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

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

A Dedicated Path to Emergent Thoracic Surgery in COVID-19 Patients: An Italian Institution Protocol

The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic pointed out that the need to ensure emergent surgery in patients positive for infection is no longer hypothetical. Among emergency procedures, thoracic surgical operations are frequent. A standardized surgical pathway is mandatory to achieve effective and safe management of this subset of patients. We briefly present the protocol adopted by our thoracic surgery division.

154 compared to 54 mmol per liter of sodium in intravenous maintenance fluid therapy for adult patients undergoing major thoracic surgery (TOPMAST): a single-center randomized controlled double-blind trial

PURPOSE

To determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders.

METHODS

We performed a randomized controlled trial of adults undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints.

FINDINGS

We randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601-2137) more positive in the Na154 arm (p < 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (p = 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0; p = 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (p < 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI - 0.2-30.4%, p = 0.05).

CONCLUSIONS

In adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia.

ERS/EACTS statement on the management of malignant pleural effusions

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.

The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database Program - Two Decades of Quality Assurance Data

Over two decades, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) cardiac surgery database program has evolved from a single state-based database to a national clinical quality registry program and is now the most comprehensive cardiac surgical registry in Australia. We report the current structure and governance of the program and its key activities.

Effectiveness of Percutaneous Intradiscal Decompression Therapy in Thoracic Disc Herniation

Aims

Although there have been many studies about lumbar and cervical ablation procedures, few studies have been performed in the thoracic region. To evaluate the clinical results of a percutaneous disc decompression device in patients with radicular symptoms and/or dorsal pain due to thoracic disc herniation.

Methods

Eleven patients with thoracic disc herniation and/or degenerative discs (all in T10-T11, or T11-T12 levels) who did not respond to conservative treatments were undergoing ablation and compression procedures. Pain and radicular symptoms consistent with the thoracolumbar region were confirmed via abnormal magnetic resonance imaging findings after detailed anamnesis and physical examination. All patients were evaluated before and 1, 3, 6, and 12 months after treatment using the visual analog scale score. The patient satisfaction scale was used to evaluate the level of patient satisfaction at the end of the treatment at 12 months.

Results

The median visual analog scale score was 7.00±0.45 points before treatment and 2.73±0.65 points at 12 months post-procedure and were statistically significant (p<0.001). The results of pairwise comparisons using the Bonferroni Corrected Wilcoxon Signed-Rank test showed that there were statistically significant differences. The mean visual analog scale score at the beginning (7.00±0.45) was significantly higher than the mean score of other months. Postoperative improvement was significant with a 99% confidence interval. No complications that may cause permanent damage occurred.

Conclusion

Percutaneous disc decompression is an effective and safe procedure to treat pain caused by lower thoracic intervertebral disc disease, which did not respond to conservative treatments.

Self-Appraised Readiness of Senior and Graduating General Surgery Residents to Perform Thoracic Surgery

OBJECTIVE

General surgeons perform up to 50% of noncardiac thoracic surgery (TS). Although data show consistent TS case volume during general surgery (GS) residency it is unknown whether this operative trend will persist given potentially limited subspecialty exposure. We sought to determine if certain aspects of residency programs and resident characteristics were associated with trainees' perceived comfort in performing certain basic TS procedures.

DESIGN

An anonymous survey was distributed to GS residents regarding program characteristics, presence of a TS residency, and intent to pursue thoracic surgical training, and estimated case volumes of individual procedures. Comfort levels for performing video-assisted thoracoscopic surgical (VATS) procedures, open lobectomy, elective thoracotomy, and sternotomy were attained through a 5-point Likert-type scale.

SETTING

This survey was administered at 50 training programs with responses recorded via an online form.

PARTICIPANTS

Fourth- and fifth-year GS residents in the United States.

RESULTS

Of 272 respondents 58% were fourth-year residents, 62% of residents trained at university-affiliated programs, and 64% reported a TS residency program at their institution and 16% stated intent to pursue TS. Fifth-year residents performed significantly more cases than fourth-year residents despite no difference in median comfort levels. Residents intending to pursue TS performed significantly more cases and were more comfortable performing a thoracotomy, sternotomy, VATS wedge resection/biopsy, and VATS decortication/pleurodesis (p = 0.044, <0.001, 0.045, 0.025). No characteristics were associated with comfort performing a lobectomy via thoracoscopic or open (thoracotomy) approaches.

