MARCH 2017 | VOLUME 102 NUMBER 3 | AMERICAN COLLEGE of SURGEONS Bulletin Contents

MARCH 2017 | VOLUME 102 NUMBER 3 | AMERICAN COLLEGE OF SURGEONS Bulletin Contents

FEATURES COVER STORY: Evolving insights for preventing surgeon errors: Balancing professionalism and cognition with knowledge and skill 10 David H. Ballard, MD; Navdeep S. Samra, MD; and F. Dean Griffen, MD, FACS

Patient-reported outcomes in surgery: Listening to patients improves quality of care 19 Jason B. Liu, MD; Andrea L. Pusic, MD, MHS, FACS; Larissa K. Temple, MD, MSc, FACS; and Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS

Value-based health care: How to succeed in a bundled care APM 24 Daniel T. Engelman, MD, FACS

| 1

ADD YOUR VOICE GET NEWS to the mix as it happens! EXPERIENCE THE SPHERE OF SURGICAL 31.2K ACS Twitter BE PART INFLUENCE Followers of all @AmCollSurgeons ACS events

@AmCollSurgeons | @ACSTrauma | @RASACS

MAR 2017 BULLETIN American College of Surgeons

2017_Bulletin_HalfPageAd_Twitter_31.2K.indd 1 2/9/2017 1:37:15 PM Contents continued

COLUMNS ACS Foundation insights: Honoring Coming next month in JACS, mentors: An ACS tradition 41 and online now 52 Looking forward 8 Sarah B. Klein, MPA Post-election health policy David B. Hoyt, MD, FACS A look at The Joint Commission: takes center stage at AMA HOD Coding and practice management The Joint Commission clarifies meeting 53 corner: Coding for nipple-sparing stance on secure text messaging of John H. Armstrong, MD, FACS, and skin-sparing mastectomies 29 patient care orders 44 and Jon H. Sutton, MBA Eric Whitacre, MD, FACS; Carlos A. Pellegrini, MD, FACS, Megan McNally, MD, FACS; FRCSI(Hon), FRCS(Hon), SCHOLARSHIPS and Jan Nagle, MS, RPh FRCSEd(Hon) International Guest Scholar: ACS NSQIP best practices case NTDB data points: What you don’t Paving the way from studies: Practice changes for see can kill you 46 reconstructive to regenerative reducing UTIs in colon and rectal surgery 56 Richard J. Fantus, MD, FACS surgery patients 31 Naichen Cheng, MD, PhD Mary Ward, RN, and Deborah International scholarships Nagle, MD, FACS, FASCRS NEWS Children’s Surgery Verification for surgical education now ACS Clinical Research Program: program officially under way 48 available 62 2 | In search of the philosopher’s stone: ACS launches AHRQ Safety First ACS/ASBrS International The ALCHEMIST study for Scholar announced 63 lung cancer 37 Program for ERAS 50 ACS NSQIP conference gets new Apply for Claude H. Organ, Jr., MD, Nirmal Veeramachaneni, MD, FACS, Traveling Fellowship 63 FACS; Dennis Wigle, MD, FACS; name, expanded focus 51 and Judy C. Boughey, MD, FACS Register for 2017 ACS Residents as MEETINGS CALENDAR From the Archives: Celebrating the Teachers and Leaders Course 52 Calendar of events 64 sesquicentennial of Lord Joseph 22 cancer care facilities receive Lister 39 biannual CoC Outstanding Don K. Nakayama, MD, MBA, FACS Achievement Award 52

V102 No 3 BULLETIN American College of Surgeons The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an CLINICAL optimal and ethical practice environment. CONGRESS EDITOR-IN-CHIEF Letters to the Editor Diane Schneidman should be sent with the writer’s 2017 DIRECTOR, DIVISION OF name, address, INTEGRATED COMMUNICATIONS e-mail address, and Lynn Kahn daytime telephone OCTOBER 22–26 SENIOR EDITOR number via e-mail to SAN DIEGO CONVENTION CENTER Tony Peregrin dschneidman@facs. SAN DIEGO, CA 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 Join Us 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 in San Diego 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.

2017_CC_Bulletin_3.75x9.83in_v03.indd 1 2/22/2017 9:41:02 AM Officers and Staff of the American College of Surgeons

Timothy J. Eberlein, MD, FACS James W. Fleshman, Jr., Patrick V. Bailey, MD, FACS Officers St. Louis, MO MD, FACS, FASCRS Medical Director, Advocacy James K. Elsey, MD, FACS Dallas, TX Christian Shalgian Courtney M. Townsend, Atlanta, GA S. Robert Todd, MD, FACS, FCCM Director Jr., MD, FACS Houston, TX Galveston, TX Henri R. Ford, MD, FACS AMERICAN COLLEGE OF PRESIDENT Los Angeles, CA SURGEONS FOUNDATION J. David Richardson, MD, FACS Gerald M. Fried, MD, FACS, FRCSC Advisory Council Shane Hollett Louisville, KY Montreal, QC Executive Director IMMEDIATE PAST-PRESIDENT James W. Gigantelli, MD, FACS to the Board ALLIANCE/AMERICAN COLLEGE OF SURGEONS Hilary A. Sanfey, MB, Omaha, NE of Regents CLINICAL RESEARCH PROGRAM BCh, MHPE, FACS B. J. Hancock, MD, FACS, FRCSC (Past-Presidents) Kelly K. Hunt, MD, FACS Springfield, IL Winnipeg, MB Chair FIRST VICE-PRESIDENT Kathryn D. Anderson, MD, FACS Enrique Hernandez, MD, FACS Eastvale, CA CONVENTION AND MEETINGS Mary C. McCarthy, MD, FACS Philadelphia, PA Dayton, OH Robert Hope W. Gerald Austen, MD, FACS Director SECOND VICE-PRESIDENT Lenworth M. Jacobs, Jr., MD, FACS Boston, MA Hartford, CT DIVISION OF EDUCATION Edward E. Cornwell III, L. D. Britt, MD, MPH, MD, FACS, FCCM L. Scott Levin, MD, FACS Ajit K. Sachdeva, MD, FACS, FCCM FACS, FRCSC Washington, DC Philadelphia, PA Norfolk, VA SECRETARY Director Mark A. Malangoni, MD, FACS John L. Cameron, MD, FACS William G. Cioffi, Jr., MD, FACS Philadelphia, PA Baltimore, MD EXECUTIVE SERVICES Providence, RI Fabrizio Michelassi, MD, FACS Maxine Rogers TREASURER Edward M. Copeland III, MD, FACS Director, Leadership Operations New York, NY Gainesville, FL David B. Hoyt, MD, FACS FINANCE AND FACILITIES Chicago, IL Leigh A. Neumayer, MD, FACS A. Brent Eastman, MD, FACS Tucson, AZ Gay L. Vincent, CPA 4 | EXECUTIVE DIRECTOR Rancho Santa Fe, CA Director Gay L. Vincent, CPA Linda G. Phillips, MD, FACS Gerald B. Healy, MD, FACS Galveston, TX HUMAN RESOURCES Chicago, IL Wellesley, MA AND OPERATIONS CHIEF FINANCIAL OFFICER Marshall Z. Schwartz, MD, FACS R. Scott Jones, MD, FACS Michelle McGovern Philadelphia, PA Charlottesville, VA Director Anton N. Sidawy, MD, FACS Edward R. Laws, MD, FACS INFORMATION TECHNOLOGY Officers-Elect Washington, DC Boston, MA Brian Harper (take office October 2017) Beth H. Sutton, MD, FACS LaSalle D. Leffall, Jr., MD, FACS Interim Director Wichita Falls, TX Barbara L. Bass, MD, FACS Washington, DC DIVISION OF INTEGRATED Houston, TX Courtney M. Townsend, Jr., LaMar S. McGinnis, Jr., MD, FACS COMMUNICATIONS PRESIDENT-ELECT MD, FACS Atlanta, GA Lynn Kahn Galveston, TX Director Charles D. Mabry, MD, FACS David G. Murray, MD, FACS Pine Bluff, AR Steven D. Wexner, MD, FACS Syracuse, NY JOURNAL OF THE AMERICAN FIRST VICE-PRESIDENT-ELECT Weston, FL COLLEGE OF SURGEONS Patricia J. Numann, MD, FACS Timothy J. Eberlein, MD, FACS Basil A. Pruitt, Jr., MD, Syracuse, NY Editor-in-Chief FACS, FCCM, MCCM San Antonio, TX Board of Carlos A. Pellegrini, MD, FACS DIVISION OF MEMBER SERVICES SECOND VICE-PRESIDENT-ELECT Seattle, WA Patricia L. Turner, MD, FACS Governors/ Richard R. Sabo, MD, FACS Director Executive Bozeman, MT M. Margaret Knudson, MD, FACS Board of Regents Committee Seymour I. Schwartz, MD, FACS Medical Director, Military Health Rochester, NY Systems Strategic Partnership Michael J. Zinner, MD, FACS Diana L. Farmer, MD, FACS Boston, MA Frank C. Spencer, MD, FACS Girma Tefera, MD, FACS Sacramento, CA Director, Operation Giving Back CHAIR CHAIR New York, NY Leigh A. Neumayer, MD, FACS Steven C. Stain, MD, FACS Andrew L. Warshaw, MD, FACS PERFORMANCE IMPROVEMENT Tucson, AZ Albany, NY Boston, MA Will Chapleau, RN, EMT-P VICE-CHAIR VICE-CHAIR Director Anthony Atala, MD, FACS Susan K. Mosier, MD, MBA, FACS DIVISION OF RESEARCH AND Winston-Salem, NC Lawrence, KS Executive Staff OPTIMAL PATIENT CARE SECRETARY Clifford Y. Ko, MD, John L. D. Atkinson, MD, FACS EXECUTIVE DIRECTOR MS, MSHS, FACS Rochester, MN Daniel L. Dent, MD, FACS David B. Hoyt, MD, FACS Director James C. Denneny III, MD, FACS San Antonio, TX DIVISION OF ADVOCACY David P. Winchester, MD, FACS Alexandria, VA Francis D. Ferdinand, MD, FACS AND HEALTH POLICY Medical Director, Cancer Margaret M. Dunn, MD, FACS Wynnewood, PA Frank G. Opelka, MD, FACS Dayton, OH Medical Director, Quality Michael F. Rotondo, MD, FACS and Health Policy Medical Director, Trauma

V102 No 3 BULLETIN American College of Surgeons Author bios*

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

a b

c d e | 5

f g

DR. ARMSTRONG (a) is affiliate associate DR. BOUGHEY (c) is professor of surgery DR. FANTUS (f) is vice-chairman, professor of surgery, University of South and vice-chair of research, department department of surgery; medical director, Florida Morsani College of Medicine, and of surgery, Mayo Clinic, Rochester, MN. trauma services; and chief, section of surgical former Florida Surgeon General and Secretary She is Chair, ACS Clinical Research critical care, Advocate Illinois Masonic of Health (2012–2016). He is a member of the Program Education Committee. Medical Center. He is clinical professor of American College of Surgeons (ACS) Health surgery, University of Illinois College of Policy and Advocacy Group, and Past-Chair, DR. CHENG (d) is a plastic and Medicine, Chicago, and Past-Chair, ad hoc ACS Professional Association political reconstructive surgeon and clinical Trauma Registry Advisory Committee, action committee (ACSPA-SurgeonsPAC). associate professor, department of surgery, ACS Committee on Trauma (COT). National Taiwan University Hospital DR. BALLARD (b) is a radiology and College of Medicine, Taipei. DR. GRIFFEN (g) is professor of clinical resident, Mallinckrodt Institute of surgery and acting chairman, department Radiology–Washington University DR. ENGELMAN (e) is medical director, of surgery, Louisiana State University School of Medicine, St. Louis, MO. heart, vascular, and critical care services, Health Sciences Center, Shreveport. Baystate Medical Center, and associate professor of surgery, University of continued on next page Massachusetts Medical School–Baystate. He was the 2016 ACS/Society of Thoracic Surgeons Health Policy Scholar.

MAR 2017 BULLETIN American College of Surgeons Author bios continued

h i j

k l 6 |

m n o

MS. KLEIN (h) is Director, Donor DR. McNALLY (k) is a surgical oncologist, MS. NAGLE (m) is an independent consultant Relations and Communications, St. Luke’s Health System, Kansas City, MO, in Chicago, IL, who assists the ACS with CPT ACS Foundation, Chicago. and assistant clinical professor, department coding education and health data analyses. of surgery, University of Missouri-Kansas DR. KO (i) is Director, ACS National City School of Medicine. She is a member DR. NAKAYAMA (n) is adjunct professor, Surgical Quality Improvement Program of the ACS General Surgery Coding Florida International University, Herbert ® (ACS NSQIP ), and Director, ACS Division and Reimbursement Committee and Wertheim College of Medicine, Sacred of Research and Optimal Patient Care. ACS alternate advisor to the American Heart Medical Group, Pensacola. DR. LIU Medical Association Current Procedural DR. PELLEGRINI (j) is a general surgery resident, Terminology (AMA CPT) Editorial Panel. (o) is chief medical University of Chicago Hospitals, IL, and officer, UW Medicine, and vice-president for an ACS Clinical Scholar in Residence. DR. NAGLE (l) is assistant professor, medical affairs, University of Washington, Harvard Medical School, Boston, MA. Seattle. He is a Past-President of the ACS. continued on next page

V102 No 3 BULLETIN American College of Surgeons Author bios continued

p q r

s t | 7

u v w

DR. PUSIC (p) is a plastic surgeon, DR. TEMPLE (s) is professor of surgery DR. WHITACRE (v) is a breast surgeon in Memorial Sloan Kettering Cancer and chief, division of colorectal surgery, Tucson, AZ, and the American Society of Center, New York, NY. University of Rochester Medical Center, NY. Breast Surgeons’ advisor to the ACS General Surgery Coding and Reimbursement DR. SAMRA (q) is assistant professor DR. VEERAMACHANENI (t) is a Committee and to the AMA Relative Value of surgery and assistant program thoracic surgeon and medical director Scale Update Committee. He is alternate director, division of trauma and critical of thoracic surgery, University of advisor to the AMA CPT Editorial Panel care surgery, department of surgery, Kansas Hospital, Kansas City. and a member of the National Quality Louisiana State University Health MS. WARD Forum’s convened Measure Applications Sciences Center, Shreveport. (u) is quality improvement Partnership Clinician Workgroup. specialist, Beth Israel Deaconess MR. SUTTON (r) is Manager, State Medical Center, Boston, MA. DR. WIGLE (w) is professor of surgery, chair Affairs, ACS Division of Advocacy and of division of thoracic surgery, department Health Policy, Washington, DC. of surgery, Mayo Clinic, Rochester.

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

Looking forward

by David B. Hoyt, MD, FACS

opping the agenda of the new presidential admin- Past-President, has noted, “There is no quality with- istration and Congress is repeal of at least some out access.” It is essential that reforms lead to health Tportions of the Affordable Care Act (ACA). Many care coverage that is more accessible and more afford- Fellows of the American College of Surgeons (ACS) able for all Americans. The ACA has led to an increase have expressed concerns about the potential conse- in the number of people who have health insurance quences of this effort, particularly if Congress passes coverage. We should seek to sustain these gains and replacement policies that have not been thoughtfully expand upon them through the development of articulated and debated. more affordable alternatives. One of the common The ACS intends to play an active role in what is cer- criticisms of the ACA is that low-income Americans tain to be a highly charged debate—just as we did when cannot afford to pay the rising premiums. We cannot the ACA was under consideration. As we enter this dis- allow new coverage paradigms to threaten access to cussion, we will advocate for the policies that we believe surgical care for at-risk populations. will have the greatest benefit toward ensuring that all The ACS has a long-standing policy of supporting surgical patients have access to necessary services. We universal access to affordable, high-quality surgical will not be swayed by politics, but rather will promote care delivered in a timely and appropriate manner. our enduring principles of meaningful change: quality To achieve this goal, the nation must have a well- and safety, patient access to surgical care, reduction of trained surgical workforce that can meet the needs 8 | health care costs, and medical liability reform. of all surgical patients. The ACS maintains that any health care reform plan should call upon the health insurance industry to address issues of cost contain- Quality and safety ment, coverage for low-income patients and those with The ACS maintains that quality improvement and pre-existing medical conditions, and administrative patient safety efforts should be at the heart of health burdens for providers. care reform. In our advocacy efforts, we will explain how the ACS uses a multifaceted approach to enhance quality and safety in health care worldwide. This Reduction of health care costs process involves four steps: setting standards, build- ACS Quality Programs, such as the ACS National Sur- ing the infrastructure necessary to comply with the gical Quality Improvement Program, the Trauma standards, using clinical registries to measure perfor- Quality Improvement Program, the Cancer Quality mance and guide improvement, and instituting peer Improvement Program, and so on, lead to higher qual- review processes to verify adherence to evidence- ity care and cost savings by preventing inefficiencies based standards. and complications. Consequently, the College will To promote quality improvement and patient advocate for continued payment reforms that pro- safety, the College supports legislation and policies that mote participation in quality improvement efforts, advance well-designed clinical comparative effective- including the development and testing of Advanced ness research, the analysis of physician quality data, Alternative Payment Models (APMs). APMs should appropriate public reporting, and the use and adoption ensure a sustainable workforce by providing fair and of health information technology. appropriate reimbursement for surgeons (see related article, page 24). Cost containment should be linked to improvement in care. If implemented, participa- Patient access to surgical care tion should be voluntary, nonpunitive, and allow As L. D. Britt, MD, MPH, DSc(Hon), FACS, access to a range of providers. FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), In addition, the ACS maintains that Congress FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), ACS should retain primary responsibility for setting

V102 No 3 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

As we enter this discussion, we will advocate for the policies that we believe will have the greatest benefit toward ensuring that all surgical patients have access to necessary services.

Medicare payment policy. This task should not be In these exchanges, the College will be direct but delegated to an unelected government body that civil and will be prepared to offer alternatives that we accepts minimal input from patients and other believe will serve the interests of surgical patients. stakeholders. No doubt, there will be—and, in fact, should be— disagreement. A certain amount of conflict and ten- sion is necessary to stimulate change and growth. Medical liability reform However, we cannot allow these discussions to dete- The mission of the ACS is to improve the care of the riorate into discord and division. surgical patient, safeguard standards of care, and For more than 100 years, Fellows of the ACS have create an ethical practice environment. The Col- been committed to serving all patients with skill and lege believes the nation’s medical liability system fidelity. Throughout our history, we have engaged | 9 is broken and that it fails both patients and physi- with state and federal lawmakers on both sides of the cians. Whereas liability reforms enacted at the state aisle to advocate for the profession and our patients. level have effectively reduced health care costs and The ACS leadership looks forward to a thoughtful improved access to care, the College will advocate reevaluation of the health care system in the months for reforms aimed at fostering safety, quality, and and years ahead. ♦ accountability; traditional tort reforms, including caps on noneconomic damages; and alternative, patient-centered reforms, such as early disclosure and offer programs, communication and resolution programs, and safe harbor protections.

Strategy going forward We are living in an era of political polarization, and health care reform certainly has been one of the most divisive issues for a number of years. As a professional organization dedicated to providing surgical patients with optimal care, it behooves the College to play a part in this round of the debate. We will urge Congress to take the College’s general principles into account as members develop a clear strategy for reforming the current policies. The ACS also will encourage legislators to provide opportunities for patients, health care professionals, and other key stakeholders to assess new proposals and to share If you have comments or suggestions about this or other issues, please their views on the best path forward. send them to Dr. Hoyt at [email protected].

