Southern Surgical Association (SSA): Annual Meeting

PALM BEACH, FLA. – More than a fifth of women in Texas with image-detected breast abnormalities failed to undergo minimally invasive breast biopsy as recently as 2008, according to a review of statewide Medicare data, even though in 2005 a U.S. consensus panel declared the minimally invasive approach the procedure of choice and that few patients should have excisional biopsy as their initial procedure.

The analysis also revealed substantial disparities in use of minimally-invasive breast biopsy (MIBB) relative to open-surgical biopsy. In several rural health service areas (HSA) of Texas during 2005-2008, fewer than 40% of women undergoing biopsy of an image-detected breast abnormality had MIBB, Dr. Taylor S. Riall said at the annual meeting of the Southern Surgical Association. During 2005-2008, 5% of Texas HSAs had MIBB rates greater than 90%, the target set by U.S. cancer organizations. The researchers also identified low levels of MIBB use for Hispanic women, and women of low socioeconomic status.

"Our studies identify targets for interventions to improve MIBB rates, such as the Hispanic disparity and geographic variations in practice pattern," she said. "Our findings highlight that the strategies for intervention need to vary by geographic region and the underlying etiology of the failure to adopt this cost-effective practice," said Dr. Riall, a cancer surgeon at the University of Texas Medical Branch in Galveston.

"This is by far the most detailed study of MIBB [practice patterns] performed to date," commented Dr. Stephen Grobmyer, a surgical oncologist and director of breast services at the Cleveland Clinic.

The data documented that surgeons were an important contributor to MIBB underuse. Throughout the 9 years of data studied by Dr. Riall and her associates during 2001-2008, 70% of MIBB were performed by radiologists, while 26% were performed by surgeons. In contrast, surgeons performed 94% of open, excisional biopsies. When a woman’s breast mass was first identified by a surgeon, 44% of the women had MIBB; when first identified by a primary care physician, 58% had MIBB; when first identified by an oncologist, 59% had MIBB; and when first identified by a gynecologist, 67% had MIBB.

The low levels of MIBB use occurred despite increasingly strong recommendations during the period studied to move MIBB to the forefront of breast-abnormality assessment. In 2001, the first international consensus conference on image-detected breast cancer, organized by the University of Southern California, said that "percutaneous biopsy is the preferred initial diagnostic procedure in most patients with mammographically detected abnormalities"(J. Amer. Coll. Surg. 2001;193:297-302).

In 2005, the second international consensus conference on image-detected breast cancer racheted up the recommendation, saying "minimally invasive breast biopsy is the optimal tissue-acquisition method and the procedure of choice for image-detected breast abnormalities. It should be readily available to all patients with image-detected lesions" (J. Amer. Coll. Surg. 2005;201:586-597).

Although the third international consensus conference did not take place until 2009, the year after the end of the period studied by Dr. Riall, the statement at that time showed how MIBB had become the clear standard of care for biopsy of suspicious breast masses. The 2009 panel said that "percutaneous needle biopsy represents ‘best practice’ and should be the new ‘gold standard’ for initial diagnosis. It should essentially replace open biopsy in this role. The Panel called on the medical community to change their current practice if they are using open surgical breast biopsy as a standard diagnostic procedure. Surgeons should audit their practice and make adjustments to decrease their rate of open biopsy for initial diagnosis to less than 5% to 10%" (J. Amer. Coll. Surg. 2009;209:504-20).

"We need to get a message out to surgeons because they are the ones doing many of the open biopsies," Dr. Riall said in an interview. "Surgeons are a group to target, but we also need to target primary care physicians and other referring physicians so that they understand that MIBB is appropriate. The decision to do MIBB versus open biopsy should be made with the surgeon and with the oncologist who will ultimately treat the breast cancer; the decision should not be made just by a radiologist," who is usually the first person to see a mass when it is first detected by mammography.

Dr. Riall also stressed that the causes of MIBB underuse are multifactorial, and require multiple solutions.

"In very rural areas, the primary problem is access to mammography. In the cases where women cluster in primary care practices that don’t do MIBB, we need to provide better physician education. In regions where there is a high density of private practice surgeons, open biopsy is driven by reimbursement. I think there is an interaction of patient preference, surgeon preference, education and training, geographic region, and availability of radiologists and mammography facilities. Trying to dissect it is very hard."

Her study identified in Texas Medicare records 67,582 unique women aged 66 years or older who underwent 75,518 unique breast mass episodes during 2001-2008, including 49,653 (66%) of masses that underwent MIBB and 25,865 (34%) that underwent open surgical biopsy. Use of MIBB rose steadily during the period, starting at 44% of masses in 2001 and increasing to 79% by 2008.

Analysis of MIBB use by Medicare health service area showed stark geographic disparities, with MIBB use as low as 21% in one HSA. During 2005-2008, MIBB use remained at 40% or less in several HSA along the Rio Grande border and in East Texas, including the HSAs in the south Texas towns of McAllen and Harlingen. In contrast, the HSA immediately adjacent to these that includes Brownsville had a MIBB rate greater than 70%. The analysis also showed than many of the HSAs with the lowest rates of MIBB use were located in Texas regions with high Hispanic populations, Dr. Riall said.

Dr. Riall and Dr. Grobmyer had no disclosures.

PALM BEACH, FLA. – More than a fifth of women in Texas with image-detected breast abnormalities failed to undergo minimally invasive breast biopsy as recently as 2008, according to a review of statewide Medicare data, even though in 2005 a U.S. consensus panel declared the minimally invasive approach the procedure of choice and that few patients should have excisional biopsy as their initial procedure.

The analysis also revealed substantial disparities in use of minimally-invasive breast biopsy (MIBB) relative to open-surgical biopsy. In several rural health service areas (HSA) of Texas during 2005-2008, fewer than 40% of women undergoing biopsy of an image-detected breast abnormality had MIBB, Dr. Taylor S. Riall said at the annual meeting of the Southern Surgical Association. During 2005-2008, 5% of Texas HSAs had MIBB rates greater than 90%, the target set by U.S. cancer organizations. The researchers also identified low levels of MIBB use for Hispanic women, and women of low socioeconomic status.

"Our studies identify targets for interventions to improve MIBB rates, such as the Hispanic disparity and geographic variations in practice pattern," she said. "Our findings highlight that the strategies for intervention need to vary by geographic region and the underlying etiology of the failure to adopt this cost-effective practice," said Dr. Riall, a cancer surgeon at the University of Texas Medical Branch in Galveston.

"This is by far the most detailed study of MIBB [practice patterns] performed to date," commented Dr. Stephen Grobmyer, a surgical oncologist and director of breast services at the Cleveland Clinic.

The data documented that surgeons were an important contributor to MIBB underuse. Throughout the 9 years of data studied by Dr. Riall and her associates during 2001-2008, 70% of MIBB were performed by radiologists, while 26% were performed by surgeons. In contrast, surgeons performed 94% of open, excisional biopsies. When a woman’s breast mass was first identified by a surgeon, 44% of the women had MIBB; when first identified by a primary care physician, 58% had MIBB; when first identified by an oncologist, 59% had MIBB; and when first identified by a gynecologist, 67% had MIBB.

The low levels of MIBB use occurred despite increasingly strong recommendations during the period studied to move MIBB to the forefront of breast-abnormality assessment. In 2001, the first international consensus conference on image-detected breast cancer, organized by the University of Southern California, said that "percutaneous biopsy is the preferred initial diagnostic procedure in most patients with mammographically detected abnormalities"(J. Amer. Coll. Surg. 2001;193:297-302).

In 2005, the second international consensus conference on image-detected breast cancer racheted up the recommendation, saying "minimally invasive breast biopsy is the optimal tissue-acquisition method and the procedure of choice for image-detected breast abnormalities. It should be readily available to all patients with image-detected lesions" (J. Amer. Coll. Surg. 2005;201:586-597).

Although the third international consensus conference did not take place until 2009, the year after the end of the period studied by Dr. Riall, the statement at that time showed how MIBB had become the clear standard of care for biopsy of suspicious breast masses. The 2009 panel said that "percutaneous needle biopsy represents ‘best practice’ and should be the new ‘gold standard’ for initial diagnosis. It should essentially replace open biopsy in this role. The Panel called on the medical community to change their current practice if they are using open surgical breast biopsy as a standard diagnostic procedure. Surgeons should audit their practice and make adjustments to decrease their rate of open biopsy for initial diagnosis to less than 5% to 10%" (J. Amer. Coll. Surg. 2009;209:504-20).

"We need to get a message out to surgeons because they are the ones doing many of the open biopsies," Dr. Riall said in an interview. "Surgeons are a group to target, but we also need to target primary care physicians and other referring physicians so that they understand that MIBB is appropriate. The decision to do MIBB versus open biopsy should be made with the surgeon and with the oncologist who will ultimately treat the breast cancer; the decision should not be made just by a radiologist," who is usually the first person to see a mass when it is first detected by mammography.

Dr. Riall also stressed that the causes of MIBB underuse are multifactorial, and require multiple solutions.

"In very rural areas, the primary problem is access to mammography. In the cases where women cluster in primary care practices that don’t do MIBB, we need to provide better physician education. In regions where there is a high density of private practice surgeons, open biopsy is driven by reimbursement. I think there is an interaction of patient preference, surgeon preference, education and training, geographic region, and availability of radiologists and mammography facilities. Trying to dissect it is very hard."

Her study identified in Texas Medicare records 67,582 unique women aged 66 years or older who underwent 75,518 unique breast mass episodes during 2001-2008, including 49,653 (66%) of masses that underwent MIBB and 25,865 (34%) that underwent open surgical biopsy. Use of MIBB rose steadily during the period, starting at 44% of masses in 2001 and increasing to 79% by 2008.

Analysis of MIBB use by Medicare health service area showed stark geographic disparities, with MIBB use as low as 21% in one HSA. During 2005-2008, MIBB use remained at 40% or less in several HSA along the Rio Grande border and in East Texas, including the HSAs in the south Texas towns of McAllen and Harlingen. In contrast, the HSA immediately adjacent to these that includes Brownsville had a MIBB rate greater than 70%. The analysis also showed than many of the HSAs with the lowest rates of MIBB use were located in Texas regions with high Hispanic populations, Dr. Riall said.

Dr. Riall and Dr. Grobmyer had no disclosures.

PALM BEACH, FLA. – More than a fifth of women in Texas with image-detected breast abnormalities failed to undergo minimally invasive breast biopsy as recently as 2008, according to a review of statewide Medicare data, even though in 2005 a U.S. consensus panel declared the minimally invasive approach the procedure of choice and that few patients should have excisional biopsy as their initial procedure.

The analysis also revealed substantial disparities in use of minimally-invasive breast biopsy (MIBB) relative to open-surgical biopsy. In several rural health service areas (HSA) of Texas during 2005-2008, fewer than 40% of women undergoing biopsy of an image-detected breast abnormality had MIBB, Dr. Taylor S. Riall said at the annual meeting of the Southern Surgical Association. During 2005-2008, 5% of Texas HSAs had MIBB rates greater than 90%, the target set by U.S. cancer organizations. The researchers also identified low levels of MIBB use for Hispanic women, and women of low socioeconomic status.

"Our studies identify targets for interventions to improve MIBB rates, such as the Hispanic disparity and geographic variations in practice pattern," she said. "Our findings highlight that the strategies for intervention need to vary by geographic region and the underlying etiology of the failure to adopt this cost-effective practice," said Dr. Riall, a cancer surgeon at the University of Texas Medical Branch in Galveston.

"This is by far the most detailed study of MIBB [practice patterns] performed to date," commented Dr. Stephen Grobmyer, a surgical oncologist and director of breast services at the Cleveland Clinic.

