicare, no additional payment is made when a robotic surgical technique is used. If your payor accepts Healthcare Common Procedure Coding System (HCPCS) Level II S-codes, you may report S2900, Surgical techniques requiring use of robotic surgical system (List separately in addition to code for primary procedure), in addition to the primary laparoscopic procedure code. However, HCPCS S-codes are not payable under Medicare.

hernia repair (49580–49587). (49650–49657) and to some of compensation for the cost of the Modifier 50, Bilateral procedure, the open hernia repair codes, mesh. Like other supplies and is used to report bilateral including inguinal (49491–49525), equipment, mesh is reimbursed hernia repair in one of two lumbar (49540), femoral (49550– to the facility where the hernia ways, by line-item format or by 49557), epigastric (49570–49572), repair is performed. Typical bundled format, depending on umbilical (49580–49587), and facility costs for prosthetic a payor’s reporting preference. spigelian (49590). The use of mesh mesh range from less than $50 The following example shows or other prosthesis is not inherent for simple polypropylene mesh both methods of reporting to the open repair of incisional or to more than $200 for some bilateral reducible inguinal ventral hernias (49560–49566). of the proprietary contoured hernia repair in an adult: Code 49568, Implantation of multilayer mesh hernia systems | 55 mesh or other prosthesis for open and more than $2,000 for • Line-item format: Report 49505 incisional or ventral hernia repair or engineered, biologic products.2 and 49505-50 on separate claim mesh for closure of debridement for In comparison, the 2017 MPFS lines and bill the full fee for each necrotizing soft tissue infection (List physician payment for the work procedure/line. separately in addition to code for the of placing the mesh is $278. incisional or ventral hernia repair), To be clear, code 49568 • Bundled format: Report 49505-50 may be reported only once in represents placement of any on one claim line and bill twice addition to the open incisional or type of mesh or other prosthesis, the full fee. ventral hernia repair code (49560– whether synthetic, biologic, 49566), as applicable. Medicare or otherwise and whether Medicare rules state that rules do not permit appending autograft, dermal graft, if a code is reported with modifier 50 to code 49568 for xenograft, or graft based on modifier 50 or is reported twice bilateral hernia repair. Code 49568 new technique or technology. on the same day by any other includes the work of placing the It would be incorrect to report means, payment will be made mesh, independent of the size a code for application of a skin based on 150 percent of the of mesh used. It is the facility’s substitute graft (15271–15274) Medicare physician fee schedule responsibility to report the type or code for implantation of a (MPFS) amount for a single code. and size of mesh used; the biologic implant for soft tissue Most payors follow this rule. surgeon only reports code 49568. reinforcement (15777) for mesh Although the surgeon is implantation in conjunction compensated for the physician with a hernia repair code. Codes When and how to report work related to placing the 15271–15274 are reported for implantation of mesh mesh, either as part of the the topical application of skin The use of mesh or other payment for the hernia repair or substitute grafts or, in the case prosthesis is considered inherent separate payment for code 49568, of 15777, for placement of non- to all laparoscopic hernia repairs the surgeon does not receive surface biological implants for

APR 2017 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

CODING TIP: HYBRID LAPAROSCOPIC AND OPEN HERNIA REPAIR Code 15734 is an open procedure. For more complicated laparoscopic hernia repair procedures that may include separation of components, report code 49659, Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy. For hernia repair procedures that are hybrid laparoscopic and open repairs, report the appropriate code for open hernia repair.

soft tissue reinforcement (for in the posterior rectus plane repair (12031–12037), and/or example, for sarcoma defects while also preserving the complex repair (13100–13102) or breast reconstruction). neurovascular bundles. of skin and subcutaneous The work related to the tissues. These codes should not hernia repair is reported with be reported separately when Complex abdominal the appropriate hernia repair the procedures are performed wall reconstruction code and the work related to in conjunction with a hernia Large or complex abdominal wall the component separation repair. Also, codes for adjacent hernias may require more than procedure is reported with code tissue transfer (14000–14302) simple suture repair or repair 15734, Muscle, myocutaneous, may not be reported with a with mesh. For these cases, a or fasciocutaneous flap, trunk. hernia repair, even if extensive technique known as “component Medicare guidelines do not allow mobilization of skin and adipose separation” (also known as the use of modifier 50 (bilateral tissue is performed. The Current separation of parts operation) may procedure) with 15734. Therefore, Procedural Terminology 2017 56 | be used to repair the hernia and if both sides of the rectus sheath Professional Edition states: reconstruct the abdominal wall are mobilized, you would report “Undermining alone of defect. Component separation one unit of 15734 plus a second adjacent tissues to achieve involves separating and creating unit of 15734 with modifier 59 closure, without additional musculofascial advancement appended (15734, 15734-59) and incisions, does not constitute flaps to facilitate closure of bill full fee for both procedures. adjacent tissue transfer.”3 large midline hernia defects. Payor software will apply For removal of mesh that In one component separation modifier 51 as appropriate and is infected or involved in an technique, an anterior release reduce payment based on the enterocutaneous fistula, report mobilizes the entire rectus sheath multiple procedure reduction code 11008, Removal of prosthetic toward the midline by incising rule. For clarity, code 15734 material or mesh, abdominal the aponeurosis of the external represents a musculofascial flap wall for infection (eg, for chronic oblique from the costal margin involving the mobilization of the or recurrent mesh infection or to the pubis. While protecting rectus muscle whether performed necrotizing soft tissue infection) the neurovascular pedicles, the with anterior or posterior (List separately in addition to code rectus flap is mobilized to bring release. Code 15734 can only be for primary procedure), in addition the more medial tissues of the reported once for each side. It to code 10180, Incision and anterior abdominal wall toward cannot be reported four times— drainage, complex, postoperative the midline. The posterior or once for each posterior and wound infection, or code 11005, transversus abdominis release anterior side. Only one muscle Debridement of skin, subcutaneous musculofascial flap is another flap is mobilized on each side. tissue, muscle and fascia for method to perform mobilization necrotizing soft tissue infection, of the rectus sheath. Using Additional coding abdominal wall, as appropriate. this method, the same rectus considerations For removal of mesh that muscle is advanced to the The hernia repair codes and is not infected, report code midline through release of code 15734 include simple repair the transversus abdominus (12001–12007), intermediate continued on page 59

V102 No 4 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

CLINICAL CODING EXAMPLES

CLINICAL SCENARIO: Patient who had previous abdominal surgery with mesh implantation presents with a large reducible recurrent incisional hernia. After extensive lysis of adhesions and excision of subcutaneous scar tissue and previously implanted mesh, the incisional hernia is repaired using musculofascial flaps (right and left posterior rectus sheath TAR release, elevation of 400 sq cm subcutaneous flaps, implantation of mesh, and complex closure). Work Total Code(s) reported Descriptor RVU RVU 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk 19.86 37.95 15734-59 Muscle, myocutaneous, or fasciocutaneous flap; trunk 19.86 37.95 49565 Repair recurrent incisional or ventral hernia; reducible 11.92 21.34 20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 5.96 12.16 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for +49568 closure of debridement for necrotizing soft tissue infection (List separately in addition to code for 4.88 7.76 the incisional or ventral hernia repair) DISCUSSION: This operation describes a hernia repair and component separation, with mobilization of both flaps. Modifier 59 is appended to the second instance of code 15734 to indicate it is a distinct and separate service. Modifier 51 could be appended to the second instance of 15734 and 49565 and 20680; however, most payors suggest not appending modifier 51 to any codes because coding software will automatically adjust payment for multiple procedures. Removal of prior mesh may be reported with 20680. The subcutaneous flaps and wound closure are inherent to the hernia repair and are not reported separately.

CLINICAL SCENARIO: Patient with significant weight loss presents with umbilical hernia and diastasis recti. The hernia is repaired and an abdominoplasty is performed. Work Total Code(s) reported Descriptor RVU RVU 49585 Repair umbilical hernia, age 5 years or older; reducible 6.59 12.85 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue 0.00 0.00 DISCUSSION: The diastasis is not a hernia and repair involves simple plication. Code 49585 is reported for the | 57 hernia repair and code 17999 is reported for the additional work of plication. Code 17999 is contractor priced, and therefore, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. If abdominoplasty is the only procedure performed, report code only 17999.

CLINICAL SCENARIO: A patient who previously underwent open left side inguinal hernia repair with mesh presents with a left side incarcerated recurrent inguinal hernia and a new reducible right inguinal hernia. At laparoscopy, both hernias are repaired with mesh. Work Total Code(s) reported Descriptor RVU RVU 49651-LT Laparoscopy, surgical; repair recurrent inguinal hernia 8.38 16.08 49650-RT Laparoscopy, surgical; repair initial inguinal hernia 6.36 12.37 DISCUSSION: Codes 49650 and 49651 do not differentiate between reducible and incarcerated/strangulated. Addition of modifiers for left and right side indicate distinct separate procedures.

