Thromboprophylaxis in an academic medical center

INTRODUCTION: Questions regarding which patients require prophylaxis for thromboembolism, what methods should be used and the appropriate duration of treatment remain unanswered. METHODS AND MATERIALS: A retrospective review from a single academic medical center was undertaken to evaluate prophylactic strategies. Multiple sources of data were used to identify patients who were prophylaxed and those who developed deep vein thrombosis or pulmonary embolism. These data were analyzed to determine factors associated with successful prophylaxis including age, type of prophylaxis and admitting services. RESULTS: A total of 22,030 patients were admitted of whom 7520 (36%) received prophylaxis and there were 523 thromboembolic events. Pneumatic compression devices and antiembolic stockings had the lowest incidence of failure, 2.2% and 3.2% respectively. There were significant differences in the rates of prophylaxis used by the five admitting services, being highest in surgery (40.8%) and lowest in gynecology (11.4%). However, these groups had the lowest incidence of venous thromboembolism (4.3%, 2.3%). Both of these groups used pneumatic compression as the method of choice (64.3% and 65.2%). CONCLUSIONS: Thromboembolism prophylaxis reduces the incidence of DVT and PE, however, our study demonstrates the variable effectiveness of each method in different types of patients. Our data suggest that patient risk of DVT should be individually assessed and an appropriate method of prophylaxis should be applied when warranted.     

Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center

Background

Turnover time (TOT) is one of the classic measures of operating room (OR) efficiency. There have been numerous efforts to reduce TOTs, sometimes through the employment of a process improvement framework. However, most examples of process improvement in the TOT focus primarily on operational changes to workflows and statistical significance. These examples of process improvement do not detail the complex organizational challenges associated with implementing, expanding, and sustaining change.

Methods

TOT data for general and gastrointestinal surgery were collected retrospectively over a 26-mo period at a large multispecialty academic institution. We calculated mean and median TOTs. TOTs were excluded if the sequence of cases was changed or cases were canceled. Data were retrieved from the perioperative nursing data entry system.

Results

Using performance improvement strategies, we determined how various events and organizational factors created an environment that was receptive to change. This ultimately led to a sustained decrease in the OR TOT both in the general and gastrointestinal surgery ORs that were the focus of the study (44.8 min versus 48.6 min; P < 0.0001) and other subspecialties (49.3 min versus 53.0 min; P < 0.0001), demonstrating that the effect traveled outside the study area.

Conclusions

There are obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. Awareness of the numerous variables that may support or impede a particular change effort can inform effective change implementation strategies that are “organizationally compatible.”     

The impact of managed care and current governmental policies on an urban academic health care center

BACKGROUND: Managed care and governmental policies have restructured hospital reimbursement. We examined reimbursement trends in trauma care to assess the impact of this market driven change on an urban academic health center. METHODS: Patients injured between January 1997 and December 1999 were analyzed for Injury Severity Score (ISS), length of hospital stay, hospital cost, payer, and reimbursement. RESULTS: Between 1997 and 1999, the volume of patients with an ISS less than 9 increased and length of stay decreased. In addition, overall cost, payment, and profit margin increased. Commercially insured patients accounted for this margin increase, because the margins of managed care and government insured patients experienced double-digit decreases. Patients with ISS of 9 or greater also experienced a volume increase and a reduction in length of stay; however, costs within this group increased greater than payments, thereby reducing profit margin. Whereas commercially insured patients maintained their margin, managed care and government insured patients did not (double- and triple-digit decreases). CONCLUSIONS: Managed care and current governmental policies have a negative impact on urban academic health center reimbursement. Commercial insurers subsidize not only the uninsured but also the government insured and managed care patients as well. National awareness of this issue and policy action are paramount to urban academic health centers and may also benefit commercial insurers.     

The expanding role of the nurse practitioner in an academic medical center and its impact on graduate medical education

PURPOSE: Academic medical centers (AMCs) have used nurse practitioners (NPs) for the provision of direct patient care for many years. However, as more NPs are hired to fill in the void created by both the 80-hour work week and the increased demands on attendings' time, their role has evolved in terms of patient care and graduate medical education. We sought to evaluate the expanded role of the NP in our large tertiary AMC to help clarify the interrelationships with the patient care delivery model and GME. METHODS: Data were collected through interviews of NPs, nurses, attendings, and residents. Data were analyzed to identify trends contributing to successful models of practice and their impact on patient care and graduate medical education (GME). RESULTS: Interviews were completed with 58/74 (78%) NPs employed at our medical center. Anonymous written surveys were completed by 41 (55%) providers. In terms of perceived impact on the role NPs played in GME, 77% of NPs surveyed felt that their role complimented the resident training; 9% felt that their role competed with resident training; and 14% felt that their role had no impact on resident training. CONCLUSION: We believe that the presence of an experienced NP on a care deliver team can enhance the educational experience of residents as well as provide continuity of patient care in the era of the 80-hour work week.     