The data documented that surgeons were an important contributor to MIBB underuse. Throughout the 9 years of data studied by Dr. Riall and her associates during 2001-2008, 70% of MIBB were performed by radiologists, while 26% were performed by surgeons. In contrast, surgeons performed 94% of open, excisional biopsies. When a woman’s breast mass was first identified by a surgeon, 44% of the women had MIBB; when first identified by a primary care physician, 58% had MIBB; when first identified by an oncologist, 59% had MIBB; and when first identified by a gynecologist, 67% had MIBB.

The low levels of MIBB use occurred despite increasingly strong recommendations during the period studied to move MIBB to the forefront of breast-abnormality assessment. In 2001, the first international consensus conference on image-detected breast cancer, organized by the University of Southern California, said that "percutaneous biopsy is the preferred initial diagnostic procedure in most patients with mammographically detected abnormalities"(J. Amer. Coll. Surg. 2001;193:297-302).

In 2005, the second international consensus conference on image-detected breast cancer racheted up the recommendation, saying "minimally invasive breast biopsy is the optimal tissue-acquisition method and the procedure of choice for image-detected breast abnormalities. It should be readily available to all patients with image-detected lesions" (J. Amer. Coll. Surg. 2005;201:586-597).

Although the third international consensus conference did not take place until 2009, the year after the end of the period studied by Dr. Riall, the statement at that time showed how MIBB had become the clear standard of care for biopsy of suspicious breast masses. The 2009 panel said that "percutaneous needle biopsy represents ‘best practice’ and should be the new ‘gold standard’ for initial diagnosis. It should essentially replace open biopsy in this role. The Panel called on the medical community to change their current practice if they are using open surgical breast biopsy as a standard diagnostic procedure. Surgeons should audit their practice and make adjustments to decrease their rate of open biopsy for initial diagnosis to less than 5% to 10%" (J. Amer. Coll. Surg. 2009;209:504-20).

"We need to get a message out to surgeons because they are the ones doing many of the open biopsies," Dr. Riall said in an interview. "Surgeons are a group to target, but we also need to target primary care physicians and other referring physicians so that they understand that MIBB is appropriate. The decision to do MIBB versus open biopsy should be made with the surgeon and with the oncologist who will ultimately treat the breast cancer; the decision should not be made just by a radiologist," who is usually the first person to see a mass when it is first detected by mammography.

Dr. Riall also stressed that the causes of MIBB underuse are multifactorial, and require multiple solutions.

"In very rural areas, the primary problem is access to mammography. In the cases where women cluster in primary care practices that don’t do MIBB, we need to provide better physician education. In regions where there is a high density of private practice surgeons, open biopsy is driven by reimbursement. I think there is an interaction of patient preference, surgeon preference, education and training, geographic region, and availability of radiologists and mammography facilities. Trying to dissect it is very hard."

Her study identified in Texas Medicare records 67,582 unique women aged 66 years or older who underwent 75,518 unique breast mass episodes during 2001-2008, including 49,653 (66%) of masses that underwent MIBB and 25,865 (34%) that underwent open surgical biopsy. Use of MIBB rose steadily during the period, starting at 44% of masses in 2001 and increasing to 79% by 2008.

Analysis of MIBB use by Medicare health service area showed stark geographic disparities, with MIBB use as low as 21% in one HSA. During 2005-2008, MIBB use remained at 40% or less in several HSA along the Rio Grande border and in East Texas, including the HSAs in the south Texas towns of McAllen and Harlingen. In contrast, the HSA immediately adjacent to these that includes Brownsville had a MIBB rate greater than 70%. The analysis also showed than many of the HSAs with the lowest rates of MIBB use were located in Texas regions with high Hispanic populations, Dr. Riall said.

Dr. Riall and Dr. Grobmyer had no disclosures.

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Renal transplant surgeons are using novel methods to expand the pool of donor organs: Using kidneys from donors with acute kidney injury, and vetting and improving the function of kidneys by applying pulsatile machine perfusion to stored kidneys pending transplant.

These approaches can overlap, as machine perfusion has become an important tool for improving the function of kidneys from donors with acute kidney injury (AKI) as well as other marginal kidneys such as those from extended-criteria donors and donation after cardiac death.

Surgeons at Wake Forest University, Winston-Salem, N.C., began transplanting kidneys from AKI donors in 2007, and by mid-2012 they had placed 84 of these organs, resulting in actuarial 5-year patient-survival and graft-survival rates that matched transplants during the same period with kidneys from non-AKI donors, Dr. Alan C. Farney said at the annual meeting of the Southern Surgical Association.

Seventy-four of these kidneys (88%) underwent machine perfusion, for a minimum of 6 hours and more often overnight, said Dr. Farney’s colleague, Dr. Robert J. Stratta, professor of surgery at Wake Forest. "We try to pump whenever possible, and in a perfect world we’d like to see all kidneys pumped" before they are transplanted, Dr. Stratta said. In addition to improving function, mechanical perfusion allows surgeons to assess kidney function. If resistance in the kidney is more than 0.4 or 0.5 mm Hg/mL per minute, "we tend to discard it," he noted.

A second report at the meeting further documented the ability of mechanical perfusion to boost kidney function. In a review of more than 50,000 adult, isolated kidney transplants done on American patients during January 2005–March 2011, machine perfusion prior to transplant led to an average 8-percentage-point cut in the rate of delayed kidney function in a pair of analyses that accounted for baseline patient differences. This means that every 13 kidneys treated before transplant with mechanical perfusion prevented a case of delayed graft function (DGF) following transplantation, resulting in fewer patients requiring hemodialysis, Dr. Glen A. Franklin reported at the meeting.

Prevention of DGF mitigates edema, reduces the need for wound drainage, and decreases the risk for infection, factors that – along with the need for dialysis – drive up costs. Preventing these complications and their associated costs potentially offsets the extra expense of routinely perfusing each kidney before transplantation, Dr. Stratta said.

Dr. Stratta and his associates reviewed the outcomes of 84 transplants of kidneys from donors with AKI done at Wake Forest since 2007 and compared this against the outcomes of 283 concurrent kidney transplants performed during the same 2007-2012 period using organs from donors without AKI. A major, statistically significant difference in protocol for the two types of organs was that 88% of the AKI-derived kidneys underwent machine perfusion before transplant, compared with 51% of the kidneys that came from non-AKI donors, reported Dr. Farney, professor of surgery at Wake Forest.

A major difference in outcomes was that the incidence of DGF following transplantation occurred in 41% of patients who received a kidney from an AKI donor, compared with a 27% DGF rate among patients whose kidneys came from non-AKI donors, a statistically-significant difference.

Despite this, actuarial 5-year patient survival was 98% among the AKI kidney recipients and 90% among the non-AKI kidney recipients. Five-year graft survival was 78% in the AKI-kidney recipients and 71% in patients who received a non-AKI organ. The between-group differences were not statistically significant, Dr. Farney said.

The data also showed an unexpected difference in the way that DGF appeared to affect graft survival. Among patients whose kidneys came from non-AKI donors, the 5-year graft survival rate was 90% among the 206 patients who did not have DGF, but fell to 68% among the 77 patients in this group who had DGF, a statistically-significant difference. In contrast, among patients who received kidneys from AKI donors, the incidence of DGF had no significant impact on long-term graft survival.

The data also showed that the severity of AKI had no significant impact on graft survival. Donors with terminal estimated glomerular filtration rates of 10-20 mL/min per 1.73 m² had graft survival rates similar to those of patients who received kidneys from AKI donors with terminal estimated glomerular filtration rates above 30 mL/min per 1.73².

Overall, the results suggest that "using kidneys from AKI donors is a safe method to significantly expand the donor pool for kidney transplantation," Dr. Farney concluded.

"I’m impressed with how, for several years, the Wake Forest group has used kidneys that others may have discarded. The outcomes they report are quite encouraging," commented Dr. Douglas P. Slakey, professor and chairman of surgery at Tulane Medical Center, New Orleans.

The impact that machine perfusion of kidneys can have on DGF before transplantation was examined in a much larger data set by Dr. Franklin and his associates at the University of Louisville (Ky.). They reviewed data collected by the United Network for Organ Sharing on 52,052 isolated, adult U.S. kidney transplants during January 2005–March 2011. The series included 19,372 kidneys (37%) that underwent machine perfusion before transplant.

A propensity-score analysis that compared 13,293 organ recipients who received perfused kidneys with 13,293 recipients who received nonperfused kidneys and matched by a variety of donor and recipient characteristics showed that the incidence of DGF during the first week following transplantation was 21% among the perfused organ recipients. The incidence among patients who received a nonperfused kidney was 29%, a statistically significant difference, said Dr. Franklin, a professor of surgery at the University of Louisville.

A second analysis focused on pairs of kidneys that came from 2,290 donors where one kidney underwent perfusion and the other did not. After adjustment for recipient differences, the incidence of DGF was 20% in recipients who received a perfused kidney and 28% in those who received a nonperfused kidney, again an 8% difference that was statistically significant.

The cost of machine perfusion of a kidney varies from region to region, but at Louisville runs about $1,000 to $2,000 per organ, said Dr. Robert M. Cannon, a surgeon at the University of Louisville and a collaborator on the study. "I think you can justify this cost based on the decrease in DGF," and because it allows scheduling of transplants during usual operating-room hours, eliminating the need for emergency transplant surgery in the middle of the night, Dr. Cannon said in an interview.

Several hours of machine perfusion also likely improves kidney function, he noted. "With cold storage, kidneys undergo intense vasospasm that damages the organ. Machine perfusion alleviates that to an extent, and gets more preservation fluid into the organ."

Dr. Farney, Dr. Stratta, Dr. Franklin, and Dr. Cannon, and Dr. Slakey had no disclosures to report.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Renal transplant surgeons are using novel methods to expand the pool of donor organs: Using kidneys from donors with acute kidney injury, and vetting and improving the function of kidneys by applying pulsatile machine perfusion to stored kidneys pending transplant.

These approaches can overlap, as machine perfusion has become an important tool for improving the function of kidneys from donors with acute kidney injury (AKI) as well as other marginal kidneys such as those from extended-criteria donors and donation after cardiac death.

Surgeons at Wake Forest University, Winston-Salem, N.C., began transplanting kidneys from AKI donors in 2007, and by mid-2012 they had placed 84 of these organs, resulting in actuarial 5-year patient-survival and graft-survival rates that matched transplants during the same period with kidneys from non-AKI donors, Dr. Alan C. Farney said at the annual meeting of the Southern Surgical Association.

Seventy-four of these kidneys (88%) underwent machine perfusion, for a minimum of 6 hours and more often overnight, said Dr. Farney’s colleague, Dr. Robert J. Stratta, professor of surgery at Wake Forest. "We try to pump whenever possible, and in a perfect world we’d like to see all kidneys pumped" before they are transplanted, Dr. Stratta said. In addition to improving function, mechanical perfusion allows surgeons to assess kidney function. If resistance in the kidney is more than 0.4 or 0.5 mm Hg/mL per minute, "we tend to discard it," he noted.

A second report at the meeting further documented the ability of mechanical perfusion to boost kidney function. In a review of more than 50,000 adult, isolated kidney transplants done on American patients during January 2005–March 2011, machine perfusion prior to transplant led to an average 8-percentage-point cut in the rate of delayed kidney function in a pair of analyses that accounted for baseline patient differences. This means that every 13 kidneys treated before transplant with mechanical perfusion prevented a case of delayed graft function (DGF) following transplantation, resulting in fewer patients requiring hemodialysis, Dr. Glen A. Franklin reported at the meeting.