MAR 2017 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

Evolving insights for preventing surgeon errors: Balancing professionalism and cognition

10 | with knowledge and skill

by David H. Ballard, MD; Navdeep S. Samra, MD; and F. Dean Griffen, MD, FACS

V102 No 3 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

prevent them were obvious and had been previously 5-8 HIGHLIGHTS reported. Since then, more complex insights have evolved. The purpose of this review is to amalgamate • Clarifies the causes of technical errors information gained over time and to provide sugges- • Describes how cognition and self-reflection tions on how we can prevent errors based on what we affect performance and outcomes have learned. • Explains how the systems in which surgeons provide care can affect the likelihood of error Technical errors • Provides a sample case of how behavioral Technical errors are common. However, these errors factors likely contributed to an adverse event are rarely the result of deficient technical skill. In a 1999 report, researchers at the Harvard School of Public Health and at Harvard’s Brigham and Women’s Hospi- tal, Boston, MA, collected data from closed claims that rrors that lead to adverse events occur in 2.9 per- confirmed the importance of technical competence in cent to 3.7 percent of hospital admissions, and the prevention of errors and that technical skill was a more than half of the adverse events that occur small part of technical competence.3 E 1-3 in surgical patients involve errors. The Institute of In 2007, the ACS Closed Claims Study reported data Medicine—now the National Academy of Medicine collected from closed claims and found that technical | 11 (NAM)—began its study of adverse events as the data errors occurred in 229 of 460 liability claims.5 How- accrued and discovered the surprising prevalence of ever, the surgeon reviewers found technical skill clearly errors. The NAM published its first report, To Err Is deficient in only 11 percent of these cases. All of these Human: Building a Safer Health System, in 1999.4 Ini- cases involved scope-of-practice issues. Admittedly, it tially, surgeons were skeptical of the findings in the was impossible to judge the surgeons’ technical skills report but gradually embraced the reality that errors in 46 percent of cases involving technical errors. For were a critical factor in complications and poor out- these claims, the reviewers either did not have access comes. This realization led the American College to information regarding the frequency of technical of Surgeons (ACS) and the surgical community as failure in a given surgeon’s experience with a specific a whole to begin studying surgical errors and to procedure or could not clearly determine the degree identify ways to broaden and improve the focus of to which confounding circumstances contributed to surgical education. the error. As a first step in examining adverse events, the Determining the technical skill of a surgeon requires ACS and other stakeholders began investigating the knowledge of the frequency of errors, not the presence causes of surgical errors. Because errors rarely were of errors. Furthermore, technical skill only can be mea- reported, the only source of information was closed sured correctly when the circumstances—systematic liability claims. Surgeons had always assumed that factors—surrounding a physician’s performance are surgical errors were largely the result of insuffi- taken into account. Our innate human limitations may cient technical skill or medical knowledge; however, lead to errors during the simplest procedures, and con- data from closed claims against surgeons indicated founding circumstances, such as peritonitis, obesity, that there were other critically important factors equipment failures, deficits in the institution’s culture, involved.5-8 This revelation has empowered the sur- dense adhesions, and anatomic enigmas, decrease the gical community to develop strategies to enhance likelihood of positive outcomes. error prevention and to improve outcomes. Even so, errors caused by the failure to stay within In the process of seeking the causes of surgical our scope of practice are unacceptable. The ACS study errors, some of the preventive measures employed to revealed scope-of-practice problems in several areas:

MAR 2017 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

• Failure to refer cases that require services outside of a surgeon’s areas of expertise TABLE 1. • Failure to consult intraoperatively when a case unexpect- ACS CLOSED CLAIMS STUDY: BEHAVIORAL FAILURES edly deviates from a surgeon’s area of expertise

Types of • Failure to refer cases to a tertiary care facility when behavioral failures n (Percentage) institutional ancillary care needs cannot be met within a Communicate with surgeon’s work environment 157 (34) patient and/or family Pursue an abnormal • Failure of attendings to provide proctoring for trainees or 117 (25) symptom or test result trainee failure to request attending supervision Pursue a postoperative 115 (25) problem • Failure of aging surgeons to scale back their scope of Assess surgical problem practice 87 (19) before surgery Enlist the support of • Failure of surgeons to properly introduce new technolo- 5 (14) proper consultant gies into practice due to inadequate training or proctoring 12 | See patient in a 60 (13) timely fashion Surgeons should realize that staying within their Cross coverage or scope of practice can minimize technical errors, reduce 54 (12) continuity of care issues complications, and improve outcomes. Communicate with 46 (10) consultants Errors and professional behavior Stay within proper 44 (10) scope of practice Behavioral traits such as diligence, tenacity, and vig- ilance affect patient care. The ACS Closed Claims Assess comorbidities 26 (6) before surgery Study identified behavioral violations in 78 percent of cases in which an error occurred, including inad- Follow patient long 29 (6) enough postoperatively equate communication with the patient and family and failure to pursue a postoperative problem (see Check test results 24 (5) Table 1, this page). Maintain other 62 (14) Reviewers were required to distinguish between practice patterns behavioral diligence and behavioral skill. For example, At least one failed 360 (78) some surgeons have excellent communication skills; practice pattern others rely more on diligence. The Accreditation Coun- Total number of cases 460 (100)* cil for Graduate Medical Education (ACGME) includes *Percentages sum to greater than 100 percent because “interpersonal and communication skills” among six reviewers could indicate more than one flaw per case. core competencies that physicians should master in training. Nonetheless, surgeon-reviewers found that Adapted from Griffen FD, Stephens LS, Alexander, JB, et al. lack of diligence and insufficient time, rather than Violations of behavioral practices revealed in closed claims lack of behavioral skill, resulted in most of these com- reviews. Ann Surg. 2008;248(3):468-474. Used with permission. munications deficiencies. In other words, most of the surgeons possessed what behavioral scientists call “behavioral capability” but did not always exercise it.9

V102 No 3 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

TABLE 2. ACS CLOSED CLAIMS STUDY: DAMAGING EVENTS WITH AND WITHOUT BEHAVIORAL FAILURES

No violations One or more violations in behavior in behavior Occurrence of damaging event n = 100 (Percentage) n = 360 (Percentage) p-value* Any diagnostic error 31 (31) 219 (61) 0.00 Delay in diagnosis 16 (16) 109 (30) 0.01 Failure to diagnose 10 (10) 90 (25) 0.00 Failure to perform diagnostic tests 5 (5) 62 (17) 0.01 Misdiagnosis 2 (2) 11 (3) 0.57 Other diagnostic events 3 (3) 33 (9) 0.04 Any treatment error 93 (93) 341 (95) 0.51 Technical error during surgery 56 (56) 173 (48) 0.16 Delayed treatment 21 (21) 141 (39) 0.00 Failure to treat 6 (6) 55 (15) 0.02 Wrong treatment 3 (3) 40 (11) 0.02 Unnecessary surgery 1 (1) 15 (4) 0.13 Failure to stay within scope of practice 0 (0) 9 (3) 0.11 Other treatment events 21 (21) 68 (19) 0.64

*p-value is based on chi-square test. †There were no significant differences between those with or without practice pattern violations by sex, wound class, functional health status, or known comorbidities. | 13

Adapted from Griffen FD, Stephens LS, Alexander, JB, et al. Violations of behavioral practices revealed in closed claims reviews. Ann Surg. 2008;248(3):468-474. Used with permission.

One review of closed claims in New York State found treatment was not statistically related to behavioral communication barriers in 24 percent of the 178 cases.10 failures. This finding is to be expected since, unlike the The relationship between behavior and knowledge treatment category, diagnostic errors do not include the is complex. The following behavioral aspects of patient element of technical skill. However, when data related care typically involve a degree of medical knowledge: to the preventability of complications and technical failure to pursue an abnormal symptom or test result, errors are compiled, the profound significance of behav- failure to pursue a postoperative problem, failure to ior among these claims is revealed (see Table 3, page 14). assess a surgical problem before surgery, and failure to Hence, when a technical error occurred in the presence assess comorbidities before surgery. Even so, the ACS of a behavioral violation, complications and their con- Closed Claims Study found that, in most cases, while sequences were markedly escalated. surgeons possessed the required knowledge, they failed Because behavioral failures do not always lead to to apply it.6 If knowledge was lacking, the behavioral errors, surgeons sometimes fail to grasp their signif- failure to stay within a proper scope of practice or the icance. Behavior is determined by its consequences. failure to enlist the support of a qualified consultant Surgeons continue to violate good behavioral practices still placed the errors within the realm of behavioral in the care of patients because errors resulting from bad deficiencies. behavior occur infrequently enough that their signifi- Behavioral failures led to a marked increase in the cance is overlooked. In addition to surgeons’ failure incidence of diagnosis-related errors, including failure to recognize the consequences of negative profes- to diagnose, delayed diagnosis, and failure to perform sional behavior, surgeons are vulnerable to behavioral diagnostic tests (see Table 2, this page). violations because we are overworked. Because Behavioral deficiencies also caused frequent treat- reimbursement rates are low, surgeons often have a ment errors. However, the incidence of errors in financial incentive to work longer or additional shifts.

MAR 2017 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

TABLE 3. ACS CLOSED CLAIMS STUDY: PREVENTABILITY OF COMPLICATION BY OCCURRENCE OF TECHNICAL ERROR AND BEHAVIOR VIOLATIONS, N (%)

Behavior No behavior violations occur violations occur Preventability of complication n = 360 n = 100 Row total When technical error occurs* n = 173 n = 56 n = 229 Preventable 134 (78) 25 (45) 159 (69) Not preventable 6 (4) 19 (34) 25 (11) Impossible to judge 33 (19) 12 (21) 45 (20) When no technical error occurs† n = 187 n = 44 n = 231 Preventable 76 (41) 0 (0) 76 (33) Not preventable 28 (15) 34 (77) 62 (27) Impossible to judge 83 (44) 10 (23) 93 (40)

*Chi-square = 42.635, df = 2 (p < 0.000). †Chi-square = 73.540, df = 2 (p < 0.000).

Adapted from Griffen FD, Stephens LS, Alexander, JB, et al. Violations of behavioral practices revealed in closed claims reviews. Ann Surg. 2008;248(3):468-474. Used with permission.

Another factor contributing to the tendency of sur- the surgeon reviewers who collected information for geons to overwork is the workforce shortage. Heavy the ACS Closed Claims Study reported a complex rela- 14 | caseloads may make it difficult to find time for atten- tionship between medical knowledge, behavior, and tion to the behavioral elements of care. Combine this cognition, although no specific data were collected.6 lack of opportunity for self-reflection with a failure to Other researchers have estimated that 80 percent of grasp the profound significance of our behavior, and misdiagnoses stem from cognitive errors.4 Although errors are the inevitable result. We stop communicat- difficult to measure, it is clear that cognitive errors are ing. We examine images instead of patients, focusing all common and frequently have disastrous results. too often on incidental imaging or lab findings instead Taking time to think is an aspect of diligent behav- of patient complaints. We make decisions on the basis ior; having the cognitive ability with which to think of numbers on a monitor reported to us by surrogates also is important. However, these qualities are not without the benefit of clinical correlation. We proceed mutually exclusive; cognitive diligence and cognitive without taking time for necessary forethought. skill are both necessary to minimize errors. Good professional behavior enhances a surgeon’s In How Doctors Think, Jerome Groopman, MD, clar- knowledge base and technical skill and helps him or ifies the complex interaction between thinking and her avoid errors and achieve the best possible outcomes. knowledge.11 The ability to recognize when we do not Especially when we are overworked and fatigued, know something can be used to prompt skillful think- we must slow down in order to accomplish ordinary ing. Realizing that what we know is based only on a tasks. Medical knowledge should be adequate if we modest level of understanding, we learn to thoughtfully work within a proper scope of practice, take the neces- challenge what we think we know when it is ques- sary time to seek and find additional information when tioned or when facts and data do not fit that piece of needed, and consult as appropriate. knowledge. Clinical certainty on the part of a surgeon can sometimes stymie meaningful thinking when it is used defensively to hide uncertainty. Uncertainty can Errors and cognitive skills be helpful and lead to reflective cognition, which is a In the Harvard medical practice study cited previously, tool for dealing with the care of a patient that involves mistakes in judgment were observed in 169 of the 258 conflicting facts or data. claims that resulted from errors, but the investigators Dr. Groopman defines several types of cognitive made no specific reference to cognition.8 However, mistakes that lead to medical errors. He illustrates these

V102 No 3 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

types of errors using real cases from his personal expe- that tend toward one extreme or the other, which may rience as a medical oncologist. For example, he defines lead to cognitive errors. Subconsciously, data and facts an availability error as a cognitive mistake resulting in may be preferentially selected to confirm a plan of care a faulty decision that is based on the ease with which a in keeping with the surgeon’s personality. These cog- relevant example comes to mind.11 For example, expe- nitive errors occur because of confirmatory bias and rienced surgeons may think the common bile duct is are preventable only if surgeons recognize these ten- the cystic duct because it looks like the last 100 cystic dencies and consciously avoid this type of cognitive ducts they have seen. mistake. For example, overly aggressive, over-confident Lawrence Way, MD, FACS, has demonstrated the surgeons must recognize when plans for antrectomy concept of illusions as causes of cognitive errors that should be abandoned in favor of pyloroplasty to prevent lead to adverse technical events.12 We suffer from the the risk of duodenal stump leak or bile duct injury in illusion that what we see is the cystic duct, causing us the face of a technically challenging penetrating duo- to injure the common bile duct and/or the common denal ulcer. Overly reticent surgeons who fear failure hepatic duct, all because we made an availability must continue with pancreatoduodenectomy instead error—a cognitive mistake. We make these errors in of choosing a bypass procedure that denies the patient haste, trying to save time, when, in fact, preventing the a reasonable chance for cure. consequences of flawed cognition by thinking skillfully Dr. Groopman also observed that some mistakes is a bigger and more effective time-saver. To think that are caused by franchise errors, which are based on the what you see is possibly an illusion unless your dissec- idea that “whom you see is what you get.”11 If you see | 15 tion has established the critical view of safety requires a surgeon for gastroesophageal reflux disease, you get no more than an instant. a laparoscopic fundoplication; if you see an internist, Sometimes we make poor decisions based on affec- you get medical management. This situation, which tive errors in cognition. These errors result from a is associated with confirmatory bias, becomes fraught decision based on what we wish to be true. Surgeons with medical errors. For example, a general surgeon often de-emphasize that which they fear. For example, seeing a patient with back pain and an umbilical hernia a surgeon will choose to think that a postoperative may preferentially select facts and data, repairing the patient’s fever and distention are due to atelectasis and hernia and ignoring the back pain. Two months later, ileus, when in reality a leaking anastomosis or intra- the patient presents to the emergency department with abdominal abscess has not been ruled out. Delayed a ruptured abdominal aortic aneurysm. diagnosis and treatment of complications frequently Search satisfaction errors occur when we fall prey stem from cognitive mistakes classified as affective to the natural tendency to stop searching and thinking errors. In these circumstances, a surgeon’s medical after making a major finding. For example, a surgeon knowledge is not applied sufficiently because of a cog- seeing a patient with left-sided abdominal pain finds a nitive error stemming from fear that proper evaluation small left inguinal hernia. Additional history of rectal will reveal a technical failure. Since this and other simi- bleeding is missed. The hernia is skillfully repaired, lar clinical patterns are often self-limiting, we do not the sutures are removed, and the patient is released. easily learn that we must always think in terms of the The pain and bleeding continue, the patient sees a worst clinical scenario to achieve the best outcomes. different physician, and colonoscopy reveals sigmoid carcinoma. A surgeon’s biases toward a patient’s culture, reli- Aggressive versus restrained behavior gion, socioeconomic status, or sexual orientation also If one thinks in terms of a bell-shaped curve, many may affect patient care. One study of physician-patient surgeons in the middle portion of the curve can walk encounters queried data from 193 physicians with 618 the line between care that is too aggressive and care patient encounters. The study found that physicians that is too restrained. Others of us have personalities had more negative perceptions of African-American

MAR 2017 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

In addition to accepting individual responsibility for the care we provide, we must also be aware of, and participate in, systems of care. Systems of care are designed to protect us from error, not to shelter us from accountability.

and low-income patients than of Caucasian and/or factors such as the complexities of the primary surgi- upper socioeconomic status patients.13 cal illnesses and comorbidities. In summary, both diligently taking time to think Peer review is a critical part of identifying the and skillful thinking are required to prevent cognitive underlying cause of a negative outcome or near miss. errors that often lead to preventable adverse events. These events are rarely the result of a single error. Even Our tendency to attribute these errors in thinking to though a surgeon errs at the point of service, closed a lack of technical skill or medical knowledge thwarts claims reviews and NAM reports have shown that the our ability to learn from our cognitive mistakes. root cause of many surgical errors is systems failure.1 One group found that 69 percent of errors are caused at least in part by systematic breaches.8 But it is not a trade- Systems affect quality of care off; systems help us succeed, and surgeon performance Surgeons work at the point of service. The quality is essential for the success of systems. For example, of the care we provide is only partly determined by when surgeons fail to use an institutional protocol for our surgical knowledge, technical skill, professional deep vein thrombosis prophylaxis, the system fails. Sur- behavior, and cognition. The other important deter- geons must be held accountable as individuals to work 16 | minants of quality are systems factors—elements of within the system.14 To enhance the reporting of errors, care that involve relationships between individuals, peer review systems are largely non-punitive, but this their tools, and the environment in which they work.8 lack of penalization should not mitigate accountabil- In the Harvard medical practice study, systems failure ity for failing to participate in systems of care. Recall contributed to errors in 82 percent of the 258 claims the ACGME’s sixth core competency: Be aware of and involving patient injury. respond to systems-based practice. In some cases, these systems closely aligned with One strategy to improve systems of care may be to the care we provide. The systems in which surgeons use checklists. A standard surgical checklist, the Surgi- practice affect the quality of mechanical equipment, cal Patient Safety System (SURPASS), was implemented devices, and surgical instruments. They also affect in six hospitals and showed a significant reduction in institutional requirements for marking a surgical site complication rates.15 Reviewing cases performed with- and prompts for ordering prophylactic anticoagulants out a checklist, another study of 294 claims identified and antibiotics. Other systems factors are more diffi- 412 contributing factors and concluded that SURPASS cult to associate with errors because they are remote likely would have prevented 29 percent of the errors to adverse events in time and place. These include identified.16 decisions at the administrative level, such as a chief In addition to accepting individual responsibility financial officer’s decision for or against participation for the care we provide, we must also be aware of, in the ACS National Surgical Quality Improvement and participate in, systems of care. Systems of care are Program (ACS NSQIP®), or at the medical staff level, designed to protect us from error, not to shelter us from such as the rules set forth by the credentials committee accountability. for safely introducing new technologies into surgical practice. Human factors also include a health care institution’s policies regarding “as needed” nurses and Sample case study nurse-to-patient ratios. Even the attitudes and knowl- The following sample case illustrates many of the edge of personnel at all levels are human factors among causes of medical errors and the complex interac- these systems that affect our ability to avoid errors at tions that make it difficult to identify the true causes the point of service. Also included are patient-related of surgeon failures.

V102 No 3 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

An otherwise healthy adult patient presented to the Gastrografin study revealed extravasation of contrast emergency department (ED) with left lower quadrant into the left lower quadrant, and a computed tomogra- pain, which had gradually increased over a two-day phy scan showed a large amount of free air throughout period, and mild nausea. The patient’s temperature the abdomen. The patient was admitted and treated was 100 degrees, and the physical exam was nega- with antibiotics and intravenous fluids. tive except for lower abdominal rebound tenderness On rounds the next morning, the findings were and guarding. Lab assessment was normal except for unchanged, but later that evening, pain increased, blood a white blood cell (WBC) count of 14,000 with a left pressure dropped to 90/60, and the pulse increased to shift. An abdominal and pelvic computed tomography 140. Oxygen saturation was 92 percent on room air. scan revealed sigmoid diverticulitis. The patient was The surgeon was called, a fluid bolus and pressors admitted, responded to antibiotics, and discharged five were given, and the patient was taken to the operat- days later. ing room. A Hartmann’s procedure was performed A month later, a colonoscopy revealed only diver- for a leaked anastomosis. In the operative note, the ticular disease. During the next six months, two more possibility that the circular stapling device may have attacks occurred that were somewhat milder but that misfired was mentioned. required outpatient antibiotics; a laparoscopic anterior Multi-organ system failure ensued. Three months resection was performed. later, after several more procedures for intra-abdominal When the stapled anastomosis was checked intra- abscesses, the patient was released from rehab with operatively with transrectal air, some air bubbles a granulating abdominal wound, loss of mental | 17 were noted. However, ongoing attempts to identify capacities, amputation of several digits, a healing tra- additional bubbles revealed none. It was decided to cheostomy site, and a colostomy. accept the anastomosis as intact without further This case involved a leaked anastomosis—a known, exploration. albeit infrequent, complication of anterior resection The patient did well initially. However, on the even in the hands of experienced, skillful surgeons. fourth postoperative day, the patient complained of Having documented favorable prior experience with mild lower abdominal pain. The patient’s tempera- laparoscopy and the double-stapling technique, the ture was normal and tenderness was compatible with primary surgeon’s technical skills and scope of prac- postoperative expectations. The WBC count was stable tice were validated. at 9,000. Because the surgeon was looking forward to Although brought into question, systems failure beginning a long weekend off and the patient was related to a failed stapling device was never proven. eager to go home, a hasty generic handoff between Systems-related problems beyond our control often the primary surgeon and call partner included plans are sought to explain failures and avoid personal for discharge on afternoon rounds. responsibility. That evening the call partner was busy and late for An intraoperative cognitive error may have rounds. The patient wanted to go home. Finally, at the occurred: Was it a false hypothesis error to conclude request of the patient, the surgeon was called. Happy that the air bubbles were trapped air, and should the to have one less patient to see, the call partner autho- procedure have been converted to open? In any case, rized discharge by verbal order. the team was diligent, making ongoing efforts to dem- The next evening, the patient presented in the ED onstrate additional bubbles, which failed and led to an with moderately severe generalized abdominal pain informed but possibly incorrect decision to complete that had increased throughout the day. The abdo- the procedure laparoscopically. Failing to think is unac- men was moderately tender with mild rebound in all ceptable; failing to think accurately is human. quadrants but worse in the left lower quadrant. Blood The clearly preventable errors that followed were pressure was 140/80, pulse was 96, and temperature was caused by behavioral and cognitive deficiencies. Dili- 99 degrees; the WBC count was 12,000. A transrectal gent professional behavior required that the call partner

