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Basic bronchoscopy coding and billing: Rules of the road
Although complex, reimbursement for bronchoscopy is based on appropriate billing, coding, and precise documentation. It is of utmost importance to have a detailed understanding of the various codes to optimize reimbursement. We understand this is a moving target and beyond the scope of this article to discuss all the specific details, so we will try to focus on “the road less travelled.”
Tip#1: When multiple techniques are performed during a bronchoscopy only one CPT® code is considered primary and fully paid while the rest are partially paid. However, there are certain CPT codes that are considered “add-ons” and, therefore, do not fall under the multiple bronchoscopy rules and are paid in full on top of the other codes.
Tip#2: When separate biopsies are performed on different sites or lesions during the same procedure, be sure to attach the Modifier 59 (distinct procedural service) code.
Tip#3: If the procedure performed was time consuming and/or difficult, attach the Modifier 22 (unusual procedural services) code as it increases the reimbursement by 20% to 25%.
Tip#4: The CPT codes for bronchoscopy with therapeutic aspiration are 31645 (initial) and 31646 (subsequent). These were revised in 2018. They are valued greater than 31622 (airway inspection).
Tip#5: Previously moderate sedation provided by the bronchoscopist was bundled in the CPT codes, but in 2017, CMS reduced the wRVUs of these codes by 0.25. This change was adapted due to the trend of billing for moderate sedation by separate providers and reflects the increased use of anesthetists in the endoscopy suite.
Different insurance companies have varying requirements regarding a lot of codes, particularly the modifiers. Therefore, physicians, hospitals, and the coders need to be aware of all the rules. Please do not hesitate to contact the Practice Operations NetWork for more information.
Salim Surani, MD, MPH, FCCP
Chair
Humayun Anjum, MD, FCCP
Vice-Chair
Additional reading:
Centers for Medicare & Medicaid Services (CMS). Fed Regist. 2017;82:52976.
Liu H, et al. JAMA. 2012;307:1178.
Nelson, ME. Chest. 2017;152:893.
Ninan N, et al. https://doi.org/10.1016/j.chest.2019.02.009
Transplant
Hepatitis C-positive donor organs and lung transplantation: Are we there yet?
The field of lung transplantation continues to be encumbered by the mismatch between organ supply and demand. Only approximately 15% of potential donor lungs are currently being used for transplantation, resulting in unacceptably high wait list mortality (17.2 deaths per 100 wait list years).
To counter this, the transplant community continues to invest in innovations such as ex vivo lung perfusion (EVLP) to increase the availability of suitable lungs for transplantation. At the same time, efforts to modify some of the existing practices are also underway. One area of interest has been the potential use of hepatitis C virus antibody positive (HCV +) donors in solid organ transplantation. Traditionally, the use of HCV + organs, especially when the donor is nucleic acid test (NAT)-positive, which indicates presence of HCV RNA, has been considered a contra-indication for solid organ transplantation. However, this has resulted in the exclusion of a significant number of potential HCV + donors (including young and otherwise healthy donor organs), the increased availability of which has been fueled by the opioid epidemic in the United States.
While kidney transplantation programs have been relatively more liberal with utilizing this subset of donors (due to requiring lesser degree of immunosuppression), heart and lung transplantation programs have shied away from this practice due to concerns for disease transmission and unfavorable outcomes, including reduced survival of the recipient (Englum BR, et al. J Heart Lung Transplant. 2016 Feb;35[2]:228).
Hepatitis C infection is one of the medical conditions for which the treatment of disease has changed substantially in the last decade. The advent of new classes of medications, direct acting antiviral agents (DAA), has ensured that a sustained virologic response (SVR), across all genotypes, is now possible in up to 98% of those who undergo treatment. Further, DAAs have a comparatively favorable pharmacokinetic profile and are well tolerated. Since the initial reports of success in the use of HCV + donor organs for lung transplantation, the results of a recently published trial lend further support to the continued use of these organs (Khan B, et al. Am J Transplant. 2017 Apr;17[4]:1129). One hundred percent of patients (n=35, 28 lung and 7 heart) who received organs from HCV + donors (NAT +) and were treated with DAA for 4 weeks (started immediately after transplantation) had an undetectable viral load and excellent graft function at 6 months posttransplantation (Woolley AE, et al. N Engl J Med. 2019 Apr 25;380[17]:1606). Similar studies with greater power and longer follow-up need to be conducted to instill greater confidence in the use of HCV + organs in potential lung recipients. In addition, ethical issues surrounding the use of HCV + organs should be carefully vetted, as the long-term outcomes regarding use of DAAs are not yet known. It is imperative that transplant centers ensure that patients who consent to receipt of HCV + organs fully comprehend the implications of doing so and have systematic posttransplant surveillance. It is also critical that ready access to the entire planned course of DAA is secured for recipients, since these agents could be cost-prohibitive in nonresearch settings. Willingness to comply with intense surveillance and therapy should also be assessed. While the notion of using HCV + donors has gained ground as a promising strategy, transplant centers have been rightfully cautious in its liberal use, until long-term outcomes are better characterized.
