Efforts to improve the billing accuracy of robotic-assisted thoracic surgery through education, updated procedure cards, and electronic medical record system changes.

Precise medical billing is essential for decreasing hospital liability, upholding environmental stewardship and ensuring fair costs for patients. We instituted a multifaceted approach to improve the billing accuracy of our robotic-assisted thoracic surgery programme by including an educational component, updating procedure cards and removing the auto-populating function of our electronic medical record. Overall, we saw significant improvements in both the number of inaccurate billing cases and, specifically, the number of cases that overcharged patients.

Impact of a Thoracic Multidisciplinary Conference on Lung Cancer Outcomes.

BACKGROUND: With the complexity of cancer treatment rising, the role of multidisciplinary conferences (MDCs) in making diagnostic and treatment decisions has become critical. This study evaluated the impact of a thoracic MDC (T-MDC) on lung cancer care quality and survival. METHODS: Lung cancer cases over 7 years were identified from the Roswell Park cancer registry system. The survival rates and treatment plans of 300 patients presented at the MDC were compared with 300 matched patients. The National Comprehensive Cancer Network (NCCN) guidelines were used to define the standard of care. The compliance of care plans with NCCN guidelines was summarized using counts and percentages, with comparisons made using the Fisher exact test. Survival outcomes were summarized using Kaplan-Meier methods. RESULTS: There was improvement in median overall survival (36.9 vs 19.3 months; P < .001) and cancer-specific survival (48 vs 28.1 months; P < .001) for lung cancer patients discussed at the T-MDC compared with controls. These differences were statistically significant in patients with stages III/IV disease but not in patients with stages I/II disease. The NCCN guidelines compliance rate of treatment plans improved from 80% to 94% (P < .001) after MDC discussion. MDC recommendations resulted in treatment plan changes in 123 of 300 patients (41%). CONCLUSIONS: Our results suggest that lung cancer patients have a survival benefit from MDC discussion compared with controls. Patients with advanced disease (stages III and IV) benefited the most. Further research is necessary to understand the precise mechanisms that drive these results.

Understanding thoracic surgeons' perceptions of administrative database analyses and guidelines in clinical decision-making.

OBJECTIVES: This study explored cardiothoracic surgeons' perceptions of health services research and practice guidelines, particularly how both influence providers' clinical decision-making. METHODS: A trained interviewer conducted open-ended, semistructured phone interviews with cardiothoracic surgeons across the United States. The interviews explored surgeons' experiences with lung cancer treatment and their perceptions of health services research and guidelines. Researchers coded the transcribed interviews using conventional content analysis. Interviews continued until thematic saturation was reached. RESULTS: The 27 surgeons interviewed mostly were general thoracic surgeons (23/27) who attend tumor board weekly (21/27). Five themes relating to physician perceptions of health services research and guidelines emerged. Databases analyses' inherent selection bias and perceived deficit of pertinent clinical variables made providers skeptical of using these studies as primary decision drivers; however, providers thought that database analyses are useful to supplement other data and drive future research. Likewise, providers generally felt that although guidelines provide a useful framework, they often have difficulty applying guidelines to individual patients. An analysis of provider characteristics revealed that younger physicians in practice for fewer years appeared more likely to report using guidelines, and physicians who were aged 50 years or more and not purely academic surgeons appeared to find database analyses less impactful. CONCLUSIONS: Health services research, including database analyses, comprise much of the surgical literature; however, this study suggests that perceptions of database analyses and guidelines are mixed and questions whether thoracic surgeons routinely use either to inform their decisions. Researchers must address how to present compelling data to influence clinical practice.

Video-Assisted Thoracoscopic or Conventional Thoracic Surgery in Infants and Children: Current Evidence.