CLINICAL SCENARIO: A patient undergoes repair of an incarcerated incisional hernia and omentectomy. Work Total Code(s) reported Descriptor RVU RVU 49561 Repair initial incisional or ventral hernia; incarcerated or strangulated 15.38 26.91 DISCUSSION: Resection of the piece of omentum contained within an incisional hernia is not reported as an omentectomy. Code 49255, Omentectomy, epiploectomy, resection of omentum (separate procedure), describes removing the entire organ, starting at the greater curvature of the stomach, and is typically performed for malignancy. Code 49255 may only be reported as a “separate procedure.” In this instance, the omental resection was part of the hernia repair. If the additional work was extensive, modifier 22 may be appended to 49561, but supporting documentation (procedure report) must be submitted with the claim to provide an adequate description of the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the service.

continued on next page

APR 2017 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

CLINICAL CODING EXAMPLES (CONTINUED)

CLINICAL SCENARIO: A patient had an umbilical hernia repair with mesh two years ago. She is having pain at the hernia repair site. At laparotomy, lysis of adhesions and mesh removal is performed. Work Total Code(s) reported Descriptor RVU RVU 44005 Enterolysis (freeing of intestinal adhesion) (separate procedure) 18.46 31.73 20680-59 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 5.96 12.16 DISCUSSION: In this case, it is acceptable to report the lysis of adhesions because it is the only work done. Removal of noninfected mesh is reported with 20680 and modifier 59 to indicate a distinct procedure. The umbilical defect will be closed incidentally as part of the laparotomy closure.

CLINICAL SCENARIO: A patient undergoing open cholecystectomy has a reducible umbilical hernia repaired during the same operative session. The cholecystectomy and hernia repair are performed through separate incisions. Work Total Code(s) reported Descriptor RVU RVU 47600 Cholecystectomy 17.48 30.90 49585-59 Repair umbilical hernia, age 5 years or older; reducible 6.59 12.85

DISCUSSION: If both procedures are performed through the same incision, the hernia repair would be inherent to the cholecystectomy and not separately reported. In this clinical scenario, the procedures are performed through separate incisions, and, therefore, both procedures may be reported. Modifier 59 is appended to the hernia repair to indicate a distinct procedure. If the cholecystectomy was performed laparoscopically, the port is typically placed through a hernia with subsequent closure of the hernia (port site). In this instance, only the laparoscopic cholecystectomy would be reported.

CLINICAL SCENARIO: A patient presents with multiple incarcerated ventral hernia defects in a midline scar and a separate single incisional hernia at an old ostomy site. Repair is accomplished with mesh. Work Total 58 | Code(s) reported Descriptor RVU RVU 49561 Repair initial incisional or ventral hernia; incarcerated or strangulated 15.38 26.91 49561-59 Repair initial incisional or ventral hernia; incarcerated or strangulated 15.38 26.91 Implantation of mesh or other prosthesis for open incisional or ventral hernia +49568 repair or mesh for closure of debridement for necrotizing soft tissue infection (List 4.88 7.76 separately in addition to code for the incisional or ventral hernia repair) DISCUSSION: The current standard for this abdominal wall hernia repair would recommend the placement of mesh as opposed to primary repair. The tenet of repair for this clinical scenario describes a single piece of mesh that overlaps all the defects. Report code 49561 twice: once for the repair of multiple “Swiss-cheese” defects in the midline scar, and once for the repair of the defect at the old ostomy site. Modifier 59 is appended to the second instance of code 49561 to indicate a distinct procedure. If one piece of mesh were placed to cover all defects, then the add-on code 49568 also should be reported. It would be unusual for a surgeon to place two separate pieces of mesh for the reasons mentioned in this column. However, if two distinct defects were repaired and separate pieces of mesh were implanted—for example, an incisional defect from previous flank incision and concomitant incisional defect for low suprapubic incision—then code 49561 and 49568 would each be reported twice and modifier 59 appended to the second instance of each code to indicate a distinct service. Modifier 51 could also be appended to the second instance of 49561, however, most payors suggest not appending modifier 51 to any codes because coding software will automatically adjust payment for multiple procedures. Modifier 51 is never reported to add-on codes and would not be appended to code 49568.

CLINICAL SCENARIO: A patient with a midline reducible incisional hernia undergoes a standard open Rives-Stoppa repair with retrorectus mesh. Work Wotal Code(s) reported Descriptor RVU RVU 49560 Repair initial incisional or ventral hernia; reducible 11.92 21.34 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for +49568 closure of debridement for necrotizing soft tissue infection (List separately in addition to code for 4.88 7.76 the incisional or ventral hernia repair) DISCUSSION: Rives-Stoppa is an incisional hernia repair procedure in which mesh or other prosthesis is placed between the rectus abdominis muscle and the posterior sheath. It is incorrect to report 15734 for a standard Rives- Stoppa repair. Code 15734 may be reported only when musculofascial flaps are created by myofascial release.

V102 No 4 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

20680, Removal of implant; Unlisted laparoscopy procedure, REFERENCES deep (eg, buried wire, pin, screw, hernioplasty, herniorrhaphy, 1. Senkowski C, Jackson J. Coding hernia metal band, nail, rod or plate). herniotomy), it is necessary and other complex abdominal repairs. Transversus abdominis plane to submit supporting Bull Am Coll Surg. 2011;96(9):42-44. (TAP) local anesthesia block documentation (procedure 2. Savarise M. Hernia and abdominal (for example, abdominal plane report) along with the claim to wall coding. In Savarise M, Senkowski C, eds. Principles of Coding block, rectus sheath block) is a provide an adequate description and Reimbursement for Surgeons. procedure that is performed on of the nature, extent, and need Switzerland: Springer; 2017:238-239. patients who undergo abdominal for the procedure, and the time, 3. American Medical Association. and/or pelvic surgery for effort, and equipment necessary Current Procedural Terminology 2017 postoperative pain control and to provide the service. Professional Edition. Chicago, IL: American Medical Association; abdominal wall analgesia. The 2017:82. TAP block is a peripheral nerve 4. American Medical Association. block applied to anesthetize the ACS Coding Hotline Transversus abdominis plane block sensory nerves of the anterior If you or your coding staff (64486-64489). CPT Asst Am Med Assoc. | 59 abdominal wall. The intention have questions, contact the 2015;25(6):3. 5. Centers for Medicare & Medicaid of this procedure is to allow ACS Coding Hotline at 800- Services. Medicare Claims Processing the instilled local anesthesia ACS-7911 (800-227-7911). The Manual. Chapter 12: Physicians/ to access multiple branches hours of operation are 8:00 nonphysician practitioners. Available of several different nerves am–5:00 pm (Central), Monday– at: www.cms.gov/Regulations- (for example, ilioinguinal, Friday, holidays excluded. ACS and-Guidance/Guidance/Manuals/ Downloads/clm104c12.pdf. Accessed iliohypogastric, subcostal, Fellows are given five free February 28, 2017. intercostal) by using a single consultation units (CU) each injection technique thereby calendar year. One CU covers providing a dermatomal a period of up to 10 minutes. sensory block over the six In addition, ACS Surgical lower thoracic and first lumbar Coding Workshop opportunities afferents.4 Medicare global are available for surgeons and/ surgery rules prevent separate or their coding staff. For more payment for postoperative pain information or to sign up for one management when provided of the 2017 ACS Surgical Coding by the physician performing Workshops, visit facs.org/advocacy/ an operative procedure.5 practmanagement/workshops. ♦ Therefore, a TAP block (64486– 64489) may not be reported by a surgeon in conjunction with an abdominal operation, including hernia repair. When reporting an unlisted code to describe a procedure or service (such as 49659,