MAR 2017 BULLETIN American College of Surgeons PREVENTING SURGEON ERRORS

see the patient prior to discharge. This behavioral REFERENCES deficiency may not have occurred if the handoff had 1. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and been more comprehensive. Regardless of the quality types of adverse events and negligent care in Utah and of the handoff, and even if the findings at the bedside Colorado. Med Care. 2000;38(3):261-271. led to discharge, diligent behavior required a clinical 2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse assessment. This exemplifies how so often more than events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370- one part of a system has to fail before an error lead- 376. ing to injury occurs. It also emphasizes the surgeon’s 3. Gawande AA, Thomas EJ, Zinner MJ, et al. The incidence critical place within systems of care. and nature of adverse events in Colorado and Utah in 1992. The on-call surgeon made additional behav- Surgery. 1999;126(1):66-75. ioral errors in the ED, including failure to pursue 4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Committee on Quality of an abnormal test and failure to cross-cover and pro- Health Care in America, Institute of Medicine. Washington, vide continuity of care. These breakdowns may have DC: National Academy Press; 2000. been caused by fatigue while taking weekend call. 5. Griffen FD, Stephens LS, Alexander JB, et al. The American Alternatively, and more incriminating, the behavior College of Surgeons’ Closed Claims Study: New insights for may have resulted from the fact that the patient did improving care. J Am Coll Surg. 2007;204(4):561-569. 6. Griffen FD, Stephens LS, Alexander JB, et al. Violations of not “belong” to the call partner. behavioral practices revealed in closed claims reviews. Ann Human factors like fatigue, attitude, and com- Surg. 2008;248(3):468-474. 18 | peting priorities can affect cognition and behavior. 7. Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns The surgeon cherry-picked the available data, favor- of technical error among surgical malpractice claims: An ing the patient’s relatively mild subjective clinical analysis of strategies to prevent injury to surgical patients. Ann Surg. 2007;246(5):705-711. presentation—99 degree temperature, moderate 8. Rogers SO, Gawande AA, Kwaan M, et al. Analysis of pain and tenderness, satisfactory blood pressure and surgical errors in closed malpractice claims at 4 liability pulse, minimal elevation of the WBC count—over insurers. Surgery. 2006;140(1):25-33. the objective findings of excessive free air and leak- 9. Bandura A. Social cognitive theory: An agentive perspective. ing contrast. The delay in treatment led to organ Ann Rev of Psych. 2001;52:1-26. 10. Zenilman JC, Haskel MA, McCabe J, Zenilman ME. Closed system failure and the dramatic escalation of the claim review from a single carrier in New York: The real consequences of the anastomotic leak. As is so often costs of malpractice in surgery and factors that determine the case, the technical error alone might have been outcomes. Am J Surg. 2012;203(6):733-740. effectively managed with acceptable temporary, albeit 11. Groopman J. How Doctors Think. Boston, MA: Houghton significant, consequences, but adding behavioral vio- Mifflin Company; 2007. 12. Way LW, Stewart L, Gantert W, et al. Causes and prevention lations and cognitive mistakes stemming from lack of of laparoscopic bile duct injuries: Analysis of 252 cases from diligence as second, third, and fourth errors created a human factors and cognitive psychology perspective. Ann an unacceptable perfect storm. Surg. 2003;237(4):460-468. 13. van Ryn M, Burke J. The effect of patient race and socioeconomic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50(6):813-828. Conclusion 14. Wachter RM, Pronovost PJ. Balancing “no blame” Surgeons are subject to fatigue, distractions, time with accountability in patient safety. N Engl J Med. constraints, competing priorities, workload, burnout, 2009;361(14):1401-1406. and other factors that occasionally affect our pro- 15. de Vries EN, Prins HA, Crolla RM, et al. Effect of a fessional behavior and cognition. Certainly, other comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937. variables over which we have little or no control can 16. de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg adversely affect our success at the point of service. SM, Gouma DJ, Boermeester MA. Prevention of surgical Nonetheless, deficiencies in professional behavior and malpractice claims by use of a surgical safety checklist. Ann cognition are frequent, avoidable causes of errors. ♦ Surg. 2011;253(3):624-628.

V102 No 3 BULLETIN American College of Surgeons PATIENT-REPORTED OUTCOMES

Patient-reported outcomes in surgery: Listening to patients improves quality of care

by Jason B. Liu, MD; Andrea L. Pusic, MD, MHS, FACS; Larissa K. Temple, MD, MSc, FACS; and Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS | 19

HIGHLIGHTS he American College of Surgeons (ACS) has a legacy of measuring outcomes to improve • Demonstrates how PROs Tpatient care. The “end result idea” introduced enhance patient engagement by Ernest Amory Codman, MD, FACS, was simple: • Identifies the role of PROMs follow each patient after an operation to deter- in translating subjective mine whether it succeeded or failed, learn from the information into objective data negative outcomes, and devise methods to ensure 1 • Summarizes guidelines future success. At a time when postoperative mor- for selecting a PROM bidity and mortality were commonplace, adverse outcomes were logically the ones most scrutinized. • Describes how measuring both Although it is still vitally important that surgeons clinical outcomes and PROs and trainees understand the cause of negative out- enhances quality of surgical care comes, the advances made in surgical care in the last 100 years have made it possible to measure quality using a broader range of metrics than morbidity and mortality. Patient-reported outcomes (PROs), which represent the views and perceptions of patients, are becoming widely recognized as important measures for use in improving patient care.2-4 Although they have their drawbacks, PROs help surgeons and other health care professionals provide patient- centered care. This article is a primer on PROs and how they increase patient engagement and foster shared decision making.

MAR 2017 BULLETIN American College of Surgeons PATIENT-REPORTED OUTCOMES

TABLE 1. PARALLELS BETWEEN COMMON MEASUREMENT SYSTEMS AND PROMS

Concept Tools Metrics Ruler, tape measure, yardstick, Length Meters, inches odometer Fingers and watch, Heart rate Beats per minute electrocardiogram, pulse oximetry Raw event rates Postoperative complications ACS NSQIP Risk-adjusted odds ratios Summary physical RAND 36-item Short Form component score Health-related quality of life Health Survey (SF-36) Summary mental component score Oxford Hip Score (OHS) OHS Pain and physical function related Hip Disability and Osteoarthritis to osteoarthritis of the knee HOOS Outcome Score (HOOS)

What are PROs and PROMs? offer meaningful and accurate measurements to com- A PRO is an assessment of health status that comes pare patient groups and to examine change over time. directly from the patient without any interpreta- We can think of PROMs in much the same way we tion by health care professionals. When patients tell think of rulers, yardsticks, tape measures, and other their physicians how they feel or function or about tools for assessing length. Objects come in many dif- their sense of well-being and their symptoms, they ferent sizes and thus there are many different types of 20 | are providing PROs. Each aspect of an individual’s rulers to appropriately measure them. Rather than mea- health status, also called a domain, is inherently suring length, PROMs measure quality of life, including subjective and differs from patient to patient. The physical, mental, or social health and fitness. They power of PROs is that they can now be collected in can also examine body image, pain, and self-efficacy. a meaningful, rigorous, and scientific manner that Broadly speaking, using a PROM is similar to using accurately translates subjective aspects of health into other common measuring devices. (See Table 1, this objective data. page, for examples of how domains and PROMs fit into A patient-reported outcome measure (PROM) is other more familiar measurement systems.) the tool that translates the subjective information into objective data. Simply stated, PROMs are ques- tionnaires or surveys that ask patients to gauge their Guidelines for selecting a PROM views on their own health. Their responses are then Thousands of different PROMs have been developed. scored, thereby assigning the patient’s perspective a SF-36, EuroQol five dimensions questionnaire (EQ-5D), numerical value. An example of this tool is the RAND BODY-Q, Knee Injury and Osteoarthritis Outcome 36-item Short Form Health Survey (SF-36). This par- Score (KOOS), and the Pediatric Quality of Life Inven- ticular PROM survey asks patients about their ability tory (PedsQL) are all PROMs designed to measure to perform routine daily tasks and queries them on specific domains from particular patients. For example, any emotional challenges they may be experienc- the SF-36 was designed to measure the impact that gen- ing. Each domain receives a rating value from 0 to eral physical and mental health status has on a person’s 100—the higher the number, the better the patient overall life across different patient populations. In this views his or her health status. Scores from different way, the SF-36 is a “generic” PROM that offers patients patients or groups of patients can then be compared with completely different conditions the opportunity to and tracked over time to assess change. answer the same questions, which allows comparisons The factors and processes used to develop a PROM between seemingly unrelated groups. For instance, are important to understanding the validity of the generic PROMs allow the outcomes of ventral hernia results it provides. When PROMs are designed in repairs to be compared with outcomes for colectomies accordance with rigorous scientific standards, they because generic PROMs only measure those domains

V102 No 3 BULLETIN American College of Surgeons PATIENT-REPORTED OUTCOMES

that both operations share, such as the ability to com- How do we collect PROs using PROMs? plete housework. PROMs are available in multiple formats. Tradi- Unlike generic PROMs, condition-specific PROMs tionally, they were paper-based forms completed are focused on a particular disease, set of conditions, by patients during clinic visits or returned via mail. or part of the body. The BODY-Q, for example, is a Because computers, and especially smartphones and condition-specific PROM that was designed for obese tablets, are now ubiquitous, PROMs administered in patients and patients who undergo bariatric and cos- electronic formats and accessible via handheld devices metic body contouring operations.5 Domains measured have become increasingly popular.7-9 For instance, are specific to this population and include body image, the International Consortium for Health Outcomes physical appearance, effect of excess skin, psychosocial Measurement (ICHOM) developed TechHub, an open function, and others. Condition-specific PROMs are marketplace that lists health information technology especially useful for evaluating outcomes associated vendors who meet ICHOM’s standards for electronic | 21 with different approaches to treatment for a single dis- outcomes measurement. Electronically captured ease. For instance, they can provide insight into how PROs, called ePROs, are more efficient, less costly, the body image of a young adult with Crohn’s disease and are user friendly. Data collected using electronic might differ after undergoing an open versus a mini- means have proven to be of equal validity to those col- mally invasive colectomy. lected using traditional methods.10 In the near future, Choosing whether to use a generic or a condition- electronic collection of PROs will be the norm. specific PROM depends on the intended purpose.6 Is the objective to gain an overall understanding of the patient’s health status, or is the goal to gain a more Why should we collect PROs? detailed view of the patient? Frequently, both generic PRO data have been shown to enhance patient and condition-specific PROMs are used together to get engagement and shared decision making when the full picture. integrated into clinical care. These data provide an Other attributes of a PROM must be considered assessment of the patient’s experience of illness (such before selection. These can include content validity, as symptoms, physical function, and vitality), their construct validity, inter-rater reliability, test-retest values and preferences, and their goals of care.2 For reliability, responsiveness, and whether it is static or instance, orthopaedic surgeons at the University of dynamic.7 “Static” is the technical term for PROMs Rochester, NY, routinely use PRO data in clinical that are administered on paper—they are static forms. care to assess whether physical therapy is helpful.11 “Dynamic” is the technical term for newer test methods If the therapy does not seem to be having a benefi- that change depending on how one answers a ques- cial effect, surgeons can use the PROs to engage a tion. A detailed description of each of these attributes patient in a discussion about whether an operation is beyond the scope of this article; however, a good rule is a viable option. Similarly, if a patient presents for of thumb is to simply read the questions posed in the preoperative evaluation and has PRO scores that are PROM. If the questions seem irrelevant or unrelated as good as those of postoperative patients, then he or to what you are trying to learn from patients, then you she may not need an operation. As such, PROs can should probably consider another PROM. be used to support patient-provider engagement by

MAR 2017 BULLETIN American College of Surgeons PATIENT-REPORTED OUTCOMES

FIGURE 1. TWO-DIMENSIONAL VIEW OF SURGICAL OUTCOMES

Surgical outcomes can be viewed from two perspectives—the clinician’s and the patient’s. We assume that these two components go hand-in-hand and move in the same direction (ideal improvement: red circle to green circle). However, experience has shown that patients and surgeons sometimes have different definitions of a successful outcome (x-axis). Certain operations can be done solely to improve the quality of life (QoL) from the patient’s perspective (y-axis). It is critical that surgeons align our views of success with those of our patients. By measuring patient-reported 22 | outcomes, we can be sure we are moving in the right direction.

assessing the severity of symptoms; provide informa- lost the ability to dress himself, did he really have a tion to track the effect of operations on short-term positive outcome? and long-term patient outcomes; assist patients and Significant progress has been made in the areas providers to set priorities for office visit discussions; of survey methodology and quality of life research. and inform treatment decisions through comparative For example, modern test techniques, such as those effectiveness and resource utility research. used by the National Institutes of Health Patient- PROs allow surgeons to understand and mea- Reported Outcomes Measurement Information sure the benefit of many of the procedures that we System (PROMIS), can reduce the number of ques- perform from the perspective of the patients them- tions patients must answer but preserve data accuracy. selves. Clinical outcomes do not always capture Patients’ perspectives on their health outcomes now the aspects of health that many patients consider can be consistently and reliably measured in most important, and frequently a gap exists between what surgical disciplines. The integration of PROs into outcomes matter to surgeons and which matter to the clinic and into outcomes assessments only will patients. PROs complement traditionally measured improve our ability to provide better care.4 clinical outcomes with the patient perspective (see Figure 1, this page). The outcomes of surgical procedures can thus be The ACS will lead the way viewed from two perspectives: clinical outcomes and The ACS continues to be a leader in surgical outcomes PROs. By viewing outcomes in this dual manner, sur- measurement to improve care, particularly through geons can gain a clearer understanding of how we its Quality Programs, such as the National Surgical can improve patient care. If a patient didn’t develop a Quality Improvement Program (ACS NSQIP®). As part urinary tract infection or a surgical site infection but of this commitment, the ACS has begun merging all

V102 No 3 BULLETIN American College of Surgeons PATIENT-REPORTED OUTCOMES

of its clinical databases into one common platform REFERENCES and, in so doing, will begin complementing the rich 1. Warshaw AL. Presidential Address: Achieving our personal clinical outcomes data in ACS NSQIP with PROs. best: Back to the future of the American College of Surgeons. The College has the opportunity to make avail- Bull Am Coll Surg. 2014;99(12):9-18. Available at: bulletin.facs. able the collection of meaningful PROs that will org/2014/12/presidential-address-achieving-our-personal- best-back-to-the-future-of-the-american-college-of-surgeons/. help promote continuous quality improvement, Accessed January 30, 2017. influence clinical care, foster patient engagement, 2. Lavallee DC, Chenok KE, Love RM, et al. Incorporating patient- promote performance excellence, and advance reported outcomes into health care to engage patients and patient-centered innovation in surgery. This ini- enhance care. Health Aff (Millwood). 2016;35(4):575-582. tiative is being guided by three key principles: (1) 3. Van Der Wees PJ, Nijhuis-Van Der Sanden MW, Ayanian JZ, et al. Integrating the use of patient-reported outcomes for both minimize patient/respondent burden, (2) maintain clinical practice and performance measurement: Views of | 23 data accuracy, and (3) enable actionable improve- experts from 3 countries. Milbank Q. 2014;92(4):754-775. ments. Complementing the ACS NSQIP with PROs 4. Basch E, Spertus J, Dudley RA, et al. Methods for developing is not without its challenges and limitations. Keep- patient-reported outcome-based performance measures (PRO- ing in mind our guiding principles, we plan to PMs). Value Health. 2015;18(4):493-504. 5. Klassen AF, Cano SJ, Alderman A, et al. The BODY-Q. Plast implement this initiative through iterative phases Reconstr Surg Glob Open. 2016;4(4):e679. to ensure success and sustainability. 6. Aaronson N, Elliott T, Greenhalgh J, et al. User’s guide to implementing patient-reported outcomes assessment in clinical practice 2015. Available at: www.isoqol.org/ Conclusion UserFiles/2015UsersGuide-Version2.pdf. Accessed January 9, 2017. 7. Deutsch A, Smith L, Gage B, Kelleher C, Garfinkel D. PRO- Historically, surgical decision making has been based performance measures for healthcare accountable entities a relatively straightforward process. If a woman 2012. Available at: www.qualityforum.org/WorkArea/linkit.asp had breast cancer, she needed a mastectomy, and x?LinkIdentifier=id&ItemID=72157. Accessed January 9, 2017. her surgeon would perform the operation. Con- 8. Wu AW, Kharrazi H, Boulware LE, et al. Measure once, cut sideration of the procedure’s effect on her body twice—adding patient-reported outcome measures to the electronic health record for comparative effectiveness research. image was generally omitted from the treat- J Clin Epidemiol. 2013;66(8 Suppl):S12-20. ment equation. Surgery is no longer only about 9. Lippa J, Fügener A, Arora J, et al. Electronic PROMs: What’s prolonging life, but also about minimizing the the right solution for your organization? 2014. Available at: negative impact of treatment, optimizing qual- www.ichom.org/files/whitepapers/ePROM-White-Paper.pdf. ity of life, and aligning treatment decisions with Accessed January 9, 2017. 10. Patient-Centered Outcomes Research Institute (PCORI). our patients’ goals. Minimally invasive surgery Patient Reported Outcomes (PRO) Infrastructure Workshop exists today because it can optimize PROs. Only Integrating PROs into EHRs Atlanta, GA. November 19-20, by measuring clinical outcomes and PROs can 2013. Available at: www.pcori.org/sites/default/files/PCORI- we ensure the provision of optimal, high-quality, PRO-Infrastructure-Workshop%20Report-111913.pdf. Accessed patient-centered surgical care. ♦ January 9, 2017. 11. Baumhauer JF, Bozic KJ. Value-based healthcare: Patient- reported outcomes in clinical decision making. Clin Orthop Relat Res. 2016;474(6):1375-1378.

MAR 2017 BULLETIN American College of Surgeons VALUE-BASED HEALTH CARE

Value-based health care: How to succeed in a bundled care APM

by Daniel T. Engelman, MD, FACS 24 |

ithin the span of five years, two pieces of legislation that significantly affect physician payment and patient care were enacted—the WAffordable Care Act (ACA) of 2010 and the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. With the passage of these laws, surgeons could no longer HIGHLIGHTS adopt a wait-and-see approach to national health care policy legislation. This article briefly summarizes the major payment provisions in the ACA • Identifies APM models and MACRA and their possible fate under the new presidential administra- that qualify as Advanced tion and Congress. It also describes lessons learned at one institution that APMs for MIPS exclusion developed bundled care packages to improve quality of care while simulta- • Describes bundling and neously controlling cost. ACOs as they relate to the Advanced APM plan • Provides guidelines on The ACA and MACRA developing bundled With little fanfare but significant potential repercussions, the Medicare phy- care packages to reduce sician payment system changed in 2010 when the U.S. Congress passed the costs and improve ACA—shifting the emphasis in determining how providers are paid from quality of care based volume to quality. Significant portions of physician reimbursement would on the experiences of now be directly tied to quality metrics. In addition, physicians participat- Baystate Medical Center ing in these new payment models would now be directly responsible for costs incurred by all other practitioners during the episode of care. They also would be accountable for costs incurred in the first few months after patients were discharged from the index admission. Although the ACA includes some adjustments to the Medicare physician fee schedule, MACRA imposes the most sweeping changes. Of particular

V102 No 3 BULLETIN American College of Surgeons VALUE-BASED HEALTH CARE

significance when MACRA passed in 2015 was the Physicians who participate in these new payment repeal of the sustainable growth rate (SGR) for- models will bear significant downside risk but will mula, which was on the brink of causing reductions receive a 5 percent payment bonus and will be exempt in physician payment of nearly 30 percent. Although from the administrative requirements and uncertain- the physician community initially greeted MACRA ties of MIPS. In addition, these physicians may receive with a favorable response, largely because of the SGR any additional payments that result from being part of repeal, the legislation imposes a number of important an approved Advanced APM system. changes in the way Medicare will pay for services in As of November 2016, CMS had identified only six the future. Most importantly, it attempts to better APMs that qualify as Advanced APMs for MIPS exclu- align quality with a reduction in unnecessary physi- sion, including the Comprehensive End-Stage Renal cian spending. Disease Care Model, the Oncology Care Model, and MACRA adds strong financial incentives for phy- the Next Generation Accountable Care Organization sicians to become more accountable for the quality (ACO) Model, among others. CMS estimates that as of care they provide and for controlling costs. These many as 90 percent of eligible clinicians will be in the incentives are provided through the Centers for Medi- MIPS program in 2017 and as few as 10 percent will care & Medicaid Services (CMS) Quality Payment be in an Advanced APM.1 It is anticipated that CMS Program (QPP). The QPP has two major components: will continue to broaden its definition of qualifying the Merit-based Incentive Payment System (MIPS), Advanced APMs.2 which adheres to the traditional fee-for-service pay- | 25 ment model, and the Advanced Alternative Payment Models (APMs) that can be used to develop innovative Ramifications of the Republican sweep reimbursement policies. November’s national elections gave the Republican Party control of both the executive and legislative branches of government. With a majority in both the MIPS and APMs House and Senate, and support from the President, Payment adjustments under MIPS will be based on a efforts to repeal the ACA were under way at press composite performance score derived from metrics: time. However, without a 60-vote supermajority in quality, resource use, advancing care information, and the Senate, Republicans may be unable to repeal the improvement activities. CMS began measuring per- entire law. Nevertheless, they may succeed in eliminat- formance in January, with payments based on MIPS ing several consequential provisions. Those portions of measures beginning in 2019. the ACA strictly dealing with spending, revenues, or Payment rates will be adjusted plus or minus 4 per- the debt ceiling can be repealed with a simple majority cent per year, increasing to 9 percent. By 2022 MIPS is through the budget reconciliation process. projected to be a budget-neutral program, which may For surgeons and other physicians, the Medicare imply a tournament model for physician rewards and spending cuts included in the ACA likely will remain penalties; that is to say, equal dollar amounts will go to intact. These cuts, combined with decreased partici- physicians who attain performance measures above the pant insurance coverage, will result in less provider benchmark with funding coming from those providers revenue. The rising government deficit and debt, com- who are facing penalties. As such, participants may be bined with an aging population, is likely to ensure that required to achieve continuous improvements in an government efforts to control spending such as those increasingly competitive environment. In addition, prescribed in MACRA will continue. Medicare fees will increase by only 2 percent through In addition, MACRA passed through Congress 2022, and then will remain flat. with strong bipartisan support (92–8 in the Senate and As an alternative to this payment structure, physi- 392–37 in the House). It is unlikely that Republican law- cians may participate in an eligible Advanced APM. makers will repeal their own legislation.