Anupam Kumar, MD
Fellow-in-Training Member
J. W. Awori Hayanga, MD, MPH, FCCP
Steering Committee
Women’s health
Women and COPD
While age-adjusted death rates from COPD declined for men in the US between 1999 and 2014, they did not change significantly for women. There have been increasing numbers of studies that have focused on differences in COPD risk factors and outcomes between men and women.
Health and disease are impacted by both sex and gender. Sex refers to biological differences, including chromosomal differences, sex organs, and endogenous hormone profiles. Gender refers to social and cultural differences and includes socially constructed roles and behaviors that vary across cultures and over time.
The prevalence of COPD is increasing more rapidly in women. Women are more likely to be misdiagnosed or have a delay in diagnosis (Chapman, et al. Chest. 2001;119[6]:1691). Evidence suggests that women with COPD have more exacerbations, worse health status, and greater dyspnea (Roche, et al. Respir Res. 2014;15:20; Celli, et al. Am J Respir Crit Care Med. 2011;183[3]:317). Women diagnosed with COPD are more likely to be nonsmokers, and those who smoke are more susceptible to the harmful effects of tobacco (Vestbo, et al. Am J Respir Crit Care Med. 2013;187[4]:347).
In examining differences in exacerbation risk/severity between men and women, 48% of patients with incident COPD were women. Women were 17% more likely to have a moderate/severe first disease exacerbation and shorter time from diagnosis to exacerbation. During three years of follow-up, women had higher annual rates of moderate to severe exacerbations, most pronounced in ages > 40 years to < 65 years (Stolz et al. Submitted for publication. Chest 2019).
NHLBI convened a workshop of experts to review the current understanding of sex and gender on lung disease. They concluded that sex-specific susceptibility to COPD is poorly understood, and gender-specific approaches to COPD are imperative (Han et al. Am J Respir Crit Care Med. 2018;198[7]:850).
Margaret Pisani, MD, MS, FCCP
Vice-Chair
Disaster response and global health
Treating penetrating trauma
The management of penetrating trauma is an unfortunate but all too common facet of critical care practice. A recent emphasis has been placed on the use of extremity tourniquets for hemorrhage control.
It has been embraced by organizations such as the Hartford Consensus Joint Committee, in which hemorrhage control is viewed as the critical step in eliminating preventable prehospital death, secondary only to neutralizing the threat posed by the shooter (Brinsfield et al. Bull Am Coll Surg. 2015;100(1 Suppl):24). Interestingly, a recent retrospective review of mass shootings incorporating 12 events and 139 fatalities indicated that only 20% of victims sustained an injury to an extremity, while 58% were shot in the head or chest.
Only 7% of deaths occurred in victims with potentially survivable wounds, while the vast majority of fatalities followed wounds to the chest (89%), and there were no reported events of potential survivors exsanguinating from extremity wounds (Smith et al. J Trauma Acute Care Surg. 2016; 81:86). This differs from recent military data, where the use of extremity tourniquets has been widely lauded for improving survival. The majority of military combat injuries has been due to blast injury (62%-74%), with a minority (22%-23%) due to gunshots (Eastridge et al. J Trauma Acute Care Surg. 2012;73:S431; Champion et al. J Trauma. 2003;54:S13). These data suggest that widespread use of pre-hospital extremity tourniquets for hemorrhage control in the treatment of gunshot wounds may not result in the anticipated survival improvement that has led to its widespread advocacy. Basic tenets of trauma care, such as rapid control of the airway and treatment of penetrating trauma to the thorax and abdomen, will continue to be of paramount importance.
Michael Powers, MD
Ryan Maves, MD, FCCP
Michael Tripp, MD, FCCP
Steering Committee Members
Dr. Powers is a United States military service member. This work was prepared as part of his official duties. Title 17 U.S.C. §105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Departments of the Navy, the Department of Defense, nor the U.S. Government.