INTRODUCTION: The pros and cons of video-assisted thoracoscopic versus conventional thoracic surgery in infants and children are still under debate. We assessed reported advantages and disadvantages of video-assisted thoracoscopy in pediatric surgical procedures, as well as the evidence level of the available data. MATERIALS AND METHODS: A systematic literature search was performed to identify manuscripts comparing video-assisted thoracoscopic and the respective conventional thoracic approach in classic operative indications of pediatric surgery. Outcome parameters were analyzed and graded for level of evidence (according to the Oxford Centre of Evidence-Based Medicine). RESULTS: A total of 48 comparative studies reporting on 12,709 patients, 11 meta-analyses, and one pilot randomized controlled trial including 20 patients were identified. More than 15 different types of advantages for video-assisted thoracoscopic surgery were described, mostly with a level of evidence 3b or 3a. Most frequently video-assisted thoracoscopic surgery was associated with shorter hospital stay, shorter postoperative ventilation, and shorter time to chest drain removal. Mortality rate and severe complications did not differ between thoracoscopic and conventional thoracic pediatric surgery, except for congenital diaphragmatic hernia repair with a lower mortality and higher recurrence rate after thoracoscopic repair. The most frequently reported disadvantage for video-assisted thoracoscopic surgery was longer operative time. CONCLUSION: The available data point toward improved recovery in pediatric video-assisted thoracoscopic surgery despite longer operative times. Further randomized controlled trials are needed to justify the widespread use of video assisted thoracoscopy in pediatric surgery.

Organization of thoracic surgical services during the COVID pandemic.

INTRODUCTION: COVID-19 presented an unprecedented challenge for healthcare workers and systems around the world. Healthcare systems have adapted differently in terms of pandemic planning of regular services, adopting infection control measures and prioritising essential hospital services in the context of a burgeoning COVID-19 patient load and inevitable surge. METHODS: We performed a review on current evidence and share our practices at a teaching hospital in Singapore. RESULTS: We outline principles and make recommendations for continuity of delivering essential thoracic surgical services during this current outbreak. CONCLUSIONS: The maintenance and provision of thoracic surgery services in this context requires good preplanning and vigilance to infection control measures across all levels.

Resident perception of standardization and credentialing for high-risk bedside procedures in cardiothoracic surgery: Results from an institutional pilot study.

OBJECTIVES: Though clear-guidelines are set by the American Board of Thoracic Surgery (ABTS) for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multidisciplinary course designed to standardize common high-risk bedside procedures and credential our trainees. The aim of this study was to survey the attitudes of residents towards and query the efficacy of such a course. METHODS: The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy, thoracentesis and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands-on simulation session. Knowledge-based pre- and post-evaluations were administered as well as a Likert-based survey regarding multiple aspects of the residents' perceptions of the course and the procedures. RESULTS: Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than by faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail tube thoracostomy, thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pretest and posttest knowledge-based evaluations. CONCLUSION: Cardiothoracic residents have favorable attitudes towards standardization and credentialing for high-risk bedside procedures and utilizing such courses may help standardize procedural techniques.

An International Study on Ventricular Assist Device Program Models.

BACKGROUND: Advanced technology and improved outcomes have led to rapid growth of ventricular assist devices (VADs) throughout the world, but little exists regarding their structure. We sought to study trends in VAD programs on a global level. METHODS: We distributed a 26-question online survey to 321 individuals who work within those programs. Four categories of questions were formed: patient management, coordinator role, multidisciplinary support, and leadership. RESULTS: Fifty-eight surveys (47 United States, 11 international) were analyzed. The majority of programs cared for 26 to 100 device-assisted patients (62%), 26% cared for ≤25 patients, and 12% cared for ≥100 patients. Advanced practice providers (APPs) were used in 69% of programs as a device coordinator. In-hospital rounding was performed equally among the APPs and registered nurses. Most programs used a social worker (90%), nutritionist (74%), pharmacist (72%), palliative care (66%), and finance coordinator (64%). Less than half (43%) included a case manager and only 33% used a pharmacist. The program leader was identified as a cardiologist (31%) or surgeon (26%) or both equally (43%). CONCLUSION: This study demonstrates differences and similarities between VAD program structures. Additional research is warranted to evaluate the effect of program structure on outcomes, job satisfaction, and retention regions.

Anesthesia for Patients Undergoing Anesthesia for Elective Thoracic Surgery During the COVID-19 Pandemic: A Consensus Statement From the Israeli Society of Anesthesiologists.

Anesthesia for thoracic surgery requires specialist intervention to provide adequate operating conditions and one-lung ventilation. The pandemic caused by severe acute respiratory syndrome-associated coronavirus 2 (SARS-CoV-2) is transmitted by aerosol and droplet spread. Because of its virulence, there is a risk of transmission to healthcare workers if appropriate preventive measures are not taken. Coronavirus disease 2019 (COVID-19) patients may show no clinical signs at the early stages of the disease or even remain asymptomatic for the whole course of the disease. Despite the lack of symptoms, they may be able to transfer the virus. Unfortunately, during current COVID-19 testing procedures, about 30% of tests are associated with a false-negative result. For these reasons, standard practice is to assume all patients are COVID-19 positive regardless of swab results. Here, the authors present the recommendations produced by the Israeli Society of Anesthesiologists for use in thoracic anesthesia for elective surgery during the COVID-19 pandemic for both the general population and COVID-19-confirmed patients. The objective of these recommendations is to make changes to some routine techniques in thoracic anesthesia to augment patients' and the medical staff's safety.