MAR 2017 BULLETIN American College of Surgeons VALUE-BASED HEALTH CARE

Central to the Advanced APM concept are bundling and ACOs. These two components enable the payment system to move from an emphasis on volume to value. They also guarantee Medicare cost savings and have a significant potential upside for the motivated provider.

Central to the Advanced APM concept are bundling reduction in the number of unnecessary physician and ACOs. These two components enable the payment services provided during hospitalization, more judi- system to move from an emphasis on volume to value. cious use of health care resources during the hospital They also guarantee Medicare cost savings and have a stay, and a reduction in post-discharge costs, includ- significant potential upside for the motivated provider. ing unnecessary post-acute care services and avoidable Bundled payments have received bipartisan support readmissions. If the costs of an episode of care are less and their development is likely to continue in spite of than the bundled payment amount, the providers (hos- the potential dissolution of the ACA-created Center for pital and physicians) can keep the difference. If the costs Medicare and Medicaid Innovation (CMMI). In fact, of care exceed the bundled payment amount, however, even if Congress does dissolve the CMMI, it is likely the providers bear financial liability. that the U.S. Department of Health and Human Ser- In the Baystate Medical Center BPCI APM, the epi- vices will continue to promote innovations in payment sode of care includes a Medicare beneficiary’s inpatient through some other means. stay in the acute care hospital, post-acute care, and all Both population health management and value- related services during the episode of care, which ends based health care have strong bipartisan support and 90 days after hospital discharge. In addition, participat- 26 | will likely thrive under the new administration. Health ing hospitals agree to a 2 percent up-front fee reduction. insurance payments will depend more heavily on out- Functioning in a bundled APM requires adminis- comes. The control of rising health care expenditures trative, financial, and infrastructure support, which is will depend on paying for the quality of care provided, best attained in a large institution. Hospitals must pro- rather than the number of procedures performed. vide appropriate data, resources, and incentives. Our Already, the popularity of value-based health care has hospital has created a replicable model to implement led to significant consolidation within the health care bundled payment programs by emphasizing collabo- sector and greater transparency. Hospitals and physi- ration among our clinical divisions and those within cians will seek to integrate in order to better control our departments of health care quality and finance. costs and improve the patient-reported experience. We also have a physician health organization that is well-versed in risk management. Despite these successes with the program, early on Ensuring success in a surgical bundle we learned some valuable lessons to ensure success Beginning in 2013, Baystate Medical Center, Spring- in a bundled payment APM, including the following: field, MA, entered into CMS’ Bundled Payments for Care Improvement initiative (BPCI) for all isolated cor- • The first step to success in a bundled payment arrange- onary artery bypass grafting procedures covered by ment is to reduce readmissions. After coronary artery Medicare. The BPCI initiative comprises four broadly bypass graft surgery, readmission rates are between 13 defined models of care, which link payments for the percent and 24 percent. As a result, predictor models multiple services beneficiaries receive during an episode have been developed, which quantified odds ratios for of care. Under the initiative, health care facilities enter readmission with risk factors such as chronic obstruc- into payment arrangements that include financial and tive pulmonary disease, renal failure, and diabetes.3 On performance accountability for episodes of care. These discharge, we identify those patients at high risk for read- models may lead to higher quality and more coordi- mission. Our clinical coordinator then follows a patient nated care at a lower cost to Medicare. at risk by phone, schedules early postoperative visits, The purpose of bundled payment is to decrease enrolls the patient in a heart failure rehabilitation clinic, spending through several mechanisms, including a and coordinates care with the patient’s primary care

V102 No 3 BULLETIN American College of Surgeons VALUE-BASED HEALTH CARE

physician. In addition, all postoperative patients entering our length of stay and facilitate the discharge of patients our emergency department trigger an electronic noti- receiving Coumadin with sub-therapeutic international fication to our inpatient service before their admission normalized ratios and close daily home blood work. for expedited review and disposition. After patients are discharged home, close follow-up by phone, with daily weights, medication reconciliation, • The post-acute disposition was the single greatest vari- and early office postoperative appointments, prevented able affecting a positive margin in our bundle. By altering emergency department visits. All readmissions were patient and family expectations, earlier frequent daily scrutinized for potentially avoidable events. mobilization, and possibly extending inpatient stays for an extra day, we were able to increase the percentage • During the index admission, physicians can reduce of patients discharged to home with visiting nurse ser- unnecessary medical expenses if they are properly vices versus discharge to a skilled nursing facility. For engaged. At our institution, an engaged physician those patients who went to a skilled nursing facility, close leads a multidisciplinary group of advanced practitio- coordination with the facility decreased the post-acute ners, residents, bedside and charge nurses, pharmacists, length of stay, which led to reduced overall costs to the rehabilitation specialists, and respiratory therapists to bundle and improved patient satisfaction. We also have ensure the delivery of coordinated care. developed a preferred provider skilled nursing facility network to align more closely with best practice stan- It is also important to maximize transparency and dards, track outcomes, and improve communication identify relevant metrics within the service line. Phy- | 27 between the primary cardiac surgical inpatient team sicians need to see differences in costs and outcomes and our post-acute care partners. and how their performance compares with that of their colleagues. Given the competitive nature of physicians • To ensure that the Medicare payment amounts are fair, and especially surgeons, peer comparisons can moti- some adjustment for patient severity must be included in vate change and drive down hospital costs. A study the calculations. If bundled payments do not account for published in 2016 in the Journal of the American Medical severity of disease, providers may not want to provide Association found that peer comparison resulted in a 16 health care services to sicker patients because of the risk percent drop in unnecessary prescriptions.4 Baystate of financial loss. More than ever, health care profession- Medical Center administrators found that by sharing als must provide accurate and complete documentation utilization metrics among the cardiac surgeons, they to correctly document level of acuity and appropriate could successfully drive down hospital costs. diagnosis-related group. Accurate coding, which incor- Medicare has already started publishing comparative porates key documentation, will improve benchmarking data and patient-reported outcomes. The Hospital Con- and expected morbidity and mortality. Medicare pay- sumer Assessment of Healthcare Providers and Systems ments in a bundle require risk adjustments, stop/loss (HCAHPS) survey is the first national, standardized, protection, and other insurance mechanisms to ensure publicly reported survey of patients’ perspectives of hos- fair payment for complex cases and protections from pital care. By making quality and satisfaction reports catastrophic outlier patient care. publicly available, Medicare has created an incentive for physicians and hospitals to improve the patient • Coordination of care is essential. A dedicated care coor- experience. dinator needs to follow this cohort of patients, beginning with preoperative education about length of stay expectations and the need for family support at home on Looking forward discharge. During hospitalization, the care coordinator In the future, surgeons likely will benefit from par- needs to identify hospital barriers to a timely discharge. ticipation in an APM, such as a BPCI. At this time, At Baystate Medical Center, we were able to decrease however, to qualify for MIPS exclusion, the only clear

MAR 2017 BULLETIN American College of Surgeons VALUE-BASED HEALTH CARE

Advanced APM option may be to join a consolidated risk-bearing REFERENCES ACO with significant downside risk. 1. Mechanic RE. When new Medicare On December 20, 2016, CMS released the Advancing Care Coor- payment systems collide. N Engl J Med. dination through Episode Payment Models (EPMs) final rule.5 The 2016;374:1706-1709. 2. Clough JD, McClellan M. Implementing rule establishes three new Medicare EPMs for acute myocardial MACRA: Implications for physicians infarction (AMI), coronary artery bypass graft (CABG), and surgi- and for physician leadership. JAMA. cal hip/femur fracture treatment (SHFFT) procedures provided in 2016;315(22):2397-2398. designated geographic areas. The rule also includes provisions to 3. Shahian DM, He X, O’Brien SM, et al. finalize the Cardiac Rehabilitation (CR) Incentive Payment program Development of a clinical registry-based 30-day readmission measure for coronary and to integrate bundled payment programs into the QPP. artery bypass grafting surgery. Circulation. Under the final rule, acute care hospitals that are reimbursed 2014;130(5):399-409. under the Inpatient Prospective Payment System and are located 4. Meeker D, Linder JA, Fox CR, et al. in 98 metropolitan statistical areas (MSAs) selected by CMS will be Effect of behavioral interventions on required to participate in retrospective EPMs for Medicare fee-for- inappropriate antibiotic prescribing among primary care practices: A randomized service beneficiaries receiving care during AMI and CABG episodes. clinical trial. JAMA. 2016; 315(6):562-570. The agency will implement the SHFFT model in 67 MSAs where 5. Centers for Medicare & Medicaid Services. the Comprehensive Care for Joint Replacement program is already Episode payment models: General in place. An AMI, CABG, or SHFFT model episode will begin with information. Available at: innovation.cms. 28 | an inpatient admission and end 90 days after discharge. The episode gov/initiatives/epm. Accessed January 24, 2017. of care will include the inpatient stay and related care covered under 6. Centers for Medicare & Medicaid Services. Medicare Parts A and B, including hospital care, post-acute care, and Notice of proposed rulemaking for physician services, within 90 days of discharge. CMS will continue bundled payment models for high-quality, to pay participating hospitals, providers, and suppliers according to coordinated cardiac and hip fracture care. the current Medicare fee-for-service rates. Available at: www.cms.gov/Newsroom/ MediaReleaseDatabase/ Fact-sheets/2016- The AMI EPM, the CABG EPM, and the CR Incentive Payment Fact-sheets-items/2016-07-25.html. program will be tested for five performance years—July 1, 2017, Accessed January 24, 2017. through December 31, 2021. CMS estimates that 1,120 acute care hospitals will participate in the AMI and CABG models, and 860 hospitals will participate in the SHFFT model. CMS has indicated that these bundled payment models should qualify for the Advanced APM track of MACRA, thereby providing exclusion from MIPS.6 The federal government will continue to support a payment system that encourages changing physician payment from fee for service to payment that is based on transparent performance metrics, patient experience, and patient outcomes. There is an early opportunity for significant financial reward from a high-value program that is focused on quality metrics, HCAHPS scores, care coordination, and the post-acute disposition. The next hurdle will be maximiz- ing reimbursement through an optimized patient-focused APM. ♦

Acknowledgment The author is grateful to the bundled care team members at Baystate Medi- cal Center for their assistance.

V102 No 3 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

Coding for nipple-sparing and skin-sparing mastectomies

by Eric Whitacre, MD, FACS; Megan McNally, MD, FACS; and Jan Nagle, MS, RPh

n December 2007, an American Assistant Newsletter article, which margins, specimen orientation, Medical Association (AMA) was published in the March 2015 and cold ischemic time. ICPT [Current Procedure issue.2 However, the earlier 2007 In contrast, subcutaneous Terminology] Assistant Newsletter article was not deleted, retracted, mastectomy is typically used article was published indicating or marked in any way to indicate to treat patients with severe that a skin-sparing mastectomy that the information featured in symptomatic fibrocystic should be reported with the article was incorrect. Because change or patients who are CPT* code 19304, Mastectomy, the 2007 and 2015 articles are undergoing breast cosmetic subcutaneous.1 The CPT article both maintained in the CPT procedures in which significant incorrectly indicated that Assistant Newsletter archives, tissue removal is necessary to | 29 nipple-sparing does not change confusion persists regarding achieve symmetry. The incision the subcutaneous dissection correct coding for skin-sparing is generally conservative and performed. The correct code to and nipple-sparing mastectomies. cosmetic, and some breast tissue report skin-sparing mastectomy Some coding consultants is left behind. Thus, it is not is 19303, Mastectomy, simple, continue to direct surgeons and a “complete” mastectomy. complete (total mastectomy). It is coders to incorrectly report worth noting that the American 19304 for procedures that should College of Surgeons (ACS) did not be reported with 19303. What to include in the provide the coding interpretation operative report published in this 2007 CPT To clarify reporting, the Assistant Newsletter article Distinctions between operative report should include regarding the code to report complete mastectomy and the wording “nipple-sparing for skin-sparing mastectomy. subcutaneous mastectomy complete mastectomy” or “skin- Moreover, the American Society A skin-sparing or nipple-sparing sparing complete mastectomy,” of Breast Surgeons (ASBrS) was mastectomy for diagnosed as well as the appropriate not a member of the AMA CPT carcinoma, or for patients who International Classification of Advisory Committee in 2007 and, are at high risk for carcinoma, Disease, 10th Revision, Clinical therefore, could not contribute to is reported with code 19303 Modification code for diagnosed CPT Assistant Newsletter articles. regardless of the amount of malignancy (such as C50.XXX In 2015 the ACS submitted skin removed or whether the or D05.XX) or for increased a clarification to the 2007 CPT nipple is preserved. These future breast cancer risk (such oncologic procedures require as Z15.01). Use of the specific *All specific references to CPT codes and removal of the entire breast term “complete mastectomy” descriptions are ©2016 American Medical tissue in one or both breasts will help direct the coders Association. All rights reserved. CPT and CodeManager are registered trademarks plus additional surgical work, to correctly report 19303, of the American Medical Association. such as attention to surgical Mastectomy, simple, complete.

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

To summarize, report code 19303 for a skin-sparing or nipple- sparing mastectomy for diagnosed carcinoma or for patients who are at high risk for carcinoma, regardless of the amount of skin removed or whether the nipple is preserved.

This change is consistent with To summarize, report REFERENCES Version 1.2017 of the National code 19303 for a skin-sparing 1. American Medical Association. Comprehensive Cancer Network or nipple-sparing mastectomy Surgery: Integumentary system. CPT Clinical Practice Guidelines for diagnosed carcinoma or for Assistant Newsletter. 2007;17(12):7. in Oncology for Breast Cancer patients who are at high risk 2. American Medical Association. Risk Reduction: “Nipple- for carcinoma, regardless of Coding brief: Coding for breast surgery. CPT Assistant Newsletter. sparing mastectomy is a total the amount of skin removed or 2015;25(3):5,11. mastectomy with preservation whether the nipple is preserved. 3. National Comprehensive Cancer of the nipple/areola and breast The “Coding and practice Network. Clinical Practice Guidelines skin. Efforts should be made management corner” column in Oncology for Breast Cancer Risk to minimize the amount of in the September 2014 Bulletin Reduction, Version 1.2017. Password 3 protected. Available at: nccn.org/ residual breast tissue.” provides additional guidance professionals/physician_gls/pdf/ 30 | 4 The distinction between a on breast surgery coding. ♦ breast_risk.pdf. Accessed January 24, simple, complete mastectomy 2017. and subcutaneous mastectomy is 4. Barney L, Savarise MT, Whitacre E. similar to the biopsy/lumpectomy Note Coding and practice management corner: Frequently asked questions distinction, which also led to Accurate coding is the responsibility about coding for breast surgery. coding confusion a decade ago of the provider. This summary is Bull Am Coll Surg. 2014; 99(9):52-54. due to incorrect coding advice. intended only to serve as a resource Available at: bulletin.facs.org/2014/09/ Today, it is well understood to assist in the billing process. frequently-asked-questions-about- that these procedures are not coding-for-breast-surgery/. Accessed reported based on the volume February 14, 2017. of tissue removed, but rather on the intent to achieve negative margins. For example, excision of a 4 cm fibroadenoma in a 19-year-old patient is reported with code 19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions (breast biopsy). In contrast, excision of an 8 mm carcinoma via a 2.5 cm surgical specimen is reported with code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy).

V102 No 3 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

Practice changes for reducing UTIs in colon and rectal surgery patients

by Mary Ward, RN, and Deborah Nagle, MD, FACS, FASCRS

Editor’s note: Hospitals that ccounting for more than delineate a number of patient- participate in the American College one-third of nosocomial related risk factors for UTI, of Surgeons National Surgical Quality Ainfections in U.S. hospitals,1 yet fail to identify physician- Improvement Program (ACS NSQIP®) urinary tract infections (UTIs) controlled modifiable risk factors. use the program’s data and reports are associated with increased However, Wald and colleagues, to improve performance and surgical morbidity, mortality, and in a study of more than 35,000 outcomes. Sites are invited to share health care costs.2,3 Defined as Medicare beneficiaries undergoing their experiences at the ACS NSQIP a nonreimbursable, “reasonably surgery, demonstrated a Annual Conference—now called the preventable” hospital-associated 21 percent increase in UTI ACS Quality and Safety Conference— complication by the Centers for incidence for postoperative through abstract submissions for Medicare & Medicaid Services,4 indwelling urinary catheterization poster and panel presentations. UTI became of particular (IUC) lasting more than 48 hours.9 Hospitals also are encouraged to relevance to surgeons after a These data—in conjunction share their quality improvement study of New York and California with a 1999 study by Benoist (QI) initiatives, so other institutions registry data showed that and colleagues that called into | 31 can learn from their experience and 70 percent of nosocomial UTIs question the long-held belief develop their own QI programs. involved patients undergoing that pelvic surgery necessitates “ACS NSQIP best practices surgical procedures.5 Moreover, protracted IUC10—forms the basis case studies” is an ongoing look the challenge of nosocomial for our proposed intervention. at these experiences. These case UTI for the colon and rectal studies have been edited to comply surgeon was recently highlighted with Bulletin style and provide a in a study using data from the Why was the QI activity description of the clinical problem ACS NSQIP, which showed undertaken? being addressed, the context that UTI rates after colon and Because the perioperative of the QI project, the planning rectal surgery (CRS) exceed management of IUC may be and development process, a risk-adjusted estimates on the service- and surgeon-dependent description of the activity, the basis of patient factors alone.6 at many institutions, researchers resources needed, the results, These results echoed the at Beth Israel Deaconess Medical and tips for other case studies. findings of a previous ACS NSQIP Center, Boston, MA, sought to study, which also identified CRS investigate whether standardized as a risk factor for UTI.7 The 2012 management of IUC placement designation of UTI prevention and duration could reduce the as a National Patient Safety Goal incidence of UTIs in CRS. As emphasizes the importance of part of our ongoing institutional UTIs as a target for QI in both efforts to reduce perioperative surgery overall and CRS.8 morbidity, we found that our The ACS NSQIP studies, UTI rate exceeded both the as well as a 2012 report of risk ACS NSQIP benchmark and factors for UTI after resection the expected rates for UTIs in of colorectal cancer in the CRS.5 We analyzed potential Nationwide Inpatient Sample, contributing factors, including