Prevention of DGF mitigates edema, reduces the need for wound drainage, and decreases the risk for infection, factors that – along with the need for dialysis – drive up costs. Preventing these complications and their associated costs potentially offsets the extra expense of routinely perfusing each kidney before transplantation, Dr. Stratta said.

Dr. Stratta and his associates reviewed the outcomes of 84 transplants of kidneys from donors with AKI done at Wake Forest since 2007 and compared this against the outcomes of 283 concurrent kidney transplants performed during the same 2007-2012 period using organs from donors without AKI. A major, statistically significant difference in protocol for the two types of organs was that 88% of the AKI-derived kidneys underwent machine perfusion before transplant, compared with 51% of the kidneys that came from non-AKI donors, reported Dr. Farney, professor of surgery at Wake Forest.

A major difference in outcomes was that the incidence of DGF following transplantation occurred in 41% of patients who received a kidney from an AKI donor, compared with a 27% DGF rate among patients whose kidneys came from non-AKI donors, a statistically-significant difference.

Despite this, actuarial 5-year patient survival was 98% among the AKI kidney recipients and 90% among the non-AKI kidney recipients. Five-year graft survival was 78% in the AKI-kidney recipients and 71% in patients who received a non-AKI organ. The between-group differences were not statistically significant, Dr. Farney said.

The data also showed an unexpected difference in the way that DGF appeared to affect graft survival. Among patients whose kidneys came from non-AKI donors, the 5-year graft survival rate was 90% among the 206 patients who did not have DGF, but fell to 68% among the 77 patients in this group who had DGF, a statistically-significant difference. In contrast, among patients who received kidneys from AKI donors, the incidence of DGF had no significant impact on long-term graft survival.

The data also showed that the severity of AKI had no significant impact on graft survival. Donors with terminal estimated glomerular filtration rates of 10-20 mL/min per 1.73 m² had graft survival rates similar to those of patients who received kidneys from AKI donors with terminal estimated glomerular filtration rates above 30 mL/min per 1.73².

Overall, the results suggest that "using kidneys from AKI donors is a safe method to significantly expand the donor pool for kidney transplantation," Dr. Farney concluded.

"I’m impressed with how, for several years, the Wake Forest group has used kidneys that others may have discarded. The outcomes they report are quite encouraging," commented Dr. Douglas P. Slakey, professor and chairman of surgery at Tulane Medical Center, New Orleans.

The impact that machine perfusion of kidneys can have on DGF before transplantation was examined in a much larger data set by Dr. Franklin and his associates at the University of Louisville (Ky.). They reviewed data collected by the United Network for Organ Sharing on 52,052 isolated, adult U.S. kidney transplants during January 2005–March 2011. The series included 19,372 kidneys (37%) that underwent machine perfusion before transplant.

A propensity-score analysis that compared 13,293 organ recipients who received perfused kidneys with 13,293 recipients who received nonperfused kidneys and matched by a variety of donor and recipient characteristics showed that the incidence of DGF during the first week following transplantation was 21% among the perfused organ recipients. The incidence among patients who received a nonperfused kidney was 29%, a statistically significant difference, said Dr. Franklin, a professor of surgery at the University of Louisville.

A second analysis focused on pairs of kidneys that came from 2,290 donors where one kidney underwent perfusion and the other did not. After adjustment for recipient differences, the incidence of DGF was 20% in recipients who received a perfused kidney and 28% in those who received a nonperfused kidney, again an 8% difference that was statistically significant.

The cost of machine perfusion of a kidney varies from region to region, but at Louisville runs about $1,000 to $2,000 per organ, said Dr. Robert M. Cannon, a surgeon at the University of Louisville and a collaborator on the study. "I think you can justify this cost based on the decrease in DGF," and because it allows scheduling of transplants during usual operating-room hours, eliminating the need for emergency transplant surgery in the middle of the night, Dr. Cannon said in an interview.

Several hours of machine perfusion also likely improves kidney function, he noted. "With cold storage, kidneys undergo intense vasospasm that damages the organ. Machine perfusion alleviates that to an extent, and gets more preservation fluid into the organ."

Dr. Farney, Dr. Stratta, Dr. Franklin, and Dr. Cannon, and Dr. Slakey had no disclosures to report.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Renal transplant surgeons are using novel methods to expand the pool of donor organs: Using kidneys from donors with acute kidney injury, and vetting and improving the function of kidneys by applying pulsatile machine perfusion to stored kidneys pending transplant.

These approaches can overlap, as machine perfusion has become an important tool for improving the function of kidneys from donors with acute kidney injury (AKI) as well as other marginal kidneys such as those from extended-criteria donors and donation after cardiac death.

Surgeons at Wake Forest University, Winston-Salem, N.C., began transplanting kidneys from AKI donors in 2007, and by mid-2012 they had placed 84 of these organs, resulting in actuarial 5-year patient-survival and graft-survival rates that matched transplants during the same period with kidneys from non-AKI donors, Dr. Alan C. Farney said at the annual meeting of the Southern Surgical Association.

Seventy-four of these kidneys (88%) underwent machine perfusion, for a minimum of 6 hours and more often overnight, said Dr. Farney’s colleague, Dr. Robert J. Stratta, professor of surgery at Wake Forest. "We try to pump whenever possible, and in a perfect world we’d like to see all kidneys pumped" before they are transplanted, Dr. Stratta said. In addition to improving function, mechanical perfusion allows surgeons to assess kidney function. If resistance in the kidney is more than 0.4 or 0.5 mm Hg/mL per minute, "we tend to discard it," he noted.

A second report at the meeting further documented the ability of mechanical perfusion to boost kidney function. In a review of more than 50,000 adult, isolated kidney transplants done on American patients during January 2005–March 2011, machine perfusion prior to transplant led to an average 8-percentage-point cut in the rate of delayed kidney function in a pair of analyses that accounted for baseline patient differences. This means that every 13 kidneys treated before transplant with mechanical perfusion prevented a case of delayed graft function (DGF) following transplantation, resulting in fewer patients requiring hemodialysis, Dr. Glen A. Franklin reported at the meeting.

Prevention of DGF mitigates edema, reduces the need for wound drainage, and decreases the risk for infection, factors that – along with the need for dialysis – drive up costs. Preventing these complications and their associated costs potentially offsets the extra expense of routinely perfusing each kidney before transplantation, Dr. Stratta said.

Dr. Stratta and his associates reviewed the outcomes of 84 transplants of kidneys from donors with AKI done at Wake Forest since 2007 and compared this against the outcomes of 283 concurrent kidney transplants performed during the same 2007-2012 period using organs from donors without AKI. A major, statistically significant difference in protocol for the two types of organs was that 88% of the AKI-derived kidneys underwent machine perfusion before transplant, compared with 51% of the kidneys that came from non-AKI donors, reported Dr. Farney, professor of surgery at Wake Forest.

A major difference in outcomes was that the incidence of DGF following transplantation occurred in 41% of patients who received a kidney from an AKI donor, compared with a 27% DGF rate among patients whose kidneys came from non-AKI donors, a statistically-significant difference.

Despite this, actuarial 5-year patient survival was 98% among the AKI kidney recipients and 90% among the non-AKI kidney recipients. Five-year graft survival was 78% in the AKI-kidney recipients and 71% in patients who received a non-AKI organ. The between-group differences were not statistically significant, Dr. Farney said.

The data also showed an unexpected difference in the way that DGF appeared to affect graft survival. Among patients whose kidneys came from non-AKI donors, the 5-year graft survival rate was 90% among the 206 patients who did not have DGF, but fell to 68% among the 77 patients in this group who had DGF, a statistically-significant difference. In contrast, among patients who received kidneys from AKI donors, the incidence of DGF had no significant impact on long-term graft survival.

The data also showed that the severity of AKI had no significant impact on graft survival. Donors with terminal estimated glomerular filtration rates of 10-20 mL/min per 1.73 m² had graft survival rates similar to those of patients who received kidneys from AKI donors with terminal estimated glomerular filtration rates above 30 mL/min per 1.73².

Overall, the results suggest that "using kidneys from AKI donors is a safe method to significantly expand the donor pool for kidney transplantation," Dr. Farney concluded.

"I’m impressed with how, for several years, the Wake Forest group has used kidneys that others may have discarded. The outcomes they report are quite encouraging," commented Dr. Douglas P. Slakey, professor and chairman of surgery at Tulane Medical Center, New Orleans.

The impact that machine perfusion of kidneys can have on DGF before transplantation was examined in a much larger data set by Dr. Franklin and his associates at the University of Louisville (Ky.). They reviewed data collected by the United Network for Organ Sharing on 52,052 isolated, adult U.S. kidney transplants during January 2005–March 2011. The series included 19,372 kidneys (37%) that underwent machine perfusion before transplant.

A propensity-score analysis that compared 13,293 organ recipients who received perfused kidneys with 13,293 recipients who received nonperfused kidneys and matched by a variety of donor and recipient characteristics showed that the incidence of DGF during the first week following transplantation was 21% among the perfused organ recipients. The incidence among patients who received a nonperfused kidney was 29%, a statistically significant difference, said Dr. Franklin, a professor of surgery at the University of Louisville.

A second analysis focused on pairs of kidneys that came from 2,290 donors where one kidney underwent perfusion and the other did not. After adjustment for recipient differences, the incidence of DGF was 20% in recipients who received a perfused kidney and 28% in those who received a nonperfused kidney, again an 8% difference that was statistically significant.

The cost of machine perfusion of a kidney varies from region to region, but at Louisville runs about $1,000 to $2,000 per organ, said Dr. Robert M. Cannon, a surgeon at the University of Louisville and a collaborator on the study. "I think you can justify this cost based on the decrease in DGF," and because it allows scheduling of transplants during usual operating-room hours, eliminating the need for emergency transplant surgery in the middle of the night, Dr. Cannon said in an interview.

Several hours of machine perfusion also likely improves kidney function, he noted. "With cold storage, kidneys undergo intense vasospasm that damages the organ. Machine perfusion alleviates that to an extent, and gets more preservation fluid into the organ."

Dr. Farney, Dr. Stratta, Dr. Franklin, and Dr. Cannon, and Dr. Slakey had no disclosures to report.

[email protected]

On Twitter @mitchelzoler

A more realistic approach to scheduling elective surgeries, and the staffing of operating rooms to support more efficient use, led to increased surgery volume but with less overtime, better staff satisfaction, and ultimately an increased margin for the hospital, according to the recent experience at one mid-size U.S. hospital.

The result was a surgical schedule that became "more predictable and reliable," and led to "increased capacity without increased operational costs," Dr. C. Daniel Smith said at the meeting.

"The issue is predictability and reliability, so that we can adapt [staffing and operating room needs] appropriately," said Dr. Smith, professor and chairman of the department of surgery at the Mayo Clinic in Jacksonville, Fla.

Dr. Smith and several other staffers at Mayo began by identifying a few shortcomings in the surgical scheduling methods at their hospital, a 214-bed facility that opened in 2008 with 21 operating rooms, 28 ICUs, and about 12,000 surgeries done each year. Operating-room volume was highly variable, fluctuating between 35 and 62 cases per day. "That’s a huge day-to-day variability. If you staff for the average you’ll be chronically understaffed or overstaffed each day," he noted.

Another big problem was that the schedule had no way to easily insert the inevitable emergency cases without severely disrupting elective cases. "As emergencies showed up, [elective] cases got bumped past 5 p.m. We had on average five cases a day where everything [scheduled] got changed. Surgeons no longer could operate with the team they expected."