APR 2017 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

Diamonds in the rough— a case for rural surgery rotations

by Edward Kreimier III, MD

t is 6:30 am. My gaze shifts half hours into the city, which, to live in northern Michigan and from my textbook to the as I recall, was likely Flint, MI, a devotion to the hospital and Iwestward facing window in order to have her operation their colleagues that allow them overlooking the water of without the support of her friends to live and work in their idyllic Michigan’s Long Lake. I wrench and family. Her carotid surgery home. Although challenges my attention back to the final went off without a hitch and such as limited resources and paragraph in the text, which she did well postoperatively. access to specialists arise, is the vascular chapter. One Next on the docket are two everyone works together final bite of my apple, and then cholecystectomies, followed with a cooperation born of it’s book closed, shoes on, and by two colonoscopies, and an mutual happiness. It is a state out the door to make my way emergent appendectomy that we of mind reinforced by personal 60 | to Alpena Regional Medical managed to squeeze in before satisfaction, strong work/ Center, MI. The drive to the lunch. Rounds after lunch are life balance, and collegiality. hospital reminds me of a Thomas punctuated by conversations with I knew that this life existed; Kinkade painting. Trees line the nursing staff as well as several I knew it was possible. But the 10-mile stretch into town, hospitalists. These exchanges the blindfold of stress, the dotted with houses and small are not idle chatter—they are pressures of residency, and businesses. I pull into the parking conversations of consequence the impulse to keep my head lot at 6:45 am and am greeted regarding patients, with genuine down had prevented me from by several nurses and staff on interest in the lives of all involved. looking up and looking forward my way into the operating Throughout the day, the specifically in this direction. room (OR) lockers. This hospital staff is welcoming. The environment in Alpena moment is the most at ease Most of the staff are aware that a was not what I was familiar I have been during residency. resident is on-site for a one-month with, as I did not grow up in the Granted, three and one-half rotation (May 2016), and those Midwest, but rather in a small years of general surgery training who are not aware of my presence mountain town—Rifle, CO. is not an eternity, but here seem to be keen to have a resident Rifle is an example of a modern I have a sense of peace that in-house. Between cases, after my rural town, where seemingly transports me outside of time. postoperative notes and orders everyone knows everyone else; are written, I sit at the OR charge Sunday church is sacred; and nurse station or at the work desk once, in high school, a student A day at Alpena in preoperative or post-anesthesia rode his horse to class. This was We start the day with a carotid care unit areas, where everyone my upbringing and a piece of endarterectomy. Our patient is seems to be interested in the my soul that I had abandoned a pleasant 81-year-old woman details of my life and how I am when I left for college. Living who has lived in Alpena her enjoying my time at Alpena. and working in Alpena gave entire life. She did not want to The staff members exhibit me the opportunity to be back have to drive the two and one- appreciation for the opportunity in a small town environment.

V102 No 4 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

Step out into the wild and encounter a side of surgery most haven’t experienced. All parties involved will benefit, and we might even ease the burden of care on America’s rural hospitals along the way.

Residents training in a rural from the presence of a resident, Stemming the rotation typically have the but the OR staff, floor nurses, and workforce shortage opportunity to experience what it even nonsurgical services will Numerous articles have been would be like to practice in their likely gain a new point of view. written on the shortage of rural hometown or someplace like it. Residents who have a rewarding physicians, specifically surgeons. Consider offering a rural surgery experience at your institution Many of these authors have rotation, even if your hospital is may be convinced to pursue rural focused on strategies for reducing landlocked. Partnerships with surgery as a career, and your rural workforce shortages. hospitals and surgery groups hospital will likely be first on their However, the personal experiences benefit both the residents seeking list of desired places to work. I describe in this column provide this experience, as well as the a resident’s perspective on rural hospitals and surgeons with surgery rotations and are intended which they work, bringing A win-win opportunity for four distinct audiences. cutting-edge techniques and I urge residents, program new and different approaches to directors, rural surgeons, and Residents from rural areas problems we all hold in common. rural hospital leaders to take For those of us from small towns advantage of the benefits that | 61 and rural settings, residency has a Practicing rural surgeons come with implementing a rural peculiar way of making us forget Experienced rural surgeons surgery rotation. I encourage the joys of our hometown and possess a wealth of knowledge surgery residents to seek out our upbringing. Whether it’s the and wisdom. Consider hosting a rural hospitals and groups that work hours, the stress of passing resident at your practice. There are eager to give back to the boards, or just keeping our heads is no better way to give back to profession. Step out into the wild above water, we tend to lose sight your profession than training and encounter a side of surgery of what we once had. Budding the next generation, and this most haven’t experienced. All surgeons need to choose surgical partnership may even provide parties involved will benefit, programs near large population you with new insights for and we might even ease the centers to ensure the case mix providing optimal care. And who burden of care on America’s and volume needed to hone their knows—during this processes rural hospitals along the way. craft is available, but this urban you may be meeting your Residents, program directors, environment can wear down future partner and colleague. surgeons, and hospitals that are even the toughest farm kid. interested in participating in or Rural hospital systems hosting a rural surgery rotation Program directors I encourage rural hospitals to are encouraged to contact Michael I would encourage program explore the possibility of hosting Sarap, MD, FACS, Chair, and directors to offer a rural surgery surgical residents. The surgical Mark Puls, MD, FACS, Vice- rotation. The surgeon workforce residency learning environment Chair, ACS Advisory Council shortage in rural America is a is carried along with a visiting for Rural Surgery. Dr. Sarap can problem that can be tempered, surgical resident, who will likely be reached at msarap@msn. and rural surgery rotations reveal to your colleagues new com, and Dr. Puls at mpuls@ provide the opportunity to techniques as well as current alpenasurgical.com. ♦ train in a variety of cases with research findings. Not only will unique practice patterns. your current surgical staff benefit

APR 2017 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

Junior investigators: Get engaged in the Alliance for Clinical Trials in Oncology

by Geoffrey L. Uy, MD; Matthew H. G. Katz, MD, FACS; and Judy C. Boughey, MD, FACS

or many clinical open trials and amendments The success of the Alliance investigators, participating to open trials. This year, the Fin the Alliance for group meetings will take place and the cooperative groups Clinical Trials in Oncology in Chicago, May 10–13 and in the National Cancer (Alliance) as a study chair November 2–4. Historically, Institute’s National Clinical or principal investigator has the Alliance hosted junior been a contributing factor to investigator sessions at its Trials Network is dependent | 62 a successful academic career. biannual group meetings to on the cooperative group’s The success of the Alliance provide an opportunity for and the cooperative groups in focused lectures on career ability to help recruit and the National Cancer Institute’s development and small group train the next generation National Clinical Trials Network discussion. The Alliance for is dependent on the cooperative Clinical Trials in Oncology of clinical researchers. group’s ability to help recruit Foundation also attracts the and train the next generation interest of the next generation of clinical researchers. The of clinical researchers by network includes NRG (formerly sponsoring two annual scholar National Surgical Bowel and awards, which are two-year, non- Bladder Project and Radiation renewable cancer research grants Therapy Oncology Group of $40,000 to support the research and Gynecologic Oncology activities of junior faculty at Group); SWOG (Southwest Alliance institutions. A call for Oncology Group); ECOG- applications for these awards ACRIN (the American College is issued in the spring, and of Radiology Imaging Network applications are due in August. and the Eastern Cooperative Even with these recruitment Oncology Group); and Children’s efforts, significant barriers inhibit Oncology Group (COG). the ability of junior investigators The Alliance holds two to participate in cooperative group meetings each year group activities. Typically, as an opportunity for the junior investigators are recruited investigators to meet and discuss from their home institutions new trial ideas, new concepts into the Alliance ranks and in development, and active mentored by senior committee

V102 No 4 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

In November 2016, the Alliance formed a YIC with the goal of breaking down the barriers that impede junior investigators from participating in Alliance programs. Specifically, the Alliance plans to pair each young investigator with a senior member of the disease site/ modality committee of interest to the junior researcher.

members. However, without this A second major initiative of • Implementation of clinical trials connection, it can be challenging the YIC is the creation of a New in a community practice setting for these young researchers to Investigator Course, which will get involved or share their ideas take place during the Alliance’s Our goal for the New with Alliance leadership and Spring Group Meeting in May. Investigator Course is to build chairs of the Alliance disease site The Alliance will provide a robust network of junior committees. The reduction in funding for approximately 30 investigators to participate funding for cooperative groups new investigators to attend in and eventually develop | 63 has decreased opportunities for this meeting. The goal is to and lead Alliance trials. face-to-face interactions during have one-hour workshops If you have any questions committee meetings. Navigating interspersed throughout the about the YIC or would like the bureaucracy and regulatory meeting to discuss trial ideas and more information about the requirements that must be met to learn about the development New Investigator Course, to translate an idea into an actual of a clinical trial. Proposed contact Geoffrey Uy, MD (guy@ proposal can be challenging for topics include the following: wustl.edu), or Denise Collins- even experienced investigators. Brennan, treasurer, Alliance • Strategies for developing a for Clinical Trials in Oncology concept and getting it through the Foundation (dcollinsbrennan@ YIC process to become an activated partners.org). ♦ In November 2016, the Alliance study (includes nuts-and-bolts formed a Young Investigator issues such as the responsibilities Committee (YIC) with the goal of a study chair) of breaking down the barriers that impede junior investigators • Clinical trials design in 2017 from participating in Alliance programs. Specifically, the • Pragmatic trials Alliance plans to pair each young investigator with a senior • Regulatory affairs, working member of the disease site/ with study statisticians and data modality committee of interest management to the junior researcher. The senior investigator will serve as a • Determining the cost of a trial, mentor and facilitate the mentee’s procuring funding and study involvement in the group. contracts