Practice operations
Basic bronchoscopy coding and billing: Rules of the road
Although complex, reimbursement for bronchoscopy is based on appropriate billing, coding, and precise documentation. It is of utmost importance to have a detailed understanding of the various codes to optimize reimbursement. We understand this is a moving target and beyond the scope of this article to discuss all the specific details, so we will try to focus on “the road less travelled.”
Tip#1: When multiple techniques are performed during a bronchoscopy only one CPT® code is considered primary and fully paid while the rest are partially paid. However, there are certain CPT codes that are considered “add-ons” and, therefore, do not fall under the multiple bronchoscopy rules and are paid in full on top of the other codes.
Tip#2: When separate biopsies are performed on different sites or lesions during the same procedure, be sure to attach the Modifier 59 (distinct procedural service) code.
Tip#3: If the procedure performed was time consuming and/or difficult, attach the Modifier 22 (unusual procedural services) code as it increases the reimbursement by 20% to 25%.
Tip#4: The CPT codes for bronchoscopy with therapeutic aspiration are 31645 (initial) and 31646 (subsequent). These were revised in 2018. They are valued greater than 31622 (airway inspection).
Tip#5: Previously moderate sedation provided by the bronchoscopist was bundled in the CPT codes, but in 2017, CMS reduced the wRVUs of these codes by 0.25. This change was adapted due to the trend of billing for moderate sedation by separate providers and reflects the increased use of anesthetists in the endoscopy suite.
Different insurance companies have varying requirements regarding a lot of codes, particularly the modifiers. Therefore, physicians, hospitals, and the coders need to be aware of all the rules. Please do not hesitate to contact the Practice Operations NetWork for more information.
Salim Surani, MD, MPH, FCCP
Chair
Humayun Anjum, MD, FCCP
Vice-Chair
Additional reading:
Centers for Medicare & Medicaid Services (CMS). Fed Regist. 2017;82:52976.
Liu H, et al. JAMA. 2012;307:1178.
Nelson, ME. Chest. 2017;152:893.
Ninan N, et al. https://doi.org/10.1016/j.chest.2019.02.009
Transplant
Hepatitis C-positive donor organs and lung transplantation: Are we there yet?
The field of lung transplantation continues to be encumbered by the mismatch between organ supply and demand. Only approximately 15% of potential donor lungs are currently being used for transplantation, resulting in unacceptably high wait list mortality (17.2 deaths per 100 wait list years).
To counter this, the transplant community continues to invest in innovations such as ex vivo lung perfusion (EVLP) to increase the availability of suitable lungs for transplantation. At the same time, efforts to modify some of the existing practices are also underway. One area of interest has been the potential use of hepatitis C virus antibody positive (HCV +) donors in solid organ transplantation. Traditionally, the use of HCV + organs, especially when the donor is nucleic acid test (NAT)-positive, which indicates presence of HCV RNA, has been considered a contra-indication for solid organ transplantation. However, this has resulted in the exclusion of a significant number of potential HCV + donors (including young and otherwise healthy donor organs), the increased availability of which has been fueled by the opioid epidemic in the United States.
While kidney transplantation programs have been relatively more liberal with utilizing this subset of donors (due to requiring lesser degree of immunosuppression), heart and lung transplantation programs have shied away from this practice due to concerns for disease transmission and unfavorable outcomes, including reduced survival of the recipient (Englum BR, et al. J Heart Lung Transplant. 2016 Feb;35[2]:228).
Hepatitis C infection is one of the medical conditions for which the treatment of disease has changed substantially in the last decade. The advent of new classes of medications, direct acting antiviral agents (DAA), has ensured that a sustained virologic response (SVR), across all genotypes, is now possible in up to 98% of those who undergo treatment. Further, DAAs have a comparatively favorable pharmacokinetic profile and are well tolerated. Since the initial reports of success in the use of HCV + donor organs for lung transplantation, the results of a recently published trial lend further support to the continued use of these organs (Khan B, et al. Am J Transplant. 2017 Apr;17[4]:1129). One hundred percent of patients (n=35, 28 lung and 7 heart) who received organs from HCV + donors (NAT +) and were treated with DAA for 4 weeks (started immediately after transplantation) had an undetectable viral load and excellent graft function at 6 months posttransplantation (Woolley AE, et al. N Engl J Med. 2019 Apr 25;380[17]:1606). Similar studies with greater power and longer follow-up need to be conducted to instill greater confidence in the use of HCV + organs in potential lung recipients. In addition, ethical issues surrounding the use of HCV + organs should be carefully vetted, as the long-term outcomes regarding use of DAAs are not yet known. It is imperative that transplant centers ensure that patients who consent to receipt of HCV + organs fully comprehend the implications of doing so and have systematic posttransplant surveillance. It is also critical that ready access to the entire planned course of DAA is secured for recipients, since these agents could be cost-prohibitive in nonresearch settings. Willingness to comply with intense surveillance and therapy should also be assessed. While the notion of using HCV + donors has gained ground as a promising strategy, transplant centers have been rightfully cautious in its liberal use, until long-term outcomes are better characterized.