When they began their self assessment in 2009, they found that their operating rooms had less than 65% utilization during prime-time hours, they routinely paid overtime for 15 full-time equivalent employees, and they had low levels of surgeon and staff satisfaction with OR management and efficiency.

They set out in 2010 to revamp their OR scheduling and staffing with the goal of increasing case volume, reducing overtime, and maintaining emergency surgeries without disrupting the elective schedule. Their strategy included designating some ORs that would handle only emergency and urgent cases. They also did not allow elective cases to be scheduled if they would finish later than 5 p.m., unless it was for a group of surgeons who consistently were used to working until the later time.

"We told surgeons [who wanted to schedule an elective case late in the day] that they would need to move the case to another day," Dr. Smith said. "The surgeons we struggled with the most were the high-volume, academic surgeons who try to handle 12 months of cases in 9 months. They run two rooms and a clustered bay. We told them that they could no longer bleed out into other rooms. They could no longer book a room that ended at 10 a.m. and then show up that morning and pound their fists and say they wanted more empty rooms to push their cases out to.

"That was a big cultural change, and it’s been hard," Dr. Smith said.

Another, ongoing facet has been to "reengineer flow out of the OR and into the hospital," he added. The goal is to "have a streamlined path from entry into the surgical practice to the postop bed and then out the door as quickly as possible."

During November 2010 to October 2011, the first year after full implementation of the revamped scheduling process, the number of surgical cases increased by nearly 500 patients, a 4% rise; prime time OR use rose from 61% to 64%; the number of overtime full-time equivalents fell by two staffers (27%) – a cost savings of more than $111,000; daily elective room changes fell by 69%; staff turnover, considered a measure of satisfaction, dropped from 20% to 12%; and the total net margin to the hospital rose by nearly $5 million, a 5% increase. That happened despite the addition of 15 full-time equivalents to the surgical staff, which boosted payroll by nearly $800,000, because the number of cases rose while the costs per case remained unchanged.

Despite these successes, Dr. Smith had a warning for any surgery department considering similar changes because of the substantial cultural change it involves: "We spent a year planning this before implementation, and that wasn’t enough time. There is never enough time. You need to take your time, find a group that likes this, get early wins, and build on that. It will take years to fully effect this; take it one step at a time."

Dr. Smith said that he had no disclosures.

A more realistic approach to scheduling elective surgeries, and the staffing of operating rooms to support more efficient use, led to increased surgery volume but with less overtime, better staff satisfaction, and ultimately an increased margin for the hospital, according to the recent experience at one mid-size U.S. hospital.

The result was a surgical schedule that became "more predictable and reliable," and led to "increased capacity without increased operational costs," Dr. C. Daniel Smith said at the meeting.

"The issue is predictability and reliability, so that we can adapt [staffing and operating room needs] appropriately," said Dr. Smith, professor and chairman of the department of surgery at the Mayo Clinic in Jacksonville, Fla.

Dr. Smith and several other staffers at Mayo began by identifying a few shortcomings in the surgical scheduling methods at their hospital, a 214-bed facility that opened in 2008 with 21 operating rooms, 28 ICUs, and about 12,000 surgeries done each year. Operating-room volume was highly variable, fluctuating between 35 and 62 cases per day. "That’s a huge day-to-day variability. If you staff for the average you’ll be chronically understaffed or overstaffed each day," he noted.

Another big problem was that the schedule had no way to easily insert the inevitable emergency cases without severely disrupting elective cases. "As emergencies showed up, [elective] cases got bumped past 5 p.m. We had on average five cases a day where everything [scheduled] got changed. Surgeons no longer could operate with the team they expected."

When they began their self assessment in 2009, they found that their operating rooms had less than 65% utilization during prime-time hours, they routinely paid overtime for 15 full-time equivalent employees, and they had low levels of surgeon and staff satisfaction with OR management and efficiency.

They set out in 2010 to revamp their OR scheduling and staffing with the goal of increasing case volume, reducing overtime, and maintaining emergency surgeries without disrupting the elective schedule. Their strategy included designating some ORs that would handle only emergency and urgent cases. They also did not allow elective cases to be scheduled if they would finish later than 5 p.m., unless it was for a group of surgeons who consistently were used to working until the later time.

"We told surgeons [who wanted to schedule an elective case late in the day] that they would need to move the case to another day," Dr. Smith said. "The surgeons we struggled with the most were the high-volume, academic surgeons who try to handle 12 months of cases in 9 months. They run two rooms and a clustered bay. We told them that they could no longer bleed out into other rooms. They could no longer book a room that ended at 10 a.m. and then show up that morning and pound their fists and say they wanted more empty rooms to push their cases out to.

"That was a big cultural change, and it’s been hard," Dr. Smith said.

Another, ongoing facet has been to "reengineer flow out of the OR and into the hospital," he added. The goal is to "have a streamlined path from entry into the surgical practice to the postop bed and then out the door as quickly as possible."

During November 2010 to October 2011, the first year after full implementation of the revamped scheduling process, the number of surgical cases increased by nearly 500 patients, a 4% rise; prime time OR use rose from 61% to 64%; the number of overtime full-time equivalents fell by two staffers (27%) – a cost savings of more than $111,000; daily elective room changes fell by 69%; staff turnover, considered a measure of satisfaction, dropped from 20% to 12%; and the total net margin to the hospital rose by nearly $5 million, a 5% increase. That happened despite the addition of 15 full-time equivalents to the surgical staff, which boosted payroll by nearly $800,000, because the number of cases rose while the costs per case remained unchanged.

Despite these successes, Dr. Smith had a warning for any surgery department considering similar changes because of the substantial cultural change it involves: "We spent a year planning this before implementation, and that wasn’t enough time. There is never enough time. You need to take your time, find a group that likes this, get early wins, and build on that. It will take years to fully effect this; take it one step at a time."

Dr. Smith said that he had no disclosures.

A more realistic approach to scheduling elective surgeries, and the staffing of operating rooms to support more efficient use, led to increased surgery volume but with less overtime, better staff satisfaction, and ultimately an increased margin for the hospital, according to the recent experience at one mid-size U.S. hospital.

The result was a surgical schedule that became "more predictable and reliable," and led to "increased capacity without increased operational costs," Dr. C. Daniel Smith said at the meeting.

"The issue is predictability and reliability, so that we can adapt [staffing and operating room needs] appropriately," said Dr. Smith, professor and chairman of the department of surgery at the Mayo Clinic in Jacksonville, Fla.

Dr. Smith and several other staffers at Mayo began by identifying a few shortcomings in the surgical scheduling methods at their hospital, a 214-bed facility that opened in 2008 with 21 operating rooms, 28 ICUs, and about 12,000 surgeries done each year. Operating-room volume was highly variable, fluctuating between 35 and 62 cases per day. "That’s a huge day-to-day variability. If you staff for the average you’ll be chronically understaffed or overstaffed each day," he noted.

Another big problem was that the schedule had no way to easily insert the inevitable emergency cases without severely disrupting elective cases. "As emergencies showed up, [elective] cases got bumped past 5 p.m. We had on average five cases a day where everything [scheduled] got changed. Surgeons no longer could operate with the team they expected."

When they began their self assessment in 2009, they found that their operating rooms had less than 65% utilization during prime-time hours, they routinely paid overtime for 15 full-time equivalent employees, and they had low levels of surgeon and staff satisfaction with OR management and efficiency.

They set out in 2010 to revamp their OR scheduling and staffing with the goal of increasing case volume, reducing overtime, and maintaining emergency surgeries without disrupting the elective schedule. Their strategy included designating some ORs that would handle only emergency and urgent cases. They also did not allow elective cases to be scheduled if they would finish later than 5 p.m., unless it was for a group of surgeons who consistently were used to working until the later time.

"We told surgeons [who wanted to schedule an elective case late in the day] that they would need to move the case to another day," Dr. Smith said. "The surgeons we struggled with the most were the high-volume, academic surgeons who try to handle 12 months of cases in 9 months. They run two rooms and a clustered bay. We told them that they could no longer bleed out into other rooms. They could no longer book a room that ended at 10 a.m. and then show up that morning and pound their fists and say they wanted more empty rooms to push their cases out to.

"That was a big cultural change, and it’s been hard," Dr. Smith said.

Another, ongoing facet has been to "reengineer flow out of the OR and into the hospital," he added. The goal is to "have a streamlined path from entry into the surgical practice to the postop bed and then out the door as quickly as possible."

During November 2010 to October 2011, the first year after full implementation of the revamped scheduling process, the number of surgical cases increased by nearly 500 patients, a 4% rise; prime time OR use rose from 61% to 64%; the number of overtime full-time equivalents fell by two staffers (27%) – a cost savings of more than $111,000; daily elective room changes fell by 69%; staff turnover, considered a measure of satisfaction, dropped from 20% to 12%; and the total net margin to the hospital rose by nearly $5 million, a 5% increase. That happened despite the addition of 15 full-time equivalents to the surgical staff, which boosted payroll by nearly $800,000, because the number of cases rose while the costs per case remained unchanged.

Despite these successes, Dr. Smith had a warning for any surgery department considering similar changes because of the substantial cultural change it involves: "We spent a year planning this before implementation, and that wasn’t enough time. There is never enough time. You need to take your time, find a group that likes this, get early wins, and build on that. It will take years to fully effect this; take it one step at a time."

Dr. Smith said that he had no disclosures.

PALM BEACH, FLA. – Surgeons who performed routine, elective operations the day after they spent all night working an in-hospital shift in the trauma unit had no increased rate of complications, no need for hospital readmissions, and no mortality among their elective cases in a single-center review of 869 cases.

The findings suggest that "there remains no compelling evidence to mandate work-hour restrictions for attending general surgeons," Dr. Martin A. Croce said at the annual meeting of the Southern Surgical Association.

"No study to date has evaluated the effect of sleep deprivation on outcomes specific to the practice of general surgery. This study looked at the impact of an overnight shift in a busy trauma center on the outcomes of typical general surgery procedures performed the next day" and found no significant difference in outcomes between post-call and non–post-call surgeons with respect to postoperative complications, readmissions, or deaths, said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center in Memphis.

"These results confirm my bias, but the study was limited by its retrospective, single-institution nature, and by only including tertiary teaching patients. Each [surgeon] must continue to use judgment when deciding whether to perform elective operations after a busy night on call," commented Dr. William G. Cioffi Jr., professor and chairman of surgery at Brown University, Providence, R.I.

"It is unclear to me that the surgical community will need to present these results because there has been no call for work-hour restrictions for attendings, nor do I feel there will be," said Dr. L.D. Britt, professor and chairman of surgery at Eastern Virginia Medical School, Norfolk.

In his study, Dr. Croce reviewed patients who underwent any of three types of general surgeries at his institution during January 2006 to April 2009 by one of the nine attending surgeons in the department. The review comprised 869 procedures: 46% were hernia repairs, 35% were cholecystectomies, and 19% were bowel operations. The primary outcomes were 30-day postsurgical mortality, 30-day postsurgical readmissions, and procedure-related complications: wound infections, seroma, injured adjacent structures, intra-abdominal abscess, hemorrhage, dehiscence, leak, or perforation of the gallbladder during laparoscopic cholecystectomy. Overall, patients had a 13% complication rate, a 5% readmission rate, and mortality of less than 1%.

Among the 869 procedures, 132 (15%) were done by surgeons following a night on call and the remaining 737 (85%) were done by surgeons not on call the prior night. In a multivariable regression analysis that controlled for patient’s age, urgency of the elective surgery, and comorbidities, the rates of complications, readmissions, and deaths were similar between those done by surgeons following a night on call and those done without working the night before, Dr. Croce reported.