Formula for surgical practice resuscitation in an academic medical center

BACKGROUND: Managing patient referrals for surgical consultation in an academic practice has traditionally emphasized clinical rather than service expertise. However, assuring both efficiency and accuracy in the initial consultation have become critical early measures of quality care. METHODS: In partnership with the academic medical center administration, current practice was analyzed. Performance and communication standards were established around an ideal patient experience. A new ambulatory consultation process was developed; and flowcharting methods for resource allocation, statistical process control, and pre-visit data collection were used to reduce patient administrative time. Automated referral reports engaged referring physicians throughout the consultation. RESULTS: Accurate insurance and referral authorization have been provided for all patients, including the 4% who are underinsured. Patient, provider, and referring physician satisfaction has increased significantly. Staff time investment has progressively declined from 52 +/- 11 (95% confidence) minutes to 34 +/- 10 minutes for most patients. Realignment of tasks has reduced the administrative time spent by the patient by 32% without compromising clinical time. New patient volume increased by 29% per year, maintaining regional market share. CONCLUSIONS: Expertise in the process of consultation delivery is feasible and will be increasingly critical to the survival of academic surgical practice in a competitive market.     

Thirty-day postoperative death rate at an academic medical center

OBJECTIVE: To improve understanding of perioperative deaths at an academic medical center. SUMMARY BACKGROUND DATA: Because published data have typically focused on specific patient populations, diagnoses, or procedures, there are few data regarding surgical deaths and complications in institutional or regional studies. Specifically, surgical adverse events and errors are generally not studied comprehensively. This limits the overall understanding of complications and deaths. METHODS: Data from all operations performed in the main operating suite of the University of Virginia Health Sciences Center from January 1 to June 30, 1999, were compared with state death records to gain a dataset of patients dying within 30 days of surgery. All clinical records from patients who died were screened for adverse events and subsequently reviewed by three surgeons who identified adverse events and errors and performed comparisons with survivors. RESULTS: One hundred nineteen deaths followed 7,379 operations performed on 6,296 patients, yielding a patient death rate of 1.9%. Patients dying within 30 days of surgery were older and had higher American Society of Anesthesiologists scores. Of 119 deaths, 86 (72.3%) were attributable to the patient's primary disease. Twenty-three patient deaths (19.3% of all deaths, 0.37% of all patients) could not be attributed to the patient's primary disease and thus were suspicious for an adverse event (AE) as the cause of the death. Of the 23 deaths suspicious for AE, 15 (12.6% of all deaths, and 65.2% of AE deaths) followed an error in care and thus were classified as potentially preventable, affecting 0.24% of the study population. CONCLUSIONS: Overall, the 30-day postoperative death rate was low in the total surgical population at an academic medical center. Errors and AEs were associated with 12.6% and 19.3% of deaths, respectively. Retrospective review inadequately characterized the nature of AEs and failed to determine causality. Prospective audits of outcomes will enhance our understanding of surgical AEs.     

Implementation of an acute care surgery service at an academic trauma center

Background

The establishment of acute care surgery is rapidly becoming a solution to meet emergency surgical needs. Challenges include competition for emergency surgery opportunities and the ability to economically sustain a practice.

Methods

Clinical activity was measured by reviewing the institutional and practice plan databases. Work relative value units and practice plan collection rates defined clinical activity and revenue.

Results

Operative procedures and intensive care unit activity accounted for 52% and 36% of activity, respectively. Although procedures on the digestive tract accounted for half of the operative activity, significant activity was observed in nearly all other systems. Overall clinical productivity remained constant but did demonstrate a 25% increase in operative work relative value units. Current billing activity supports 4.0 clinical full-time equivalents, but estimated collections would cover <73% of physician direct costs.

Conclusions

The authors describe the implementation of an acute care surgery service that combines trauma, emergency general surgery, and surgical critical care in an established academic surgery department. Developing a sustainable economic model must include income sources other than patient service revenue.     

DRGs, orthopedic surgery, and age at an academic medical center

The federal Medicare Diagnostic Related Group (DRG) hospital reimbursement system has been on line for 5 years. Hospitals contend that profit margins have dropped to dangerously low levels, due to the federal DRG Prospective Payment System. The authors analyzed all orthopedic surgical admissions to a large academic medical center under DRG reimbursement and characterized patients by age, resource utilization, and outcome. Total costs for the 1,040 orthopedic patients analyzed during a 15-month period added up to $9,718,800. Mean hospital cost per patient, mean hospital length of stay, percent outliers, and mortality generally increased with age. All age categories of patients 65 years of age and above generated financial losses under DRGs. Older orthopedic patients consumed a disproportionately larger share of resources than younger patients, and were more frequent users of the SICU and blood. The current DRG reimbursement scheme may be inequitable in relation to the older orthopedic surgery patient. If these findings are demonstrated at other medical centers, older orthopedic surgical patients could be limited in both their access and quality of care in the future.     

Emergency intraoperative vascular surgery consultations at a tertiary academic center

ObjectiveVascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center.MethodsWe queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved.ResultsThere were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m². The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%.ConclusionsVascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons.     