Standardization improves postoperative patient handoff experience for junior clinicians.

OBJECTIVES: Effective communication among health care providers is critically important for patient safety. Handoff of patient care from the operating room (OR) to the intensive care unit (ICU) is particularly prone to errors. The process is more complicated in an academic environment in which junior clinicians are being trained. Standardization of, and training in, transitions of care can be a crucial means to improve patient safety. STUDY DESIGN: Pre- and postintervention surveys of health care providers. METHODS: Based on a workflow analysis and qualitative needs assessments, we developed a 3-step protocol to standardize the handoff of care from the OR to the ICU for adult patients after cardiac surgery and to provide an effective learning environment. The process starts during surgery, continues when the patient leaves the OR, and concludes with the actual face-to-face transfer of care between providers, at the bedside, in the ICU. We conducted pre- and postimplementation surveys among physician trainees and nursing staff regarding their perception of the handoff process. RESULTS: We surveyed 42 clinicians before and 33 after implementation of the handoff process. Prior to implementation, most clinicians expressed a need to improve the current process; this perceived need was significantly greater in health care professionals with 4 or fewer years of experience. Post implementation, clinicians saw a significant improvement in information provided, efficiency, relevance to patient care, and psychological safety, a concept in which participants feel accepted and respected in a group setting without fear of negative consequences or judgement. CONCLUSIONS: Our workflow-oriented, standardized process for handoff of care from the OR to the ICU can improve perceived communication and psychological safety, especially for junior clinicians.

A call to action becomes practice: cardiac and vascular surgery during the COVID-19 pandemic based on the Lombardy emergency guidelines.

OBJECTIVES: During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, Northern Italy had to completely reorganize its hospital activity. In Lombardy, the hub-and-spoke system was introduced to guarantee emergency and urgent cardiovascular surgery, whereas most hospitals were dedicated to patients with coronavirus disease 2019 (COVID-19). The aim of this study was to analyse the results of the hub-and-spoke organization system. METHODS: Centro Cardiologico Monzino (Monzino) became one of the four hubs for cardiovascular surgery, with a total of eight spokes. SARS-CoV-2 screening became mandatory for all patients. New flow charts were designed to allow separated pathways based on infection status. A reorganization of spaces guaranteed COVID-19-free and COVID-19-dedicated areas. Patients were also classified into groups according to their pathological and clinical status: emergency, urgent and non-deferrable (ND). RESULTS: A total of 70 patients were referred to the Monzino hub-and-spoke network. We performed 41 operations, 28 (68.3%) of which were emergency/urgent and 13 of which were ND. The screening allowed the identification of COVID-19 (three patients, 7.3%) and non-COVID-19 patients (38 patients, 92.7%). The newly designed and shared protocols guaranteed that the cardiac patients would be divided into emergency, urgent and ND groups. The involvement of the telematic management heart team allowed constant updates and clinical discussions. CONCLUSIONS: The hub-and-spoke organization system efficiently safeguards access to heart and vascular surgical services for patients who require ND, urgent and emergency treatment. Further reorganization will be needed at the end of this pandemic when elective cases will again be scheduled, with a daily increase in the number of operations.

Proposals for managing patients with thoracic malignancies during COVID-19 pandemic.

The objective of this document is to formalize a degraded mode management for patients with thoracic cancers in the context of the COVID-19 pandemic. The proposals are based on those of the French High Council for Public Health, on published data outside the context of COVID-19, and on a concerted analysis of the risk-benefit ratio for our patients by a panel of experts specialized on thoracic oncology under the aegis of the French-Language Society of Pulmonology (SPLF)/French-language oncology group. These proposals are evolving (10 April 2020) according to the situations encountered, which will enrich it, and are to be adapted to our institutional organisations and to the evolution of resources during the COVID-19 epidemic. Patients with symptoms and/or COVID-19+ are not discussed in this document and are managed within the framework of specific channels.