MAR 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

FIGURE 1. UTI RATES

previously identified modifiable Control group justification for maintaining use. and non-modifiable risk factors. An institutional program of The clinical notation of pelvic We considered the length of daily reassessment of the need dissection or pelvic surgery was time that the catheter remained for IUC was instituted at our not considered to be sufficient indwelling and the method of tertiary care hospital across all for IUC use beyond 48 hours, IUC insertion as modifiable risk service lines in January 2010. as studies have documented factors. We found no outcomes However, no specific actions the safety of removing IUC data in the literature on the were attached to these guidelines, on the first postoperative 32 | optimal strategy for placing and we saw no significant day.12 This EHR order was operative IUCs or the potential decrease in UTIs. This group activated in February 2011. impact thereof. Our hospital served as the control population practice for catheter placement against which subsequent Intervention group 2 was in line with the 2009 interventions were compared. In July 2012, a system of update of the U.S. Centers for service-specific sterile IUC Disease Control and Prevention Intervention group 1 placement was implemented. Guideline for Prevention In response to the persistently All patients who received CRS of Catheter-Associated elevated UTI rate, a daily services were included. Patients Urinary Tract Infections.11 electronic order was developed who underwent colorectal to maintain an IUC for more procedures through general than 24 hours. Specifically, an surgery and acute care surgery How was the QI activity electronic health record (EHR) services were omitted. put into place? prompt was created such that Before the intervention, Based on the January 2012 ACS each time an IUC was ordered IUCs were placed in the NSQIP Semiannual Report to be inserted, a query appeared operating room (OR) after that placed our CRS UTI rate every 24 hours about the need perineal antiseptic preparation in the 10th decile, the division for continued catheterization. by a member of the operating chief for colorectal surgery The provider was required to team. Team members who identified the problem, piloted enter clinical justification for the performed IUC insertion interventions, met with the continued need for the IUC for included nurses, residents, and colorectal team to discuss the ensuing 24 hours, and no supervised medical students. interventions, engaged all further orders could be entered We changed our practice to team members, and selected until the prompt was addressed. specify that, for cases done in a protocol to standardize and All of the perioperative the lithotomy position, IUC be modify provider behavior IUCs were removed within 48 inserted after the surgeon had through simple interventions. hours unless there was clinical prepped the patient, scrubbed

V102 No 3 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

TABLE 1. 30-DAY POSTOPERATIVE OUTCOMES

All Control Stage 1 Stage 2 Complication; n (%) p-value n = 811 n = 215 n = 476 n = 120 Overall morbidity 273 (33) 79 (37) 165 (35) 29 (24) 0.05 UTI 29 (4) 15 (7) 13 (3) 1 (1) 0.004 Length of stay, days; 6.2 (6.1) 6.7 (5) 6.2 (6) 5.3 (5) 0.11 mean (standard deviation [SD]) Mortality 19 (2) 3 (2) 16 (3) 0 (0) 0.07

and gowned themselves, and cohort, we used the procedural the X2 or Fisher’s exact test then draped the patient. terminology codes described where appropriate. Continuous For cases performed in the by Ingraham and colleagues.14 variables were compared using supine position, the patient We analyzed demographics, the 2-tailed sample t test or was fully prepped, including patient comorbidities, Analysis of Variance (also known the perineum, in the frog leg perioperative morbidity, type as ANOVA) as appropriate. position with antiseptic prep. of operation (abdominal versus Multiviable logistic regression The IUC was then placed and pelvic surgery), and rate of was performed to determine the patient was repositioned and UTI. We analyzed patients independent predictors of UTI. draped. The surgeon or resident who developed a UTI in our All of the variables with a p-value who placed the IUC changed population and classified them <0.05 on bivariate analysis were gloves after placement. The as having no risk factors (that included in the model. Forward catheter was suspended from is, perioperative insertion stepwise selection was used to the drapes over the inner thigh alone), reinsertion of catheter determine final independent with a clamp so that it remained in the postoperative period, or predictors. Throughout all | 33 away from the anal area in the IUC for more than 48 hours. of the analyses, statistical event of a transanal anastomosis significance was determined or perineal procedure. We by a criterion of p < 0.05. continued our 100 percent What resources were used? A total of 811 cases were compliance with perioperative The CRS team, composed of identified that met inclusion antibiotic administration. attending surgeons and residents, criteria across the three ACS NSQIP criteria were nurse practitioners, and study periods: the control used to define a UTI.13 Excluded registered nurses, were involved period (January 2010 to from analysis were patients from the inception of the new February 14, 2011) included 215 who had shown signs of a pre- practice changes and continue cases; intervention 1 (February 15, existing UTI. Patients with to be engaged in maintaining 2011, to June 2012) included 476 enterovesical, colovesical, or the sterile IUC protocol. cases; and intervention 2 (July colon or rectal vaginal fistulae No funding was allocated 2012 to December 2012) included were classified as having a to piloting and implementing 120 cases. Demographics, preexisting UTI. The three these changes, and no additional including patient comorbidities groups from our institution’s costs were incurred to develop and American Society of ACS NSQIP abstracted data or sustain this practice. Anesthesiologists (ASA) include the following: between classification, were similar January 2010 and February 14, across all of the study periods. 2011 (control group); February 15, What were the results? Operations without pelvic 2011, to June 2012 (intervention 1 All of the analyses were dissection—that is, segmental group: electronic order prompt); conducted using IBM statistical colectomy or total abdominal and July 2012 to December 2012 package for the social sciences colectomy—comprised (intervention 2 group: sterile (SPSS) statistics version 21.0.0 63 percent of the whole. Overall, intraoperative IUC placement) for Macintosh. Categorical 37 percent of the cases required were compared. To identify our variables were analyzed using pelvic surgery, defined as

MAR 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

Based on the January 2012 ACS NSQIP Semiannual Report that placed our CRS UTI rate in the 10th decile, the division chief for colorectal surgery identified the problem, piloted interventions, met with the colorectal team to discuss interventions, engaged all team members, and selected a protocol to standardize and modify provider behavior through simple interventions.

RECOMMENDATIONS TO proctectomy, proctocolectomy, the immediate postoperative OTHER INSTITUTIONS and abdominoperineal resection. period is to replace IUC for SEEKING TO REDUCE Within intervention group 2, urinary retention rather than to COMPLICATIONS 45 percent of the cases required use intermittent catheterization. • Don’t accept the status quo pelvic surgery. This outcome was For the control patients and • Engage the entire team attributed to the fact that only patients in intervention colorectal surgeons adopted this group 1, documentation of • Think flexibly about intervention. This difference IUC removal and reinsertion interventions should theoretically bias toward was not consistently available • Provide ongoing education a higher UTI rate in group 2. to provide reliable data. to residents as they rotate However, the UTI rate in the Bivariate analysis was used to through the service control group and intervention further compare patients who • Question current practices group 1 did not differ on the developed UTI (n = 29) with and identify whether basis of surgeon specialty. those who did not (n = 782). 34 | improvements can be made UTI occurred at a rate Independent predictors of UTI • Understand that compliance of 6.9 percent in the control on multivariable regression is easier with system support group, dropped to 2.7 percent are shown in Table 3, page 36. • Review Semiannual Report after intervention 1, and was Superficial surgical site infection and interim Semiannual 0.8 percent in intervention predicted UTI development Report to access progress group 2 (See Figure 1, page 32). (OR, 3.7 [95 percent CI, 1.4–9.8]), and sustainability The decrease in UTI across the whereas the study interventions • Know that institutional groups was statistically significant were each protective when adoption still remains at p < 0.004 (see Table 1, page compared with controls a challenge 33). After initiation of sterile (group 1: OR, 0.4 [95 percent intraoperative IUC placement, CI, 0.2–0.8]; group 2: OR, 0.1 no ACS NSQIP UTIs were [95 percent CI, 0.0–0.8]). identified on the CRS service Postoperative 30-day outcomes during an initial four-month were notable for this significant study period (106 cases). In the decrease in UTIs, as well as an ensuing two months, one patient overall decrease in morbidity developed a UTI after having (p = 0.05). The decreased rate of ureteral reconstruction and UTIs contributed to a decrease double-J stent placement at the in overall morbidity in the time of colorectal operation. intervention 2 group to 24 percent Mean duration of IUC for compared with 35 percent for intervention group 2 was 2.2 days. the control and intervention 1 Overall, 77 percent of the patients groups (see Table 1, page 33). in this group had IUC removal All of the UTI patients were by postoperative day two. IUC stratified as having no risk factors reinsertion rate in this group was 11 percent. Our practice in continued on page 36

V102 No 3 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

TABLE 2. COMPARISON OF UTI CASES WITH NON-UTI CASES

All No UTI UTI p-value n = 811 n = 782 n = 29 Study group; n (%) 0.004 Control 215 (27) 200 (26) 15 (52) Group 1 476 (59) 463 (59) 13 (45) Group 2 120 (15) 119 (15) 1 (3) 62.3 0.73 Age, years; mean (SD) 61.3 (16) 61.2 (16) (14.3) Female; n (%) 440 (54) 422 (54) 18 (62) 0.45 Race; n (%) 0.69 White 662 (82) 638 (82) 24 (83) Black 61 (6) 60 (8) 1 (3) Asian 12 (2) 11 (1) 1 (3) Unknown 76 (9) 73 (9) 3 (10) Body mass index; mean (SD) 27.1 (6) 27.2 (6) 25.6 (6) 0.17 Diabetes mellitus; n (%) 108 (14) 105 (14) 3 (10) 0.69 Pulmonary comorbidity; n (%) 120 (15) 115 (15) 5 (17) 0.43 Smoker; n (%) 131 (16) 126 (16) 5 (17) 0.80 Dialysis dependent; n (%) 8 (1) 8 (1) 0 (0) 1.00 Steroid use; n (%) 127 (16) 121 (16) 6 (21) 0.44 Indication; n (%) 0.82 Colon cancer 181 (22) 173 (22) 8 (28) Colon polyp 65 (8) 64 (8) 1 (3) Rectal cancer 70 (9) 67 (9) 3 (10) Rectal polyp 6 (1) 6 (1) 0 (0) Inflammatory bowel disease 115 (14) 109 (14) 6 (21) Diverticulitis 153 (19) 149 (19) 4 (14) | 35 Other 221 (27) 214 (27) 7 (24) ASA Class; n (%) 0.89 I 19 (2) 18 (2) 1 (3) II 354 (43) 343 (44) 11 (38) III 364 (45) 349 (45) 15 (52) IV 64 (8) 62 (8) 2 (7) V 10 (1) 10 (1) 0 (0) Independent functional status; n (%) 744 (92) 718 (92) 26 (90) 0.77 Procedure, n (%) 0.08 Segmental colectomy 460 (57) 449 (57) 11 (38) Proctectomy 238 (29) 229 (29) 9 (31) Total colectomy 50 (6) 46 (6) 4 (14) Proctocolectomy 48 (6) 44 (6) 4 (14) Abdominal perineal resection 15 (2) 14 (2) 1 (3) Emergency case; n (%) 144 (18) 141 (18) 3 (10) 0.46 Elective case; n (%)* 453 (60) 442 (61) 11 (46) 0.20 Wound classification; n (%) 0.61 Clean 3 (0) 3 (0) 0 (0) Clean/contaminated 489 (60) 469 (60) 20 (69) Contaminated 159 (20) 153 (20) 6 (21) Dirty/infected 160 (20) 157 (20) 3 (10) Overall morbidity; n (%) 273 (33) 244 (31) 14 (48)† 0.07 Postoperative superficial surgical site infection; n (%) 58 (7) 52 (7) 6 (21) 0.01 Length of stay, days; mean (SD) 6.2 (6.1) 6.1 (6.0) 9.1 (7.9) 0.06 Mortality 19 (2) 19 (2) 0 (0) 1.00

*Indicates incomplete data availability. †Figure represents morbidity rate other than UTI for this group.

MAR 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

TABLE 3. INDEPENDENT PREDICTORS OF UTI

Odds ratio (95% confidence interval) Postoperative superficial surgical site infection 3.7 (1.4–9.8) Study group (versus control) Group 1 (EMR prompt) 0.4 (0.2–0.8) Group 2 (Intraoperative placement) 0.1 (0.0–0.8)

(43 percent), IUC greater than 48 REFERENCES hours (30 percent), reinsertion of IUC 1. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care- (10 percent), and reinsertion of IUC associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166. for more than 48 hours (17 percent). 2. Saint S. Clinical and economic consequences of nosocomial catheter-related Among patients who required IUC bacteriuria. Am J Infect Control. 2000;28(1):68-75. reinsertion, IUC for more than 48 3. Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with hours, or both, 59 percent had pelvic nosocomial urinary-tract infection. N Engl J Med. 1982;307(11):637-642. surgery and more than 10 percent had 4. Centers for Medicare & Medicaid Services. U.S. Department of Health and Human Services. Medicare Program; Proposed Changes to the Hospital pelvic radiation therapy. The patients Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates. Fed Reg. who had no risk factors for UTI other 2007;72:24679-24726. than the perioperative placement of the 5. Ricciardi R, Baxter NN, Read TE, Marcello PW, Schoetz DJ, Roberts PL. IUC were found solely in the control Surgeon involvement in the care of patients deemed to have “preventable” and intervention 1 groups (see Table 2, conditions. J Am Coll Surg. 2009;209(6):707-711. 6. Regenbogen SE, Read TE, Roberts PL, Marcello PW, Schoetz DJ, Ricciardi page 35, and Table 3, this page ). R. Urinary tract infection after colon and rectal resections: More common | 36 than predicted by risk-adjustment models. J Am Coll Surg. 2011;213(6):784-792. 7. Attaluri V, Kiran RP, Vogel J, Remzi F, Church J. Risk factors for urinary tract What conclusions did we infections in colorectal compared with vascular surgery: A need to review draw from the findings? current present-on-admission policy? J Am Coll Surg. 2011;212(3):356-361. 8. The Joint Commission. 2011–2012 National Patient Safety Goals. Available As the authors of this article reported at: http://www.jointcommission.org/mobile/standards_information/ in 2014, the protocol of sterile national_patient_safety_goals.aspx. Accessed February 14, 2017. intraoperative catheter placement 9. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter alone essentially eliminated UTIs use in the postoperative period: Analysis of the national surgical infection associated with catheter placement.15 prevention project data. Arch Surg. 2008;143(6):551-557. 10. Benoist S, Panis Y, Denet C, Mauvais F, Mariani P, Valleur P. Optimal The somewhat simple change from duration of urinary drainage after rectal resection: A randomized controlled preoperative to intraoperative sterile trial. Surgery. 1999;125(2):135-141. urinary catheterization also had 11. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare significant impact on reducing UTIs in Infection Control Practices Advisory Committee. Guideline for prevention our CRS patients. This practice change of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-326. was really a culture change that involved 12. Zmora O, Madbouly K, Tulchinsky H, Hussein A, Khaikin M. Urinary the CRS service. Nursing engagement bladder catheter drainage following pelvic surgery–is it necessary for that continues to drive this practice and long? Dis Colon Rectum. 2010;53(3):321-326. ensure compliance by all team members. 13. American College of Surgeons User guide for the 2008 participant use data This practice essentially eliminated file. American College of Surgeons. ACS NSQIP. Available at: facs.org/~/ media/files/quality%20programs/NSQIP/UG08.pdf. Accessed February 14, UTIs that were associated only by the 2017. fact that an indwelling catheter was 14. Ingraham AM, Cohen ME, Bilimoria KY, et al. Comparison of hospital placed under sterile conditions. ♦ performance in nonemergency versus emergency colorectal operations at 142 hospitals. J Am Coll Surg. 2010;210(2):155-165. 15. Nagle D, Curran T, Anez-Bustillos L, Poylin V. Reducing urinary tract infections in colon and rectal surgery. Dis Colon Rectum. 2014,57(1):91-97.

V102 No 3 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

In search of the philosopher’s stone: The ALCHEMIST study for lung cancer

by Nirmal Veeramachaneni, MD, FACS; Dennis Wigle, MD, FACS; and Judy C. Boughey, MD, FACS

espite advances in surgical is recommended after surgical mutations, such as erlotinib, and technique, radiation resection. Unfortunately, the lung anaplastic lymphoma kinase Dtherapy, and chemotherapy adjuvant cisplatin evaluation, also (ALK) gene rearrangements, regimens, survival for non-small known as LACE, meta-analysis such as crizotinib, are now cell lung cancer (NSCLC) remains determined the absolute benefit available. By directly attacking uniformly low. Most patients of traditional chemotherapy and abrogating the abnormal in the U.S. have advanced stage added to surgical resection cell signaling cascade, targeted lung disease at time of diagnosis to be 5.4 percent.† Efforts to therapy is emerging as the | 37 and are not amenable to surgical improve these results have not chemotherapeutic method of treatment. When the cancer resulted in significant change choice. Unfortunately, only has spread outside the confines within the last two decades. an estimated 10 percent to of the lung, five-year survival is 15 percent of patients with reported to be 4 percent.* For NSCLC adenocarcinoma have patients with earlier stages of Improving survival EGFR mutations, and only disease (disease confined to the Alchemists, including Sir Isaac 5 percent to 6 percent of patients lung, or with nodal disease not Newton, searched for the magical have ALK gene rearrangements. including the mediastinum) substance—the philosopher’s For patients without these treated with multimodal therapy, stone—to transform lead to mutations, immunotherapy is survival is better, but remains gold, and to create the elixir of emerging as a potential option. poor at 55 percent at five years.* immortality. Today, thoracic The programmed death For patients with either oncologists are searching for (PD)-L1 and PD-L2 ligand is nodal disease or primary tumors the optimal regimen to treat present in some tumors, allowing greater than 4 cm, adjuvant an often incurable disease. the tumor to evade the immune chemotherapy with a doublet Unlike the alchemists of system by suppressing activated regimen of two agents, including old, who had an incomplete T-cells. A number of different either cisplatin or carboplatin understanding of the cancers have responded well *Howlader N, Noone AM, Krapcho M, et building blocks of matter, to PD-1 inhibition, preventing al (eds). SEER Cancer Statistics Review, our understanding of the the immunosuppressive 1975-2013, National Cancer Institute. molecular drivers of cancer has interaction of the tumor cell Bethesda, MD. Available at: seer.cancer.gov/ csr/1975_2013/. Accessed January 23, 2017. had a dramatic effect on the and the T-cell. Nivolumab is a †Pignon JP, Tribodet H, Scagliotti GV, management of more advanced- monoclonal antibody against et al. LACE Collaborative Group. Lung stage lung cancer. Highly specific PD-1 that has demonstrated adjuvant cisplatin evaluation: A pooled analysis by the LACE Collaborative agents that target epidermal efficacy in advanced-stage Group. J Clin Oncol. 2008;26(21):3552-3559. growth factor receptor (EGFR) lung cancer, both in squamous

MAR 2017 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

FIGURE 1. OVERALL SCHEMA OF ALCHEMIST

Stage IB (>4cm), II, and IIIA NSCLC n = 1517/8300

Surgical resection

Molecular testing

Adjuvant therapy

EGFR mutation positive ALK positive EGFR & ALK negative n = 86/450 n = 29/450 n = 46/714

Erlotinib or placebo Crizotinib or placebo Nivolumab or placebo

and adenocarcinoma, tumors) versus placebo. With be randomized to crizotinib regardless of PD-L1 expression emerging data on the role of PD-1 versus placebo. The goal of this 38 | on the tumor cell.‡ mediated immunotherapy, in study is to accrue 450 patients 2016, a third arm was added to the to each of these treatment arms study, which permits the inclusion of the ALCHEMIST trials, ALCHEMIST studies may yield of patients without ALK or EGFR with a goal of accruing 714 revolutionary therapy options mutations and randomizes them patients in the immunotherapy In 2014, the Adjuvant Lung to nivolumab versus placebo. adjuvant treatment arm. Cancer Enrichment Marker Patients with squamous cell The ALCHEMIST trials have Identification and Sequencing NSCLC—as well as patients with the potential to revolutionize Trials, or ALCHEMIST, opened. adenocarcinoma NSCLC who adjuvant therapy for patients with The goals of the trials are to are ALK and EGFR mutation- operable lung cancer. With the identify the prevalence of EGFR negative—are now eligible addition of the immunotherapy and ALK mutations in patients for inclusion in this landmark arm to this trial, all patients with who are eligible for adjuvant trial due to the addition of this operable NSCLC adenocarcinoma chemotherapy, and to evaluate the third arm evaluating adjuvant and squamous histology can and benefit of targeted chemotherapy immunotherapy in this setting. should have the opportunity in the adjuvant setting. Patients A total of 1,060 sites are to participate. We know that with stage IB (>4cm) through IIIA accruing patients in this the current standard of care of disease are eligible. Depending nationwide trial. At press time, cisplatin-based chemotherapy on EGFR or ALK mutational 1,517 patients were enrolled. The offers little benefit in the adjuvant status, patients are randomized to goal is to enroll 8,300 patients. setting. The addition of targeted targeted drug therapy (erlotinib Also as of press time, screening therapy in the context of a tumor for EGFR mutant tumors or for EGFR and ALK mutations having a specific mutation—or crizotinib for ALK-rearranged had resulted in 86 patients with immunotherapy to prevent the EGFR mutations able to be escape of tumor cells from our ‡Brahmer J, Reckamp KL, Baas P, et al. randomized to erlotinib versus natural immune defenses—may Nivolumab versus docetaxel in advanced squamous-cell non-small-cell lung cancer. placebo, and 29 patients with improve long-term survival New Engl J Med. 2015;373(2):123-135. ALK rearrangements able to in patients with NSCLC. ♦

