Unsupervised procedures by surgical trainees: a windfall for private insurance at the expense of graduate medical education.

BACKGROUND: Surgical faculty cannot always be present while trainees perform minor procedures. Fees are not obtained for these unsupervised services because Medicare rules do not allow residents and fellows to bill. Medicare already supplements hospitals via medical education funds and thus reimbursement for trainee services would constitute double billing. Private insurance companies, however, do not supplement trainees' salaries and thus benefit when they are not charged for these procedures. The objective is to determine whether significant revenue is lost to private insurers for unsupervised procedures performed by surgical trainees. METHODS: We retrospectively evaluated a prospective database of procedures performed by residents and fellows from March 1998 through 2007. All procedures were entered by the trainees into a computerized electronic note system. Unsupervised procedures were not billed to insurance carriers. RESULTS: During the study period, 14,497 minor procedures were performed without attending supervision, of which 13,343 had valid current procedural terminology codes. Total charges for these procedures would have been $10,096,931. For patients with private insurance companies (PICs), $6,876,000 could have been billed. Using our historic collection ratios, $2,269,083 in revenue was lost, or $232,726 annually. CONCLUSIONS: Trainees perform a significant number of unsupervised procedures on patients with private insurance without charge. This pro bono service represents a significant amount of lost income for teaching institutions. Private insurance companies benefit financially from Medicare billing regulations without contributing to education. Billing for these services might help offset the costs of graduate medical education.

Electronic medical records and mortality in trauma patients.

BACKGROUND: The Electronic Medical Record (EMR) has been proposed as a way to reduce medical errors. It can also be used to document clinician involvement, which may affect outcomes. We sought to determine whether the EMR could be used to improve attending involvement in daily care, enhance surgical revenue, and lower mortality of patients with trauma. METHODS: In 2004, the Trauma Division adopted a software program (CARE, Miami, FL) for creating an EMR and implemented a weekly report that was distributed to all members of the division and also to Departmental decision makers. Before initiation, explicit instructions were given to all surgeons that daily notes in the EMR were expected and would be followed by weekly reports. Before this, most notes were recorded in the paper chart and were difficult to track. Differences among proportions were determined with z test or chi, where appropriate with significance defined as p < 0.05. RESULTS: With implementation of the EMR, daily and weekly reports were immediately available. Both attending surgeon documented notes and divisional annual revenue increased. A reduction in mortality was also observed. CONCLUSION: The EMR can be used to change attending surgeon involvement in patient care and procedures. The increase in attending involvement was associated with an increase in revenue. Use of the EMR was associated with a significant reduction in hospital mortality.

Predicting success: A comparative analysis of student performance on the surgical clerkship and the NBME surgery subject exam.

BACKGROUND: The National Board of Medical Examiners surgery shelf is a well-established terminal measure of student medical knowledge. No study has explored the correlation between intraclerkship quizzes and shelf exam performance. METHODS: Weekly quiz and National Board of Medical Examiners scores were collected from 156 third-year students who participated in a 12-week surgical clerkship from 2015 to 2017. Kruskal-Wallis, Wilcoxon rank sum, and linear regression analysis was completed. RESULTS: Trauma/Burns, Esophagus/Anorectal, and Wound/Intensive Care Unit quiz content corresponded with increased National Board of Medical Examiners performance with ß-coefficients of 1.57 (P < .001), 1.42 (P < .001), 1.38 (P < .001), respectively. Wound/Intensive Care Unit and Cardio/Vascular content corresponded with decreased likelihood of scoring < 70 points on the National Board of Medical Examiners (OR: 0.75 (P = .03), and 0.68 (P = .02)). Aggregate quiz scores stratified by academic block were 67 (IQR 64-69.5), 77 (IQR 74.5-80), 76.5 (IQR of 67-89.5), 83 (IQR of 76-85) corresponding to academic blocks 1, 2, 3, and 4, respectively (P < .001). CONCLUSION: Modeling National Board of Medical Examiners outcomes as a function of weekly quizzes taken during a 12-week surgery clerkship is a viable concept.

Four-factor prothrombin complex concentrate is associated with improved survival in trauma-related hemorrhage: A nationwide propensity-matched analysis.