Further analyses showed no significant difference between the two surgeon subgroups when the types of procedures were broken down into hernia repair, cholecystectomy, or bowel operation.

A limitation of the study was that the findings apply only to these three types of surgeries; they should not be extrapolated to other, more complex surgeries, said Dr. John P. Sharpe, a surgeon at the University of Tennessee who collaborated with Dr. Croce on the study.

Dr. Croce, Dr. Cioffi, Dr. Britt, and Dr. Sharpe had no disclosures.

PALM BEACH, FLA. – Surgeons who performed routine, elective operations the day after they spent all night working an in-hospital shift in the trauma unit had no increased rate of complications, no need for hospital readmissions, and no mortality among their elective cases in a single-center review of 869 cases.

The findings suggest that "there remains no compelling evidence to mandate work-hour restrictions for attending general surgeons," Dr. Martin A. Croce said at the annual meeting of the Southern Surgical Association.

"No study to date has evaluated the effect of sleep deprivation on outcomes specific to the practice of general surgery. This study looked at the impact of an overnight shift in a busy trauma center on the outcomes of typical general surgery procedures performed the next day" and found no significant difference in outcomes between post-call and non–post-call surgeons with respect to postoperative complications, readmissions, or deaths, said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center in Memphis.

"These results confirm my bias, but the study was limited by its retrospective, single-institution nature, and by only including tertiary teaching patients. Each [surgeon] must continue to use judgment when deciding whether to perform elective operations after a busy night on call," commented Dr. William G. Cioffi Jr., professor and chairman of surgery at Brown University, Providence, R.I.

"It is unclear to me that the surgical community will need to present these results because there has been no call for work-hour restrictions for attendings, nor do I feel there will be," said Dr. L.D. Britt, professor and chairman of surgery at Eastern Virginia Medical School, Norfolk.

In his study, Dr. Croce reviewed patients who underwent any of three types of general surgeries at his institution during January 2006 to April 2009 by one of the nine attending surgeons in the department. The review comprised 869 procedures: 46% were hernia repairs, 35% were cholecystectomies, and 19% were bowel operations. The primary outcomes were 30-day postsurgical mortality, 30-day postsurgical readmissions, and procedure-related complications: wound infections, seroma, injured adjacent structures, intra-abdominal abscess, hemorrhage, dehiscence, leak, or perforation of the gallbladder during laparoscopic cholecystectomy. Overall, patients had a 13% complication rate, a 5% readmission rate, and mortality of less than 1%.

Among the 869 procedures, 132 (15%) were done by surgeons following a night on call and the remaining 737 (85%) were done by surgeons not on call the prior night. In a multivariable regression analysis that controlled for patient’s age, urgency of the elective surgery, and comorbidities, the rates of complications, readmissions, and deaths were similar between those done by surgeons following a night on call and those done without working the night before, Dr. Croce reported.

Further analyses showed no significant difference between the two surgeon subgroups when the types of procedures were broken down into hernia repair, cholecystectomy, or bowel operation.

A limitation of the study was that the findings apply only to these three types of surgeries; they should not be extrapolated to other, more complex surgeries, said Dr. John P. Sharpe, a surgeon at the University of Tennessee who collaborated with Dr. Croce on the study.

Dr. Croce, Dr. Cioffi, Dr. Britt, and Dr. Sharpe had no disclosures.

PALM BEACH, FLA. – Surgeons who performed routine, elective operations the day after they spent all night working an in-hospital shift in the trauma unit had no increased rate of complications, no need for hospital readmissions, and no mortality among their elective cases in a single-center review of 869 cases.

The findings suggest that "there remains no compelling evidence to mandate work-hour restrictions for attending general surgeons," Dr. Martin A. Croce said at the annual meeting of the Southern Surgical Association.

"No study to date has evaluated the effect of sleep deprivation on outcomes specific to the practice of general surgery. This study looked at the impact of an overnight shift in a busy trauma center on the outcomes of typical general surgery procedures performed the next day" and found no significant difference in outcomes between post-call and non–post-call surgeons with respect to postoperative complications, readmissions, or deaths, said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center in Memphis.

"These results confirm my bias, but the study was limited by its retrospective, single-institution nature, and by only including tertiary teaching patients. Each [surgeon] must continue to use judgment when deciding whether to perform elective operations after a busy night on call," commented Dr. William G. Cioffi Jr., professor and chairman of surgery at Brown University, Providence, R.I.

"It is unclear to me that the surgical community will need to present these results because there has been no call for work-hour restrictions for attendings, nor do I feel there will be," said Dr. L.D. Britt, professor and chairman of surgery at Eastern Virginia Medical School, Norfolk.

In his study, Dr. Croce reviewed patients who underwent any of three types of general surgeries at his institution during January 2006 to April 2009 by one of the nine attending surgeons in the department. The review comprised 869 procedures: 46% were hernia repairs, 35% were cholecystectomies, and 19% were bowel operations. The primary outcomes were 30-day postsurgical mortality, 30-day postsurgical readmissions, and procedure-related complications: wound infections, seroma, injured adjacent structures, intra-abdominal abscess, hemorrhage, dehiscence, leak, or perforation of the gallbladder during laparoscopic cholecystectomy. Overall, patients had a 13% complication rate, a 5% readmission rate, and mortality of less than 1%.

Among the 869 procedures, 132 (15%) were done by surgeons following a night on call and the remaining 737 (85%) were done by surgeons not on call the prior night. In a multivariable regression analysis that controlled for patient’s age, urgency of the elective surgery, and comorbidities, the rates of complications, readmissions, and deaths were similar between those done by surgeons following a night on call and those done without working the night before, Dr. Croce reported.

Further analyses showed no significant difference between the two surgeon subgroups when the types of procedures were broken down into hernia repair, cholecystectomy, or bowel operation.

A limitation of the study was that the findings apply only to these three types of surgeries; they should not be extrapolated to other, more complex surgeries, said Dr. John P. Sharpe, a surgeon at the University of Tennessee who collaborated with Dr. Croce on the study.

Dr. Croce, Dr. Cioffi, Dr. Britt, and Dr. Sharpe had no disclosures.

PALM BEACH, FLA. – Simultaneous and staged removal of primary colorectal cancer and associated liver metastases worked equally well, a review of more than 1,000 cases at four international centers has shown.

"Long-term outcome of patients with synchronous colorectal liver metastases is dictated by biology, not by surgical strategy," Dr. Timothy M. Pawlik, FACS, said at the annual meeting of the Southern Surgical Association.

About a quarter of patients with advanced colorectal cancer present with synchronous liver metastases, and surgeons have used three different resection strategies. The classic approach has been staged removal of the primary, colorectal cancer first, followed by removal of the liver disease in a separate operation at a later time. In a much smaller number of cases, the staged approach is reversed, with initial excision of the liver disease followed later by removal of the primary tumor. The third option has been to do both excisions during a single operation. Until now, assessments that compared these approaches mostly have used data from a single center, and in several cases the reviews included relatively few patients, said Dr. Pawlik, a surgical oncologist at Johns Hopkins University in Baltimore.

The review done by Dr. Pawlik and his associates involved 1,004 patients treated between 1982 and 2011 at four major hepatobiliary centers in the United States and Europe. The series included 647 patients treated by removal of their primary colorectal tumor followed by a second surgery to remove their liver metastases, 329 patients who had both excisions done during a single operation, and 28 patients who had their liver metastases removed first and then had the primary tumor removed in a second operation.

The data showed no statistically significant difference for any outcome measure, including the incidence of complications, 90-day mortality, local recurrences, median survival, or rate of 5-year survival. For example, during a median follow-up of 34 months, the recurrence rate was 57% among patients treated with a classic, staged approach and 60% among patients who had a simultaneous excision, a difference that was not statistically significant. And in a multivariate regression analysis of factors associated with mortality during follow-up, simultaneous excision linked with an 8% higher mortality rate relative to a classic staged approach, but again the difference was not statistically significant.

"Long-term survival was associated with the location and extent of disease, but not with the surgical strategy," Dr. Pawlik said.

But he also qualified these findings with a couple of caveats. First, the findings "should only be extrapolated to academic centers, major hepatobiliary centers. The findings cannot be extrapolated to the community setting," he said.

Second, he agreed with the discussants of his report that a prospective, randomized trial should be done to definitively prove that surgical strategy has no impact on outcomes.

Dr. Pawlik said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Simultaneous and staged removal of primary colorectal cancer and associated liver metastases worked equally well, a review of more than 1,000 cases at four international centers has shown.

"Long-term outcome of patients with synchronous colorectal liver metastases is dictated by biology, not by surgical strategy," Dr. Timothy M. Pawlik, FACS, said at the annual meeting of the Southern Surgical Association.

About a quarter of patients with advanced colorectal cancer present with synchronous liver metastases, and surgeons have used three different resection strategies. The classic approach has been staged removal of the primary, colorectal cancer first, followed by removal of the liver disease in a separate operation at a later time. In a much smaller number of cases, the staged approach is reversed, with initial excision of the liver disease followed later by removal of the primary tumor. The third option has been to do both excisions during a single operation. Until now, assessments that compared these approaches mostly have used data from a single center, and in several cases the reviews included relatively few patients, said Dr. Pawlik, a surgical oncologist at Johns Hopkins University in Baltimore.

The review done by Dr. Pawlik and his associates involved 1,004 patients treated between 1982 and 2011 at four major hepatobiliary centers in the United States and Europe. The series included 647 patients treated by removal of their primary colorectal tumor followed by a second surgery to remove their liver metastases, 329 patients who had both excisions done during a single operation, and 28 patients who had their liver metastases removed first and then had the primary tumor removed in a second operation.

The data showed no statistically significant difference for any outcome measure, including the incidence of complications, 90-day mortality, local recurrences, median survival, or rate of 5-year survival. For example, during a median follow-up of 34 months, the recurrence rate was 57% among patients treated with a classic, staged approach and 60% among patients who had a simultaneous excision, a difference that was not statistically significant. And in a multivariate regression analysis of factors associated with mortality during follow-up, simultaneous excision linked with an 8% higher mortality rate relative to a classic staged approach, but again the difference was not statistically significant.

"Long-term survival was associated with the location and extent of disease, but not with the surgical strategy," Dr. Pawlik said.

But he also qualified these findings with a couple of caveats. First, the findings "should only be extrapolated to academic centers, major hepatobiliary centers. The findings cannot be extrapolated to the community setting," he said.

Second, he agreed with the discussants of his report that a prospective, randomized trial should be done to definitively prove that surgical strategy has no impact on outcomes.

Dr. Pawlik said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Simultaneous and staged removal of primary colorectal cancer and associated liver metastases worked equally well, a review of more than 1,000 cases at four international centers has shown.

"Long-term outcome of patients with synchronous colorectal liver metastases is dictated by biology, not by surgical strategy," Dr. Timothy M. Pawlik, FACS, said at the annual meeting of the Southern Surgical Association.

About a quarter of patients with advanced colorectal cancer present with synchronous liver metastases, and surgeons have used three different resection strategies. The classic approach has been staged removal of the primary, colorectal cancer first, followed by removal of the liver disease in a separate operation at a later time. In a much smaller number of cases, the staged approach is reversed, with initial excision of the liver disease followed later by removal of the primary tumor. The third option has been to do both excisions during a single operation. Until now, assessments that compared these approaches mostly have used data from a single center, and in several cases the reviews included relatively few patients, said Dr. Pawlik, a surgical oncologist at Johns Hopkins University in Baltimore.