APR 2017 BULLETIN American College of Surgeons YOUR ACS BENEFITS

ACS Case Reviews in Surgery and AHRQ Safety Program for ERAS: New ACS programs enhance quality patient care

by Whitney Greer and Stacey McSwine

he American College electronically six times per Users may claim up to 36 Self- of Surgeons (ACS) is year. Each issue will be Assessment CME Credits Tintroducing two new peer reviewed by leaders in per annual subscription. programs this spring to academic U.S. surgery and For surgeons interested help surgeons improve their will feature 10 case reports, in earning CME (including surgical skills and to enhance along with a CME posttest. Self-Assessment Credits), an the provision of evidence- Unlike many other current annual subscription to ACS based perioperative care. online case report journals, Case Reviews in Surgery can be The ACS Case Reviews in surgeons will not be charged purchased for $125. For surgery Surgery is a new product that to submit or publish their case residents, medical students, and supports surgeons’ continuing reports. “It has become difficult other members of the surgical medical education (CME) and to get case reports published in community who do not have Maintenance of Certification major journals,” Dr. Isenberg CME Credit needs, an annual 64 | (MOC) needs. Specifically, ACS said. “Yet, there is a need from subscription is available for $75. Case Reviews in Surgery allows an educational standpoint to Surgeons who are interested surgeons to learn through the publish interesting cases while in submitting case reports for review of actual surgical cases. meeting strict publication review are encouraged to send guidelines.” Surgery residents them to [email protected]. and medical students also Contact Dr. Isenberg at Gerald. ACS Case Reviews in Surgery will have the opportunity to [email protected], or The ACS Division of Education begin publishing early in their Whitney Greer at wgreer@ has launched a new online surgical careers by having facs.org with any questions journal, ACS Case Reviews in select reports featured in ACS or comments regarding ACS Surgery, which will cover an Case Reviews in Surgery. Case Reviews in Surgery. extensive array of specialties, Ajit K. Sachdeva, MD, FACS, including breast, colorectal, FRCSC, Director, ACS Division pediatric, transplant, acute of Education, added, “ACS Case ERAS program to lower costs, care, trauma, general, and Reviews in Surgery will publish improve patient safety rural surgery. This journal and disseminate peer-reviewed The ACS, in collaboration with will link to other College information relating to the Johns Hopkins Medicine publications that cover similar interesting surgical cases. This Armstrong Institute for Patient topics, including the Journal of practical resource should be of Safety and Quality, Baltimore, the American College of Surgeons, great interest to surgeons in MD, has launched the Enhanced Selected Readings in General practice and surgery residents.” Recovery After Surgery Surgery, and Evidence-Based (ERAS) program—a new Decisions in Surgery modules. CME credit surgical quality improvement Gerald A. Isenberg, MD, ACS Case Reviews in Surgery is initiative funded and guided FACS, is the Editor-in-Chief intended to be a convenient and by the Agency for Healthcare of ACS Case Reviews in Surgery, effective source for attaining Research and Quality (AHRQ). which will be published Self-Assessment CME Credit. The ACS announced plans

V102 No 4 BULLETIN American College of Surgeons YOUR ACS BENEFITS

in February to enroll at least Unit-based Safety Program Centers for Medicare & Medicaid 750 hospitals to participate (CUSP) across hospitals in the Services (CMS), including in this program.* Hospitals U.S. CUSP is a proven strategy reduction in opioid prescribing, in the U.S., Puerto Rico, and to engage in culture change in prevention of SSIs, CAUTIs, and the District of Columbia are pursuit of patient safety. This VTEs, as well as the creation of a eligible to participate across five quality improvement program culture of safety and teamwork. cohorts: colorectal, orthopaedic, has been used successfully to For health care practitioners, bariatric, gynecology, and prevent central line-associated the AHRQ Safety Program emergency general surgery. bloodstream infections and for ERAS aligns with the catheter-associated urinary requirements under the Medicare Key elements of ERAS tract infections, as well as Access and CHIP (Children’s ERAS aims to promote the other preventable conditions. Health Insurance Program) delivery of evidence-based Hospitals that participate Reauthorization Act (MACRA) perioperative care and reduces in the ERAS program will of 2015. More specifically, variability. Key elements of the have access to the following: provider participation in ERAS ERAS program include patient may include certain clinical and family engagement, including • Leading experts in ERAS, practice improvement activities counseling about expectations perioperative quality, and established by CMS under the for surgery and recovery; state- implementation science from the Quality Payment Program to | 65 of-the-art analgesia, which fields of surgery, anesthesiology, ensure compliance with MACRA. minimizes the use of narcotics and nursing The AHRQ Safety Program and promotes multimodal for ERAS is especially analgesia; early mobility and • Evidence-based, locally adaptable useful to hospitals that meet restoration of functional status; ERAS protocols the following criteria: avoidance of prolonged periods of fasting; and evidence-based • Tools, including coaching calls, • No prior ERAS implementation best practices for surgical to assist with ERAS protocols experience site infections (SSI), venous implementation thromboembolism (VTE), and • Hospitals that have implemented catheter-associated urinary tract • Ad hoc implementation support ERAS in one area and are looking infections (CAUTI) prevention. from a quality improvement nurse to expand ERAS to other units consultant ERAS within a CUSP framework • Hospitals that have attempted The goal of the AHRQ • ACS-based ERAS data collection to implement ERAS but did Safety Program for ERAS is platform and access to an ACS not experience significant to disseminate and support ERAS clinical support team improvements or were unable to implementation of evidence- sustain the program based ERAS protocols within the • Face-to-face training and site visits framework of the Comprehensive Recruitment efforts will For hospitals, the AHRQ begin in spring 2017, with the *American College of Surgeons. ACS will recruit 750 hospitals for new program to Safety Program for ERAS first cohort beginning in June lower costs, improve safety, and shorten program aligns with five of the 11 2017. For more information, recovery times for surgical patients. Hospital Improvement Innovation contact Stacey McSwine, Press release. February 6, 2017. Available at: facs.org/media/press-releases/2017/ Networks (HIIN) core areas Enrollment Project Manager, at eras020617. Accessed February 22, 2017. targeted for improvement by the [email protected]. ♦

APR 2017 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

New resources for surgeons to obtain true informed consent

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

btaining informed should be presented in a humble consent is one of the and patient-centered way. Omost important tasks Communication errors in the that a surgeon completes, course of obtaining informed and yet a number of factors consent are among the most can complicate this process— frequent root causes of serious especially miscommunication adverse events reported to between patients and health The Joint Commission. care providers. In an effort Communication starts with to help surgeons and hospital intent, but as it moves through administrators feel confident the phases of creating and that they are obtaining true delivering the message, as well as 66 | informed consent, the Agency the reception and interpretation for Healthcare Research and by the other party, the message Quality (AHRQ) and The Joint is influenced by the way it is Commission have developed formulated and delivered, as new informed consent well as by the receiving party’s resources, which are described health care literacy, personal in this month’s column. values, and beliefs. Through the process of communication, a message may metamorphose into Communication and a meaning that is far different informed consent from the one intended.* Indeed, Informed consent is much communication is affected by a more than a signed form. It number of factors, such as the entails a thorough discussion nature of the patient’s disease; the of the rationale, potential family and social environment; benefits, and risks associated the cultural context around the with the proposed procedure. patient, family, and physician; and Appropriate communication their overall level of information between the physician and the about the problem at hand.* patient and family is at the heart Failure to adequately of informed consent, and with communicate with the patient this in mind, this information induces mistrust and can *Pellegrini CA. Trust: The keystone of potentially lead to complications the patient-physician relationship. Bull and other unfortunate Am Coll Surg. 2017;102(1):58-61. Available circumstances, which makes at: bulletin.facs.org/2017/01/trust- the-keystone-of-the-physician-patient- the need for a more effective relationship/. Accessed March 14, 2017. exchange of information between

V102 No 4 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Two new e-learning modules offered by the AHRQ can help hospital leaders and clinicians improve the informed consent process.