INTRODUCTION: Post-traumatic hemorrhage is the most common preventable cause of death in trauma. Numerous small single-center studies have shown the superiority of four-factor prothrombin complex concentrate (4-PCC) along with fresh frozen plasma (FFP) over FFP alone in resuscitation of trauma patients. The aim of our study was to evaluate outcomes of severely injured trauma patients who received 4-PCC + FFP compared to FPP alone. METHODS: Two-year (2015-2016) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age ≥18 years) trauma patients who received 4-PCC + FFP or FFP alone were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups: 4-PCC + FFP versus FFP alone and were matched in a 1:1 ratio using propensity score matching for demographics, vitals, injury parameters, comorbidities, and level of trauma centers. Outcome measures were packed red blood cells, plasma and platelets transfused, complications, and mortality. RESULTS: A total of 468 patients (4-PCC + FFP, 234; FFP alone, 234) were matched. Mean age was 50 ± 21 years; 70% were males; median injury severity score was 27 [20-36], and 86% had blunt injuries. Four-PCC + FFP was associated with a decreased requirement for packed red blood cells (6 units vs. 10 units; p = 0.02) and FFP (3 units vs. 6 units; p = 0.01) transfusion compared to FFP alone. Patients who received 4-PCC + FFP had a lower mortality (17.5% vs. 27.7%, p = 0.01) and lower rates of acute respiratory distress syndrome (1.3% vs. 4.7%, p = 0.04) and acute kidney injury (2.1% vs. 7.3%, p = 0.01). There was no difference in the rates of deep venous thrombosis (p = 0.11) and pulmonary embolism (p = 0.33), adverse discharge disposition (p = 0.21), and platelets transfusion (p = 0.72) between the two groups. CONCLUSIONS: Our study demonstrates that the use of 4-PCC as an adjunct to FFP is associated with improved survival and reduction in transfusion requirements compared to FFP alone in resuscitation of severely injured trauma patients. Further studies are required to evaluate the role of addition of PCC to the massive transfusion protocol. LEVEL OF EVIDENCE: Therapeutic studies, level III.

Resuscitation with pressors after traumatic brain injury.

BACKGROUND: The purpose of the study was to compare initial resuscitation with arginine vasopressin (AVP), phenylephrine (PE), or isotonic crystalloid fluid alone after traumatic brain injury and vasodilatory shock. STUDY DESIGN: Anesthetized, ventilated swine (n = 39, 30 +/- 2 kg) underwent fluid percussion traumatic brain injury followed by hemorrhage (30 +/- 2mL/kg) to a mean arterial pressure < 30mmHg, then were randomized to 1 of 5 groups to maintain mean arterial pressure > 60mmHg for 30 to 60minutes, then cerebral perfusion pressure > 60mmHg for 60 to 300minutes, either unlimited crystalloid fluid only (n = 9), arginine vasopressin + fluid (n = 9), phenylephrine + fluid (n = 9), arginine vasopressin only (n = 5), or phenylephrine only (n = 5). Heterologous transfusions were administered if hematocrit was < 13, and mannitol was administered if intracranial pressure was > 20 mmHg. Cerebrovascular reactivity was evaluated with serial CO(2) challenges. RESULTS: In all groups, physiologic variables were similar at baseline and at the end of shock. On resuscitation, all achieved mean arterial pressure and cerebral perfusion pressure goals. Brain tissue PO(2)s were similar. With fluid only, more blood and mannitol were required, intracranial pressure and peak inspiratory pressure were higher, and cerebrovascular reactivity was decreased (all p < 0.05 versus pressor + fluid). With either pressor + fluid, cardiac output, heart rate, lactate, and mixed venous O(2) saturation were similar to fluid only, but total fluid requirements and urine output were both reduced (p < 0.05). With either pressor only, intracranial pressure remained low, but mixed venous O(2) saturation, cardiac output, and urine output were decreased (all p < 0.05 versus other groups). CONCLUSIONS: To correct vasodilatory shock after traumatic brain injury, a resuscitation strategy that combined either phenylephrine or arginine vasopressin plus crystalloid was superior to either fluid alone or pressor alone.

Effects of duty hours and time of day on surgery resident proficiency.

BACKGROUND: Night floats have evolved in the era of limited resident work hours. This study was designed to define the effect of restricted nighttime duty hours on the psychomotor and cognitive skills of surgery residents. METHODS: To quantify the effect of fatigue on the skills of residents on day-shift and night-float rotations, residents were asked to complete visuohaptic simulations before and after 12-hour duty periods and to rate their fatigue level with questionnaires. RESULTS: Both groups showed significant decrements in proficiency measures after their shifts compared with baseline. The night-float group showed more significant declines (P < .05) in all areas assessed than the day-shift group. The night-float group was significantly less proficient in cognitive tasks after their shifts compared with the day-shift group. CONCLUSIONS: The deterioration of surgical proficiency is to a degree dependent on the time of day during which call occurs, not solely on the length of call.

Prehospital HBOC-201 after traumatic brain injury and hemorrhagic shock in swine.