Anupam Kumar, MD
Fellow-in-Training Member
J. W. Awori Hayanga, MD, MPH, FCCP
Steering Committee
Women’s health
Women and COPD
While age-adjusted death rates from COPD declined for men in the US between 1999 and 2014, they did not change significantly for women. There have been increasing numbers of studies that have focused on differences in COPD risk factors and outcomes between men and women.
Health and disease are impacted by both sex and gender. Sex refers to biological differences, including chromosomal differences, sex organs, and endogenous hormone profiles. Gender refers to social and cultural differences and includes socially constructed roles and behaviors that vary across cultures and over time.
The prevalence of COPD is increasing more rapidly in women. Women are more likely to be misdiagnosed or have a delay in diagnosis (Chapman, et al. Chest. 2001;119[6]:1691). Evidence suggests that women with COPD have more exacerbations, worse health status, and greater dyspnea (Roche, et al. Respir Res. 2014;15:20; Celli, et al. Am J Respir Crit Care Med. 2011;183[3]:317). Women diagnosed with COPD are more likely to be nonsmokers, and those who smoke are more susceptible to the harmful effects of tobacco (Vestbo, et al. Am J Respir Crit Care Med. 2013;187[4]:347).
In examining differences in exacerbation risk/severity between men and women, 48% of patients with incident COPD were women. Women were 17% more likely to have a moderate/severe first disease exacerbation and shorter time from diagnosis to exacerbation. During three years of follow-up, women had higher annual rates of moderate to severe exacerbations, most pronounced in ages > 40 years to < 65 years (Stolz et al. Submitted for publication. Chest 2019).
NHLBI convened a workshop of experts to review the current understanding of sex and gender on lung disease. They concluded that sex-specific susceptibility to COPD is poorly understood, and gender-specific approaches to COPD are imperative (Han et al. Am J Respir Crit Care Med. 2018;198[7]:850).
Margaret Pisani, MD, MS, FCCP
Vice-Chair
Disaster response and global health
Treating penetrating trauma
The management of penetrating trauma is an unfortunate but all too common facet of critical care practice. A recent emphasis has been placed on the use of extremity tourniquets for hemorrhage control.
It has been embraced by organizations such as the Hartford Consensus Joint Committee, in which hemorrhage control is viewed as the critical step in eliminating preventable prehospital death, secondary only to neutralizing the threat posed by the shooter (Brinsfield et al. Bull Am Coll Surg. 2015;100(1 Suppl):24). Interestingly, a recent retrospective review of mass shootings incorporating 12 events and 139 fatalities indicated that only 20% of victims sustained an injury to an extremity, while 58% were shot in the head or chest.
Only 7% of deaths occurred in victims with potentially survivable wounds, while the vast majority of fatalities followed wounds to the chest (89%), and there were no reported events of potential survivors exsanguinating from extremity wounds (Smith et al. J Trauma Acute Care Surg. 2016; 81:86). This differs from recent military data, where the use of extremity tourniquets has been widely lauded for improving survival. The majority of military combat injuries has been due to blast injury (62%-74%), with a minority (22%-23%) due to gunshots (Eastridge et al. J Trauma Acute Care Surg. 2012;73:S431; Champion et al. J Trauma. 2003;54:S13). These data suggest that widespread use of pre-hospital extremity tourniquets for hemorrhage control in the treatment of gunshot wounds may not result in the anticipated survival improvement that has led to its widespread advocacy. Basic tenets of trauma care, such as rapid control of the airway and treatment of penetrating trauma to the thorax and abdomen, will continue to be of paramount importance.
Michael Powers, MD
Ryan Maves, MD, FCCP
Michael Tripp, MD, FCCP
Steering Committee Members
Dr. Powers is a United States military service member. This work was prepared as part of his official duties. Title 17 U.S.C. §105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Departments of the Navy, the Department of Defense, nor the U.S. Government.