The review done by Dr. Pawlik and his associates involved 1,004 patients treated between 1982 and 2011 at four major hepatobiliary centers in the United States and Europe. The series included 647 patients treated by removal of their primary colorectal tumor followed by a second surgery to remove their liver metastases, 329 patients who had both excisions done during a single operation, and 28 patients who had their liver metastases removed first and then had the primary tumor removed in a second operation.

The data showed no statistically significant difference for any outcome measure, including the incidence of complications, 90-day mortality, local recurrences, median survival, or rate of 5-year survival. For example, during a median follow-up of 34 months, the recurrence rate was 57% among patients treated with a classic, staged approach and 60% among patients who had a simultaneous excision, a difference that was not statistically significant. And in a multivariate regression analysis of factors associated with mortality during follow-up, simultaneous excision linked with an 8% higher mortality rate relative to a classic staged approach, but again the difference was not statistically significant.

"Long-term survival was associated with the location and extent of disease, but not with the surgical strategy," Dr. Pawlik said.

But he also qualified these findings with a couple of caveats. First, the findings "should only be extrapolated to academic centers, major hepatobiliary centers. The findings cannot be extrapolated to the community setting," he said.

Second, he agreed with the discussants of his report that a prospective, randomized trial should be done to definitively prove that surgical strategy has no impact on outcomes.

Dr. Pawlik said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – A commercially available computer program designed to calculate optimal insulin dosages for postsurgical ICU patients halved the rate of hyperglycemic episodes that patients experienced while dropping the rate of hypoglycemic events by 95% in a single-center, U.S. experience with a total of more than 2,000 patients.

The computer program also resulted in a dramatic reduction in the number of blood glucose measures the nursing staff performed, cutting testing down from 7,495 blood glucose measures/month before the system began to 4,072 blood measures/month once it was in place, Dr. Christopher C. Baker, FACS, said at the annual meeting of the Southern Surgical Association.

An additional associated benefit was a substantial reduction in hospital-acquired infections in the postsurgery patients once computer-guided insulin dosing came online, but this was only a temporal association that may have also been driven by other improvements in patient management that happened at about the same time, said Dr. Baker, chairman of surgery at the Carilion Clinic in Roanoke, Va.

"People have shied away from glucose controls systems [like the one introduced at the Carilion Clinic] because the results from the NICE-SUGAR [Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation] trial (N. Engl. J. Med. 2009;360:1283-97) showed that hypoglycemia episodes increase when you do this," commented Dr. David Herndon, FACS, professor of surgery at the University of Texas Medical branch in Galveston. "What is important in the Carilion results is that the computerized support system reduced hypoglycemia. If that can be done across the board, they might have a winner. We need to better control sugar in the ICU."

The next step is to prove the efficacy of this computer program in a prospective, randomized controlled trial, said Dr. Herndon, a suggestion that Dr. Baker also endorsed.

"The reduced incidence of hypoglycemia was incredibly impressive," commented Dr. Michael Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C., who also called for results from a prospective, controlled study.

Surgeons at Carilion introduced the computerized support program for insulin dosing in early 2010 into five surgical intensive care departments: surgical ICU, trauma ICU, neurotrauma ICU, cardiac surgery ICU, and the cardiac surgery progressive care unit. Dr. Baker and his associates compared data collected on patients from all five units with the computerized system in place during July 2010-December 2011, a total of 1,682 patients treated using the computer program, with 449 patients treated in the five units during July 2009-December 2009, before use of the computer program started.

When using the program, nurses take an initial blood specimen from a patient newly arrived at the unit and enter the blood glucose level into the program along with the patient’s weight and blood creatinine level. The program then immediately calculates the appropriate bolus insulin dose, the insulin infusion rate, and the time to the next blood draw, said Dr. Sandy L. Fogel, FACS, a surgeon at Carilion who collaborated on the study. At first, the next blood draw is specified for about 15-30 minutes following the first, but subsequently the blood draws are directed to occur at longer and longer intervals as the patient’s blood glucose comes under control, within the target range of 70-150 mg/dL. Eventually, draws occur at 6-8 hour intervals, Dr. Fogel said.

During the 6-month historical control, nurses drew 44,972 blood specimens for glucose measurement, an average of 7,495/month, compared with 73,290 blood draws during the 18-month period with the program in place, an average of 4,072 blood specimens drawn/month.

During the 18 months with the program in use, hyperglycemic episodes, defined as a blood glucose level greater than 150 mg/dL, dropped by 45%-57% across the five units using the system compared with each unit’s historical control. Overall, hyperglycemic events fell by 50%, a statistically significant difference.

The incidence of hypoglycemic episodes, defined as a blood glucose level below 40 mg/dL, fell from a 1% rate during the historical control period, to rates that ranged from zero to 0.12% with the program in place, with an overall rate across all five units of 0.05%, a 95% relative decrease that was statistically significant.

The substantial decline in hypoglycemic episodes "was a surprise for us," Dr. Fogel said. In addition, out of all the blood measures performed using the computer program 17% had glucose levels of 60-69 mg/dL, and 3% were below 60 mg/dL. In short, the computer program "did not increase hypoglycemic episodes by any way you measure it," Dr. Fogel said.

The insulin-dosing program used at Carilion is the EndoTool, marketed by Hospira, Inc.

Dr. Baker, Dr. Herndon, Dr. Rotondo, and Dr. Fogel had no disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – A commercially available computer program designed to calculate optimal insulin dosages for postsurgical ICU patients halved the rate of hyperglycemic episodes that patients experienced while dropping the rate of hypoglycemic events by 95% in a single-center, U.S. experience with a total of more than 2,000 patients.

The computer program also resulted in a dramatic reduction in the number of blood glucose measures the nursing staff performed, cutting testing down from 7,495 blood glucose measures/month before the system began to 4,072 blood measures/month once it was in place, Dr. Christopher C. Baker, FACS, said at the annual meeting of the Southern Surgical Association.

An additional associated benefit was a substantial reduction in hospital-acquired infections in the postsurgery patients once computer-guided insulin dosing came online, but this was only a temporal association that may have also been driven by other improvements in patient management that happened at about the same time, said Dr. Baker, chairman of surgery at the Carilion Clinic in Roanoke, Va.

"People have shied away from glucose controls systems [like the one introduced at the Carilion Clinic] because the results from the NICE-SUGAR [Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation] trial (N. Engl. J. Med. 2009;360:1283-97) showed that hypoglycemia episodes increase when you do this," commented Dr. David Herndon, FACS, professor of surgery at the University of Texas Medical branch in Galveston. "What is important in the Carilion results is that the computerized support system reduced hypoglycemia. If that can be done across the board, they might have a winner. We need to better control sugar in the ICU."

The next step is to prove the efficacy of this computer program in a prospective, randomized controlled trial, said Dr. Herndon, a suggestion that Dr. Baker also endorsed.

"The reduced incidence of hypoglycemia was incredibly impressive," commented Dr. Michael Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C., who also called for results from a prospective, controlled study.

Surgeons at Carilion introduced the computerized support program for insulin dosing in early 2010 into five surgical intensive care departments: surgical ICU, trauma ICU, neurotrauma ICU, cardiac surgery ICU, and the cardiac surgery progressive care unit. Dr. Baker and his associates compared data collected on patients from all five units with the computerized system in place during July 2010-December 2011, a total of 1,682 patients treated using the computer program, with 449 patients treated in the five units during July 2009-December 2009, before use of the computer program started.

When using the program, nurses take an initial blood specimen from a patient newly arrived at the unit and enter the blood glucose level into the program along with the patient’s weight and blood creatinine level. The program then immediately calculates the appropriate bolus insulin dose, the insulin infusion rate, and the time to the next blood draw, said Dr. Sandy L. Fogel, FACS, a surgeon at Carilion who collaborated on the study. At first, the next blood draw is specified for about 15-30 minutes following the first, but subsequently the blood draws are directed to occur at longer and longer intervals as the patient’s blood glucose comes under control, within the target range of 70-150 mg/dL. Eventually, draws occur at 6-8 hour intervals, Dr. Fogel said.

During the 6-month historical control, nurses drew 44,972 blood specimens for glucose measurement, an average of 7,495/month, compared with 73,290 blood draws during the 18-month period with the program in place, an average of 4,072 blood specimens drawn/month.

During the 18 months with the program in use, hyperglycemic episodes, defined as a blood glucose level greater than 150 mg/dL, dropped by 45%-57% across the five units using the system compared with each unit’s historical control. Overall, hyperglycemic events fell by 50%, a statistically significant difference.

The incidence of hypoglycemic episodes, defined as a blood glucose level below 40 mg/dL, fell from a 1% rate during the historical control period, to rates that ranged from zero to 0.12% with the program in place, with an overall rate across all five units of 0.05%, a 95% relative decrease that was statistically significant.

The substantial decline in hypoglycemic episodes "was a surprise for us," Dr. Fogel said. In addition, out of all the blood measures performed using the computer program 17% had glucose levels of 60-69 mg/dL, and 3% were below 60 mg/dL. In short, the computer program "did not increase hypoglycemic episodes by any way you measure it," Dr. Fogel said.

The insulin-dosing program used at Carilion is the EndoTool, marketed by Hospira, Inc.

Dr. Baker, Dr. Herndon, Dr. Rotondo, and Dr. Fogel had no disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – A commercially available computer program designed to calculate optimal insulin dosages for postsurgical ICU patients halved the rate of hyperglycemic episodes that patients experienced while dropping the rate of hypoglycemic events by 95% in a single-center, U.S. experience with a total of more than 2,000 patients.

The computer program also resulted in a dramatic reduction in the number of blood glucose measures the nursing staff performed, cutting testing down from 7,495 blood glucose measures/month before the system began to 4,072 blood measures/month once it was in place, Dr. Christopher C. Baker, FACS, said at the annual meeting of the Southern Surgical Association.

An additional associated benefit was a substantial reduction in hospital-acquired infections in the postsurgery patients once computer-guided insulin dosing came online, but this was only a temporal association that may have also been driven by other improvements in patient management that happened at about the same time, said Dr. Baker, chairman of surgery at the Carilion Clinic in Roanoke, Va.

"People have shied away from glucose controls systems [like the one introduced at the Carilion Clinic] because the results from the NICE-SUGAR [Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation] trial (N. Engl. J. Med. 2009;360:1283-97) showed that hypoglycemia episodes increase when you do this," commented Dr. David Herndon, FACS, professor of surgery at the University of Texas Medical branch in Galveston. "What is important in the Carilion results is that the computerized support system reduced hypoglycemia. If that can be done across the board, they might have a winner. We need to better control sugar in the ICU."

The next step is to prove the efficacy of this computer program in a prospective, randomized controlled trial, said Dr. Herndon, a suggestion that Dr. Baker also endorsed.

"The reduced incidence of hypoglycemia was incredibly impressive," commented Dr. Michael Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C., who also called for results from a prospective, controlled study.

Surgeons at Carilion introduced the computerized support program for insulin dosing in early 2010 into five surgical intensive care departments: surgical ICU, trauma ICU, neurotrauma ICU, cardiac surgery ICU, and the cardiac surgery progressive care unit. Dr. Baker and his associates compared data collected on patients from all five units with the computerized system in place during July 2010-December 2011, a total of 1,682 patients treated using the computer program, with 449 patients treated in the five units during July 2009-December 2009, before use of the computer program started.

When using the program, nurses take an initial blood specimen from a patient newly arrived at the unit and enter the blood glucose level into the program along with the patient’s weight and blood creatinine level. The program then immediately calculates the appropriate bolus insulin dose, the insulin infusion rate, and the time to the next blood draw, said Dr. Sandy L. Fogel, FACS, a surgeon at Carilion who collaborated on the study. At first, the next blood draw is specified for about 15-30 minutes following the first, but subsequently the blood draws are directed to occur at longer and longer intervals as the patient’s blood glucose comes under control, within the target range of 70-150 mg/dL. Eventually, draws occur at 6-8 hour intervals, Dr. Fogel said.