BACKGROUND: Data are limited on the actions of hemoglobin based oxygen carriers (HBOCs) after traumatic brain injury (TBI). This study evaluates neurotoxicity, vasoactivity, cardiac toxicity, and inflammatory activity of HBOC-201 (Biopure, Cambridge, Mass.) resuscitation in a TBI model. METHODS: Swine received TBI and hemorrhage. After 30 minutes, resuscitation was initiated with 10 mL/kg normal saline (NS), followed by either HBOC-201 (6 mL/kg, n = 10) or NS control (n = 10). Supplemental NS was administered to both groups to maintain mean arterial pressure (MAP) >60 mm Hg until 60 minutes, and to maintain cerebral perfusion pressure (CPP) >70 mm Hg from 60 to 300 minutes. The control group received mannitol (1 g/kg) and blood (10 mL/kg) at 90 minutes and half (n = 5) received CPP directed phenylephrine (PE) therapy after 120 minutes. Serum cytokines were measured with ELISA and coagulation was evaluated with thromboelastography. Brains were harvested for neuropathology. RESULTS: With HBOC administration, MAP, CPP, and brain tissue PO2 were restored within 30 minutes and maintained until 300 minutes. Clot strength and fibrin formation were maintained and 9/10 successfully extubated. In contrast, with control, MAP and brain tissue PO2 did not correct until 120 minutes, after mannitol, transfusion and 40% more crystalloid. Furthermore, without PE, CPP did not reach target and 0/5 could be extubated. Lactate, heart rate, cardiac output, mixed venous oxygenation, muscle oxygenation, serum cytokines, and histology did not differ between groups. CONCLUSIONS: After TBI, a single HBOC-201 bolus with minimal supplements provided rapid resuscitation, while maintaining CPP and improving brain oxygenation, without causing cardiac dysfunction, coagulopathy, cytokine release, or brain structural changes.

Effects of arginine vasopressin during resuscitation from hemorrhagic hypotension after traumatic brain injury.

OBJECTIVE: Two series of experiments were designed to evaluate whether early arginine vasopressin improves acute outcome following resuscitation from traumatic brain injury and severe hemorrhagic hypotension. DESIGN: Prospective randomized, blinded animal study. SETTING: University laboratory. SUBJECTS: Thirty-three swine. INTERVENTIONS: In series 1 (n = 19), after traumatic brain injury with hemorrhage and 12 mins of shock (mean arterial pressure approximately 20 mm Hg), survivors (n = 16) were initially resuscitated with 10 mL/kg crystalloid. After 30 mins, crystalloid and blood with either 0.1 unit x kg(-1) x hr(-1) arginine vasopressin or placebo was titrated to a mean arterial pressure target >or=60 mm Hg. After 90 mins, all received mannitol and the target was cerebral perfusion pressure >or=60 mm Hg. To test cerebrovascular function, 7.5% inhaled CO2 was administered periodically. In series 2 (n = 14), the identical protocol was followed except the shock period was 20 mins and survivors (n = 10) received a bolus of either arginine vasopressin (0.2 units/kg) or placebo during the initial fluid resuscitation. MEASUREMENTS AND MAIN RESULTS: In series 1, by 300 mins after traumatic brain injury with arginine vasopressin (n = 8) vs. placebo (n = 8), the fluid and transfusion requirements were reduced (both p < .01), intracranial pressure was improved (11 +/- 1 vs. 23 +/- 2 mmHg; p < .0001), and the CO2-evoked intracranial pressure elevation was reduced (7 +/- 2 vs. 26 +/- 3 mm Hg, p < .001), suggesting improved compliance. In series 2, with arginine vasopressin vs. placebo, cerebral perfusion pressure was more rapidly corrected (p < .05). With arginine vasopressin, five of five animals survived 300 mins, whereas three of five placebo animals died. The survival time with placebo was 54 +/- 4 mins (p < .05 vs. arginine vasopressin). CONCLUSIONS: Early supplemental arginine vasopressin rapidly corrected cerebral perfusion pressure, improved cerebrovascular compliance, and prevented circulatory collapse during fluid resuscitation of hemorrhagic shock after traumatic brain injury.

Simulation training for a mass casualty incident: two-year experience at the Army Trauma Training Center.