providers and patients imperative. that he or she has received Accountability Act authorization Effective communication and understands what the from potential research subjects. depends on clinicians’ and provider has communicated This toolkit is available online patients’ individual capacity to to them regarding a at www.ahrq.gov/funding/policies/ communicate in a competent treatment or procedure. informedconsent/index.html. manner, and on each party’s The Joint Commission also ability to adapt behavior published an issue of Quick Safety and to align perspectives to New resources in February 2016, outlining accomplish shared goals.* Two new e-learning modules best practices for obtaining Processes for obtaining offered by the AHRQ can help effective informed consent, informed consent vary from hospital leaders and clinicians including the following:† state to state, although national improve the informed consent standards are in place to guide process. The first module, • Promote informed consent | 67 health care providers. In essence, Making Informed Consent an as a process of effective informed consent processes Informed Choice: Training for communication between a typically emphasize the patient’s Health Care Leaders, is geared provider and patient, rather than need to understand the proposed toward hospital administrators the act of simply obtaining a course of treatment. To be and provides guidance on patient’s signature successful, informed consent developing policies and ensuring processes should factor in any organizational support. The • Develop a written policy on potential barriers to effective other module, Making Informed informed consent and provide communication between the Consent an Informed Choice: formal training for physicians provider and the patient, such Training for Health Care as health literacy, language, Professionals, provides clinicians • Use everyday language instead or cultural differences. with strategies to communicate of medical jargon when The process culminates clearly and offers to tools to assist communicating with patients ♦ with a signed consent form in the proper documentation of or document that serves as an informed consent. The modules, attestation from the patient which are free, are available Disclaimer through The Joint Commission’s The thoughts and opinions *Pellegrini CA. Trust: The keystone of learning management system for expressed in this column are the patient-physician relationship. Bull Am Coll Surg. 2017;102(1):58-61. Available continuing medical education solely those of Dr. Pellegrini and at: bulletin.facs.org/2017/01/trust- credit. The AHRQ also has do not necessarily reflect those the-keystone-of-the-physician-patient- created the Informed Consent of The Joint Commission or the relationship/. Accessed March 14, 2017. †The Joint Commission. Informed consent: and Authorization Toolkit for American College of Surgeons. More than getting a signature. Quick Safety. Minimal Risk Research, which Issue 21. February 2016. Available at: www. helps facilitate the process of jointcommission.org/assets/1/23/Quick_ Safety_Issue_Twenty-One_February_2016. obtaining informed consent and pdf. Accessed February 23, 2017. Health Insurance Portability and

APR 2017 BULLETIN American College of Surgeons NTDB DATA POINTS

Make no bones about it

by Richard J. Fantus, MD, FACS

he human thighbone has an described by location (proximal, interesting past—it has been shaft, distal), as well as by The NTDB Annual Report 2016 Tused as a natural club or mechanism of injury. The three is available on the American other tool, and in some cultures major mechanisms of injury are College of Surgeons’ website it has been used as a musical high-energy traumatic fractures, instrument in sacred ceremonies. low-energy pathologic fractures, as a PDF file at facs.org/ As the only bone found and stress fractures as a result quality-programs/trauma/ in the thigh, the femur is not of repetitive motion. The femur only the longest, but also the is a highly vascularized bone, ntdb. In addition, information strongest bone in the human and when it is fractured it may is available on our website skeleton. A healthy human result in significant bleeding about how to obtain NTDB femur can resist forces of up to into the thigh. As many as 40 2,500 pounds. Consequently, percent of isolated fractures data for more detailed study. 68 | it takes a significant amount may require a transfusion, as of force or weight, such as a these injuries can account for substantial fall or a motor vehicle up to three units of blood.‡ crash, to fracture a femur.* Another notable fact about the femur is the role it plays Slow recovery in determining an individual’s To examine the occurrence vertical height. Feldesman of femur fractures contained and colleagues sampled the in the National Trauma Data femur/stature ratio on 51 Bank® (NTDB®) research dataset different populations around admission year 2015, medical the world and found that the records were searched using femur is responsible for, on the International Classification average, more than a quarter of Diseases, Ninth Revision, of a person’s height.† Clinical Modification codes. The spectrum of femur Specifically searched were fractures varies widely from records that included a diagnosis non-displaced stress fractures code of 820 (fracture of neck to those associated with severe of femur) or 821 (fracture of comminution and major soft other and unspecified parts tissue injury. Fractures are of femur). A total of 105,460 records were found, of which *Healthline Media. Femur. Available at: www.healthline.com/human-body- 97,117 contained a discharge maps/femur. Accessed March 6, 2017. status, including 33,888 patients †Feldesman MR, Kleckner JG, Lundy JK. discharged to home, 21,495 to Femur/stature ratio and estimates of stature in mid- and late-Pleistocene fossil hominids. acute care/rehab, and 38,836 to Am J Phys Anthropol.1990;83(3):359–372. skilled nursing facilities; 2,898

V102 No 4 BULLETIN American College of Surgeons NTDB DATA POINTS

The three major mechanisms of injury are high-energy traumatic fractures, low-energy pathologic fractures, and stress fractures as a result of repetitive motion.

FIGURE 1. HOSPITAL DISCHARGE STATUS

| 69

died. Women accounted for one-third) were discharged to website as a PDF file at facs. 55 percent of these patients who, home. (See Figure 1, this page.) org/quality-programs/trauma/ on average, were 62.8 years of Make no bones about it, the ntdb. In addition, information is age, had an average hospital femur is a special bone, both available on our website about length of stay of 6.9 days, an for its place in history and for how to obtain NTDB data for intensive care unit length of the role it plays in determining more detailed study. If you are stay of 6.3 days, an average an individual’s skeletal height interested in submitting your injury severity score of 11.7, and its weight-bearing capacity. trauma center’s data contact and were on the ventilator for Whether you suffer a traumatic Melanie L. Neal, Manager, an average of 6.6 days. Of those fracture, pathologic fracture, or NTDB at [email protected]. ♦ tested for alcohol, more than stress fracture, it will be a while 28 percent (6,373 out of 22,376) before you are able to get back tested positive. Only a minority up on your feet and walk again. of patients (approximately Throughout the year, we will be highlighting these data ‡Romeo NM, Deitch JR, DePasquale through brief monthly reports in TG. Femur injuries and fractures. the Bulletin. The NTDB Annual Medscape. October 2015. Available at: emedicine.medscape.com/article/90779- Report 2016 is available on the overview. Accessed March 6, 2017. American College of Surgeons’

APR 2017 BULLETIN American College of Surgeons NEWS

In memoriam: Denton A. Cooley, MD, FACS, a fierce competitor

by Charles D. Fraser, Jr., MD, FACS Dr. Cooley

A giant sequoia of surgery has call him anything other than Dr. School of Medicine, Baltimore, fallen. Denton A. Cooley, MD, Cooley. The names others people MD, from which he graduated FACS, a cardiothoracic surgeon used—Darl, Daddy, Granddaddy, with highest honors in 1944. and Past-Governor of the Denton, Bubba, Buckwheat—all Dr. Cooley joined the surgical American College of Surgeons had their place, and he enjoyed house staff of the Johns Hopkins (ACS), was born on August 22, the personal nature of those Hospital under the direction 1920, in Houston, TX. He passed designations. Yet, I always chafed of Alfred Blalock, MD, FACS. away just a few miles from his a bit when he was referred Dr. Cooley quickly earned a place of birth, surrounded by to by any name other than reputation for surgical dexterity 70 | family, on November 18, 2016. Dr. Cooley. I believe he earned and intellect. At Hopkins, In an iconic life of 96 years, that degree of reverence. Perhaps Dr. Cooley was present for the name Cooley became in sharing my own viewpoints, Dr. Blalock’s first “blue-baby synonymous with bold surgical I may conjure up some of other operation” in November of 1944. innovations that shaped the Fellows’ personal recollections This was an inspiring time for field of cardiovascular surgery. as we celebrate his life. him, as was his association with Dr. Cooley leaves a professional other residents on the Halsted legacy of technical advances; bold surgical service, most of whom institutional vision; loyal and A man of many loves went on to assume positions of successful trainees; and, most The heart is known to most influence in American surgery. important to him, the nearly of us as the symbol of love. After completing his residency, countless patients who benefitted Dr. Cooley, who became famous he served as senior surgical from the care he and his as a healer of the heart, had many registrar at the Royal Brompton colleagues provided at the Texas professional loves—starting Hospital, London, U.K. But Heart Institute (THI), Houston. with the city of Houston, where Dr. Cooley was determined to The following comments he attended San Jacinto High return home to Houston. In 1952, are personal reflections on School. His university and he joined the Baylor College of the man I knew for almost 40 medical education and surgical Medicine surgical faculty under years—a man I loved, admired, training took place in a variety the direction of department chair and respected. He was my wife’s of locations, but ultimately, he Michael E. DeBakey, MD, FACS. father, a personal mentor, and always found his way home. He He held this position for 18 years an interested, engaged colleague completed his undergraduate and was enormously productive. to the end. We shared much in studies at the University of Texas- In 1967, Dr. Cooley established life—family, profession, and the Austin. Medical school started at what is perhaps his most enduring Texas Medical Center (TMC), the University of Texas Medical and visionary legacy—the Texas Houston. Despite this closeness, Branch, Galveston, and ended Heart Institute at neighboring I could never bring myself to at Johns Hopkins University St. Luke’s Episcopal Hospital,