CONCLUSION

Most senior or graduating GS residents state they are comfortable performing certain thoracic procedures with those pursuing additional thoracic surgical training more comfortable overall. No characteristics were associated with comfort performing a lobectomy. These findings may advise residency curriculum design to ensure continued thoracic surgical exposure and recommend against non-fellowship trained surgeons performing a pulmonary lobectomy.

Start-up of a Cardiology Day Hospital: Activity, Quality Care and Cost-effectiveness Analysis of the First Year of Operation

INTRODUCTION AND OBJECTIVES

The cardiology day hospital (CDH) is an alternative to hospitalization for scheduled cardiological procedures. The aims of this study were to analyze the activity, quality of care and the cost-effectiveness of a CDH.

METHODS

An observational descriptive study was conducted of the health care activity during the first year of operation of DHHA. The quality of care was analyzed through the substitution rate (outpatient procedures), cancellation rates, complications, and a satisfaction survey. For cost-effectiveness, we calculated the economic savings of avoided hospital stays.

RESULTS

A total of 1646 patients were attended (mean age 69 ± 15 years, 60% men); 2550 procedures were scheduled with a cancellation rate of 4%. The most frequently cancelled procedure was electrical cardioversion. The substitution rate for scheduled invasive procedures was 66%. Only 1 patient required readmission after discharge from the CDH due to heart failure. Most surveyed patients (95%) considered the care received in the CDH to be good or very good. The saving due to outpatient-converted procedures made possible by the CDH was € 219 199.55, higher than the cost of the first year of operation.

CONCLUSIONS

In our center, the CDH allowed more than two thirds of the invasive procedures to be performed on an outpatient basis, while maintaining the quality of care. In the first year of operation, the expenses due to its implementation were offset by a significant reduction in hospital admissions.

Revision of Immediate Post-Open Heart Surgery Education for Critical Care RNs

Responding to the complex nature of critical care is imperative, as extensive clinical judgment is required during those vital moments when patients are experiencing complications related to open heart surgery, post-vessel bypass, or valve replacement. Critical care registered nurses must rely on evidence-based foundational knowledge and skills particular to cardiovascular pathophysiology, hemodynamic monitoring, and medications. This article reports on the critical care educator's revision of the immediate post-open heart surgery curriculum. Mixed educational methods within the plan were foundational to develop clinicians for competent care of these complex patients (within the first 8 hours). The revision included experiential learning and learner centeredness to bolster the learner's confidence, reduce the time to competence, and, most important, ensure positive patient outcomes. Kirkpatrick's classic four-level model provided the framework for evaluation. Lessons learned were discussed following the program initiation.

Perioperative diabetes care: room for improving the person centredness

AIMS

Person centredness is an important principle for delivering high-quality diabetes care. In this study, we assess the level of person centredness of current perioperative diabetes care.

METHODS

We conducted a survey in six Dutch hospitals, among 690 participants with diabetes who underwent major abdominal, cardiac or large-joint orthopaedic surgery. The survey included questions regarding seven dimensions of person-centred perioperative diabetes care.

RESULTS

Complete data were obtained from 298 participants. The survey scores were low for many of the dimensions of person centredness. The dimensions 'information', 'patient involvement' and 'coordination and integration of care' had the lowest scores. Only half the participants had received information about perioperative diabetes treatment, and approximately one-third had received information about the effect of surgery on blood glucose values, target glucose values and glucose measurement times. Similarly, half the participants had an opportunity to ask questions preoperatively, and only one-third of the participants felt involved in the decision-making regarding diabetes treatment. Most participants knew neither the caregiver in charge of perioperative diabetes treatment nor whom to contact in case of diabetes-related problems during their hospital stay.

CONCLUSIONS

Current perioperative diabetes care is characterized by a lack of patient information and limited patient involvement. These results indicate that there is ample room for improving the person centredness of perioperative diabetes care.