During the 6-month historical control, nurses drew 44,972 blood specimens for glucose measurement, an average of 7,495/month, compared with 73,290 blood draws during the 18-month period with the program in place, an average of 4,072 blood specimens drawn/month.

During the 18 months with the program in use, hyperglycemic episodes, defined as a blood glucose level greater than 150 mg/dL, dropped by 45%-57% across the five units using the system compared with each unit’s historical control. Overall, hyperglycemic events fell by 50%, a statistically significant difference.

The incidence of hypoglycemic episodes, defined as a blood glucose level below 40 mg/dL, fell from a 1% rate during the historical control period, to rates that ranged from zero to 0.12% with the program in place, with an overall rate across all five units of 0.05%, a 95% relative decrease that was statistically significant.

The substantial decline in hypoglycemic episodes "was a surprise for us," Dr. Fogel said. In addition, out of all the blood measures performed using the computer program 17% had glucose levels of 60-69 mg/dL, and 3% were below 60 mg/dL. In short, the computer program "did not increase hypoglycemic episodes by any way you measure it," Dr. Fogel said.

The insulin-dosing program used at Carilion is the EndoTool, marketed by Hospira, Inc.

Dr. Baker, Dr. Herndon, Dr. Rotondo, and Dr. Fogel had no disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Only a small percent of all trauma and acute care surgery patients require more than 10 days in the ICU, but the ones who do rack up an enormous chunk of ICU costs, a single-center study with more than 6,000 U.S. patients has shown.

A more detailed look at what contributes to these very prolonged ICU stays and their costs may provide new opportunities for hospital cost controls, Dr. Samir M. Fakhry, FACS, said at the annual meeting of the Southern Surgical Association.

"I think we need a paradigm shift in how these patients are managed," such as a step-down protocol that allows them to exit the ICU and wean off their ventilator, said Dr. Fakhry, professor and chief of general surgery at the Medical University of South Carolina in Charleston.

But trauma and acute care surgery patients who need less than a day in the ICU can’t be ignored either. Although their per-patient cost is relatively small, their aggregate cost is high, because many patients fall into this group.

"You need two approaches" for trying to save on surgical ICU costs, one for patients who need prolonged intensive care and a second approach for patients who require only a day, he said. "For patients with short lengths of stay and lower costs, small things like one or two fewer doses of an antibiotic or fewer tests would make a difference" when multiplied by thousands of patients, Dr. Fahkry said. Further insight into ICU costs and cost-saving approaches could come from expanding his analysis to a larger number of U.S. surgical ICUs, he added.

His analysis of data collected by the surgical ICU at the Medical University of South Carolina, a level 1 trauma center, during 2007-2011 also highlighted that the number of patients admitted to the unit jumped by 26%, rising from 1,084 patients in fiscal year 2007 to 1,364 in FY 2011. The rise was especially pronounced among nontrauma patients, increasing from 319 in 2007 to 502 in 2011, a 57% rise.

Dr. Fahkry and his associates analyzed data from a total of 6,008 patients admitted to his hospital’s surgical ICU during the 5-year period studied. Costs for this care rose from $17,243 per patient in 2007 to $26,468 in 2011, a 53% increase.

A total of 423 of these patients, 7%, stayed in the ICU for more than 10 days. This group consisted primarily of trauma patients, 320 (76%) of the 423 patients. The average length of stay among the prolonged-stay patients was about 17 days, with an overall duration of hospitalization of 31 days. About three-quarters of these patients had at least three comorbidities. Mortality was also high in this subgroup, especially in the nontrauma patients, who had a 40% death rate; in-hospital mortality among the trauma patients with prolonged ICU stays was 10%.

Although accounting for just 7% of all surgical ICU patients, this subgroup racked up 41% of total ICU costs during the 5 years studied. In contrast, 4,236 surgical ICU patients who remained in the unit for less than a full day, 71% of all patients in the analysis, were responsible for 30% of total surgical ICU costs.

The analysis also identified another marker of substantially increased ICU costs: patients who ultimately died during their index hospitalization. Among nontrauma patients who died while hospitalized, the average costs were nearly $60,000 per patient, almost eightfold higher than for the nontrauma patients who survived hospitalization. Among the trauma patients, those who died ran up more than $31,000 in costs, nearly threefold higher than the trauma patients who survived.

Dr. Fahkry said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Only a small percent of all trauma and acute care surgery patients require more than 10 days in the ICU, but the ones who do rack up an enormous chunk of ICU costs, a single-center study with more than 6,000 U.S. patients has shown.

A more detailed look at what contributes to these very prolonged ICU stays and their costs may provide new opportunities for hospital cost controls, Dr. Samir M. Fakhry, FACS, said at the annual meeting of the Southern Surgical Association.

"I think we need a paradigm shift in how these patients are managed," such as a step-down protocol that allows them to exit the ICU and wean off their ventilator, said Dr. Fakhry, professor and chief of general surgery at the Medical University of South Carolina in Charleston.

But trauma and acute care surgery patients who need less than a day in the ICU can’t be ignored either. Although their per-patient cost is relatively small, their aggregate cost is high, because many patients fall into this group.

"You need two approaches" for trying to save on surgical ICU costs, one for patients who need prolonged intensive care and a second approach for patients who require only a day, he said. "For patients with short lengths of stay and lower costs, small things like one or two fewer doses of an antibiotic or fewer tests would make a difference" when multiplied by thousands of patients, Dr. Fahkry said. Further insight into ICU costs and cost-saving approaches could come from expanding his analysis to a larger number of U.S. surgical ICUs, he added.

His analysis of data collected by the surgical ICU at the Medical University of South Carolina, a level 1 trauma center, during 2007-2011 also highlighted that the number of patients admitted to the unit jumped by 26%, rising from 1,084 patients in fiscal year 2007 to 1,364 in FY 2011. The rise was especially pronounced among nontrauma patients, increasing from 319 in 2007 to 502 in 2011, a 57% rise.

Dr. Fahkry and his associates analyzed data from a total of 6,008 patients admitted to his hospital’s surgical ICU during the 5-year period studied. Costs for this care rose from $17,243 per patient in 2007 to $26,468 in 2011, a 53% increase.

A total of 423 of these patients, 7%, stayed in the ICU for more than 10 days. This group consisted primarily of trauma patients, 320 (76%) of the 423 patients. The average length of stay among the prolonged-stay patients was about 17 days, with an overall duration of hospitalization of 31 days. About three-quarters of these patients had at least three comorbidities. Mortality was also high in this subgroup, especially in the nontrauma patients, who had a 40% death rate; in-hospital mortality among the trauma patients with prolonged ICU stays was 10%.

Although accounting for just 7% of all surgical ICU patients, this subgroup racked up 41% of total ICU costs during the 5 years studied. In contrast, 4,236 surgical ICU patients who remained in the unit for less than a full day, 71% of all patients in the analysis, were responsible for 30% of total surgical ICU costs.

The analysis also identified another marker of substantially increased ICU costs: patients who ultimately died during their index hospitalization. Among nontrauma patients who died while hospitalized, the average costs were nearly $60,000 per patient, almost eightfold higher than for the nontrauma patients who survived hospitalization. Among the trauma patients, those who died ran up more than $31,000 in costs, nearly threefold higher than the trauma patients who survived.

Dr. Fahkry said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Only a small percent of all trauma and acute care surgery patients require more than 10 days in the ICU, but the ones who do rack up an enormous chunk of ICU costs, a single-center study with more than 6,000 U.S. patients has shown.

A more detailed look at what contributes to these very prolonged ICU stays and their costs may provide new opportunities for hospital cost controls, Dr. Samir M. Fakhry, FACS, said at the annual meeting of the Southern Surgical Association.

"I think we need a paradigm shift in how these patients are managed," such as a step-down protocol that allows them to exit the ICU and wean off their ventilator, said Dr. Fakhry, professor and chief of general surgery at the Medical University of South Carolina in Charleston.

But trauma and acute care surgery patients who need less than a day in the ICU can’t be ignored either. Although their per-patient cost is relatively small, their aggregate cost is high, because many patients fall into this group.

"You need two approaches" for trying to save on surgical ICU costs, one for patients who need prolonged intensive care and a second approach for patients who require only a day, he said. "For patients with short lengths of stay and lower costs, small things like one or two fewer doses of an antibiotic or fewer tests would make a difference" when multiplied by thousands of patients, Dr. Fahkry said. Further insight into ICU costs and cost-saving approaches could come from expanding his analysis to a larger number of U.S. surgical ICUs, he added.

His analysis of data collected by the surgical ICU at the Medical University of South Carolina, a level 1 trauma center, during 2007-2011 also highlighted that the number of patients admitted to the unit jumped by 26%, rising from 1,084 patients in fiscal year 2007 to 1,364 in FY 2011. The rise was especially pronounced among nontrauma patients, increasing from 319 in 2007 to 502 in 2011, a 57% rise.

Dr. Fahkry and his associates analyzed data from a total of 6,008 patients admitted to his hospital’s surgical ICU during the 5-year period studied. Costs for this care rose from $17,243 per patient in 2007 to $26,468 in 2011, a 53% increase.

A total of 423 of these patients, 7%, stayed in the ICU for more than 10 days. This group consisted primarily of trauma patients, 320 (76%) of the 423 patients. The average length of stay among the prolonged-stay patients was about 17 days, with an overall duration of hospitalization of 31 days. About three-quarters of these patients had at least three comorbidities. Mortality was also high in this subgroup, especially in the nontrauma patients, who had a 40% death rate; in-hospital mortality among the trauma patients with prolonged ICU stays was 10%.

Although accounting for just 7% of all surgical ICU patients, this subgroup racked up 41% of total ICU costs during the 5 years studied. In contrast, 4,236 surgical ICU patients who remained in the unit for less than a full day, 71% of all patients in the analysis, were responsible for 30% of total surgical ICU costs.

The analysis also identified another marker of substantially increased ICU costs: patients who ultimately died during their index hospitalization. Among nontrauma patients who died while hospitalized, the average costs were nearly $60,000 per patient, almost eightfold higher than for the nontrauma patients who survived hospitalization. Among the trauma patients, those who died ran up more than $31,000 in costs, nearly threefold higher than the trauma patients who survived.

Dr. Fahkry said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA.  – Florida’s statewide trauma triage system, one of America’s oldest and best organized state systems, did an increasingly better job over time from 1996 through 2010 funneling severely injured children and adults to one the state’s 22 designated trauma centers, according to data collected by the state government.

Florida’s program has had less clear-cut success triaging the elderly population with severe, acute trauma injuries to designated trauma centers, but the raw data may be misleading, Dr. David J. Ciesla, FACS, said at the annual meeting of the Southern Surgical Association.

Data collected by Florida’s Agency for Health Care Administration showed that during 2010, 41% of severely injured patients older than 65 years were discharged from a designated trauma center (DTC), compared with an 85% rate among adults 16-65 years old, and a 93% rate among children under age 16, said Dr. Ciesla, medical director of the Regional Trauma Program at Tampa General Hospital.

But the strikingly lower rate of elderly patient referral to a DTC may be an artifact of how Dr. Ciesla and his associates defined severe injury in their analysis. Their definition relied on survival. Using the ICD-9 Injury Severity Score (ICISS) to rate a patient’s need for DTC referral, they rated patients with ICISS of less than 0.85 (a less than 85% survival rate) as severely injured and candidates for DTC triage. But this criterion starts to break down for older patients, he explained.