V102 No 4 BULLETIN American College of Surgeons As a surgeon, he knew where he where he knew asurgeon, As on competition. but he thrived wit, acharming had and polite to lose. He was not like he did that learned Dr. Cooley quickly to know who came Anyone Fierce competitor to shape. he helped that and him shaped that institutions of the proud Dr. Cooley immensely was should. each they as own, its as him claims and tribute him paid has institutions storied of these Each chairs. and facilities, athletic endowments, scholarships, he showedand it through institutions, to these grateful and Dr. Cooley loyal was respect. and reverence with back loved him they and much, very institutions throughout professional his life. focus of grounding point Dr. Cooley’s remained THI The surgery. and medicine cardiovascular in of leaders generation next the educated and research, cutting-edge conducted of patients, thousands of hundreds treated has THI the 50 years, For last the research. and education treatment, disease on cardiovascular focus a singular with institution first-of-its-kind a He loved all of these of these He loved all implanted the world’s first total total world’s the first implanted Dr. when Cooley started feud that a40-year to as referred been has Dr. Dr. Cooley DeBakey. and It between competition of the world aware is medical entire disease. cardiac acquired for of surgery explosion the ultimately, and surgery, heart surgery, vascular congenital in successes early into translated courage and accuracy, Speed, seven minutes. time pump bypass”—total lung and of heart support with of Fallot of tetralogy correction “Complete breathtaking. and succinct report operative Dr. Cooley. original the Ifound by repair of Fallot tetralogy index his after some 50 years replacement valve pulmonary a who required on apatient to operate opportunity the had Irecently Formade. example, era of the colleagues his and Dr. Cooley leaps that surgical of the magnitude the grasp fully to myself, including surgeon, creative. he was bold, and he was motto. fast, He was simplify, his was apply” manner—“Modify, expedient direct, most the in how there to get and to go wanted It is safe to say that almost the the almost to say that safe It is for acardiovascular hard It is The 1958 Baylor department of surgery. Dr. Cooley is in the front row, second row, second front is in the Dr. Cooley surgery. of department 1958 Baylor The NEWS from right; Dr. DeBakey is in the front row, center. front is in the Dr. DeBakey right; from in-law), I came to Houston in in-law), in to Houston Icame (and Dr.surgeon Cooley’s son- heart congenital ayoung As Cooley/DeBakey the quarrel. surrounding hyperbole and on some myth of the perspective subject. on that him prod to try Dr. Idid DeBakey, and about negatively speak Dr.never once Cooley heard I approach, and personality, physicalbackground, stature, in differences vast their Despite history. in point that at medicine cardiovascular of epicenter the as TMC, the specifically and Houston, established and surgery heart development rapid ofthe catalyzed which race, horse Texas strange competition—a fierce as relationship DeBakey Cooley/ the characterize to Ichoose ensued, that activities. for these College by the censured subsequently Dr. Cooley fact, was In ensued. divorce aprofessional and furious, was heart, artificial a total on developing focused been had MD. Dr. DeBakey,Liotta, who Domingo colleague DeBakey developed by been Cooley/had that device a heart, artificial APR 2017APR BULLETIN I may have a unique I may have aunique drama public the Despite American College of Surgeons of College American

71 72 V102 4BULLETIN No

| of American History, 2012. History, American of Memoir ASurgeon’s Hearts: DA. 100,000 *Cooley equivalent as implantation heart artificial total world’sthe first later, one year 1968 U.S. and, in the in transplant heart human successful first the Icount them, Among repair. cardiac acquired and vascular, of congenital, spectrum the spanned and inspiring is “firsts” of surgical list His beneficiary. the was world the opportunity—and an he when saw to act hesitated competitor, Dr. Cooley never the from benefitedattention. personally also one another. Each admired and respected quietly But they hospital. same the in to field, work developing the to lead determination their in personalities, their in large too simply were giants two These for Dr. Cooley.but compliments him from anything never heard Dr. DeBakey, I with meetings Dr. Cooley. personal many In to work for Dr. DeBakey, not went thereby and of Medicine, College Baylor and Hospital 1995 Texas to join Children’s As a talented, bold a talented, As . Austin, TX: Briscoe Center Center Briscoe TX: . Austin, American College of Surgeons of College American Dr. Cooley receiving the Presidential Medal of of Medal Presidential the receiving Dr. Cooley Freedom from Reagan President inFreedom 1984. lifestyle for us all to emulate. all for us lifestyle aphysician-leader embodied day. work every hard Hethe doing trenches, the in line, front the on He was first. patient the of putting principle to the true leader, he remained surgeon a As of patients. care take go and early and bright morning up on get Monday then would and received awards, dignitaries, world, met the with traveled Cooley Dr. life. throughout physician adedicated remained he attention, public the awards, the notoriety, the Despite purpose. of his never sight lost He aphysician. as core identity to his adherence of his result the were successes career enduring Dr. Cooley’s and consistent Dr. Cooley, physician the Clinton. William President Technology and byof Science Medal National the and Reagan Ronald of Freedom by President Medal Presidential the awarded led to Dr. others, Cooley being among accomplishments, moon. These on the footsteps Armstrong’s to Neil scope in NEWS Dr. Cooley receiving the National Medal of Science Science of Medal National the receiving Dr. Cooley and Technology from President Clinton in 1999. Clinton President from Technology and accolades—from professional professional accolades—from amazing in resulted and worldwide attention attracted accomplishments His globe. the traveling meant this and lecturer, grammar. and punctuation for proper astickler He was ASurgeon’sHearts: Memoir 100,000 in life incredible his He chronicled textbooks. numerous and articles journal 1,400 peer-reviewed than more to contributing author, Dr. Cooley aprolific was celebrity aparadoxical and Author, investigator, speaker, Association. Surgical American and Association, Surgical Southern Association, Surgical Western Surgeons, University of Society Surgery, for Thoracic Association American Surgeons, of Thoracic Society Surgery, for Vascular Society Surgery, of Society International of the member aprominent was also (1965−1968). aGovernor was He 1952 ACS ofa Fellow the in and He became leadership. medical He was a highly sought-after sought-after ahighly He was in for all example an He was .* .*

FROM DR. COOLEY’S PERSONAL ARCHIVE I came to know. Despite his to know. his I came Despite Dr. the Cooley epitomized This fork. same the with Atticus and himself fed Cooley alternately Dr. as disbelief in I watched Dr. as Cooley’s tray TV plate. same on the chin his who rested Atticus, dog, Cooley family the was my attention caught what but meal, his on with carried me, he greeting After surgeons. world’s living the famous most other, one of the was fork in and one hand in remote control table, TV on aTV dinner with chair, asoft in expected—seated not I was what Ifound What long days. of end his at the meal evening Cooley his had Dr. where library family the at Helen’s entered home and memorable day,that we arrived On of my then-girlfriend. father the also and surgeon cardiac world-renowned the from expect to what not 1982. know Idid in meet home Dr. Cooley at his approachable. incredibly Yet countries. he remained numerous and queens, Pope, kings, the Presidents, U.S. universities, societies, handshake from Dr. Cooley, marking an an Dr. marking from Cooley, handshake Cardiovascular Surgery Society with a a with Society Surgery Cardiovascular membership in the Denton A. Cooley Cooley A. Denton in the membership I had the opportunity to first to first opportunity the I had end to their decades-long silence. decades-long to their end Dr. DeBakey accepting honorary honorary accepting Dr. DeBakey accomplishment in heart surgery. surgery. heart in accomplishment institutional and of personal journey unbelievable almost determination. and vision MD, for his Willerson, Jim of THI, president as successor able his to loyal particularly Dr. Cooley was disease. heart against fight the in frontiers new exploring innovators and researchers intrepid the of excellence,”“symbol including THI iconic the personify care of cardiovascular aspects all in of professionals team The world. the in surgeons best the whom he considered THI, at colleagues proud of his Dr. Cooley enormously was disease. heart with for patients world the it changed Indeed, 1962. in thinking radical was disease cardiovascular with of patients care to the dedicated institution for aunified vision His THI. the in embodied is Dr. Cooley’s legacy professional builder A ways. unexpected to in relate all we could celebrity, aman he was 100,000 Hearts NEWS recounts the the recounts 17 great-grandchildren. and 16 as well grandchildren as Cooley Helen Fraser, my wife, Davis); and Richard (husband, MD Cooley Davis, Louise M. Cooley,MD); Susan PhD; Jr., Craddock John (husband, Cooley Craddock Mary daughters, by four survived Cooley. Thomas Louise He is 70 years, of almost wife by his he cherished. so family the in and trained, and worked with whom he with caregivers the he touched, lives and hearts the on in lives legacy His innovation. to surgical dedication and knowledge his from who benefited patients the and worldbut the of medicine TMCthe not only influence and Dr. Cooley able was to reach immeasurable. is work THI of the of the impact The 47 countries. in now practice trainees His fellows. Hands”—and 927 cardiovascular “Cooley the as residents—known surgery cardiothoracic 136 Dr. Cooley that educated Consider even larger. Yet, is story the APR 2017APR BULLETIN Dr. Cooley was predeceased Dr. Cooley predeceased was roles, many his Through American College of Surgeons of College American

