ACS Surgery News

The 2014 Resident and Associate Society of the American College of Surgeons (RAS-ACS) Symposium at the ACS Clinical Congress, will take place Sunday, October 26, 2014, from 3:00 to 5:30 pm at the Moscone Center in San Francisco, CA, and will focus on the future of general surgery training. Five-Year General Surgery Residency: Fix It or Flush It? will review the impact of the Affordable Care Act on reimbursement, and distribution of Accreditation Council for Graduate Medical Education funds on surgical training. Should residents adapt to change, or will they wear "blinders" until things return to the way they were? RAS-ACS members may join the discussion and submit essays that express their opinions on whether surgical training is due for reform or for revolution.

First-place winners on both sides of the debate will be invited to present their viewpoints. Third- and fourth-place winners will have their submissions published in the Bulletin of the American College of Surgeons. Audience questions and discussion will follow.

Submission information:

•Maximum 1,000 word essay as a Word document

• References not required, but preferred

• Include name, facility, city, state, phone number, and e-mail address

• Submissions are due at 5:00 pm (CDT) on Friday, May 2, 2014 to [email protected].

The 2014 Resident and Associate Society of the American College of Surgeons (RAS-ACS) Symposium at the ACS Clinical Congress, will take place Sunday, October 26, 2014, from 3:00 to 5:30 pm at the Moscone Center in San Francisco, CA, and will focus on the future of general surgery training. Five-Year General Surgery Residency: Fix It or Flush It? will review the impact of the Affordable Care Act on reimbursement, and distribution of Accreditation Council for Graduate Medical Education funds on surgical training. Should residents adapt to change, or will they wear "blinders" until things return to the way they were? RAS-ACS members may join the discussion and submit essays that express their opinions on whether surgical training is due for reform or for revolution.

First-place winners on both sides of the debate will be invited to present their viewpoints. Third- and fourth-place winners will have their submissions published in the Bulletin of the American College of Surgeons. Audience questions and discussion will follow.

Submission information:

•Maximum 1,000 word essay as a Word document

• References not required, but preferred

• Include name, facility, city, state, phone number, and e-mail address

• Submissions are due at 5:00 pm (CDT) on Friday, May 2, 2014 to [email protected].

The 2014 Resident and Associate Society of the American College of Surgeons (RAS-ACS) Symposium at the ACS Clinical Congress, will take place Sunday, October 26, 2014, from 3:00 to 5:30 pm at the Moscone Center in San Francisco, CA, and will focus on the future of general surgery training. Five-Year General Surgery Residency: Fix It or Flush It? will review the impact of the Affordable Care Act on reimbursement, and distribution of Accreditation Council for Graduate Medical Education funds on surgical training. Should residents adapt to change, or will they wear "blinders" until things return to the way they were? RAS-ACS members may join the discussion and submit essays that express their opinions on whether surgical training is due for reform or for revolution.

First-place winners on both sides of the debate will be invited to present their viewpoints. Third- and fourth-place winners will have their submissions published in the Bulletin of the American College of Surgeons. Audience questions and discussion will follow.

Submission information:

•Maximum 1,000 word essay as a Word document

• References not required, but preferred

• Include name, facility, city, state, phone number, and e-mail address

• Submissions are due at 5:00 pm (CDT) on Friday, May 2, 2014 to [email protected].

The webcasts of select 2013 Clinical Congress sessions are available for viewing on demand through the American College of Surgeons (ACS) Division of Education. The webcasts may be used for self-assessment and continuing medical education credit. Purchasers of the sessions may choose from three packages:

• Complete Best Value Package, which allows the user to access all 38 webcast sessions from 2013 and 36 from 2012 and includes audio access to 35 select Panel Sessions from 2013

• Webcast Package, which provides access to all 38 webcast sessions from 2013

• Webcast Pick 12, which allows the purchaser to select 12 out of 38 webcast sessions from 2013

Go the ACS website for ordering and access information at http://acswebcast.sclivelearningcenter.com/index.aspx?PID=10151.

The webcasts of select 2013 Clinical Congress sessions are available for viewing on demand through the American College of Surgeons (ACS) Division of Education. The webcasts may be used for self-assessment and continuing medical education credit. Purchasers of the sessions may choose from three packages:

• Complete Best Value Package, which allows the user to access all 38 webcast sessions from 2013 and 36 from 2012 and includes audio access to 35 select Panel Sessions from 2013

• Webcast Package, which provides access to all 38 webcast sessions from 2013

• Webcast Pick 12, which allows the purchaser to select 12 out of 38 webcast sessions from 2013

Go the ACS website for ordering and access information at http://acswebcast.sclivelearningcenter.com/index.aspx?PID=10151.

The webcasts of select 2013 Clinical Congress sessions are available for viewing on demand through the American College of Surgeons (ACS) Division of Education. The webcasts may be used for self-assessment and continuing medical education credit. Purchasers of the sessions may choose from three packages:

• Complete Best Value Package, which allows the user to access all 38 webcast sessions from 2013 and 36 from 2012 and includes audio access to 35 select Panel Sessions from 2013

• Webcast Package, which provides access to all 38 webcast sessions from 2013

• Webcast Pick 12, which allows the purchaser to select 12 out of 38 webcast sessions from 2013

Go the ACS website for ordering and access information at http://acswebcast.sclivelearningcenter.com/index.aspx?PID=10151.

The International Relations Committee of the American College of Surgeons (ACS) has announced the availability of the ACS Traveling Fellowship to Japan. This fellowship is intended to encourage international exchange of surgical scientific information. The ACS Traveling Fellow will visit Japan, and a Japanese Traveling Fellow will visit North America. Applications for the Fellowship will be accepted through June 2, 2014.

Requirements

The scholarship is available to a Fellow of the ACS in most of the surgical specialties who meets the following requirements:

• Has a major interest and accomplishment in clinical and basic science related to surgery

• Holds a current full-time academic appointment in Canada or the U.S.

• Is less than 45 years of age on the date the application is filed

• Is enthusiastic, personable, and possesses good communication skills

Activities

The Fellow is required to spend a minimum of two weeks in Japan and engage in the following activities:

• Attend and participate in the annual meeting of the Japan Surgical Society (JSS), which will be held in Nagoya April 16–18, 2015

• Attend the Japan ACS Chapter meeting during the JSS meeting

• Visit at least two medical centers outside of the annual meeting city before or after the JSS conference to lecture and to share clinical and scientific expertise with local surgeons

The academic and geographic aspects of the itinerary will be finalized in consultation and mutual agreement between the Fellow and designated representatives of the JSS and the Japan ACS Chapter. The surgical centers to be visited would depend to some extent on the special interests and expertise of the Fellow and previously established professional contacts the Fellow has with surgeons in Japan.

The successful applicant’s spouse is welcome to accompany the Fellow on the trip. There will be opportunities for social interaction, in addition to professional activities.

Financial support

The College will provide $7,500 (U.S.) to the successful applicant, who will also be exempted from registration fees for the JSS annual meeting.