Practice operations
Basic bronchoscopy coding and billing: Rules of the road
Although complex, reimbursement for bronchoscopy is based on appropriate billing, coding, and precise documentation. It is of utmost importance to have a detailed understanding of the various codes to optimize reimbursement. We understand this is a moving target and beyond the scope of this article to discuss all the specific details, so we will try to focus on “the road less travelled.”
Tip#1: When multiple techniques are performed during a bronchoscopy only one CPT® code is considered primary and fully paid while the rest are partially paid. However, there are certain CPT codes that are considered “add-ons” and, therefore, do not fall under the multiple bronchoscopy rules and are paid in full on top of the other codes.
Tip#2: When separate biopsies are performed on different sites or lesions during the same procedure, be sure to attach the Modifier 59 (distinct procedural service) code.
Tip#3: If the procedure performed was time consuming and/or difficult, attach the Modifier 22 (unusual procedural services) code as it increases the reimbursement by 20% to 25%.
Tip#4: The CPT codes for bronchoscopy with therapeutic aspiration are 31645 (initial) and 31646 (subsequent). These were revised in 2018. They are valued greater than 31622 (airway inspection).
Tip#5: Previously moderate sedation provided by the bronchoscopist was bundled in the CPT codes, but in 2017, CMS reduced the wRVUs of these codes by 0.25. This change was adapted due to the trend of billing for moderate sedation by separate providers and reflects the increased use of anesthetists in the endoscopy suite.
Different insurance companies have varying requirements regarding a lot of codes, particularly the modifiers. Therefore, physicians, hospitals, and the coders need to be aware of all the rules. Please do not hesitate to contact the Practice Operations NetWork for more information.
Salim Surani, MD, MPH, FCCP
Chair
Humayun Anjum, MD, FCCP
Vice-Chair
Additional reading:
Centers for Medicare & Medicaid Services (CMS). Fed Regist. 2017;82:52976.
Liu H, et al. JAMA. 2012;307:1178.
Nelson, ME. Chest. 2017;152:893.
Ninan N, et al. https://doi.org/10.1016/j.chest.2019.02.009
Transplant
Hepatitis C-positive donor organs and lung transplantation: Are we there yet?
The field of lung transplantation continues to be encumbered by the mismatch between organ supply and demand. Only approximately 15% of potential donor lungs are currently being used for transplantation, resulting in unacceptably high wait list mortality (17.2 deaths per 100 wait list years).
To counter this, the transplant community continues to invest in innovations such as ex vivo lung perfusion (EVLP) to increase the availability of suitable lungs for transplantation. At the same time, efforts to modify some of the existing practices are also underway. One area of interest has been the potential use of hepatitis C virus antibody positive (HCV +) donors in solid organ transplantation. Traditionally, the use of HCV + organs, especially when the donor is nucleic acid test (NAT)-positive, which indicates presence of HCV RNA, has been considered a contra-indication for solid organ transplantation. However, this has resulted in the exclusion of a significant number of potential HCV + donors (including young and otherwise healthy donor organs), the increased availability of which has been fueled by the opioid epidemic in the United States.
While kidney transplantation programs have been relatively more liberal with utilizing this subset of donors (due to requiring lesser degree of immunosuppression), heart and lung transplantation programs have shied away from this practice due to concerns for disease transmission and unfavorable outcomes, including reduced survival of the recipient (Englum BR, et al. J Heart Lung Transplant. 2016 Feb;35[2]:228).
Hepatitis C infection is one of the medical conditions for which the treatment of disease has changed substantially in the last decade. The advent of new classes of medications, direct acting antiviral agents (DAA), has ensured that a sustained virologic response (SVR), across all genotypes, is now possible in up to 98% of those who undergo treatment. Further, DAAs have a comparatively favorable pharmacokinetic profile and are well tolerated. Since the initial reports of success in the use of HCV + donor organs for lung transplantation, the results of a recently published trial lend further support to the continued use of these organs (Khan B, et al. Am J Transplant. 2017 Apr;17[4]:1129). One hundred percent of patients (n=35, 28 lung and 7 heart) who received organs from HCV + donors (NAT +) and were treated with DAA for 4 weeks (started immediately after transplantation) had an undetectable viral load and excellent graft function at 6 months posttransplantation (Woolley AE, et al. N Engl J Med. 2019 Apr 25;380[17]:1606). Similar studies with greater power and longer follow-up need to be conducted to instill greater confidence in the use of HCV + organs in potential lung recipients. In addition, ethical issues surrounding the use of HCV + organs should be carefully vetted, as the long-term outcomes regarding use of DAAs are not yet known. It is imperative that transplant centers ensure that patients who consent to receipt of HCV + organs fully comprehend the implications of doing so and have systematic posttransplant surveillance. It is also critical that ready access to the entire planned course of DAA is secured for recipients, since these agents could be cost-prohibitive in nonresearch settings. Willingness to comply with intense surveillance and therapy should also be assessed. While the notion of using HCV + donors has gained ground as a promising strategy, transplant centers have been rightfully cautious in its liberal use, until long-term outcomes are better characterized.