V102 No 3 BULLETIN American College of Surgeons FROM THE ARCHIVES

Celebrating the sesquicentennial of Lord Joseph Lister

FRANKLIN MARTIN, MD, FACS, by Don K. Nakayama, MD, MBA, FACS FOUNDER OF THE AMERICAN COLLEGE OF SURGEONS

he sesquicentennial acid was a favored compound, anniversary of the removing the unpleasant publication of Lord Joseph smells without apparent ill T 4,5 Lister’s (1827–1912) first paper effects on grazing cattle. on carbolic acid and antisepsis Lister made the connection in The Lancet is March 16.1 Even between the stench of human though physicians, including waste and gangrene and the Lister himself, abandoned the use potential of carbolic acid to of carbolic acid only two decades function as a disinfectant, and later, he remained the leading so he began to use carbolic acid advocate of the application of in dressings in patients with germ theory in the care of surgical open fractures. Of his first 11 patients in Great Britain.2 Harold patients, only two died, which Ellis, CBE, FRCS, has called the was a result he viewed as a achievement “the watershed stunning improvement.6 Many | 39 between two eras of surgery, the surgeons adopted Lister’s so- primitive and the modern, since called antiseptic system, including it was the first to be performed spraying carbolic acid over the as an antiseptic procedure.”3 operative field, a practice he advocated a few years later, and which would eventually Controversial from the start be known as “Listerism.”7 Lister, a Scottish surgeon, Other surgeons and scientists struggled with the one-in-two remained skeptical. Carbolic mortality rate from wound acid burned uninvolved skin Lord Lister in 1902 infection that surrounded surgery and irritated the eyes, nose, in the mid-19th century. Thomas and hands of anyone exposed Anderson—a Glasgow professor to it. In 1886, Howard Atwood and an expert in agricultural Kelly, MD, of the University of chemistry—advised Lister to Pennsylvania, Philadelphia, said, read Louis Pasteur’s papers, “If used in strength sufficient “Recherches sur la putrefaction,” to certainly prevent sepsis, the which described the role of patient is very often killed along microbes in spoiled wine and with the germs.”8 Furthermore, milk. Lister reasoned that other surgeons reported the same phenomenon could rates of infection and death occur in decomposing flesh. that were lower than Lister’s Lister and Anderson discussed without using the chemical.9 the latter’s work to deodorize In 1881, German physician sewage and render it suitable for and microbiologist Robert agricultural manure. Carbolic Koch found that bacilli

MAR 2017 BULLETIN American College of Surgeons FROM THE ARCHIVES

An artist’s depiction of Lister spraying phenol over a patient

thrived in wounds treated with carbolic acid. He REFERENCES advocated the use of pressurized steam to sterilize 1. Lister J. On a new method of treating compound anything that came in contact with the patient, from fracture, abscess, etc. With observations on the conditions of suppuration. The Lancet. instruments to the surgeon’s garb, an approach that 1867;89(2273):357-359. proved effective in controlling surgical infection. 2. Worboys M. Spreading Germs. Disease Theories and Within a decade, asepsis supplanted Listerism.10 Medical Practice in Britain, 1865-1890. Cambridge, UK: Cambridge University Press; 2000. 3. Ellis H. The first “antiseptic” operation. J Perioper Lister’s legacy Pract. 2015;25(4):87-88. 4. Anderson T, Bateman JF. Report on the Means of Why is Lister celebrated in the history of surgery? He was Deodorizing the Sewage of Glasgow. Glasgow, Scotland: not the first to use carbolic acid or to apply antisepsis. In University Press, 1858. Available at: archive.org/ 1901, Dr. Kelly wrote that Jules Lemaire, a Paris, France- details/b21467316. Accessed January 20, 2017. based physician, was the first to use carbolic acid in 5. Report from the Select Committee on Sewage of surgery in 1864, three years before Lister’s papers were Towns; together with the Minutes of Evidence and 11 Appendix. Ordered by the House of Commons published. In 1970, Owen H. Wangensteen, MD, FACS, to be printed, April and July, 1862. Br J Psychiatry. 40 | opined that Ignaz Semmelweis’ use of hypochlorous 1863;9(45):143-144. Available at: bjp.rcpsych.org/ acid in 1847 to prevent puerperal fever was rightly the content/9/45/143. (Password protected). Accessed first use of antiseptic in preventing surgical infection.12 January 23, 2017. 6. Lister J. On the antiseptic principle in the practice of Michael Worboys, former director of the Centre surgery. Br Med J. 1867;2(351):246-248. for the History of Science, Technology and Medicine, 7. Lister J. On a case illustrating the present aspect University of Manchester, U.K., argues that Lister’s of the antiseptic treatment in surgery. Br Med J. contribution to the evolution of surgery is based on how 1871;1(524):30-35. he incorporated Pasteur’s findings into his practice of 8. Kelly HA. Asepsis not antisepsis. A plea for 13 principles, not paraphernalia, in laparotomy. surgery. His exacting techniques of wound dressings Transactions of the Obstetrical Society of and antiseptic mists, however ineffective, were based Philadelphia. Am J Obstet Dis Women Child. on his understanding of science. Lister’s work showed 1886;19(10):1076-1081. that surgery had evolved from the heroics of Scottish 9. Greenwood A. Lawson Tait and opposition to germ surgeon Robert Liston’s bravura 30-second amputations theory: Defining science in surgical practice. J Hist Med Allied Sci. 1998;53(2):99-131. and its 300 percent mortality rate—the patient, the 10. Schlich T. Asepsis and bacteriology: A realignment assistant who lost a finger, and a bystander who died of surgery and laboratory science. Med Hist. from shock after nearly being sliced by Liston’s errant 2012;56(3):308-334. scalpel. Perhaps Lister’s contribution to modern medicine 11. Kelly HA. Jules Lemaire: The first to recognize the can best be summed up by Rev. Thomas Gariepy, true nature of wound infection and inflammation, and the first to use carbolic acid in medicine and CSC, professor and chair of healthcare administration, surgery. JAMA. 1901;36(16):1083-1088. Stonehill College, Easton, MA: “Antiseptic surgery… 12. Wangensteen OH. Nineteenth century wound fostered the alliance between science and medicine.”14 management of the parturient uterus and While carbolic acid vaporizers are now relics, Lister and compound fracture: The Semmelweis-Lister priority Lemaire based their practices on Pasteur’s revolutionary controversy. Bull NY Acad Sci. 1970;46(8):565-596. 13. Worboys M. Practice and science of medicine in the discoveries. When Professor Koch, the next great figure nineteenth century. Isis. 2011;102(1):109-115. in microbiology, determined that bacilli caused human 14. Gariepy TP. The introduction and acceptance of disease, the field was thus prepared to accept asepsis Listerian antisepsis in the United States. J Hist Med as the next significant development in surgery. ♦ Allied Sci. 1994;49(2):167-206.

V102 No 3 BULLETIN American College of Surgeons ACS FOUNDATION INSIGHTS

Honoring mentors: An ACS tradition

by Sarah B. Klein, MPA

entorships in the surgical Traveling Fellowship, which Graduate Medical Education, profession are greatly serves as a lasting memorial and adjunct professor of Mvalued, and many to the ACS Past-President’s surgery, the University of Texas mentor/mentee relationships extraordinary life and work. Medical School at Houston. have been formed through Dr. Organ was a renowned The annual Claude Organ networking opportunities and general surgeon, educator, and Traveling Fellowship is awarded formal programs offered by the advocate for underrepresented to an outstanding young American College of Surgeons populations entering the surgeon from the SBAS, AWS, or (ACS). The College matches surgical profession. In 1987, he Surgical Section of the National mentors and mentees through its became a founding member of Medical Association (see page Young Fellows Association, the the Society of Black Academic 63 for information on applying Women in Surgery Committee Surgeons (SBAS), and in 1993 for the 2017 fellowship). This (WiSC), and the Committee he became the first and, to year represents a milestone for on Trauma. Many Fellows date, only male recipient of the the Organ Fellowship, as the | 41 have expressed their gratitude Nina Starr Braunwald Award 10th recipient will be named. to mentors in essays and from the Association of Women Patricia L. Turner, MD, other articles featured in ACS Surgeons (AWS) for “outstanding FACS, Director, ACS Division publications, whereas others have service to the advancement of Member Services, was the acknowledged their advisors by of women in surgery.”1 first Organ Fellow in 2008. making tribute gifts to the ACS Dr. Organ’s commitment She used her fellowship award Foundation. Since its founding to mentoring residents was to perform collaborative in 2005, the ACS Foundation unwavering, as many residents research on patient history and has assisted in the development and mentees who benefited from surgical outcomes with the of tribute programs, and the his guidance would confirm. “If anesthesia outcome research contributions raised are used to he never did an operation (he group at Cleveland Clinic, OH. sustain the legacy of inspiring did thousands), if he never gave Subsequent Organ Fellows surgical teachers. Notable a talk, wrote a chapter or wrote have used the fellowship to examples are the Claude H. an article (he did hundreds of cultivate their leadership and Organ, Jr., MD, FACS, Traveling them), if he never held an office mentorship skills, and the Fellowship; the Thomas R. in a major surgical organization 2013 Organ Fellow, Anees B. Russell, MD, FACS, Faculty (he held dozens), he would still Chagpar, MD, MPH, FACS, Research Fellowship; and the be a giant in American surgery used her award to study global Olga M. Jonasson Lectureship. simply for having helped so cancer care management.2 many of us make our own small contribution,” wrote Claude H. Organ, Jr., MD, FACS John R. Potts III, MD, FACS, Thomas R. Russell, MD, FACS Soon after his death in 2005, the one of Dr. Organ’s mentees.1 The Thomas R. Russell, family and friends of Dr. Organ Dr. Potts is now senior vice- MD, FACS, Faculty Research provided funding for the Claude president, surgical accreditation, Fellowship (Russell Fellowship) H. Organ, Jr., MD, FACS, Accreditation Council for fund was established to honor

MAR 2017 BULLETIN American College of Surgeons ACS FOUNDATION INSIGHTS

Dr. Organ Dr. Russell Dr. Jonasson

the former ACS Executive Dr. Russell believed that in the U.S., and the first woman Director, under the leadership the future of the surgical to serve as director of an ACS of whom the College advanced profession rests in the hands of division. She was a devoted the mission of providing the young surgeons who will teacher and mentor to countless optimal surgical patient care. develop into tomorrow’s leaders. surgeons, both men and women. He was a proponent of surgical Thus, the Russell Fellowship Many donors contributed funds research and of those surgeons is targeted at young surgeons to establish an endowment to who followed this career path. who embody the College’s ensure the ongoing presentation Dr. Russell’s positive influence mission of advancing excellence of the Jonasson lectureship. as a mentor was apparent in patient care, identifying and “As one of the first women when many of his mentees and supporting leadership potential, to have a successful career in friends generously contributed and encouraging a strong interest surgery, Dr. Jonasson created a a collective $306,000 in a in research and education. pathway for all of us to follow. 42 | campaign led by ACS Foundation To date, two surgeons have Her leadership, determination, Past Vice-Chair Richard B. been recipients of the Russell and tenacity in breaking down Reiling, MD, FACS, for the Fellowship: Kathleen B. To, barriers enabled and inspired Russell Fellowship fund. MD, FACS, who is studying us to pursue our dreams and Carlos A. Pellegrini, MD, performance improvement in achieve success,” said Hilary FACS, FRCSI(Hon), FRCS(Hon), emergency general surgery A. Sanfey, MB, BCh, FACS, FRCSEd(Hon), ACS Past- at the University of Michigan ACS First-Vice President, and President and Past-Chair, ACS department of surgery, Chair of the Olga M. Jonasson Board of Regents, presented Ann Arbor; and Anthony Lectureship campaign. the ACS Lifetime Achievement D. Yang, MD, FACS, who is The first Jonasson Lecture Award posthumously to working with a 55-hospital was presented at the ACS Dr. Russell during the collaborative to improve venous Clinical Congress 2007 by Nancy Convocation at Clinical thromboembolism prevention at L. Ascher, MD, FACS, who spoke Congress 2014 in San Francisco, Northwestern University Feinberg on The Ultimate in Surgical CA. During the award School of Medicine, Chicago, IL. Translation: Transplantation. presentation, Dr. Pellegrini Each subsequent lecturer has remarked, “In choosing epitomized Dr. Jonasson’s Dr. Thomas Russell, the College Olga M. Jonasson, MD, FACS key attributes of leadership, is not only recognizing his The WiSC and friends and education, research, and service contributions and service to colleagues of Dr. Jonasson to others. Additionally, the the organization’s mission, but established the Olga M. lecture serves as an annual, also is recognizing a dedicated Jonasson Lecture in 2007 to living testament to Dr. Jonasson leader, a compassionate honor her legacy. Dr. Jonasson and her many groundbreaking humanitarian, and a man who was a pioneer and trailblazer, accomplishments as a transplant touched many lives in ways exemplified by her position as surgeon and as an outstanding that left us all better people the first woman to chair an teacher and mentor for many for having known him.”3 academic surgery department women and minority surgeons.4

V102 No 3 BULLETIN American College of Surgeons ACS FOUNDATION INSIGHTS

Dr. Chagpar, 2013 Organ Dr. To, 2015 Russell Pauline W. Chen, MD, FACS, Fellowship recipient Fellowship recipient delivering the 2013 Olga M. Jonasson Lecture

selfless with his mentorship, and REFERENCES The tradition continues never pushed us to be a clone of 1. U.S. National Library of Medicine. More recent fundraising him,” said Dr. Brown. Dr. Shah Opening Doors: Contemporary initiatives in gratitude to mentors also expressed his admiration of African American academic surgeons. also were completed through Dr. Healy, stating, “Not a week 2011. Available at: www.nlm.nih.gov/ the ACS Foundation. As a result, goes by where I do not reflect exhibition/aframsurgeons/organ. the College offers fellowships on a point that was conveyed html. Accessed January 23, 2017. 2. American College of Surgeons. and scholarships honoring ACS to me by Dr. Healy. One of my Member Services. Claude H. Organ, Distinguished Service Award favorites is his imploring us to Jr., MD, FACS, Traveling Fellowship. recipient Murray F. Brennan, MD, just walk down the hall or pick up Available at: facs.org/member- FACS; the late Jameson L. Chassin, the phone and speak to someone services/scholarships/special/organ. MD, FACS; and Dr. Pellegrini. rather than sending an e-mail. Accessed January 7, 2017. 3. American College of Surgeons. In 2015, David J. Brown, MD, The value Dr. Healy placed on Carlos A. Pellegrini, MD, FACS, ACS | associate vice-president and ensuring we realized the value of presents Lifetime Achievement Award 43 associate dean for health equity the personal touch has been an posthumously to Dr. Russell. Bull Am and inclusion, University of invaluable part of my career.” Coll Surg. 2014;99(12):57-58. Available Michigan, Ann Arbor; and Rahul In 2016, the ACS Foundation at: bulletin.facs.org/2014/12/acs- presents-lifetime-achievement-award- K. Shah, MD, FACS, vice-president began a new tradition on posthumously-to-dr-russell/. Accessed and chief quality and safety National Doctors’ Day with January 30, 2017. officer, Children’s National Health a fundraising campaign that 4. American College of Surgeons. System, Washington, DC, led provides the opportunity for Women in Surgery Committee. The the effort to establish a traveling all Fellows and ACS members Olga M. Jonasson Lecture. Available at: facs.org/about-acs/governance/ mentorship award named for ACS to honor their mentors with a acs-committees/women-in-surgery- Past-President and Past-Chair, tribute gift. On March 30, the ACS committee/jonasson. Accessed ACS Board of Regents, Gerald B. Foundation is again participating January 23, 2017. Healy, MD, FACS, FRCS(Hon), in the 2017 National Doctors’ 5. American College of Surgeons. ACS FRCSI(Hon).5 The intent of Day. Any donor who makes a Foundation. Healy award fundraising initiative achieves goal. Available at: the Gerald B. Healy Traveling contribution in honor of a mentor facs.org/about-acs/acs-foundation/ Mentorship Award is to provide a will be recognized in the ACS initiatives/healy. Accessed January 23, young surgeon with the resources Bulletin, ACS NewsScope, on the 2017. needed to travel and meet with ACS website, and at Clinical one or more mentors. Recipients Congress. As a courtesy, an are expected to then report on acknowledgement letter will lessons learned. Drs. Brown and be sent to the donor’s honoree Shah created this fellowship or family, if in memoriam. to honor Dr. Healy’s highly For more information, respected mentorship of many visit facs.org/acsfoundation residents and medical students. or call 312-202-5338. ♦ “Dr. Healy always looked out for our best interests, was

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

The Joint Commission clarifies stance on secure text messaging of patient care orders

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

ommunication is an essential component of the safe and effective practice of medicine and, Cin particular, surgery. In today’s digital age, communication takes place across various platforms. A 2015 study by the Pew Research Center showed that nearly two-thirds of Americans (64 percent) own a smartphone, and that text messaging is the most widely used feature on these devices.* In the 18–29-year-old demographic, nearly 100 percent of the respondents said they used their smartphones for text messaging, whereas nearly 98 percent of respondents ages 30–49 said they use their phones to text message. 44 |

Texting in health care: The debate continues Texting may be a popular and effective way to communicate with friends and family, but in recent years The Joint Commission and other stakeholders have debated its appropriateness in the health care environment. In May 2016, The Joint Commission acknowledged advancements that have resulted in enhanced security for text message data.† As a result, The Joint Commission revised its previous position that advised against secure texting of patient care orders and decided to allow licensed independent practitioners (LIPs) to use secure text messaging platforms to send patient care orders, provided the systems met certain criteria. However, after concerns were raised about security issues related to transmitting orders via text in December 2016, The Joint Commission, in collaboration with the Centers for Medicare & Medicaid Services (CMS), decided to reverse its May 2016 position to

*Pew Research Center. U.S. smartphone use in 2015. Pew Research Center American trends panel experience sampling survey, November 10–16, 2014. Available at: www.pewinternet.org/2015/04/01/ us-smartphone-use-in-2015/. Accessed January 20, 2017. †Joint Commission Resources. Update: Texting orders. Perspectives. May 2016. Available at: www.jointcommission.org/assets/1/6/ Update_Texting_Orders.pdf. Accessed January 12, 2017.

V102 No 3 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

The Joint Commission decided that the use of secure text orders was unacceptable for a number of reasons.

allow secure texting for patient with CMS was that text advancements in technology care orders and issued the messaging of orders would shape this issue and will following recommendations:‡ place an increased burden on continue to consult with key nurses. If more providers texted stakeholders to determine • All health care organizations patient care orders, nurses how best to address the issue should have policies prohibiting would have to enter those in the future. Any questions the use of unsecured text orders into the EHR manually, regarding text orders and The messaging, also known as short which would add time and Joint Commission’s stance can message service, from a personal could lead to the introduction be e-mailed to textingorders@ mobile device for communicating of errors. Another concern jointcommission.org. ♦ protected health information. centers on the challenges this technology presents regarding • The Joint Commission and CMS detailed conversations. As the Disclaimer | 45 agree that computerized provider patient care order becomes The thoughts and opinions order entry (CPOE), which more detailed, a conversation expressed in this column are refers to any system in which becomes more necessary—for solely those of Dr. Pellegrini and clinicians directly place orders example, a discussion regarding do not necessarily reflect those electronically, should be the how medication might interfere of The Joint Commission or the preferred method for submitting with other prescriptions. Because American College of Surgeons. orders, as it allows providers to text messaging is not integrated directly enter orders into the into the EHR system, crucial electronic health record (EHR). information could be overlooked. Another reason The Joint • In the event that a CPOE Commission issued the new or written order cannot be recommendations on text submitted, a verbal order is messaging is the possibility acceptable on an infrequent basis. of a clinical decision support alert during the order entry The Joint Commission process into the EHR, when the decided that the use of secure individual keying in the order text orders was unacceptable may need to contact the ordering for a number of reasons. One health care professional for concern raised in discussions more information. When the information is communicated ‡Joint Commission Resources. Clarification: Use of secure text messaging for patient verbally, the clarification is care orders is not acceptable. Perspectives. immediate, whereas an order by December 2016. Available at: www. text could potentially face delays. jointcommission.org/assets/1/6/ Clarification_Use_of_Secure_Text_ The Joint Commission Messaging.pdf. Accessed January 12, 2017. will continue to monitor how

MAR 2017 BULLETIN American College of Surgeons NTDB DATA POINTS

What you don’t see can kill you

by Richard J. Fantus, MD, FACS

he retroperitoneal injury and the location of the space, also known as hematoma. Mortality ranges Traumatic retroperitoneal Tthe retroperitoneum, is widely based on location and defined as the area between etiology of the hematoma. hematoma is a potentially the parietal peritoneum and life-threatening condition the muscles and bones of the posterior abdominal wall. A stealth killer associated with both Sandwiched between this thin To examine the occurrence blunt and penetrating tissue layer and the rigid back of injured patients with are solid organs, hollow viscera, retroperitoneal hematoma injury mechanisms to the and vascular structures. from a blunt mechanism structures in that region. Traumatic retroperitoneal contained in the National hematoma is a potentially Trauma Data Bank® (NTDB®) 46 | life-threatening condition research dataset admission year associated with both blunt and 2015, medical records were penetrating injury mechanisms searched using the International to the structures in that region. Classification of Diseases, Ninth Hematomas are divided Revision, Clinical Modification into three zones based codes. Specifically searched on their location in the were records that included an retroperitoneum. Zone I is a external cause of injury code centrally located hematoma that represented a blunt trauma of the upper retroperitoneum mechanism, along with a and is concerning for injury diagnosis code of 868.04 (injury to the aorta, inferior vena to other intra-abdominal organs cava, pancreas, or duodenum. without mention of open wound Zone II, or the lateral zones, into cavity, retroperitoneum). are on either side of zone I A total of 4,583 records and include the kidney and its were found, of which 4,167 associated structures as well records contained a discharge as parts of the colon. Zone status, including 1,981 patients III is located in the pelvis and discharged to home, 1,023 to often associated with blunt acute care/rehab, and 560 to pelvic fractures or iliofemoral skilled nursing facilities; 603 died vascular injuries. Each zone (see Figure 1, page 47). Of these presents unique challenges to patients, 70 percent were men, diagnosis, as well as treatment. on average 48.3 years of age, had Treatment is divided into an average hospital length of stay operative and nonoperative of 10.6 days, an intensive care based upon mechanism of unit length of stay of 7.9 days, an

V102 No 3 BULLETIN American College of Surgeons NTDB DATA POINTS

Traumatic injuries often are visually obvious or easily diagnosed with routine studies in the trauma resuscitation area. However, given the location and occult nature of retroperitoneal hematomas, what you don’t see can kill you.