The Fellow must meet all travel and living expenses. Senior JSS and Japan ACS Chapter representatives will consult with the Fellow about the centers to be visited in Japan, the local arrangements for each center, and other advice and recommendations about travel schedules. The Fellow must make travel arrangements in North America to have access to reduced fares and travel packages for travel in Japan.

Application process

The ACS International Relations Committee will select the Fellow after review and evaluation of the final applications. A personal interview may be requested before the final selection.

Applications for this traveling fellowship are available at http://www.facs.org/memberservices/acsjapan.html or by e-mailing the International Liaison at [email protected].

The successful applicant and an alternate will be selected and notified by November 30, 2014.

The International Relations Committee of the American College of Surgeons (ACS) has announced the availability of the ACS Traveling Fellowship to Japan. This fellowship is intended to encourage international exchange of surgical scientific information. The ACS Traveling Fellow will visit Japan, and a Japanese Traveling Fellow will visit North America. Applications for the Fellowship will be accepted through June 2, 2014.

Requirements

The scholarship is available to a Fellow of the ACS in most of the surgical specialties who meets the following requirements:

• Has a major interest and accomplishment in clinical and basic science related to surgery

• Holds a current full-time academic appointment in Canada or the U.S.

• Is less than 45 years of age on the date the application is filed

• Is enthusiastic, personable, and possesses good communication skills

Activities

The Fellow is required to spend a minimum of two weeks in Japan and engage in the following activities:

• Attend and participate in the annual meeting of the Japan Surgical Society (JSS), which will be held in Nagoya April 16–18, 2015

• Attend the Japan ACS Chapter meeting during the JSS meeting

• Visit at least two medical centers outside of the annual meeting city before or after the JSS conference to lecture and to share clinical and scientific expertise with local surgeons

The academic and geographic aspects of the itinerary will be finalized in consultation and mutual agreement between the Fellow and designated representatives of the JSS and the Japan ACS Chapter. The surgical centers to be visited would depend to some extent on the special interests and expertise of the Fellow and previously established professional contacts the Fellow has with surgeons in Japan.

The successful applicant’s spouse is welcome to accompany the Fellow on the trip. There will be opportunities for social interaction, in addition to professional activities.

Financial support

The College will provide $7,500 (U.S.) to the successful applicant, who will also be exempted from registration fees for the JSS annual meeting.

The Fellow must meet all travel and living expenses. Senior JSS and Japan ACS Chapter representatives will consult with the Fellow about the centers to be visited in Japan, the local arrangements for each center, and other advice and recommendations about travel schedules. The Fellow must make travel arrangements in North America to have access to reduced fares and travel packages for travel in Japan.

Application process

The ACS International Relations Committee will select the Fellow after review and evaluation of the final applications. A personal interview may be requested before the final selection.

Applications for this traveling fellowship are available at http://www.facs.org/memberservices/acsjapan.html or by e-mailing the International Liaison at [email protected].

The successful applicant and an alternate will be selected and notified by November 30, 2014.

The International Relations Committee of the American College of Surgeons (ACS) has announced the availability of the ACS Traveling Fellowship to Japan. This fellowship is intended to encourage international exchange of surgical scientific information. The ACS Traveling Fellow will visit Japan, and a Japanese Traveling Fellow will visit North America. Applications for the Fellowship will be accepted through June 2, 2014.

Requirements

The scholarship is available to a Fellow of the ACS in most of the surgical specialties who meets the following requirements:

• Has a major interest and accomplishment in clinical and basic science related to surgery

• Holds a current full-time academic appointment in Canada or the U.S.

• Is less than 45 years of age on the date the application is filed

• Is enthusiastic, personable, and possesses good communication skills

Activities

The Fellow is required to spend a minimum of two weeks in Japan and engage in the following activities:

• Attend and participate in the annual meeting of the Japan Surgical Society (JSS), which will be held in Nagoya April 16–18, 2015

• Attend the Japan ACS Chapter meeting during the JSS meeting

• Visit at least two medical centers outside of the annual meeting city before or after the JSS conference to lecture and to share clinical and scientific expertise with local surgeons

The academic and geographic aspects of the itinerary will be finalized in consultation and mutual agreement between the Fellow and designated representatives of the JSS and the Japan ACS Chapter. The surgical centers to be visited would depend to some extent on the special interests and expertise of the Fellow and previously established professional contacts the Fellow has with surgeons in Japan.

The successful applicant’s spouse is welcome to accompany the Fellow on the trip. There will be opportunities for social interaction, in addition to professional activities.

Financial support

The College will provide $7,500 (U.S.) to the successful applicant, who will also be exempted from registration fees for the JSS annual meeting.

The Fellow must meet all travel and living expenses. Senior JSS and Japan ACS Chapter representatives will consult with the Fellow about the centers to be visited in Japan, the local arrangements for each center, and other advice and recommendations about travel schedules. The Fellow must make travel arrangements in North America to have access to reduced fares and travel packages for travel in Japan.

Application process

The ACS International Relations Committee will select the Fellow after review and evaluation of the final applications. A personal interview may be requested before the final selection.

Applications for this traveling fellowship are available at http://www.facs.org/memberservices/acsjapan.html or by e-mailing the International Liaison at [email protected].

The successful applicant and an alternate will be selected and notified by November 30, 2014.

The 2014 Rural Surgery Symposium—Advocacy, Economics, and Patient Care—will take place at the American College of Surgeons (ACS) headquarters in Chicago, IL, May 9–10. Register online for this limited-space meeting.

The symposium will address issues that affect rural surgery, trends in rural surgery practice, and ACS resources for rural surgeons. Tyler G. Hughes, MD, FACS, an ACS Governor and Chair of the ACS Advisory Council for Rural Surgery, from McPherson, KS; and David C. Borgstrom, MD, FACS, a Member of the Advisory Council for Rural Surgery, from Cooperstown, NY, are the Symposium Directors.

Symposium participants will gain an understanding of national and local influences on surgical care in rural America as well as how changes in surgical education may affect future rural surgical care. Participants also will attend sessions examining health care reform’s influence on surgical care in rural America and staffing needs in rural health care.

To register, go to the ACS website at http://www.facs.org/about/councils/advrural/symposium.html.

Symposium topics will include the following:

• Rural Health Care Systems—Surgical Perspective

• Benign Liver Lesions– Practical Surgical Management

• Rural Cancer Care

• The Economic Impact of a General Surgeon to a Rural Community

• Emergency Medical Treatment and Labor Act, Stark Law, Critical Access Hospitals—What You Need to Know

• Unusual Cases from the Frontier—"Stump the Chumps" (Participants should bring a case study to share for a panel discussion).

The 2014 Rural Surgery Symposium—Advocacy, Economics, and Patient Care—will take place at the American College of Surgeons (ACS) headquarters in Chicago, IL, May 9–10. Register online for this limited-space meeting.

The symposium will address issues that affect rural surgery, trends in rural surgery practice, and ACS resources for rural surgeons. Tyler G. Hughes, MD, FACS, an ACS Governor and Chair of the ACS Advisory Council for Rural Surgery, from McPherson, KS; and David C. Borgstrom, MD, FACS, a Member of the Advisory Council for Rural Surgery, from Cooperstown, NY, are the Symposium Directors.