Race effects on pathological and functional outcomes after robotic partial nephrectomy in a single academic tertiary care center

To explore the potential effects of race on pathological outcomes of renal tumor and on kidney function preservation in the patients undergoing robotic partial nephrectomy (RPN) at our center. Retrospective review of our institutional review board approved database for African-American (AA) patients undergoing RPN from 2006 to 2014 was performed. AA and non-AA groups were compared with regards to demographics, tumor characteristics, functional data and, oncological outcomes. For functional outcomes, groups were matched (1:1) in terms of age, preoperative estimated glomerular filtration rate (eGFR) and R.E.N.A.L score. From the total of 1005 patients, 84 were AA. Age and the tumor size were comparable between the two groups (2.7 vs. 3 cm; p = 0.29). Proportion of patients with papillary RCC was higher among AAs compared to non-AAs (43.3 vs. 19.4 %; p < 0.001). After matching AA patients with non-AA counterparts (1:1 matching), eGFR preservation at latest follow up after surgery was comparable between groups (84.3 vs. 85 %; p = 0.25). AA race (OR 3.62, p < 0.001), male gender (OR 2.05, p < 0.001) and low preoperative eGFR (OR 0.97, p < 0.001) were predictors of papillary RCC on multivariate analyses. The incidence of papillary RCC is higher in AA patients undergoing RPN. There was no difference in kidney function recovery after robotic partial nephrectomy in both AA and non-AA groups. AA race itself is not a significant factor in determining renal malignancy. Further studies are needed to clarify the impact of higher prevalence of papillary tumors in AA group in terms of long-term oncological and functional outcomes.     

Potential role of abbreviated MRI for breast cancer screening in an academic medical center

The purpose is to determine whether an abbreviated MRI protocol (ABMR) is ready to be used for breast cancer screening in an academic practice setting. Two hundred and fifty nine breast MRIs from 1/1/2012 to 6/30/2012 were retrospectively reviewed using ABMR (MIP, Pre‐contrastT1, single dynamic post‐contrastT1, and subtraction). Five breast radiologists (4‐28 year‐expr) participated in this reader study performed in two phases: Phase1 ‐ radiologist's privy to clinical history but not to comparison imaging. Phase2 ‐ radiologists provided comparison imaging. For phase1, studies were reviewed using three steps: (a) MIP only (positive/negative/intermediate); (b) ABMR (recall/no recall) and (c) With T2 (for changes in recommendations). Radiologist also recorded total time for interpretation. In Phase2 the MRIs coded as "recall” were re‐reviewed with available comparison studies, noting changes in final recommendation. The abnormal interpretation rates (AIRs) were calculated for phase1 and phase2 results with comparison to the original full protocol. Of the 259 patients (avg. age‐52 years; range 26‐78), there were seven cancers (three invasive, three DCIS and one breast lymphoma). Acquisition time for ABMR was 3 minutes, ABMR + T2‐8 minutes, and original full protocol 16 minutes. Average MIP was positive or indeterminate in 86% (6/7) and negative in 14% (1/7) cancers. The average AIR for MIP only was 20.8% (sens‐77.1%; spec‐80.8%. The AIR w/o comparisons was 25.6% (sens‐91.4%; spec‐ 76.2%); however the average AIR decreased in phase 2 with comparisons to 13.7% (sens‐91.4%; spec‐88.5%). The AIR of the original full protocol read was 16.2% (sens‐100%; spec‐85.7%). Addition of T2 changed assessment in only 3% (1.2%‐6.5%). Avg. read time for ABMR including T2 was 2.5 minutes (1.6‐4.0 minutes). ABMR is reliable for breast cancer screening, with acceptable interpretation time and acceptable AIR.     

Prostate cancer screening at an equal access tertiary care center: its impact 10 years after the introduction of PSA

INTRODUCTION AND OBJECTIVES: Dwight D. Eisenhower Army Medical Center has been involved in Prostate Cancer Awareness Week (PCAW) screening during the period 1995-2000. The purpose of this study is to review the results of screening in a self-selected population of military beneficiaries at our institution. MATERIALS AND METHODS: Screening involving a brief urologic history, digital rectal examination (DRE) and serum prostatic specific antigen (PSA) measurement was offered to our screening population. Patients with an elevated PSA (>4.0 ng/ml) and/or a suspicious DRE were considered for transrectal ultrasonography with prostate needle biopsy (TRUS/PNB). Patient health records were reviewed retrospectively and analyzed to determine patient demographic characteristics, PSA distribution, DRE results and cancer detection rates. RESULTS: A total of 455 screening visits were performed from 1995 to 2000, of which 426 visits were included for analysis. Mean age of the study population was 57.4 y (40-83). Seventy-one percent of the patients reported prior PSA screening visits. Forty-four patients met indications for biopsy. A total of 30 TRUS/PNB were performed demonstrating presence of cancer in three patients for an overall cancer detection rate of 0.7%. CONCLUSIONS: Our study shows that the overall prostate cancer detection rate at our institution is lower than detection rates previously reported in the literature. Potential reasons for this finding may include that the subjects participating in PCAW screening tended to be younger than in other series and that a majority of them had already undergone prior screening. These findings suggest the need to modify prostate cancer screening recommendations and to improve prostate cancer screening efficacy.