FIGURE 1. HOSPITAL DISCHARGE STATUS

| 47

average injury severity score of undiagnosed or undertreated our website about how to 24.5, and were on the ventilator can result in fatalities. obtain NTDB data for more for an average of eight days. Traumatic injuries often are detailed study. If you are Searching these records visually obvious or easily interested in submitting your for the data field for comorbid diagnosed with routine studies trauma center’s data, contact condition number four (bleeding in the trauma resuscitation Melanie L. Neal, Manager, disorder) revealed that only area. However, given the NTDB, at [email protected]. ♦ 7 percent (331 of the 4,583) had location and occult nature of a contributing factor, such retroperitoneal hematomas, as chronic anticoagulation, what you don’t see can kill you. Acknowledgment prior to sustaining an injury. Throughout the year, we Statistical support for this article Of those tested for alcohol, will be highlighting these data was provided by Chrystal Caden- almost one-third (717 out through brief monthly reports Price, Data Analyst, NTDB. of 2,471) tested positive. in the Bulletin. The NTDB With such a diverse Annual Report 2016 is available presentation and potential on the ACS website as a PDF constellation of associated file at facs.org/quality-programs/ injuries, it is no wonder that trauma/ntdb. In addition, retroperitoneal hematomas left information is available on

MAR 2017 BULLETIN American College of Surgeons NEWS

Children’s Surgery Verification program officially under way

The American College of Furthermore, specialized have immediate access to Level Surgeons (ACS) Children’s pediatric anesthesia is critical for I or Level II institutions. These Surgery Verification™ (CSV) safe, contemporary children’s centers should be capable of Quality Improvement Program surgery.6-8 A specialized providing prompt assessment, officially opened its verification children’s environment also is resuscitation, emergency process in January with the important to achieve optimal operations, and stabilization and goal of ensuring that pediatric outcomes at a population level should be able to arrange for surgical patients have access for some relatively simple possible transfer to a facility that to high-quality care. This pediatric surgical problems can provide definitive surgical new program defines the such as intussusception, pyloric care. To access the standards, resources necessary to achieve stenosis, and appendicitis in visit facs.org/quality-programs/ optimal patient outcomes for children ages five and younger.6,9 childrens-surgery/childrens- children receiving surgical The CSV program evaluates surgery-verification/standards. care at certain health care applicant centers to verify that facilities. The CSV program optimal children’s resource 48 | is administered by the ACS standards are met and matched A collaborative effort and the ACS CSV Committee to the expected scope of practice This program is the result of and offers institutional at the hospital. Centers may the work of the Task Force verification to sites that meet provide Level I, Level II, or Level for Children’s Surgical Care, the prescribed standards. III children’s specific resources. a multidisciplinary group To qualify as a Level I of leaders representing all children’s surgical center, the aspects of the children’s A pressing need hospital must be a regional, surgical community. The task The ACS has a long history tertiary-care facility that is force began meeting in the of activities directed toward central to the children’s health spring of 2012 to develop best the improvement of surgical care system. This facility must practices and approaches to care. The ACS developed the have the capability of providing optimize children’s surgical CSV program because a large leadership and comprehensive care. From these meetings, the proportion of children’s surgical care for all aspects of children’s task force collaborated with care in the U.S. is provided in surgical needs. To fulfill this the ACS Division of Research nonspecialized environments. central role, the Level I center and Optimal Patient Care to Some of the procedures provided must have adequate depth develop the requirements for in these facilities are relatively of resources and personnel. verification. These standards simple, but others are done on For Level II designation, the are the nation’s first and only high-risk patients and are of children’s surgical center is multispecialty benchmarks greater complexity.1 A specialized expected to provide initial aimed at improving surgical environment is associated with children’s surgical care, care for infants and children. better clinical outcomes for regardless of the complexity “The vision is to see that these children, particularly of the case, and definitive care every child in need of surgical high-risk patients needing when appropriate. The Level care will receive this care congenital heart surgery, trauma III children’s surgical centers in an environment with care, and neonatal surgery.2-5 serve communities that do not resources optimal for his/her

V102 No 3 BULLETIN American College of Surgeons NEWS

“The vision is to see that every child in need of surgical care will receive this care in an environment with resources optimal for his/her individual needs.” —Dr. Oldham

individual needs,” said Keith pediatric nurses who review REFERENCES T. Oldham, MD, FACS, Chair, the center's structure, process, 1. Somme S, Bronsert M, Morrato E, Children’s Surgery Verification and clinical outcomes data. The Ziegler M. Frequency and variety of Quality Improvement Optimal Resources for Children’s inpatient pediatric surgical procedures in the United States. Pediatrics. Program, and surgeon-in- Surgical Care manual drives 2013;123(6):e1466-1472. chief, Children’s Hospital of the application and is used as a 2. Chang RKR, Klitzner TS. Can Wisconsin, Milwaukee. guide in conducting the survey. regionalization decrease the number The CSV pilot program The CSV program has of deaths for children who undergo launched in April 2015 at six garnered key endorsements cardiac surgery? A theoretical analysis. Pediatrics. 2002;109(2):173-181. sites of various sizes, types, from multiple specialty societies 3. Pasquali SK, Dimick JB, Ohye RG. and verification levels. All of including the American Time for a more unified approach the sites were visited, and the Academy of Pediatrics, to pediatric health care policy?: The pilot was concluded successfully American Pediatric Surgical case of congenital heart care. JAMA. in the fall of 2016. The ACS Association, and Society of 2015;314 (16):1689-1690. CSV Committee finalized the Pediatric Anesthesiology. 4. Sathya C, Alali AS, Wales PW, et al. Mortality among injured children | 49 standards manual and pre- Verified centers are listed treated at different trauma center review questionnaire (PRQ) at facs.org/quality-programs/ types. JAMA Surg. 2015;150(9):874-881. based on lessons learned in the childrens-surgery/childrens- 5. Kastenberg ZJ, Lee HC, Profit J, pilot phase of the program. surgery-verification/centers. For Gould JB, Sylvester KG. Effect of deregionalized care on mortality in A number of changes were more information, contact very low-birth-weight infants with identified in this process, [email protected]. ♦ necrotizing enterocolitis. JAMA Pediatr. such as the need for defined 2016;169(1):26-32. alternative training pathways 6. McAteer JP, Richards MK, Stergachis for pediatric anesthesiology, A, et al. Influence of hospital and patient location on early postoperative pediatric emergency medicine, outcomes after appendectomy and and pediatric radiology. pyloromyotomy. J Ped Surg. 2015;50(9): 1549-1555. 7. Mamie C, Habre W, Delhumeau C, Applying for verification Argiroffo CB, Morabia A. Incidence and risk factors of perioperative Centers seeking verification must respiratory adverse events in children first submit a pre-application. undergoing elective surgery. Pediatr The pre-application and PRQ Anesth. 2004;14:218-224. must be submitted via the 8. Auroy Y, Ecoffey C, Messiah A, online application portal at Rouvier B. Relationship between complications of pediatric anesthesia accreditation.facs.org/programs/csv. and volume of pediatric anesthetics. After submitting an Anesth Analg. 1997;84:234-235. application, centers seeking 9. McAteer JP, Kwon S, Lariviere CA, verification undergo an Oldham KT, Golding AB. Pediatric extensive site visit by a team specialist care is associated with a lower risk of bowel resection in of ACS surveyors, comprising children with intussusception: A experienced pediatric surgeons, population based analysis. J Am Coll pediatric anesthesiologists, and Surg. 2013;217(2):226-232.

MAR 2017 BULLETIN American College of Surgeons NEWS

ACS launches AHRQ Safety Program for ERAS The American College of Surgeons (ACS), in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, has launched the AHRQ (Agency for Healthcare Research and Quality) Safety Program for Enhanced Recovery after Surgery (ERAS). This new surgical quality improvement program is funded and guided by AHRQ. The AHRQ Safety Program for ERAS will support hospitals in implementing perioperative evidence-based protocols to meaningfully improve clinical outcomes, reduce health care utilization, and improve the patient experience. This program aims to enroll at least 750 hospitals throughout the five-year contract. Hospitals within the U.S., Puerto Rico, and the District of Columbia are eligible to participate across five service lines: colorectal, orthopaedic, bariatric, gynecology, and emergency general surgery. Participating hospitals will have access to the international leaders in ERAS, including representatives of surgery, anesthesiology, and nursing; prototype ERAS protocols developed for five procedures based on up-to-date evidence review; literature to support protocols; tools and educational materials to facilitate implementation; quality improvement specialist support; and coaching calls to support hospital work. Program enrollment will begin in spring 2017. For more information, contact [email protected]. ♦

50 |

Make the ACS a part of your daily life.

Visit web4.facs.org/ebusiness to purchase official ACS-branded lab coats, surgical caps, and more!

16-1928-OS-ACS e-Commerce Ad-halfpage-v03.indd 1 2/16/2017 8:46:10 AM V102 No 3 BULLETIN American College of Surgeons NEWS

ACS NSQIP conference gets new name, expanded focus

To provide a more comprehensive goal of improving quality, to heart, lung, kidney, and liver look at the American College presenters and organizers failure, as well as the loss of both of Surgeons (ACS) quality are striving to accomplish legs; however, after an intensive improvement efforts, the the following objectives: rehabilitation regimen, he was College has announced that the able to attend and graduate ACS National Surgical Quality • Provide a forum to share the from college and law school. Improvement Program (ACS most up-to-date knowledge Another conference NSQIP®) Annual Conference will pertaining to local, national, highlight will be abstract now be the 2017 ACS Quality and and international quality competitions in four categories: Safety Conference. The meeting improvement initiatives in surgery Medical Student and Surgical will take place July 21–24 at the Resident Abstract Competition, New York Hilton Midtown, NY. • Present methods used to SCR Abstract Competition, The annual ACS NSQIP analyze clinical registry data Clinical Abstract Competition, conference has grown rapidly in and demonstrate practical and Abstract Poster Competition. recent years—the 2016 conference ways to use the data Clifford Y. Ko, MD, MS, in San Diego, CA, drew nearly 1,500 MSHS, FACS, FASCRS, Director, surgeon champions, surgical clinical • Assist hospitals in analyzing, ACS Division of Research and reviewers (SCRs), and other quality managing, and interpreting Optimal Patient Care, which improvement professionals. The data by providing education oversees all ACS Quality | 51 ACS Quality and Safety Conference on proven methods that will Programs, is enthusiastic about will build on that success, featuring empower hospitals to make a the newly expanded ACS Quality leaders in surgery as speakers and positive impact on patient care and Safety Conference. “We are various presentations focused excited to have multiple quality on ACS NSQIP, while offering • Enhance the learning experience programs of the American expanded content on the following by offering breakout sessions College of Surgeons coming ACS Quality Programs: that educate attendees on topic together for this conference areas of interest to them, with so that we can all learn how • ACS NSQIP Pediatric consideration of their level to get better, become more of experience in ACS quality efficient, and provide high-value • Metabolic and Bariatric Surgery improvement programs care in all types of settings,” Accreditation and Quality Dr. Ko said. “This is the first Improvement Program time we’ve put together a Conference highlights conference like this, which we • Children’s Surgery Verification™ In addition to talks from surgical hope will be the first of many.” Quality Improvement Program leaders, the 2017 ACS Quality More information about the and Safety Conference will 2017 ACS Quality and Safety • Surgeon Specific Registry offer other notable events. Conference can be found Keynote speaker Blake at facs.org/quality-programs/ Haxton, a member of the 2016 quality-safety-conference. ♦ Achieving quality U.S. Paralympic Team in rowing, The theme of the expanded will share his unique insight conference, Achieving Quality: with attendees. Mr. Haxton Present and Future, will serve contracted necrotizing fasciitis as the basis of the meeting’s in March 2009, in his senior year proceedings. To achieve the of high school. The infection led

MAR 2017 BULLETIN American College of Surgeons NEWS

Register for 2017 ACS 22 cancer care facilities Residents as Teachers receive biannual and Leaders Course CoC Outstanding Achievement Award Registration is open for the 11th annual Residents as Teachers and Leaders Course hosted by the The Commission on Cancer (CoC) American College of Surgeons (ACS) Division of the American College of Surgeons of Education. The 2017 program, April 28−30 at (ACS) has granted its year-end 2016 the ACS headquarters in Chicago, IL, is designed Outstanding Achievement Award (OAA) specifically for surgery residents and will to a select group of 22 accredited cancer address the essential nonclinical skills—teaching programs throughout the U.S. and leading—that are required for success as Award criteria were based on qualitative surgeons and members of the health care team. and quantitative surveys conducted July 1 The course faculty, all experts in resident through December 31, 2016. The biannual education, will provide an interactive award was established in 2004 to recognize learning environment. Residents will learn cancer programs that strive for excellence to lead a team more effectively, resolve in demonstrating compliance with the conflict, be better teachers, give constructive CoC standards and are committed to feedback, and apply these skills during and ensuring high-quality cancer care. after residency. The number of participants A CoC-accredited cancer program is is limited to allow ample interaction with eligible to earn the OAA after completing faculty and to facilitate networking. This the accreditation survey and receiving course is targeted at mid- to senior-level a performance report that indicates an 52 | residents, but all are welcome to attend. accreditation award of “Three-Year with Registration information and a brochure Commendation.” Specifically, the program are available at the course website at must receive commendation ratings for the facs.org/residentsteachers; early bird registration seven commendation level standards and no ends April 1. Note that last year’s course deficiencies for the remaining 27 standards. was oversubscribed, so register soon if View the list of this year’s first group you are interested in attending. Contact of OAA recipients on the ACS website Cherylnn Sherman at [email protected] at facs.org/quality-programs/cancer/coc/ or at 312-202-5424 with any questions. ♦ info/outstanding/2016-part-2. ♦

Coming next month in JACS, and online now

Distal cholangiocarcinoma and pancreas cancer: A 13-institution study from the U.S. extrahepatic biliary malignancy consortium and the central pancreas consortium

Cecilia G. Ethun, MD; Alexandra G. Lopez-Aguiar, MD; Timothy Pawlik, MD, MPH, PhD, FACS; and colleagues found that while distal cholangiocarcinoma (DC) and pancreatic ductal adenocarcinoma (PDAC) are distinct entities, DC has a more favorable prognosis than PDAC. Current adjuvant therapy regimens are only associated with improved survival in PDAC, not DC. Treatment paradigms used for PDAC should not be extrapolated to DC, despite similar operative approaches, and novel therapies for DC should be explored. This article and all other JACS content is available at www.journalacs.org. ♦

V102 No 3 BULLETIN American College of Surgeons NEWS

Post-election health policy takes center stage at AMA HOD meeting

by John H. Armstrong, MD, FACS, and Jon H. Sutton, MBA

The American Medical refreshed their hands-on skills by eight health professional Association (AMA) Interim in bleeding control and became organizations and the American House of Delegates (HOD) advocates for bringing the course Bar Association to reduce the meeting took place November back to their communities. public health consequences 12–15, 2016, in Orlando, FL. A Course success was recognized of firearm-related injury. total of 530 state medical society before the entire HOD. and specialty society delegates, including the six members U.S. elections put health of the American College of Surgical Caucus focuses on care system in spotlight Surgeons’ (ACS) delegation, mass casualty readiness Five resolutions covering a debated the policy implications The Surgical Caucus sponsored spectrum of opinions about AMA of 32 reports and 101 resolutions. a one-hour educational session, engagement in ACA reform were Occurring within a week of The Hartford Consensus: discussed. The five proposals the national elections, a central Strategies to Enhance were consolidated into one | 53 focus of the meeting was the Survival in Active Shooter adopted resolution, which calls uncertainty about the future of and Intentional Mass Casualty for the AMA, in collaboration the Affordable Care Act (ACA). Events. Dr. Weireter shared with state and specialty medical On the other hand, the Stop an overview of the Hartford societies, to actively discuss the the Bleed® program received Consensus recommendations future of health care reform an enthusiastic reception. for effective response to active with the new presidential shooter and mass casualty administration and Congress. events and highlighted the AMA executive vice-president ACS delegation sponsors Stop value of the Stop the Bleed James Madera, MD, sent a letter the Bleed skills course course in improving survival of to congressional leaders on AMA meetings provide an casualties from these events. January 3 emphasizing the AMA’s opportunity for the ACS delegates Orlando trauma surgeon interest in proposals that “make to share College initiatives Michael Cheatham, MD, FACS, coverage more affordable, provide with physician leaders from a gave a synopsis of the Orlando greater choice, and increase the breadth of geographic locations, Regional Medical Center number of those insured.” specialties, and career stages. response to the Pulse nightclub The ACS delegation focused In this spirit, ACS delegates, shooting in June 2016. In addition on the ACS Health Care all of whom are Stop the Bleed to conducting relevant readiness Reform General Principles, instructors, along with Leonard J. drills, he emphasized the which promote a systems- Weireter, MD, FACS, Vice-Chair, importance of including casualty based approach to health care ACS Committee on Trauma, family assistance and post- quality and safety, patient access presented the skills course event hospital staff counseling to surgical care, reduction of to 125 practicing physicians, in mass casualty plans. health care costs, and medical residents, and medical student At this meeting, the AMA liability reform. (See “Looking delegates. Through four half- endorsed recommendations forward” on page 8 of this hour sessions, participants from a 2015 call to action issue for more information.)

MAR 2017 BULLETIN American College of Surgeons NEWS

At this meeting, the AMA endorsed recommendations from a 2015 call to action by eight health professional organizations and the American Bar Association to reduce the public health consequences of firearm-related injury.

ACS DELEGATION AT THE AMA HOD Maintenance of Certification Surgeon management of General disaffection with patients with perioperative pain John H. Armstrong, MD, FACS Maintenance of Certification A resolution intended to reduce (Delegation Chair), acute (MOC) requirements persists perioperative opioid consumption care surgery, Ocala, FL in multiple specialties, with was introduced, calling for Brian J. Gavitt, MD, MPH (also particular concerns related to hospitals to adopt practices for Young Physicians Section delegate), its use in credentialing and perioperative pain management, general surgery, Cincinnati, OH privileging decisions. The HOD which include services dedicated adopted a policy that directs to acute pain management. Jacob Moalem, MD, FACS (also the AMA to increase efforts This proposal generated a Young Physicians Section delegate), to ensure that MOC does not great deal of concern among general surgery, Rochester, NY become a requirement for surgical and anesthesiology 54 | Leigh A. Neumayer, MD, FACS, insurance panel participation, delegates. The HOD appreciated state medical licensure, and that surgeons are trained to general surgery, Tucson, AZ; medical staff membership manage the perioperative Vice-Chair, ACS Board of Regents (initial and ongoing). pain of their patients and may Naveen F. Sangji, MD, consult for additional services general surgery resident, as needed. Thus, existing Boston, MA Medical student and AMA efforts to promote resident training appropriate clinical use of opioid Patricia L. Turner, MD, FACS, Delegates agreed with a need analgesics were reaffirmed general surgery, Chicago, IL; for formal leadership training in lieu of the resolution. Director, ACS Division of Member during medical school. The Services; Chair, AMA Council AMA now advocates for the on Medical Education creation of leadership programs Next meeting that emphasize experiential The next meeting of the AMA learning of skills necessary to HOD is scheduled for June 10–14 lead inter-professional teams. in Chicago. This meeting will be Delegates also recognized the first since the inauguration the importance of having of President Donald Trump, and training program policies the ACS delegates anticipate that that support residents who national health care policy will are breastfeeding. As a result, again dominate the discussion. the AMA will now work ACS members with suggestions with appropriate professional for potential resolutions should regulatory organizations to forward them to Jon Sutton put policies for protected times at [email protected]. ♦ and locations for breastfeeding into program requirements.