Symposium participants will gain an understanding of national and local influences on surgical care in rural America as well as how changes in surgical education may affect future rural surgical care. Participants also will attend sessions examining health care reform’s influence on surgical care in rural America and staffing needs in rural health care.

To register, go to the ACS website at http://www.facs.org/about/councils/advrural/symposium.html.

Symposium topics will include the following:

• Rural Health Care Systems—Surgical Perspective

• Benign Liver Lesions– Practical Surgical Management

• Rural Cancer Care

• The Economic Impact of a General Surgeon to a Rural Community

• Emergency Medical Treatment and Labor Act, Stark Law, Critical Access Hospitals—What You Need to Know

• Unusual Cases from the Frontier—"Stump the Chumps" (Participants should bring a case study to share for a panel discussion).

The 2014 Rural Surgery Symposium—Advocacy, Economics, and Patient Care—will take place at the American College of Surgeons (ACS) headquarters in Chicago, IL, May 9–10. Register online for this limited-space meeting.

The symposium will address issues that affect rural surgery, trends in rural surgery practice, and ACS resources for rural surgeons. Tyler G. Hughes, MD, FACS, an ACS Governor and Chair of the ACS Advisory Council for Rural Surgery, from McPherson, KS; and David C. Borgstrom, MD, FACS, a Member of the Advisory Council for Rural Surgery, from Cooperstown, NY, are the Symposium Directors.

Symposium participants will gain an understanding of national and local influences on surgical care in rural America as well as how changes in surgical education may affect future rural surgical care. Participants also will attend sessions examining health care reform’s influence on surgical care in rural America and staffing needs in rural health care.

To register, go to the ACS website at http://www.facs.org/about/councils/advrural/symposium.html.

Symposium topics will include the following:

• Rural Health Care Systems—Surgical Perspective

• Benign Liver Lesions– Practical Surgical Management

• Rural Cancer Care

• The Economic Impact of a General Surgeon to a Rural Community

• Emergency Medical Treatment and Labor Act, Stark Law, Critical Access Hospitals—What You Need to Know

• Unusual Cases from the Frontier—"Stump the Chumps" (Participants should bring a case study to share for a panel discussion).

TAMPA – Outpatient palliative care consultations are associated with decreased symptom burden in women with gynecologic malignancies, but American Society of Clinical Oncology recommendations for referral are often ignored, according to retrospective data and a review of patient records.

In one study, 78 patients seen between June 2007 and March 2013 at an outpatient symptom management clinic for follow-up within 90 days of their initial consultation completed a questionnaire at each visit, including the nine-item Edmonton Symptom Assessment System. The responses, along with information from the patients’ charts, showed significant improvements in almost all symptoms over time, Dr. Rachel Ruskin, a clinical fellow at the University of California, San Francisco, reported at the annual meeting of the Society of Gynecologic Oncology.

For example, mean pain, fatigue, anxiety, depression, nausea, drowsiness, and appetite scores decreased between 0.7 and 1.5 points from the median baseline scores (on a 10 point scale). A decline in shortness of breath score also approached significance.

No difference was seen with respect to symptom improvement between patients with and without disease, although there appeared to be a trend toward a difference in anxiety scores, Dr. Ruskin noted.

Patients who were treated with concurrent cancer-directed therapies had improvements in pain and fatigue, but to a lesser extent than did those who did not receive treatment, she said.

Among the 35 patients who attended at least two follow-up visits, the improvements in nausea and shortness of breath seen at the first visit persisted at the second, and symptoms of depression and drowsiness continued to improve at each visit. Of those 35 patients, 58% had ovarian, fallopian tube, or peritoneal cancer; 20% had uterine cancer; and 15% had cervical cancer. Most (81%) had stage III, IV, or recurrent cancer.

Mean age at study entry was 57 years, 85% of patients had disease present, and 62% were undergoing treatment. The vast majority (87%) had received chemotherapy, 30% received radiation, and 8% had undergone surgery.

In patients for whom relevant data were available, there was evidence of mild hematologic, renal, and nutritional compromise, and nearly 25% of these patients had been hospitalized within the prior month.

"Notably, in our cohort the improvement in symptoms cannot be attributed to antineoplastic therapies, since – if anything – treatment by traditional oncologic modalities was associated with less benefit in some symptoms," Dr. Ruskin said, adding that future research should focus on "which aspects of palliative care are effective and by what mechanisms," as this information would be helpful for determining best practices that can be replicated across settings and for designing prospective concurrent standard oncologic and palliative care trials.

"In the meantime, we hope that these data will encourage providers to consider referral to their outpatient palliative care colleagues," she concluded.

Findings from another study presented at the meeting suggest there is some work to do in that regard.

In that study, Dr. Carolyn Lefkowits of the University of Pittsburgh found that oncologists are falling short when it comes to following the 2012 ASCO recommendation to consider early palliative care integration for "any patient with metastatic cancer and/or high symptom burden."

Of 340 women with a gynecologic malignancy who were admitted to a gynecologic oncology service between February 2012 and August 2012, only 32% were referred to palliative care, Dr. Lefkowits said.

The patients had a median age of 62 years, and an equal number had early- and late-stage disease. Nearly 25% had recurrent disease by the end of the study period.

Multivariate logistic regression identified independent predictors of palliative care consultation, including number of admission (odds ratio, 17.4 for greater than three vs. three or fewer admissions), admission for symptom management (OR, 22.0), and death within 6 months (OR, 15.7).

Notably, only 16% of the patients died within 6 months of the last admission during the study period, and although 25% of patients overall were referred to palliative care, 54% of those who died within 6 months were referred, suggesting that most referrals are not made for patients who are early in their disease course.

Furthermore, only 53% of patients with recurrent disease – all of whom should have been considered for palliative care integration based on the ASCO recommendations – were seen for palliative care, including 59% who had received three or more lines of chemotherapy, Dr. Lefkowits said.

The findings suggest that the group of patients referred for palliative care is characterized by high symptom burden and poor prognosis. In fact, most of those referred were likely already at the point where they would be considered hospice eligible, she said.

An analysis of referrals based on each ASCO recommendation category showed that the highest referral rate was for "symptom admission" (79%), and the lowest was for recurrent disease (52%).

"So, although the predictors of consultation are in keeping, I think, with the spirit of the ASCO recommendations, we’re still not comprehensively capturing these high-risk subgroups," Dr. Lefkowits said.

She added that she hopes the findings will serve as a "conversation starter, spurring us to address questions, including which gynecologic oncology patients are most appropriate to target for consistent palliative care referral."

Other questions to consider include which systems might help improve referral rates among those patients and which patients (and at what rates) should be referred for specialized palliative care.