BACKGROUND: Civilian and military mass casualty incidents (MCI) are an unfortunate reality in the 21st century, but there are few situational training exercises (STX) to prepare for them. To fill this gap, we developed a MCI STX for U.S. Army Forward Surgical Teams (FST) in conjunction with the U.S. Army Trauma Training Center. METHODS: After a standardized briefing, each FST has 60 minutes to unpack, setup, and organize a standard equipment cache into an emergency room, operating room, and intensive care unit. In an adjacent room, five anesthetized swine are prepared with standardized, combat-relevant injuries. The number and acuity of the total casualties are unknown to the FST and arrive in waves and without warning. A realistic combat environment is simulated by creating resource limitations, power outages, security breaches, and other stressors. The STX concludes when all casualties have died or are successfully treated. FSTs complete a teamwork self-assessment card, while staff and FST surgeons evaluate organization, resource allocation, communication, treatment, and overall performance. Feedback from each FST can be incorporated into an updated design for the next STX. RESULTS: From 2003-2005, 16 FSTs have completed the STX. All FSTs have had collapses in situational triage, primary/ secondary surveys, and/or ATLS principles (basic ABCs), resulting in approximately 20% preventable deaths. CONCLUSIONS: We concluded (1) a MCI can overwhelm even combat- experienced FSTs; (2) adherence to basic principles of emergency trauma care by all FST members is essential to effectively and efficiently respond to this MCI; (3) by prospectively identifying deficiencies, future military or civilian performance during an actual MCI may be improved; and (4) this MCI STX could provide a template for similar programs to develop, train, and evaluate civilian surgical disaster response teams.

Systemic coagulation changes caused by pulmonary artery catheters: laboratory findings and clinical correlation.

BACKGROUND: A higher rate of pulmonary embolism has been associated with pulmonary artery (PA) catheters; however, no mechanism has been described. Conventional tests of coagulation reveal no changes related to PA catheterization. The purpose of this study was to determine whether PA catheterization resulted in a hypercoagulable state detectable by thrombelastography (TEG). ANIMAL: Healthy, anesthetized, swine (n = 19) underwent PA catheterization. Samples were drawn from 7F femoral arterial catheters before and two hours after PA catheterization, at 5 mL/min, and analyzed (native whole blood, n = 15, kaolin activated blood, n = 4) by TEG (Hemoscope, Niles, IL) at precisely two minutes. Human: An IRB-approved prospective, observational trial was conducted in critically ill patients (n = 19). Samples were drawn from 22-gauge radial artery catheters, before and three hours after PA catheterization. Kaolin-activated TEG samples were analyzed at precisely five minutes. Data are mean +/- SE; Groups were compared with analysis of variance and significance was assessed at the 95% confidence interval. RESULTS: In both animals and patients, PA catheterization truncated R times (time to initial fibrin formation). In swine, the R times were 17.6 +/- 1.3 minutes (native) and 3.8 +/- 0.4 (kaolin) before PA catheterization, and decreased to 6.3 +/- 1.0 minutes (p = 0.002) and 1.9 +/- 0.5 minutes (p = 0.010) afterward. There were no changes in pH or temperature during the experiment. In patients, 4 of 19 were excluded for protocol violations. The R time was 6.3 +/- 1.0 minutes (kaolin) before and 3.0 +/- 0.3 minutes after catheterization (p = 0.003). No changes were observed in conventional coagulation parameters, temperature or pH. CONCLUSION: In healthy swine, and critically ill patients, PA catheters may enhance thrombin formation and fibrin polymerization, indicating a systemic hypercoagulable state. This may explain why PA catheters are associated with an increased risk of pulmonary emboli.

Early vasopressin improves short-term survival after pulmonary contusion.

UNLABELLED: Arginine vasopressin (AVP) is a promising treatment for several types of irreversible shock, but its therapeutic potential has not been examined after severe chest trauma. Two series of experiments were performed to fill this gap. METHODS: Series 1: anesthetized, mechanically-ventilated pigs (n = 20, 29 +/- 1 kg) received a blast to the chest, followed by a "controlled" arterial hemorrhage to a mean arterial pressure (MAP) <30 mm Hg. At 20 minutes, a 10 mL/kg normal saline (NS) bolus was followed by either 0.1 U/kg AVP bolus or NS, in randomized, blinded fashion. From 30-300 minutes, either AVP (0.4 U/kg/hr plus NS) or NS alone was infused as needed to MAP>70 mm Hg. Series 2: Swine (n = 15) received the chest injury followed by partial left hepatectomy to produce "uncontrolled" hemorrhage. Resuscitation was the same as in series 1. RESULTS: The blast created bilateral parenchymal contusions (R > L), hemo/pneumothorax and progressive cardiopulmonary distress. In Series 1, there were 3/20 deaths before randomization, 0/8 deaths after resuscitation with AVP versus 4/9 deaths with NS (p = 0.029). In surviving animals, with AVP versus NS, fluid requirements and peak airway pressures were lower while P/F was higher (all p < 0.05). In Series 2, with uncontrolled hemorrhage, there were 5/15 deaths before randomization. Upon resuscitation with AVP versus NS, survival time and blood loss were both improved, but the differences did not reach statistical significance. CONCLUSIONS: After severe chest trauma with controlled hemorrhage, early AVP decreased mortality, reduced fluid requirements and improved pulmonary function. With uncontrolled hemorrhage, early AVP did not increase the risk for bleeding.