V102 No 3 BULLETIN American College of Surgeons ACS Practice Management Course for R ES I D E N T S and YO U N G S U R G EO N S

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

Available Online or in Print

Using an interactive/lecture format, NEW topic in each volume: the three separate courses cover a variety of topics, including: zzVolume 1: Interpersonal and Communication Skills—An Important zzPros and cons of a career Competency for Risk Management in private practice zzVolume 2: Professionalism—A Critical zzSurgical practice organization Risk Management Tool

zzCoding for surgical residents zzVolume 3: Post-Adverse Event Communication—The Key! zzSurgical financial management reports

zzInsurance processing

zzAccumulation planning To access the ACS Practice zzGoal planning and risk management Management Course today, visit facs.org/education/resources/elearning. zzNegotiation

zzLiability equation changes For more information, contact Olivier Petinaux, Senior Manager, Distance Education and E-Learning, at [email protected] or 866-475-4696.

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

2017_ED_Ad_PracticeManagement_BULL_7.5x10.25in_02-14-17_RELEASE.indd 1 2/14/2017 11:17:23 AM SCHOLARSHIPS

International Guest Scholar: Paving the way from reconstructive to regenerative surgery

by Naichen Cheng, MD, PhD

Plastic surgeons treat many had the privilege of visiting include biomedical engineering, complex wounds that require Stanford University, CA, and molecular biology, cytology, soft tissue reconstruction, the University of Chicago, IL, animal assays, drug release, such as diabetic foot ulcers, before going to Washington, genetic engineering, and postoperative breast DC, for Clinical Congress tissue rejection reactions. reconstruction, severe infection, 2016. The trip was focused Dr. Gurtner explained how and reconstruction after major on understanding the impact he uses time management, 56 | trauma. Traditionally, structural regenerative medicine may delegation, and collaboration defects rely on replacement have on the practice of plastic strategies to conduct high- with autologous tissue or surgery in the future, particularly quality research while still allogeneic materials. Although with respect to wound healing performing clinical work. a certain degree of success and breast reconstruction. Because I, too, have done has been achieved, the final considerable research on outcome has rarely been ideal. regenerative medicine for In recent years, developments Stanford University wound healing, Dr. Gurtner in regenerative medicine have My first stop was Stanford invited me to speak at the provided new opportunities for University. My host was Geoffrey plastic surgery grand rounds. more effective care. The essential Gurtner, MD, FACS, Johnson I had a nice discussion with part of regenerative medicine is & Johnson Professor of Surgery some senior physicians in the tissue engineering, defined as and professor of surgery and audience after the presentation, the application of engineering bioengineering. Dr. Gurtner including Michael Longaker, and life science principles and has conducted many important MD, FACS, who also specializes methods toward the development studies in wound healing, with in wound healing research. of biological substitutes in order a focus on the interaction of I visited Dr. Gurtner’s clinic to restore, maintain, or improve tissue regeneration and fibrosis at the Stanford Advanced Wound the function of biological tissue.* pathways during wound healing Care Center, Redwood City, CA. It was my great honor subsequent to skin injury. I had In addition to plastic surgeons, to be the 2016 Elias Hanna the opportunity to speak with the center hires physicians International Guest Scholar. the members of his research team who specialize in metabolic With the support of this and to attend the lab meeting. diseases, cardiovascular surgery, American College of Surgeons The laboratory is equipped rehabilitation, and infectious (ACS) scholarship, I also with state-of-the-art instruments disease. The center is equipped *Langer R, Vacanti JP. Tissue engineering. for a variety of wound healing with two hyperbaric oxygen Science. 1993;260(5110):920-926. studies, and research topics chambers, along with other

V102 No 3 BULLETIN American College of Surgeons SCHOLARSHIPS

Dr. Cheng (right) and Dr. Gurtner Dr. Cheng with Dr. Song at the at Stanford University University of Chicago resources for providing state- surgery and is the immediate of-the-art wound care. past-president of the American The trip was focused on Dr. Gurtner has conducted Society of Plastic Surgeons. several clinical trials aimed at The incidence of breast cancer understanding the impact promoting the application of continues to rise in many regenerative medicine regenerative medicine principles countries, and consequently, the in the treatment of chronic demand for breast reconstruction may have on the practice wounds, including the use of has increased. For women, breast of plastic surgery in the | 57 amniotic membrane products reconstruction can significantly future, particularly with with live cells to enhance the reduce the psychological trauma healing of chronic wounds. of patients after mastectomy. respect to wound healing With the increase in the elderly Breast reconstruction is now a and breast reconstruction. population globally, the incidence mature technique with multiple of diabetic ulcers, bed sores, and approaches, including prosthesis lower extremity arterial ulcers and autologous tissue transfer. is expected to rise in the future, Although artificial implant is creating a great challenge for still the most common form the medical care and social of breast reconstruction, supportive systems. Therefore, a autologous tissue reconstruction wound care center equipped with generally is considered to yield hyperbaric oxygen therapy and better aesthetic results. other cutting-edge wound care Dr. Song specializes in several facilities is necessary to provide methods of autologous breast a full range of treatment options reconstruction, including deep to patients with chronic wounds. inferior epigastric perforator flap, superior gluteal artery perforator flap, superficial inferior University of Chicago epigastric artery flap, epigastric My next stop was the University artery flap, and thoracodorsal of Chicago, where I met with artery perforator flap. I had the my host David Song, MD, FACS, privilege of observing Dr. Song chief of plastic surgery. Dr. Song as he performed some of these is an internationally recognized operations and learned quite expert in breast reconstruction a few surgical techniques.

MAR 2017 BULLETIN American College of Surgeons SCHOLARSHIPS

Clinical Congress 2016: Dr. Cheng receiving the International Guest Scholar award from Guiseppe R. Nigri, MD, FACS, Chair, ACS Scholarships Committee

Dr. Song has conducted autologous fat transplantation that can separate adipose stem several clinical trials related has become a reliable cosmetic cells from fat extracts has not to chest wall reconstruction, and reconstructive surgical yet been approved in the U.S. breast tumor resection, and technique. The most common and is therefore unavailable breast reconstruction. application is treating the facial at most hospitals, including During my visit, I also defects caused by trauma or the University of Chicago. participated in clinical teaching subcutaneous fat atrophy. 58 | activities, such as journal club, Whereas excessive adipose and I had a chance to interact tissue can frequently be found Clinical Congress with residents, fellows, and in the abdomen or other parts As the highlight of my visit, I the faculty regarding debated of the body, it is usually possible traveled to Washington, DC, to issues in wound care and to harvest enough fat for attend the ACS Clinical Congress breast reconstruction. transfer with minimal donor 2016. Since my residency, I In a conversation with site morbidity. Consequently, have met several Honorary Dr. Song, he acknowledged its application in the treatment Fellows of the ACS, so I was the value of autologous fat of breast defects has flourished excited to have the opportunity transplantation for breast in recent years. In particular, to attend Clinical Congress. reconstruction and said he recent studies have shown that The scale of the conference believes that adipose tissue- adipose tissue contains a large and the variety of educational related technologies and amount of mesenchymal stem sessions were amazing. products represent an important cells, which are a valuable cell I appreciated the opportunity adjunct in breast reconstruction. source for regenerative medicine to attend a few scientific sessions Autologous fat grafts have been or tissue engineering. Cell- for free. Maurice Nahabedian, used for more than 100 years assisted lipotransfer, as described MD, FACS, professor of plastic in plastic and reconstructive by Prof. Takaro Yoshimura from surgery, Georgetown University, surgery. The early autologous Japan, depicted a procedure Washington, DC, delivered a fat transplant procedures had a that separates adipose-derived comprehensive overview on high incidence of complications, stem cells from adipose tissue breast reconstruction at the such as infection, fat resorption, and mixes them with fat to session Atypical Breast Lesions: fat necrosis, and calcification. increase the concentration Defining and Managing this With improvements in of stem cells within fat, thus High Risk Population. After liposuction, including refined increasing the survival and the session, I discussed with procedures of purification, regeneration of the transplanted Dr. Nahabedian his surgical separation, and injection, fat. However, the machine technique of complete coverage

V102 No 3 BULLETIN American College of Surgeons SCHOLARSHIPS

I appreciated the prospect of the ACS extending its reach beyond North America and promoting communication among the surgical communities around the world. Global outreach will benefit not only the ACS, but also surgeons and surgical patients worldwide.

of prosthesis with artificial dermis medicine, to surgical education are used at these U.S. institutions in implant-based reconstruction. and humanitarian aid. I gave a for general skin closure. In the Another session, Wound Care: speech titled Paving the Way outpatient clinic, physicians have Mentoring the Mentors, also from Reconstructive Surgery plenty of time to communicate was helpful for me. The speakers to Regenerative Surgery. The with patients and their caregivers. covered a range of wound care concept of promoting tissue However, high quality results issues, including infection regeneration with bioactive in high medical expenses in the control, negative pressure wound scaffolds or cell therapy has U.S., rendering medical insurance | 59 therapy, nutrition support, captured the attention of the unaffordable for low-income and choice of dressings. plastic and reconstructive Americans. These complex health Thanks to the arrangement of surgery community. However, care issues are being debated in the ACS International Relations transplanting isolated adipose- many countries around the world. Committee (IRC), International derived stem cells into injured For example, my research Guest Scholars from various tissue often results in early cell topic of applying adult stem cells countries had a chance to meet on death with limited therapeutic in regenerative medicine and several occasions, including the effects. Our study explored the tissue repair will be an expensive welcome reception and luncheon. use of cell sheet technology, treatment modality. Striking We were invited to participate which can exhibit excellent a balance between developing in the Opening Ceremony and biological properties, resulting cutting-edge medical technologies the Annual Meeting of the IRC. in enhanced wound healing and making them affordable for I appreciated the prospect of and tissue regeneration. most people will be a challenge. the ACS extending its reach I would like to thank the beyond North America and ACS again for the award and promoting communication Striking a balance between the opportunity to attend the among the surgical communities cost and quality Clinical Congress. I believe around the world. Global I was impressed with the quality the research done in the outreach will benefit not only of the medical services at Stanford laboratory will eventually the ACS, but also surgeons and University and the University of lead us to achieve the clinical surgical patients worldwide. Chicago. The operating rooms application of regenerative At a session for all of the IGS housed all kinds of advanced medicine in wound healing recipients, I was impressed by equipment and devices. For and breast reconstruction. ♦ the diversity of the background example, feather sutures, which of the scholars, ranging from are used only for endoscopic or basic research and clinical cosmetic operations in Taiwan,

MAR 2017 BULLETIN American College of Surgeons he career path you chose to become a surgeon was not an easy one. TDid you have a trusted mentor to help guide you? Tribute gifts—gifts made in memory of or in honor of someone—are a thoughtful way to say thank you.

March 30 is National Doctors’ Day, and the ACS Foundation will help you honor your mentor on this special day.

Make a donation on or before March 30, and the ACS Foundation will send an acknowledgment letter to your honoree (or family if in memoriam) noting the National Doctors’ Day celebration. A special recognition page, sponsored by the ACS Foundation, will feature all participating donors and honorees in the Bulletin, ACS NewsScope, and on the ACS website.

Your generous contribution will show your gratitude while simultaneously advancing the ACS mission of saving lives.

I have been fortunate in my life to have had many great mentors, some for my entire career and some for shorter time periods. Whether it was decisions in medical school or residency, early career needs, or recent job decisions, my community of mentors has always been there to encourage and empower me to succeed both professionally and personally. The lessons and guidance that have been given to me by Drs. Lohr and Gahtan are invaluable and lifelong. Though their mentoring was voluntary, I do hope to repay them by providing the same to my own mentees.

— Ruth L. Bush, md, facs, giving in honor of Vivian Gahtan, md, facs, and Joann M. Lohr, md, facs

2017_FD_Ad_NationalDoctorsDay_BulletinSpread15x10.25in_02-14-2017_v04_RELEASE.indd 1 2/14/2017 11:23:11 AM I gave in honor of Dr. Sawyers, who inspired me to be the best general surgeon I could be, to become a teacher of surgery, and become involved in the ACS. He was a superb surgeon and taught me so much about taking care of patients, being a meticulous and technically excellent surgeon, and to inspire students and surgical residents. He was very actively involved with surgery on a national basis through the ACS, the ABS, and the SSAT and challenged me to follow his lead.

— Kenneth W. Sharp, md, facs, giving in honor of the late John L. Sawyers, md, facs

As an avid boater, I am well aware of the purpose of lighthouses. They serve as a tower and beacon in treacherous waterways and are illuminating. As a mentor, Dr. Murayama is my lighthouse. He has served as a tower and beacon to me throughout my career and has helped me, as well as so many others, safely navigate treacherous surgical waterways.

— Shanu N. Kothari, md, facs, giving in honor of Kenric M. Murayama, md, facs

I chose to honor Dr. Numann, as she is a true surgical legend. Over the past 15 or so years she has hosted meetings for women surgeons in South Africa, Canada, Australia, Japan, and Thailand. Dr. Numann has been tireless in support of economically challenged surgeons and used her year as President of the ACS to travel around the globe to highlight the need for a global approach to education and to health care. She is an inspiration to all of us.

— Hilary A. Sanfey, mb bch, facs, giving in honor of Patricia J. Numann, md, facs

Give online at facs.org/acsfoundation or call the acs foundation at 312-202-5338

2017_FD_Ad_NationalDoctorsDay_BulletinSpread15x10.25in_02-14-2017_v04_RELEASE.indd 2 2/14/2017 11:23:49 AM SCHOLARSHIPS

International scholarships for surgical education now available

The American College of Following the Clinical education and training, such as Surgeons (ACS) Division of Congress, each scholar will visit involvement in the development Education and the International two Level I ACS Accredited and evaluation of education Relations Committee (IRC) have Education Institutes (AEIs) modules, use of novel teaching announced two international selected in advance based on and assessment strategies, or scholarships focused on surgical the scholar’s interest areas in curriculum design. In addition, education. These awards will surgical education and training. applicants must submit a one- offer faculty members from At the conclusion of the Clinical paragraph description of their countries other than the U.S. Congress and his or her visits education philosophies, a list and Canada the opportunity to the ACS-AEIs, each scholar of specific educational goals to participate in a variety of will submit to the IRC and and objectives for their visits, faculty development activities to the Division of Education and evidence of support of to acquire new knowledge and a brief report outlining their these goals and objectives skills in surgical education achievements as a result of the from the leadership at their and training, which will be scholarship, specifically focusing home institutions. These 62 | useful in improving surgical on achievement of the objectives documents will be reviewed education and training in the outlined in the initial application. by the Division of Education scholar’s home institution The scholarships will facilitate as part of the selection and country. All application the scholars’ involvement process. At least five years of materials and supporting in subsequent collaborative experience is required beyond documents are due no later than ventures in education and completion of all training and May 1, 2017, for attendance at training under the aegis of the fellowships. Scholarships must Clinical Congress 2017 in San ACS Division of Education. be used in the year awarded; Diego, CA, October 22–26. Each scholarship provides a they may not be postponed. stipend of $10,000, supporting Full scholarship requirements travel and per diem in North for this program may be Educational opportunities America, and the cost of courses reviewed at facs.org/member- The two scholars will participate undertaken at the Clinical services/scholarships/international/ in Clinical Congress 2017, Congress and at the ACS AEIs. issurged. The application for the including the Surgical Education: Clinical Congress registration scholarship may be accessed at Principles and Practice Course, and fees for attendance at the the bottom of the requirements as well as other plenary sessions Surgical Education: Principles page. Questions should be and courses that address surgical and Practice course will be directed to the ACS International education and training across provided gratis. Assistance will Liaison at [email protected]. ♦ the continuum of professional be offered to reserve affordable development. This continuum housing in San Diego. may include the needs of practicing surgeons across their entire careers, as well as Award criteria the needs of surgery residents, Applicants must provide medical students, and other documentation of prior members of the surgical team. experience in surgical

V102 No 3 BULLETIN American College of Surgeons SCHOLARSHIPS

First ACS/ASBrS International Scholar announced

Juan José Cossa Morchio, MD, FACS, a general surgeon at Clinics Hospital, Montevideo, Uruguay, was recently selected to receive the first American College of Surgeons/American Society of Breast Surgeons (ACS/ASBrS) International Scholarship. Dr. Cossa manages complex breast cancer cases in a developing country that has one of the highest breast cancer incidence rates in the world. The $5,000 award will subsidize his attendance at the annual meeting of the ASBrS in Las Vegas, NV, in April 2017. He will then visit the National Accreditation Program for Breast Centers, located at ACS headquarters in Chicago, IL, to learn how to develop a multidisciplinary breast cancer program and database. The next application deadline is anticipated to be in November 2017 for attendance and participation at the 2018 Dr. Cossa ASBrS annual meeting. ♦

| 63 Apply for Claude H. Organ, Jr., MD, FACS, Traveling Fellowship The American College of Surgeons (ACS) of his or her choice. The experience can be is now accepting applications for the 2017 tailored to the recipient’s research interests. Claude H. Organ, Jr., MD, FACS, Traveling Past awardees have used their fellowships Fellowship. The deadline for receipt of all in creative ways to develop their careers. application materials is June 1, 2017. The 2016 fellow, Stephanie Bonne, MD, The family and friends of the late is researching a successful hospital- Dr. Organ, an ACS Past-President, established based violence intervention program in an endowment through the ACS Foundation San Francisco, CA, to help her to develop to provide funding for an annual fellowship to one at her home institution, Rutgers be awarded to an outstanding young surgeon University Hospital, Newark, NJ, where from the Society of Black Academic Surgeons, she is assistant professor of surgery. the Association of Women Surgeons, or the The full requirements for the Claude H. Surgical Section of the National Medical Organ Traveling Fellowship are posted at Association. The fellowship, established after facs.org/member-services/scholarships/special/organ. Dr. Organ’s death in 2005, is in the amount of Applicants will be informed of the award $5,000 and enables a U.S. or Canadian Fellow decision by August. Questions and application or Associate Fellow younger than 45 years old materials should be submitted to the ACS who is a member of one of the aforementioned Scholarships Administrator at [email protected]. ♦ societies to attend an educational meeting or make an extended visit to an institution

MAR 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.

Florida Chapter 2017 ACS Surgical MARCH April 28–29 Coding Workshop Orlando, FL May 11–12 Latin American Congress Contact: Stacy Manthos, Oakbrook, IL March 14–17 [email protected] Contact: Jan Nagle, Lima, Peru [email protected] Contact: Dr. David Ortega, North Dakota and [email protected], South Dakota Chapters West Virginia Chapter scgp.org/congreso2017/ April 28–29 May 11–13 West Fargo, ND White Sulphur Springs, WV Second European Meeting Contact: Leann Benson, Contact: Sharon Bartholomew, of ACS Region 15 Chapters [email protected] [email protected] March 21 Munich, Germany Northern California Chapter Ohio Chapter Contact: Dr. Norbert J. Senninger, April 28–29 May 12–13 [email protected] Berkeley, CA Cleveland, OH Contact: Christina McDevitt, Contact: Emily Maurer, [email protected], [email protected], | 64 APRIL www.nccacs.org www.ohiofacs.org Alberta Chapter Michigan Chapter April 7–8 May 17–19 Edmonton, AB MAY Boyne Falls, MI Contact: Dr. John Kortbeek, Contact: Carrie Steffen, [email protected] Italy Chapter [email protected], May 4–5 www.michiganacs.org Minnesota Surgical Society: Catania, Sicily A Chapter of the ACS Contact: Dr. Antonio Di Cataldo, April 7–8 [email protected], Minneapolis, MN www.facsitaly.org FUTURE CLINICAL Contact: Janna Pecquet, CONGRESSES [email protected], Chile Chapter mnsurgicalsociety.org May 7 2017 Viña del Mar, Chile October 22–26 Indiana Chapter Contact: Dr. Owen Korn Bruzzone, San Diego, CA April 21–22 Tel. +5 (622) 264-1878 Indianapolis, IN 2018 Contact: Tom Dixon, Biennial Meeting of the October 21–25 [email protected], www.infacs.org Israeli Surgical Society Boston, MA May 9–11 Japan Chapter Kfar Blum, Israel 2019 April 28 Contact: Dr. Joseph Klausner, October 27–31 Yokohama, Japan [email protected] San Francisco, CA Contact: Dr. Kazuhiko Yoshida, [email protected]

V102 No 3 BULLETIN American College of Surgeons