All of the patients in the ASCO categories should be receiving palliative care, but it remains unclear what percentage need specialized palliative care, she said

As for improving the rate of palliative care consultations, Dr. Lois M. Ramondetta of the University of Texas M.D. Anderson Cancer Center, Houston, said during a "lecturette" following the presentations by Dr. Ruskin and Dr. Lefkowits, that "branding" is important.

One study showed that 70% of Americans don’t even know what palliative care is, and many of those who do – including both patients and health care providers – equate palliative care with end-of-life care.

Simply changing the name of the palliative care clinic at M.D. Anderson to the "supportive care clinic" led to a 40% increase in consultations, she said.

Most patients and physicians reacted favorably to the concept of supportive care, she explained, noting that palliative care should be rebranded as an extra layer of support, and it should be offered throughout the treatment process.

Studies consistently show that palliative care provides multiple benefits, including decreased hospital length of stay, fewer intensive care admissions, and reduced costs and need for potentially harmful procedures. Some studies have suggested palliative care is associated with improved overall survival, she said.

A number of efforts to improve palliative care skills and to increase referral for palliative care consultations are underway through both ASCO and the SGO, including a virtual learning collaborative being developed by ASCO, efforts to incorporate palliative care education into training and recertification programs, and the revival of a palliative care task force to address these issues.

Dr. Ruskin, Dr. Lefkowits, and Dr. Ramondetta each reported having no disclosures.

[email protected]

TAMPA – Outpatient palliative care consultations are associated with decreased symptom burden in women with gynecologic malignancies, but American Society of Clinical Oncology recommendations for referral are often ignored, according to retrospective data and a review of patient records.

In one study, 78 patients seen between June 2007 and March 2013 at an outpatient symptom management clinic for follow-up within 90 days of their initial consultation completed a questionnaire at each visit, including the nine-item Edmonton Symptom Assessment System. The responses, along with information from the patients’ charts, showed significant improvements in almost all symptoms over time, Dr. Rachel Ruskin, a clinical fellow at the University of California, San Francisco, reported at the annual meeting of the Society of Gynecologic Oncology.

For example, mean pain, fatigue, anxiety, depression, nausea, drowsiness, and appetite scores decreased between 0.7 and 1.5 points from the median baseline scores (on a 10 point scale). A decline in shortness of breath score also approached significance.

No difference was seen with respect to symptom improvement between patients with and without disease, although there appeared to be a trend toward a difference in anxiety scores, Dr. Ruskin noted.

Patients who were treated with concurrent cancer-directed therapies had improvements in pain and fatigue, but to a lesser extent than did those who did not receive treatment, she said.

Among the 35 patients who attended at least two follow-up visits, the improvements in nausea and shortness of breath seen at the first visit persisted at the second, and symptoms of depression and drowsiness continued to improve at each visit. Of those 35 patients, 58% had ovarian, fallopian tube, or peritoneal cancer; 20% had uterine cancer; and 15% had cervical cancer. Most (81%) had stage III, IV, or recurrent cancer.

Mean age at study entry was 57 years, 85% of patients had disease present, and 62% were undergoing treatment. The vast majority (87%) had received chemotherapy, 30% received radiation, and 8% had undergone surgery.

In patients for whom relevant data were available, there was evidence of mild hematologic, renal, and nutritional compromise, and nearly 25% of these patients had been hospitalized within the prior month.

"Notably, in our cohort the improvement in symptoms cannot be attributed to antineoplastic therapies, since – if anything – treatment by traditional oncologic modalities was associated with less benefit in some symptoms," Dr. Ruskin said, adding that future research should focus on "which aspects of palliative care are effective and by what mechanisms," as this information would be helpful for determining best practices that can be replicated across settings and for designing prospective concurrent standard oncologic and palliative care trials.

"In the meantime, we hope that these data will encourage providers to consider referral to their outpatient palliative care colleagues," she concluded.

Findings from another study presented at the meeting suggest there is some work to do in that regard.

In that study, Dr. Carolyn Lefkowits of the University of Pittsburgh found that oncologists are falling short when it comes to following the 2012 ASCO recommendation to consider early palliative care integration for "any patient with metastatic cancer and/or high symptom burden."

Of 340 women with a gynecologic malignancy who were admitted to a gynecologic oncology service between February 2012 and August 2012, only 32% were referred to palliative care, Dr. Lefkowits said.

The patients had a median age of 62 years, and an equal number had early- and late-stage disease. Nearly 25% had recurrent disease by the end of the study period.

Multivariate logistic regression identified independent predictors of palliative care consultation, including number of admission (odds ratio, 17.4 for greater than three vs. three or fewer admissions), admission for symptom management (OR, 22.0), and death within 6 months (OR, 15.7).

Notably, only 16% of the patients died within 6 months of the last admission during the study period, and although 25% of patients overall were referred to palliative care, 54% of those who died within 6 months were referred, suggesting that most referrals are not made for patients who are early in their disease course.

Furthermore, only 53% of patients with recurrent disease – all of whom should have been considered for palliative care integration based on the ASCO recommendations – were seen for palliative care, including 59% who had received three or more lines of chemotherapy, Dr. Lefkowits said.

The findings suggest that the group of patients referred for palliative care is characterized by high symptom burden and poor prognosis. In fact, most of those referred were likely already at the point where they would be considered hospice eligible, she said.

An analysis of referrals based on each ASCO recommendation category showed that the highest referral rate was for "symptom admission" (79%), and the lowest was for recurrent disease (52%).

"So, although the predictors of consultation are in keeping, I think, with the spirit of the ASCO recommendations, we’re still not comprehensively capturing these high-risk subgroups," Dr. Lefkowits said.

She added that she hopes the findings will serve as a "conversation starter, spurring us to address questions, including which gynecologic oncology patients are most appropriate to target for consistent palliative care referral."

Other questions to consider include which systems might help improve referral rates among those patients and which patients (and at what rates) should be referred for specialized palliative care.

All of the patients in the ASCO categories should be receiving palliative care, but it remains unclear what percentage need specialized palliative care, she said

As for improving the rate of palliative care consultations, Dr. Lois M. Ramondetta of the University of Texas M.D. Anderson Cancer Center, Houston, said during a "lecturette" following the presentations by Dr. Ruskin and Dr. Lefkowits, that "branding" is important.

One study showed that 70% of Americans don’t even know what palliative care is, and many of those who do – including both patients and health care providers – equate palliative care with end-of-life care.

Simply changing the name of the palliative care clinic at M.D. Anderson to the "supportive care clinic" led to a 40% increase in consultations, she said.

Most patients and physicians reacted favorably to the concept of supportive care, she explained, noting that palliative care should be rebranded as an extra layer of support, and it should be offered throughout the treatment process.

Studies consistently show that palliative care provides multiple benefits, including decreased hospital length of stay, fewer intensive care admissions, and reduced costs and need for potentially harmful procedures. Some studies have suggested palliative care is associated with improved overall survival, she said.

A number of efforts to improve palliative care skills and to increase referral for palliative care consultations are underway through both ASCO and the SGO, including a virtual learning collaborative being developed by ASCO, efforts to incorporate palliative care education into training and recertification programs, and the revival of a palliative care task force to address these issues.