♦

FROM DR. COOLEY’S PERSONAL ARCHIVE |

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2017_ED_PartnerACS_Ad_Bulletin_7.5x10.25in_v02.indd 1 3/14/2017 3:14:56 PM NEWS

Chapter news

by Luke Moreau and Brian Frankel

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Metropolitan Philadelphia Chapter: Winners of the Resident Jeopardy Tournament (front row, from left), Drs. Brady, Rivera, Nowak, Gianonne, and Hall. Back row, from left: Drs. Butcher, Kolff, and Johnson.

Pennsylvania competed for the in the 2017 tournament should Metropolitan Philadelphia trophy. Adam Johnson, MD, contact the MPACS staff office Chapter hosts second annual Chair of the chapter’s Resident at [email protected]. Resident Jeopardy Tournament Subcommittee, chaired the The Metropolitan Philadelphia Jeopardy Planning Committee. Chapter of the American College Jeffrey Butcher, MD, FACS, Connecticut Chapter sponsors of Surgeons (MPACS) held its Chapter President-Elect, served statewide ABSITE review course second Annual Resident Jeopardy as emcee, and Jeffrey Kolff, MD, The Residents’ Committee of Tournament on November 10, FACS, Chapter President, and the Connecticut Chapter of 2016. Approximately 60 fellows, Sameer Patel, MD, FACS, Chapter the ACS sponsored the first residents, and guests were in Secretary, were the official judges. statewide, daylong review session attendance to watch as resident The Philadelphia College of on January 7 to help prepare teams from Abington Health Osteopathic Medicine team was trainees to take the American Network, Thomas Jefferson the winner of the event. Team Board of Surgery In-Training University Hospital, Temple members included John Brady, Examination (ABSITE). The University Hospital, Einstein DO; James Gianonne, DO; Committee, chaired by Swathi Medical Center, Mercy Catholic Georgia Hall, DO; Natalie Nowak, Reddy, MD, a postgraduate Medical Center, Philadelphia DO; and Laura Rivera, DO. year (PGY)-2 resident at Yale College of Osteopathic Medicine, The 2017 Jeopardy Tournament School of Medicine, New Haven, Drexel University College of will take place November 9. comprises members from all Medicine, and University of Teams interested in competing six training programs in the

APR 2017 BULLETIN American College of Surgeons NEWS

Southern California Chapter: Dr. de Virgilio (left) with Dr. Rowe.

state: Yale University; Stamford goals and share common problems Non-Operative Management of Hospital; Waterbury Hospital; encountered during training. Acute Appendicitis: The Evidence Danbury Hospital; Saint Mary’s Based on feedback from the event, and Next Steps. Kathy Magliato, Hospital, Waterbury; and the the committee is working on MD, FACS, a cardiothoracic University of Connecticut, Storrs. organizing a regional Mock Orals surgeon at Providence Saint John’s The review was hosted by preparation program for 2018. Health Center, Santa Monica, Saint Mary’s Hospital, and surgical The Connecticut Chapter spoke to a sold-out audience at residents from all residency Residents’ Committee seeks the Women in Surgery luncheon. programs in the state were to improve inter-residency Her presentation, Leading with invited. Attending surgeons from communication, encourage Your Heart—Life Lessons in these institutions volunteered educational and research Leadership, was live streamed. their time to cover high-yield collaboration, encourage residents A highlight of the conference 76 | topics through interactive lectures. to become active members is the annual Surgical Jeopardy The speakers included ACS of surgical communities, and competition at the Annual Governor Philip Corvo, MD, engage in legislative advocacy. Scientific Meeting. For the second MA, FACS, chairman, Stanley J. year in a row, the team from Dudrick department of surgery the University of California, and director, surgical critical care, Southern California Irvine, represented by Sarath Saint Mary’s Hospital; Sajid Khan, Chapter hosts three-day Sujatha-Bhaskar, MD, general MD, FACS, assistant professor of conference in January surgery, and John Gahagan, surgery; Matthew O. Hubbard, The Southern California Chapter MD, general surgery, won the MD, MS, assistant professor of of the ACS (SCCACS) hosted competition. In this standing- surgery, Yale New Haven Hospital; its annual three-day Scientific room-only session, residency Scott H. Kurtzman, MD, FACS, Conference January 20–22. The programs in Southern California program director, general surgery conference, which attracted 420 compete for a coveted prize and residency program, and chairman, surgeons and residents, featured bragging rights. Previous winning department of surgery, Waterbury 40 plenary oral presentations, programs include Harbor- Hospital; and Sam Banerjee, MD, 19 oral poster presentations, UCLA; Kern Medical Center, FACS, a colon and rectal surgeon and nine subspecialty sessions. Bakersfield; and Cedars Sinai and clinical associate professor of Surgical residents from 12 Medical Center, Los Angeles. surgery, University of Connecticut. surgical training programs in In addition, the SCCACS Despite competing with 2017’s Southern California participated. announced newly elected officers first blizzard, 50 residents attended The meeting featured two during its annual membership the session and agreed it was well- invited speakers. Steven L. Lee, meeting January 21. Outgoing organized, efficient, and targeted MD, FACS, FAAP, professor of Chapter President Christian toward commonly tested topics clinical surgery and pediatrics de Virgilio, MD, FACS, led the and pitfalls. The event also offered and chief, pediatric surgery, meeting and announced the roster ample time for residents to meet Harbor-University of California, of new chapter officers: Vincent with their peers to discuss career Los Angeles (UCLA), presented Rowe, MD, FACS, President; Ninh

V102 No 4 BULLETIN American College of Surgeons NEWS

Greece Chapter: Professor Daikos (far right) is congratulated for his significant contribution to Greek-American medical education by (from left) K. Konstantinidis, MD, FACS, Honorary President, ACS-Greece Chapter; Dr. Linos, Governor; and Prof. A. Dimopoulos, MD, rector, National and Kapodistrian University of Athens.

Nguyen, MD, FACS, President- January 29. The keynote speaker Athens to New York, NY. While Elect; J. Craig Collins, MD, FACS, was the U.S. Ambassador to in Boston, Professor Daikos Vice-President; and Kenji Inaba, Greece, Geoffrey Pyatt. was introduced to the Harvard MD, FACS, Secretary/Treasurer. At the ceremony, Prof. George University postgraduate education L. Daikos, MD, professor of program by Panos Doukakis, MD, medicine and infectious disease, father of former Massachusetts U.S. Ambassador to National and Kapodistrian Gov. Michael Dukakis. ACS Greece speaks at chapter’s University of Athens, was Governor Dimitrios Linos, MD, annual dinner recognized for his contributions FACS, who hosted the event, The members and friends of to Greek-American medical and asked the members of the Greek- the Greece Chapter of the academic relationships. In 1949, American medical community ACS participated in their Prof. Daikos arrived in Boston, to continue the legacy and annual dinner in Athens on MA, after a 55-day boat trip from example of their elder leaders. ♦ | 77

Access new surgeon and resident well-being resources Personal and professional well-being are vital to the success of members of the American College of Surgeons (ACS) and your patients. Many health care professionals experience periods of distress, yet few physicians seek help. In an effort to provide relief to interested surgeons, the ACS has compiled several resources to support surgeons and residents as they confront the challenges associated with surgical care. One of these new resources is the Physician Well-Being Index. All U.S. Fellows and Associate Fellows in active practice, as well as Resident Members and Fellows in training, are invited to use this validated screening tool that provides an opportunity for you to better understand your overall well-being and identify areas of risk in comparison with physicians and residents across the nation. (Access for International Members is not yet available.) Local and national resources also will be tailored to you based on your results. The tool is completely anonymous. Your information and score is private, and your individual score will not be shared with anyone, including the ACS. Visit the ACS Surgeon Well-Being page at facs.org/burnout to learn more about the tool and how to access it, as well as to review other helpful resources. ♦