"We defined injury severity as the risk of death, but that can be age related as well as injury related. It could be that older patients are more elderly than they are injured," he said.

Many of the elderly patients who were hospitalized for trauma "may be injured, but were they severely injured, or did they have high mortality because of their age or their comorbidities?" Dr. Ciesla said in an interview.

"I think the Florida system works well. We have shown [in these data] that the system can identify severely injured children and adults and get them to designated trauma centers. The elderly patients we’re calling ‘severely injured’ may just be elderly who can be appropriately treated in community hospitals," he said.

This interpretation received support from several surgeons who heard the talk at the meeting.

"The distribution of trauma centers on the basis of need is a critical issue in the 21st century health care paradigm. While we must assure equitable access to care delivered at the highest standard, and matched to the patient’s needs, we must assure that this is accomplished in a fiscally responsible way which avoids unnecessary duplication of resources and services. The work presented here today begins to probe this highly complex challenge," commented Dr. Michael F. Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C.*

"Does Florida have enough trauma centers? These data basically say yes, we have enough," said Dr. Joseph J. Tepas III, FACS, professor and chief of pediatric surgery at the University of Florida in Jacksonville and a coauthor of the study. "Ninety percent of the patients were direct transfers" to a DTC, indicating that "paramedic triage discretion seems to work quite well" in routing injured patients to the appropriate hospital, he said.

The study run by Dr. Ciesla, Dr. Tepas, and their associates reviewed all patients discharged from Florida hospitals during 1996-2010 using data collected by the state agency. The researchers identified injured patients by their diagnostic codes, and analyzed them by their discharge hospital and by their home zip codes. The analysis showed that the percent of severely injured patients discharged from a DTC rose from fewer than half of the state’s patients in this category in 1996 to 63% in 2010.

Among 225 severely injured children, 210 (93%) were discharged from a DTC, with only 15 children who did not receive DTC treatment. The 2010 database also included 7,469 severely injured adults, with 85% discharged from a DTC, and 7,825 elderly patients, with 41% discharged from a DTC.

The analysis of DTC discharges of severely injured patients by their home zip codes identified an area of the Florida panhandle, near Panama City, where several adult patients failed to receive care at a DTC, suggesting that residents in this area of the state might be better served by opening another, nearby DTC, said Dr. Ciesla, who is also director of acute care surgery at the University of South Florida in Tampa.

"You need enough centers to cover everyone geographically, but not so many that you dilute" patient volume at individual centers, he said. The researchers have not yet analyzed the best DTC volume to produce optimal patient outcomes, he added.

Dr. Ciesla said that he and Dr. Tepas and their associates had no disclosures. Dr. Rotondo had no disclosures.

*CORRECTION: This story originally misquoted Dr. Michael F. Rotondo. His quote should have read: "The distribution of Trauma Centers on the basis of need is a critical issue in the 21st century health care paradigm. While we must assure equitable access to care delivered at the highest standard, and matched to the patient’s needs, we must assure that this is accomplished in a fiscally responsible way which avoids unnecessary duplication of resources and services. The work presented here today begins to probe this highly complex challenge."

PALM BEACH, FLA.  – Florida’s statewide trauma triage system, one of America’s oldest and best organized state systems, did an increasingly better job over time from 1996 through 2010 funneling severely injured children and adults to one the state’s 22 designated trauma centers, according to data collected by the state government.

Florida’s program has had less clear-cut success triaging the elderly population with severe, acute trauma injuries to designated trauma centers, but the raw data may be misleading, Dr. David J. Ciesla, FACS, said at the annual meeting of the Southern Surgical Association.

Data collected by Florida’s Agency for Health Care Administration showed that during 2010, 41% of severely injured patients older than 65 years were discharged from a designated trauma center (DTC), compared with an 85% rate among adults 16-65 years old, and a 93% rate among children under age 16, said Dr. Ciesla, medical director of the Regional Trauma Program at Tampa General Hospital.

But the strikingly lower rate of elderly patient referral to a DTC may be an artifact of how Dr. Ciesla and his associates defined severe injury in their analysis. Their definition relied on survival. Using the ICD-9 Injury Severity Score (ICISS) to rate a patient’s need for DTC referral, they rated patients with ICISS of less than 0.85 (a less than 85% survival rate) as severely injured and candidates for DTC triage. But this criterion starts to break down for older patients, he explained.

"We defined injury severity as the risk of death, but that can be age related as well as injury related. It could be that older patients are more elderly than they are injured," he said.

Many of the elderly patients who were hospitalized for trauma "may be injured, but were they severely injured, or did they have high mortality because of their age or their comorbidities?" Dr. Ciesla said in an interview.

"I think the Florida system works well. We have shown [in these data] that the system can identify severely injured children and adults and get them to designated trauma centers. The elderly patients we’re calling ‘severely injured’ may just be elderly who can be appropriately treated in community hospitals," he said.

This interpretation received support from several surgeons who heard the talk at the meeting.

"The distribution of trauma centers on the basis of need is a critical issue in the 21st century health care paradigm. While we must assure equitable access to care delivered at the highest standard, and matched to the patient’s needs, we must assure that this is accomplished in a fiscally responsible way which avoids unnecessary duplication of resources and services. The work presented here today begins to probe this highly complex challenge," commented Dr. Michael F. Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C.*

"Does Florida have enough trauma centers? These data basically say yes, we have enough," said Dr. Joseph J. Tepas III, FACS, professor and chief of pediatric surgery at the University of Florida in Jacksonville and a coauthor of the study. "Ninety percent of the patients were direct transfers" to a DTC, indicating that "paramedic triage discretion seems to work quite well" in routing injured patients to the appropriate hospital, he said.

The study run by Dr. Ciesla, Dr. Tepas, and their associates reviewed all patients discharged from Florida hospitals during 1996-2010 using data collected by the state agency. The researchers identified injured patients by their diagnostic codes, and analyzed them by their discharge hospital and by their home zip codes. The analysis showed that the percent of severely injured patients discharged from a DTC rose from fewer than half of the state’s patients in this category in 1996 to 63% in 2010.

Among 225 severely injured children, 210 (93%) were discharged from a DTC, with only 15 children who did not receive DTC treatment. The 2010 database also included 7,469 severely injured adults, with 85% discharged from a DTC, and 7,825 elderly patients, with 41% discharged from a DTC.

The analysis of DTC discharges of severely injured patients by their home zip codes identified an area of the Florida panhandle, near Panama City, where several adult patients failed to receive care at a DTC, suggesting that residents in this area of the state might be better served by opening another, nearby DTC, said Dr. Ciesla, who is also director of acute care surgery at the University of South Florida in Tampa.

"You need enough centers to cover everyone geographically, but not so many that you dilute" patient volume at individual centers, he said. The researchers have not yet analyzed the best DTC volume to produce optimal patient outcomes, he added.

Dr. Ciesla said that he and Dr. Tepas and their associates had no disclosures. Dr. Rotondo had no disclosures.

*CORRECTION: This story originally misquoted Dr. Michael F. Rotondo. His quote should have read: "The distribution of Trauma Centers on the basis of need is a critical issue in the 21st century health care paradigm. While we must assure equitable access to care delivered at the highest standard, and matched to the patient’s needs, we must assure that this is accomplished in a fiscally responsible way which avoids unnecessary duplication of resources and services. The work presented here today begins to probe this highly complex challenge."

PALM BEACH, FLA.  – Florida’s statewide trauma triage system, one of America’s oldest and best organized state systems, did an increasingly better job over time from 1996 through 2010 funneling severely injured children and adults to one the state’s 22 designated trauma centers, according to data collected by the state government.

Florida’s program has had less clear-cut success triaging the elderly population with severe, acute trauma injuries to designated trauma centers, but the raw data may be misleading, Dr. David J. Ciesla, FACS, said at the annual meeting of the Southern Surgical Association.

Data collected by Florida’s Agency for Health Care Administration showed that during 2010, 41% of severely injured patients older than 65 years were discharged from a designated trauma center (DTC), compared with an 85% rate among adults 16-65 years old, and a 93% rate among children under age 16, said Dr. Ciesla, medical director of the Regional Trauma Program at Tampa General Hospital.

But the strikingly lower rate of elderly patient referral to a DTC may be an artifact of how Dr. Ciesla and his associates defined severe injury in their analysis. Their definition relied on survival. Using the ICD-9 Injury Severity Score (ICISS) to rate a patient’s need for DTC referral, they rated patients with ICISS of less than 0.85 (a less than 85% survival rate) as severely injured and candidates for DTC triage. But this criterion starts to break down for older patients, he explained.

"We defined injury severity as the risk of death, but that can be age related as well as injury related. It could be that older patients are more elderly than they are injured," he said.

Many of the elderly patients who were hospitalized for trauma "may be injured, but were they severely injured, or did they have high mortality because of their age or their comorbidities?" Dr. Ciesla said in an interview.

"I think the Florida system works well. We have shown [in these data] that the system can identify severely injured children and adults and get them to designated trauma centers. The elderly patients we’re calling ‘severely injured’ may just be elderly who can be appropriately treated in community hospitals," he said.

This interpretation received support from several surgeons who heard the talk at the meeting.

"The distribution of trauma centers on the basis of need is a critical issue in the 21st century health care paradigm. While we must assure equitable access to care delivered at the highest standard, and matched to the patient’s needs, we must assure that this is accomplished in a fiscally responsible way which avoids unnecessary duplication of resources and services. The work presented here today begins to probe this highly complex challenge," commented Dr. Michael F. Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C.*

"Does Florida have enough trauma centers? These data basically say yes, we have enough," said Dr. Joseph J. Tepas III, FACS, professor and chief of pediatric surgery at the University of Florida in Jacksonville and a coauthor of the study. "Ninety percent of the patients were direct transfers" to a DTC, indicating that "paramedic triage discretion seems to work quite well" in routing injured patients to the appropriate hospital, he said.

The study run by Dr. Ciesla, Dr. Tepas, and their associates reviewed all patients discharged from Florida hospitals during 1996-2010 using data collected by the state agency. The researchers identified injured patients by their diagnostic codes, and analyzed them by their discharge hospital and by their home zip codes. The analysis showed that the percent of severely injured patients discharged from a DTC rose from fewer than half of the state’s patients in this category in 1996 to 63% in 2010.

Among 225 severely injured children, 210 (93%) were discharged from a DTC, with only 15 children who did not receive DTC treatment. The 2010 database also included 7,469 severely injured adults, with 85% discharged from a DTC, and 7,825 elderly patients, with 41% discharged from a DTC.

The analysis of DTC discharges of severely injured patients by their home zip codes identified an area of the Florida panhandle, near Panama City, where several adult patients failed to receive care at a DTC, suggesting that residents in this area of the state might be better served by opening another, nearby DTC, said Dr. Ciesla, who is also director of acute care surgery at the University of South Florida in Tampa.

"You need enough centers to cover everyone geographically, but not so many that you dilute" patient volume at individual centers, he said. The researchers have not yet analyzed the best DTC volume to produce optimal patient outcomes, he added.

Dr. Ciesla said that he and Dr. Tepas and their associates had no disclosures. Dr. Rotondo had no disclosures.

*CORRECTION: This story originally misquoted Dr. Michael F. Rotondo. His quote should have read: "The distribution of Trauma Centers on the basis of need is a critical issue in the 21st century health care paradigm. While we must assure equitable access to care delivered at the highest standard, and matched to the patient’s needs, we must assure that this is accomplished in a fiscally responsible way which avoids unnecessary duplication of resources and services. The work presented here today begins to probe this highly complex challenge."