Dr. Ruskin, Dr. Lefkowits, and Dr. Ramondetta each reported having no disclosures.

[email protected]

TAMPA – Outpatient palliative care consultations are associated with decreased symptom burden in women with gynecologic malignancies, but American Society of Clinical Oncology recommendations for referral are often ignored, according to retrospective data and a review of patient records.

In one study, 78 patients seen between June 2007 and March 2013 at an outpatient symptom management clinic for follow-up within 90 days of their initial consultation completed a questionnaire at each visit, including the nine-item Edmonton Symptom Assessment System. The responses, along with information from the patients’ charts, showed significant improvements in almost all symptoms over time, Dr. Rachel Ruskin, a clinical fellow at the University of California, San Francisco, reported at the annual meeting of the Society of Gynecologic Oncology.

For example, mean pain, fatigue, anxiety, depression, nausea, drowsiness, and appetite scores decreased between 0.7 and 1.5 points from the median baseline scores (on a 10 point scale). A decline in shortness of breath score also approached significance.

No difference was seen with respect to symptom improvement between patients with and without disease, although there appeared to be a trend toward a difference in anxiety scores, Dr. Ruskin noted.

Patients who were treated with concurrent cancer-directed therapies had improvements in pain and fatigue, but to a lesser extent than did those who did not receive treatment, she said.

Among the 35 patients who attended at least two follow-up visits, the improvements in nausea and shortness of breath seen at the first visit persisted at the second, and symptoms of depression and drowsiness continued to improve at each visit. Of those 35 patients, 58% had ovarian, fallopian tube, or peritoneal cancer; 20% had uterine cancer; and 15% had cervical cancer. Most (81%) had stage III, IV, or recurrent cancer.

Mean age at study entry was 57 years, 85% of patients had disease present, and 62% were undergoing treatment. The vast majority (87%) had received chemotherapy, 30% received radiation, and 8% had undergone surgery.

In patients for whom relevant data were available, there was evidence of mild hematologic, renal, and nutritional compromise, and nearly 25% of these patients had been hospitalized within the prior month.

"Notably, in our cohort the improvement in symptoms cannot be attributed to antineoplastic therapies, since – if anything – treatment by traditional oncologic modalities was associated with less benefit in some symptoms," Dr. Ruskin said, adding that future research should focus on "which aspects of palliative care are effective and by what mechanisms," as this information would be helpful for determining best practices that can be replicated across settings and for designing prospective concurrent standard oncologic and palliative care trials.

"In the meantime, we hope that these data will encourage providers to consider referral to their outpatient palliative care colleagues," she concluded.

Findings from another study presented at the meeting suggest there is some work to do in that regard.

In that study, Dr. Carolyn Lefkowits of the University of Pittsburgh found that oncologists are falling short when it comes to following the 2012 ASCO recommendation to consider early palliative care integration for "any patient with metastatic cancer and/or high symptom burden."

Of 340 women with a gynecologic malignancy who were admitted to a gynecologic oncology service between February 2012 and August 2012, only 32% were referred to palliative care, Dr. Lefkowits said.

The patients had a median age of 62 years, and an equal number had early- and late-stage disease. Nearly 25% had recurrent disease by the end of the study period.

Multivariate logistic regression identified independent predictors of palliative care consultation, including number of admission (odds ratio, 17.4 for greater than three vs. three or fewer admissions), admission for symptom management (OR, 22.0), and death within 6 months (OR, 15.7).

Notably, only 16% of the patients died within 6 months of the last admission during the study period, and although 25% of patients overall were referred to palliative care, 54% of those who died within 6 months were referred, suggesting that most referrals are not made for patients who are early in their disease course.

Furthermore, only 53% of patients with recurrent disease – all of whom should have been considered for palliative care integration based on the ASCO recommendations – were seen for palliative care, including 59% who had received three or more lines of chemotherapy, Dr. Lefkowits said.

The findings suggest that the group of patients referred for palliative care is characterized by high symptom burden and poor prognosis. In fact, most of those referred were likely already at the point where they would be considered hospice eligible, she said.

An analysis of referrals based on each ASCO recommendation category showed that the highest referral rate was for "symptom admission" (79%), and the lowest was for recurrent disease (52%).

"So, although the predictors of consultation are in keeping, I think, with the spirit of the ASCO recommendations, we’re still not comprehensively capturing these high-risk subgroups," Dr. Lefkowits said.

She added that she hopes the findings will serve as a "conversation starter, spurring us to address questions, including which gynecologic oncology patients are most appropriate to target for consistent palliative care referral."

Other questions to consider include which systems might help improve referral rates among those patients and which patients (and at what rates) should be referred for specialized palliative care.

All of the patients in the ASCO categories should be receiving palliative care, but it remains unclear what percentage need specialized palliative care, she said

As for improving the rate of palliative care consultations, Dr. Lois M. Ramondetta of the University of Texas M.D. Anderson Cancer Center, Houston, said during a "lecturette" following the presentations by Dr. Ruskin and Dr. Lefkowits, that "branding" is important.

One study showed that 70% of Americans don’t even know what palliative care is, and many of those who do – including both patients and health care providers – equate palliative care with end-of-life care.

Simply changing the name of the palliative care clinic at M.D. Anderson to the "supportive care clinic" led to a 40% increase in consultations, she said.

Most patients and physicians reacted favorably to the concept of supportive care, she explained, noting that palliative care should be rebranded as an extra layer of support, and it should be offered throughout the treatment process.

Studies consistently show that palliative care provides multiple benefits, including decreased hospital length of stay, fewer intensive care admissions, and reduced costs and need for potentially harmful procedures. Some studies have suggested palliative care is associated with improved overall survival, she said.

A number of efforts to improve palliative care skills and to increase referral for palliative care consultations are underway through both ASCO and the SGO, including a virtual learning collaborative being developed by ASCO, efforts to incorporate palliative care education into training and recertification programs, and the revival of a palliative care task force to address these issues.

Dr. Ruskin, Dr. Lefkowits, and Dr. Ramondetta each reported having no disclosures.

[email protected]

I would like to respond to the recent Point/Counterpoint column on the Surgical Care Improvement Project ("Are SCIP recommendations effective in improving quality of care?" January 2014, p. 3). Without dispute, the primary goal of SCIP to reduce the morbidity and mortality from surgical infections by 25% by 2010 was not achieved. Where SCIP succeeded instead was in improving the quality of hospital documentation, through efforts often motivated by pay-for-performance incentives. Ironically, SCIP may result in increased rates of infection nationally, by capturing wound infections that would otherwise not have been reported.

SCIP generated numerous studies in the literature with unclear and conflicting results. The majority are single institution studies, and suggest either marginal improvement, or no reduction, in the rates of wound infection after adherence to SCIP measures. Many of these studies are unpowered or suffer from study design flaws that limit their ability to show a difference. The confusing state of the literature is reflected by the debate published in the January issue of Surgery News, in which two debaters highlighted different parts of the same study and came to opposite conclusions. A handful of reports are from single programs in which extraordinary investments of staff, resources, and time resulted in significant reductions in wound infections, but these heroic local efforts are likely neither sustainable nor generalizable nationally.