Anupam Kumar, MD
Fellow-in-Training Member
J. W. Awori Hayanga, MD, MPH, FCCP
Steering Committee
Women’s health
Women and COPD
While age-adjusted death rates from COPD declined for men in the US between 1999 and 2014, they did not change significantly for women. There have been increasing numbers of studies that have focused on differences in COPD risk factors and outcomes between men and women.
Health and disease are impacted by both sex and gender. Sex refers to biological differences, including chromosomal differences, sex organs, and endogenous hormone profiles. Gender refers to social and cultural differences and includes socially constructed roles and behaviors that vary across cultures and over time.
The prevalence of COPD is increasing more rapidly in women. Women are more likely to be misdiagnosed or have a delay in diagnosis (Chapman, et al. Chest. 2001;119[6]:1691). Evidence suggests that women with COPD have more exacerbations, worse health status, and greater dyspnea (Roche, et al. Respir Res. 2014;15:20; Celli, et al. Am J Respir Crit Care Med. 2011;183[3]:317). Women diagnosed with COPD are more likely to be nonsmokers, and those who smoke are more susceptible to the harmful effects of tobacco (Vestbo, et al. Am J Respir Crit Care Med. 2013;187[4]:347).
In examining differences in exacerbation risk/severity between men and women, 48% of patients with incident COPD were women. Women were 17% more likely to have a moderate/severe first disease exacerbation and shorter time from diagnosis to exacerbation. During three years of follow-up, women had higher annual rates of moderate to severe exacerbations, most pronounced in ages > 40 years to < 65 years (Stolz et al. Submitted for publication. Chest 2019).
NHLBI convened a workshop of experts to review the current understanding of sex and gender on lung disease. They concluded that sex-specific susceptibility to COPD is poorly understood, and gender-specific approaches to COPD are imperative (Han et al. Am J Respir Crit Care Med. 2018;198[7]:850).
Margaret Pisani, MD, MS, FCCP
Vice-Chair
Disaster response and global health
Treating penetrating trauma
The management of penetrating trauma is an unfortunate but all too common facet of critical care practice. A recent emphasis has been placed on the use of extremity tourniquets for hemorrhage control.
It has been embraced by organizations such as the Hartford Consensus Joint Committee, in which hemorrhage control is viewed as the critical step in eliminating preventable prehospital death, secondary only to neutralizing the threat posed by the shooter (Brinsfield et al. Bull Am Coll Surg. 2015;100(1 Suppl):24). Interestingly, a recent retrospective review of mass shootings incorporating 12 events and 139 fatalities indicated that only 20% of victims sustained an injury to an extremity, while 58% were shot in the head or chest.
Only 7% of deaths occurred in victims with potentially survivable wounds, while the vast majority of fatalities followed wounds to the chest (89%), and there were no reported events of potential survivors exsanguinating from extremity wounds (Smith et al. J Trauma Acute Care Surg. 2016; 81:86). This differs from recent military data, where the use of extremity tourniquets has been widely lauded for improving survival. The majority of military combat injuries has been due to blast injury (62%-74%), with a minority (22%-23%) due to gunshots (Eastridge et al. J Trauma Acute Care Surg. 2012;73:S431; Champion et al. J Trauma. 2003;54:S13). These data suggest that widespread use of pre-hospital extremity tourniquets for hemorrhage control in the treatment of gunshot wounds may not result in the anticipated survival improvement that has led to its widespread advocacy. Basic tenets of trauma care, such as rapid control of the airway and treatment of penetrating trauma to the thorax and abdomen, will continue to be of paramount importance.
Michael Powers, MD
Ryan Maves, MD, FCCP
Michael Tripp, MD, FCCP
Steering Committee Members
Dr. Powers is a United States military service member. This work was prepared as part of his official duties. Title 17 U.S.C. §105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Departments of the Navy, the Department of Defense, nor the U.S. Government.