APR 2017 BULLETIN American College of Surgeons NEWS

Associate Fellows: Apply now for ACS Fellowship

Associate Fellows who are is limited to surgeons who have The application requests basic interested in pursuing the next been in practice less than six years. information regarding licensure, level of membership and who certification, education, and meet the criteria for Fellowship hospital affiliations. Applicants are encouraged to start the Requirements also are asked to provide the application process now. The basic requirements for names of five Fellows of the Applications for American Domestic (U.S. and Canada) College, preferably from their College of Surgeons (ACS) Fellowship are as follows: current practice location, to Fellowship for induction at the serve as references. Applicants 2018 Clinical Congress in Boston, • Certification by an appropriate do not need to request letters MA, are due December 1, 2017. American Board of Medical of recommendation; simply list ACS Fellowship is granted Specialties surgical specialty the names in your application, to physicians who devote their board, an American Osteopathic and the College staff will practice entirely to surgical Association surgical specialty contact your references. services and who agree to practice board, or the Royal College If you need assistance finding in accordance with the College’s of Surgeons in Canada ACS Fellows in your area, go professional and ethical standards. to facs.org and click on the The College’s Fellowship • One year of surgical practice “Find a Surgeon” button. 78 | Pledge and Statements on after the completion of all formal When your application is Principles, found on the ACS training (including fellowships) processed, you will receive an website at facs.org, outline the e-mail notification providing ACS standards of practice. All • A current appointment at details about the application ACS Fellows and applicants a primary hospital with no timeline along with a request for Fellowship are expected to reportable action pending for your surgical case list. adhere to these standards. All Fellowship applicants Surgeons voluntarily submit A full list of the domestic are required to participate in applications for Fellowship, requirements can be accessed a personal interview by an thereby inviting an evaluation at facs.org/member-services/ ACS committee in their local of their practice by their peers. join/fellows. The list of area. Exceptions are made for In evaluating the eligibility of requirements for International military applicants. Following Fellowship applicants, the College Fellowship is online at facs.org/ the interview, you will receive investigates each applicant’s entire member-services/join/international. notification by July 15 of the surgical practice. Applicants Associate Fellows who are action taken on your application. for Fellowship are required current with their membership Approved applicants are to provide to the appointed dues may apply online for free by designated as Initiates to be committees of the College all visiting facs.org/member-services/ inducted as Fellows during information deemed necessary for join and clicking on the link for the Convocation Ceremony the investigation and evaluation either Fellow or International at the Clinical Congress. of their surgical practice. Fellow. You will need your log- Contact Member Services It is our intention that all in information to access the with questions at any time Associate Fellows consider application. If you do not have throughout the application applying for Fellowship within your log-in information, contact process. We look forward to the first six years of their surgical the College’s Member Services you becoming a Fellow of the practice. To encourage that staff at 800-293-9623 or via e-mail American College of Surgeons. ♦ transition, Associate Fellowship at [email protected].

V102 No 4 BULLETIN American College of Surgeons NEWS

Capitol Hill lawmakers participate in bleeding control simulations Leaders of the American College of Surgeons aware of the importance of bleeding control. (ACS) and the ACS Committee on Trauma “Our Committee on Trauma is leading the (COT) hosted a congressional briefing to advancement in the care of the injured patient, highlight the ACS and Hartford Consensus and it’s important to see their message gaining bleeding control program. Special guests support on Capitol Hill,” Dr. Hoyt said. included Chairman of the Committee on Ronald Stewart, MD, FACS, Chairman Energy and Commerce Health Subcommittee of the ACS COT, spoke on the importance Rep. Michael Burgess, MD (R-TX), and ranking of this program and how events like the member Rep. Gene Green (D-TX), as well Capitol Hill simulation are increasing general as Reps. Richard Hudson (R-NC), and Bill awareness about bleeding control. “One of Flores (R-TX), members of the Committee on the most vital things we can do is make the Energy and Commerce. Lawmakers had the public aware of techniques to stop the bleed opportunity to participate in simulations on and to keep hosting bleeding control events how to treat multiple severe bleeding injuries. in our communities,” Dr. Stewart said. Just as individuals trained in cardiopulmonary Other COT representatives who led the resuscitation are better equipped to save heart simulations included Leonard J. Weireter, attack patients, civilians familiar with basic MD, FACS, Vice-Chair; Michael Coburn, MD, bleeding control techniques are better able to help FACS; Mark Gestring, MD, FACS; Robert people who have been traumatically injured in a Winchell, MD, FACS; Eileen Bulger, MD, FACS; mass casualty event. The College’s effort to make Ronald Simon, MD, FACS; and Brian Gavitt, this training available to the public is driven by MD, MPH, on behalf of the U.S. Air Force. | 79 the goal of reducing or eliminating preventable For more information on bleeding control, death from bleeding from traumatic injury. visit BleedingControl.org. To learn more about The ACS has been a long-standing champion trauma advocacy, contact Justin Rosen, of programs that improve the quality of health Congressional Lobbyist, ACS Division of care. ACS Executive Director David B. Hoyt, Advocacy and Health Policy, at [email protected]. ♦ MD, FACS, a trauma surgeon, is acutely

Coming next month in JACS, and online now

Public perceptions of overlapping surgery

Michael Kent, MD, FACS; Richard Whyte, MD, FACS; Aaron Fleishman; David Tomich, MD; Lachlan Forrow, MD; and James Rodrigue, PhD, found in their survey that a small minority of the general public is aware of the practice of overlapping surgery. The majority of responders were not supportive of the practice, although they would consider it acceptable in specific circumstances. However, responders consistently reported that the practice of overlapping surgery should be disclosed during the informed consent process. This article and all other JACS content is available at www.journalacs.org. ♦

APR 2017 BULLETIN American College of Surgeons MEETINGS CALENDAR

Calendar of events*

*Dates and locations subject to change. For more information on College events, visit facs.org/events or facs.org/member-services/chapters/meetings.

Northern California Chapter Michigan Chapter APRIL April 28–29 May 17–19 Berkeley, CA Boyne Falls, MI Alberta Chapter Contact: Christina McDevitt, Contact: Carrie Steffen, April 7–8 [email protected], www.nccacs.org [email protected], Edmonton, AB www.michiganacs.org Contact: Dr. John Kortbeek, [email protected] Illinois Chapter MAY May 18–20 Minnesota Surgical Society: Italy Chapter Champaign, IL A Chapter of the ACS May 4–5 Contact: Luann White, April 7–8 Catania, Sicily [email protected], Minneapolis, MN Contact: Dr. Antonio Di Cataldo, www.ilchapteracs.org Contact: Janna Pecquet, [email protected], www.facsitaly.org [email protected], Maine Chapter mnsurgicalsociety.org Chile Chapter May 19–21 May 7 Bar Harbor, ME Indiana Chapter Viña del Mar, Chile Contact: Gordon Smith, 80 | April 21–22 Contact: Dr. Owen Korn Bruzzone, [email protected], Indianapolis, IN Tel. +5 (622) 264-1878 www.mainefacs.org Contact: Tom Dixon, [email protected], Biennial Meeting of the Metro Philadelphia Chapter www.infacs.org Israeli Surgical Society May 22 May 9–11 Philadelphia, PA Japan Chapter Kfar Blum, Israel Contact: Lauren Newmaster, April 28 Contact: Dr. Joseph Klausner, [email protected] Yokohama, Japan [email protected] Contact: Dr. Kazuhiko Yoshida, [email protected] 2017 ACS Surgical Coding Workshop FUTURE CLINICAL Florida Chapter May 11–12 CONGRESSES April 28–29 Oakbrook, IL Orlando, FL Contact: Jan Nagle, [email protected] 2017 Contact: Stacy Manthos, October 22–26 [email protected] West Virginia Chapter San Diego, CA May 11–13 North Dakota and White Sulphur Springs, WV 2018 South Dakota Chapters Contact: Sharon Bartholomew, October 21–25 April 28–29 [email protected] Boston, MA West Fargo, ND Contact: Leann Benson, Ohio Chapter 2019 [email protected] May 12–13 October 27–31 Cleveland, OH San Francisco, CA Contact: Emily Maurer, [email protected], www.ohiofacs.org

V102 No 4 BULLETIN American College of Surgeons