A long-standing tradition in surgery has been to analyze undesirable patient outcomes through the morbidity and mortality conference, to understand the contributing causes of the event and what might be done differently in the future. Applying that tradition here, what did we learn from the significant national effort to comply with SCIP? The literature strongly suggests that patients who have a greater number of comorbid conditions, who are in a higher ASA class, and who underwent colon or more complex procedures, were less likely to have adherence to SCIP, and more likely to suffer a surgical site infection. Others have suggested that the principal unrealized benefit of SCIP could have been for patients with exclusion criteria, which precluded their participation in the program. Focusing infection prevention practices upon these patient populations in the future might be worthwhile.

Why did SCIP fail? Perhaps greater initial input by surgeons into the selection of SCIP measures would have been helpful. Some of the measures were more successful than others. The data for SCIP Inf-2 (giving the correct antibiotics) are perhaps the strongest, as they also makes the most clinical sense. On the other hand, SCIP Inf-3 (stopping antibiotics within 24 hrs) could reasonably have been expected to reduce antimicrobial resistance, decrease the incidence of medication side effects such as nephrotoxicity, and save costs, but on reflection, stopping antibiotics earlier in uncertain situations should not have been expected to reduce infections.

And then there is the fraud in the scientific literature. Only years after SCIP was launched was the evidence upon which the initial beta-blocker recommendations were made recognized to be fraudulent. The Dutch researcher has been accused of scientific misconduct, and independent investigations have concluded that more patients were harmed and died than benefitted, by complying with the beta-blocker recommendations in this study.

We should recognize that the key intent of SCIP remains unfulfilled. Wound infections continue to result in prolonged hospital stays and increased health care costs worldwide. In the interest of patient safety, surgeons should consider taking the next step forward to transform the well-intended SCIP effort. We know all too well that improving clinical care is quite difficult, and policy makers will need our insights to reflect upon the valuable lessons learned to reduce surgical infections. Until then, caution is advised for federal efforts that seek to incorporate SCIP into value-based purchasing initiatives. Those attempts are likely premature until better data are available that withstands the test of time.

John Maa, MD, FACS

President, Northern California Chapter of the American College of Surgeons

I would like to respond to the recent Point/Counterpoint column on the Surgical Care Improvement Project ("Are SCIP recommendations effective in improving quality of care?" January 2014, p. 3). Without dispute, the primary goal of SCIP to reduce the morbidity and mortality from surgical infections by 25% by 2010 was not achieved. Where SCIP succeeded instead was in improving the quality of hospital documentation, through efforts often motivated by pay-for-performance incentives. Ironically, SCIP may result in increased rates of infection nationally, by capturing wound infections that would otherwise not have been reported.

SCIP generated numerous studies in the literature with unclear and conflicting results. The majority are single institution studies, and suggest either marginal improvement, or no reduction, in the rates of wound infection after adherence to SCIP measures. Many of these studies are unpowered or suffer from study design flaws that limit their ability to show a difference. The confusing state of the literature is reflected by the debate published in the January issue of Surgery News, in which two debaters highlighted different parts of the same study and came to opposite conclusions. A handful of reports are from single programs in which extraordinary investments of staff, resources, and time resulted in significant reductions in wound infections, but these heroic local efforts are likely neither sustainable nor generalizable nationally.

A long-standing tradition in surgery has been to analyze undesirable patient outcomes through the morbidity and mortality conference, to understand the contributing causes of the event and what might be done differently in the future. Applying that tradition here, what did we learn from the significant national effort to comply with SCIP? The literature strongly suggests that patients who have a greater number of comorbid conditions, who are in a higher ASA class, and who underwent colon or more complex procedures, were less likely to have adherence to SCIP, and more likely to suffer a surgical site infection. Others have suggested that the principal unrealized benefit of SCIP could have been for patients with exclusion criteria, which precluded their participation in the program. Focusing infection prevention practices upon these patient populations in the future might be worthwhile.

Why did SCIP fail? Perhaps greater initial input by surgeons into the selection of SCIP measures would have been helpful. Some of the measures were more successful than others. The data for SCIP Inf-2 (giving the correct antibiotics) are perhaps the strongest, as they also makes the most clinical sense. On the other hand, SCIP Inf-3 (stopping antibiotics within 24 hrs) could reasonably have been expected to reduce antimicrobial resistance, decrease the incidence of medication side effects such as nephrotoxicity, and save costs, but on reflection, stopping antibiotics earlier in uncertain situations should not have been expected to reduce infections.

And then there is the fraud in the scientific literature. Only years after SCIP was launched was the evidence upon which the initial beta-blocker recommendations were made recognized to be fraudulent. The Dutch researcher has been accused of scientific misconduct, and independent investigations have concluded that more patients were harmed and died than benefitted, by complying with the beta-blocker recommendations in this study.

We should recognize that the key intent of SCIP remains unfulfilled. Wound infections continue to result in prolonged hospital stays and increased health care costs worldwide. In the interest of patient safety, surgeons should consider taking the next step forward to transform the well-intended SCIP effort. We know all too well that improving clinical care is quite difficult, and policy makers will need our insights to reflect upon the valuable lessons learned to reduce surgical infections. Until then, caution is advised for federal efforts that seek to incorporate SCIP into value-based purchasing initiatives. Those attempts are likely premature until better data are available that withstands the test of time.

John Maa, MD, FACS

President, Northern California Chapter of the American College of Surgeons

I would like to respond to the recent Point/Counterpoint column on the Surgical Care Improvement Project ("Are SCIP recommendations effective in improving quality of care?" January 2014, p. 3). Without dispute, the primary goal of SCIP to reduce the morbidity and mortality from surgical infections by 25% by 2010 was not achieved. Where SCIP succeeded instead was in improving the quality of hospital documentation, through efforts often motivated by pay-for-performance incentives. Ironically, SCIP may result in increased rates of infection nationally, by capturing wound infections that would otherwise not have been reported.

SCIP generated numerous studies in the literature with unclear and conflicting results. The majority are single institution studies, and suggest either marginal improvement, or no reduction, in the rates of wound infection after adherence to SCIP measures. Many of these studies are unpowered or suffer from study design flaws that limit their ability to show a difference. The confusing state of the literature is reflected by the debate published in the January issue of Surgery News, in which two debaters highlighted different parts of the same study and came to opposite conclusions. A handful of reports are from single programs in which extraordinary investments of staff, resources, and time resulted in significant reductions in wound infections, but these heroic local efforts are likely neither sustainable nor generalizable nationally.

A long-standing tradition in surgery has been to analyze undesirable patient outcomes through the morbidity and mortality conference, to understand the contributing causes of the event and what might be done differently in the future. Applying that tradition here, what did we learn from the significant national effort to comply with SCIP? The literature strongly suggests that patients who have a greater number of comorbid conditions, who are in a higher ASA class, and who underwent colon or more complex procedures, were less likely to have adherence to SCIP, and more likely to suffer a surgical site infection. Others have suggested that the principal unrealized benefit of SCIP could have been for patients with exclusion criteria, which precluded their participation in the program. Focusing infection prevention practices upon these patient populations in the future might be worthwhile.

Why did SCIP fail? Perhaps greater initial input by surgeons into the selection of SCIP measures would have been helpful. Some of the measures were more successful than others. The data for SCIP Inf-2 (giving the correct antibiotics) are perhaps the strongest, as they also makes the most clinical sense. On the other hand, SCIP Inf-3 (stopping antibiotics within 24 hrs) could reasonably have been expected to reduce antimicrobial resistance, decrease the incidence of medication side effects such as nephrotoxicity, and save costs, but on reflection, stopping antibiotics earlier in uncertain situations should not have been expected to reduce infections.

And then there is the fraud in the scientific literature. Only years after SCIP was launched was the evidence upon which the initial beta-blocker recommendations were made recognized to be fraudulent. The Dutch researcher has been accused of scientific misconduct, and independent investigations have concluded that more patients were harmed and died than benefitted, by complying with the beta-blocker recommendations in this study.

We should recognize that the key intent of SCIP remains unfulfilled. Wound infections continue to result in prolonged hospital stays and increased health care costs worldwide. In the interest of patient safety, surgeons should consider taking the next step forward to transform the well-intended SCIP effort. We know all too well that improving clinical care is quite difficult, and policy makers will need our insights to reflect upon the valuable lessons learned to reduce surgical infections. Until then, caution is advised for federal efforts that seek to incorporate SCIP into value-based purchasing initiatives. Those attempts are likely premature until better data are available that withstands the test of time.

John Maa, MD, FACS

President, Northern California Chapter of the American College of Surgeons

On April 9, officials at the Centers for Medicare & Medicaid Services released an unprecedented amount of data detailing the payments made to more than 880,000 physicians and other health care providers.

The searchable files released by CMS include the provider name, address, specialty, and National Provider Identifier, as well as Medicare charges submitted and allowed and total Medicare payment for the year.

The data dump was harshly criticized by the American Medical Association, which said that the government had not given physicians a chance to review and correct their data. The data also lack context about quality of care, patient population, and site of service, the AMA said.

"Thoughtful observers concluded long ago that payments or costs were not the only metric to evaluate medical care," Dr. Ardis Dee Hoven, president of the AMA, said in a statement. "Quality, value, and outcomes are critical yardsticks for patients. The information released by CMS will not allow patients or payers to draw meaningful conclusions about the value or quality of care."

CMS will hold a press conference on the data dump on April 9. For more information on how to manage this new development in your practice, visit this website later this afternoon.

[email protected]

On Twitter @maryellenny

On April 9, officials at the Centers for Medicare & Medicaid Services released an unprecedented amount of data detailing the payments made to more than 880,000 physicians and other health care providers.

The searchable files released by CMS include the provider name, address, specialty, and National Provider Identifier, as well as Medicare charges submitted and allowed and total Medicare payment for the year.

The data dump was harshly criticized by the American Medical Association, which said that the government had not given physicians a chance to review and correct their data. The data also lack context about quality of care, patient population, and site of service, the AMA said.

"Thoughtful observers concluded long ago that payments or costs were not the only metric to evaluate medical care," Dr. Ardis Dee Hoven, president of the AMA, said in a statement. "Quality, value, and outcomes are critical yardsticks for patients. The information released by CMS will not allow patients or payers to draw meaningful conclusions about the value or quality of care."

CMS will hold a press conference on the data dump on April 9. For more information on how to manage this new development in your practice, visit this website later this afternoon.

[email protected]

On Twitter @maryellenny

On April 9, officials at the Centers for Medicare & Medicaid Services released an unprecedented amount of data detailing the payments made to more than 880,000 physicians and other health care providers.

The searchable files released by CMS include the provider name, address, specialty, and National Provider Identifier, as well as Medicare charges submitted and allowed and total Medicare payment for the year.

The data dump was harshly criticized by the American Medical Association, which said that the government had not given physicians a chance to review and correct their data. The data also lack context about quality of care, patient population, and site of service, the AMA said.

"Thoughtful observers concluded long ago that payments or costs were not the only metric to evaluate medical care," Dr. Ardis Dee Hoven, president of the AMA, said in a statement. "Quality, value, and outcomes are critical yardsticks for patients. The information released by CMS will not allow patients or payers to draw meaningful conclusions about the value or quality of care."

CMS will hold a press conference on the data dump on April 9. For more information on how to manage this new development in your practice, visit this website later this afternoon.

[email protected]

On Twitter @maryellenny

Along with many others who are rapidly fading from the American surgical scene, I was born as a baby boomer. Most of us from that generation who embraced surgery as a career held fast to the values of the era. First and foremost among these was a high premium put on hard work, long hours, and an unwavering dedication to our profession and to our patients. We were particularly proud of the continuity of care that we provided to our patients.

During my early years as a surgeon, it was a 24/7 job. Saturday mornings were consumed by Surgery Grand Rounds followed by usually prolonged and detailed patient rounds. Most of us visited our hospitalized patients 7 days a week. When one of my patients developed a complication, I, rather than the surgeon on call, managed it. I missed soccer matches, baseball games, dance recitals, and even some family birthdays because etched into my conscience was the concept that duty to my patients trumped duty to my family. Although there is much to admire in this singular focus on patient care, it took its toll on the other aspects of what should be a more balanced professional life.

Two factors, one of them cultural and the other regulatory, have altered this all-consuming aspect of a surgeon’s life, with implications for the ideal of continuity of care. First was the arrival of freshly minted surgeons from generations X and Y who had a different set of priorities than their predecessors. They insisted on a more even balance between professional and family obligations. In part this resulted from the need for them to be more involved in child rearing since many of their spouses were engaged in time-intensive careers of their own. As they gravitated onto academic surgical faculties and joined private practice groups, they insisted on moving educational programs such as Surgery Grand Rounds to weekdays so they could participate in family activities. They entrusted the care of their patients to their partners, freeing them for entire weekends that could be devoted to family events.

The healthier balance they have brought to a career in surgery is to be admired. Much to the benefit of their senior colleagues, it has become their way of life as well. The trade-off has been some decay of the ideals of patient ownership and continuity of care.

The next and potentially more serious challenge to the cherished concept of continuous care of our patients was the mandate of an 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. As to its effects on graduate surgical education, I believe the 80-hour work week has been a double-edged sword. On the positive side, at a time when interest in general surgery was waning, institution of duty hours restrictions along with the advent of minimally invasive surgery made our specialty more attractive to medical school graduates, including women, who now constitute 50% of most medical school classes. Another plus was that teaching hospitals were forced to hire physician extenders and other personnel to perform some of the noneducational tasks previously carried out by residents.

On the negative side, since many of the lost hours were in the evenings and weekends, residents’ exposure to urgent and emergency cases was diminished. More significantly, surgery residents began to work in shifts to accommodate increasingly inflexible rules. Ownership of their patients could no longer be held as a high priority in surgical education. Several classes of surgery residents who were educated under these fairly restrictive guidelines have now graduated and have brought a "shift mentality" with them to their positions in private practice groups and on academic faculties.

Since work hour restrictions are highly unlikely to disappear from our training programs and may in fact be applied in the future to all working physicians and surgeons, what can be done to preserve the time-honored value of continuous care of our patients? The answer probably lies in seeking reasonable flexibility within the rules rather than elimination of them. A bright light in this regard is an upcoming randomized controlled trial to assess the feasibility of more flexible work hours rules for general surgery residents. This trial is sponsored by the American Board of Surgery and the American College of Surgeons, and has the support of the ACGME. It will be conducted in hospitals that have instituted the National Surgical Quality Improvement Program (NSQIP) and also sponsor general surgery residencies. Beginning in July 2014, these residencies will be randomized to one of two arms – one using the extensive and rigid present duty hour standards and the second utilizing more flexible standards limited to an 80-hour work week, one night in three on call, and one day in seven free of clinical responsibilities, all averaged over a month. Patient outcomes in each arm will be determined from NSQIP data.

The trial will be conducted over 1 year, with residents’ opinions being surveyed at its midpoint. If patient outcomes are similar in the two arms or superior in the arm with more flexible rules and resident opinion is favorable, this would lend strong support for more flexibility in all general surgery residencies. As of this date, more than 100 general surgery programs have agreed to randomization.

The sponsoring agencies are to be congratulated for designing a trial that for the first time will objectively evaluate just how restrictive work rules need to be. Their efforts may effectively preserve a value that is at the core of our profession – the continuous care of our surgical patients.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

Along with many others who are rapidly fading from the American surgical scene, I was born as a baby boomer. Most of us from that generation who embraced surgery as a career held fast to the values of the era. First and foremost among these was a high premium put on hard work, long hours, and an unwavering dedication to our profession and to our patients. We were particularly proud of the continuity of care that we provided to our patients.

During my early years as a surgeon, it was a 24/7 job. Saturday mornings were consumed by Surgery Grand Rounds followed by usually prolonged and detailed patient rounds. Most of us visited our hospitalized patients 7 days a week. When one of my patients developed a complication, I, rather than the surgeon on call, managed it. I missed soccer matches, baseball games, dance recitals, and even some family birthdays because etched into my conscience was the concept that duty to my patients trumped duty to my family. Although there is much to admire in this singular focus on patient care, it took its toll on the other aspects of what should be a more balanced professional life.

Two factors, one of them cultural and the other regulatory, have altered this all-consuming aspect of a surgeon’s life, with implications for the ideal of continuity of care. First was the arrival of freshly minted surgeons from generations X and Y who had a different set of priorities than their predecessors. They insisted on a more even balance between professional and family obligations. In part this resulted from the need for them to be more involved in child rearing since many of their spouses were engaged in time-intensive careers of their own. As they gravitated onto academic surgical faculties and joined private practice groups, they insisted on moving educational programs such as Surgery Grand Rounds to weekdays so they could participate in family activities. They entrusted the care of their patients to their partners, freeing them for entire weekends that could be devoted to family events.

The healthier balance they have brought to a career in surgery is to be admired. Much to the benefit of their senior colleagues, it has become their way of life as well. The trade-off has been some decay of the ideals of patient ownership and continuity of care.

The next and potentially more serious challenge to the cherished concept of continuous care of our patients was the mandate of an 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. As to its effects on graduate surgical education, I believe the 80-hour work week has been a double-edged sword. On the positive side, at a time when interest in general surgery was waning, institution of duty hours restrictions along with the advent of minimally invasive surgery made our specialty more attractive to medical school graduates, including women, who now constitute 50% of most medical school classes. Another plus was that teaching hospitals were forced to hire physician extenders and other personnel to perform some of the noneducational tasks previously carried out by residents.

On the negative side, since many of the lost hours were in the evenings and weekends, residents’ exposure to urgent and emergency cases was diminished. More significantly, surgery residents began to work in shifts to accommodate increasingly inflexible rules. Ownership of their patients could no longer be held as a high priority in surgical education. Several classes of surgery residents who were educated under these fairly restrictive guidelines have now graduated and have brought a "shift mentality" with them to their positions in private practice groups and on academic faculties.

Since work hour restrictions are highly unlikely to disappear from our training programs and may in fact be applied in the future to all working physicians and surgeons, what can be done to preserve the time-honored value of continuous care of our patients? The answer probably lies in seeking reasonable flexibility within the rules rather than elimination of them. A bright light in this regard is an upcoming randomized controlled trial to assess the feasibility of more flexible work hours rules for general surgery residents. This trial is sponsored by the American Board of Surgery and the American College of Surgeons, and has the support of the ACGME. It will be conducted in hospitals that have instituted the National Surgical Quality Improvement Program (NSQIP) and also sponsor general surgery residencies. Beginning in July 2014, these residencies will be randomized to one of two arms – one using the extensive and rigid present duty hour standards and the second utilizing more flexible standards limited to an 80-hour work week, one night in three on call, and one day in seven free of clinical responsibilities, all averaged over a month. Patient outcomes in each arm will be determined from NSQIP data.

The trial will be conducted over 1 year, with residents’ opinions being surveyed at its midpoint. If patient outcomes are similar in the two arms or superior in the arm with more flexible rules and resident opinion is favorable, this would lend strong support for more flexibility in all general surgery residencies. As of this date, more than 100 general surgery programs have agreed to randomization.

The sponsoring agencies are to be congratulated for designing a trial that for the first time will objectively evaluate just how restrictive work rules need to be. Their efforts may effectively preserve a value that is at the core of our profession – the continuous care of our surgical patients.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

Along with many others who are rapidly fading from the American surgical scene, I was born as a baby boomer. Most of us from that generation who embraced surgery as a career held fast to the values of the era. First and foremost among these was a high premium put on hard work, long hours, and an unwavering dedication to our profession and to our patients. We were particularly proud of the continuity of care that we provided to our patients.

During my early years as a surgeon, it was a 24/7 job. Saturday mornings were consumed by Surgery Grand Rounds followed by usually prolonged and detailed patient rounds. Most of us visited our hospitalized patients 7 days a week. When one of my patients developed a complication, I, rather than the surgeon on call, managed it. I missed soccer matches, baseball games, dance recitals, and even some family birthdays because etched into my conscience was the concept that duty to my patients trumped duty to my family. Although there is much to admire in this singular focus on patient care, it took its toll on the other aspects of what should be a more balanced professional life.

Two factors, one of them cultural and the other regulatory, have altered this all-consuming aspect of a surgeon’s life, with implications for the ideal of continuity of care. First was the arrival of freshly minted surgeons from generations X and Y who had a different set of priorities than their predecessors. They insisted on a more even balance between professional and family obligations. In part this resulted from the need for them to be more involved in child rearing since many of their spouses were engaged in time-intensive careers of their own. As they gravitated onto academic surgical faculties and joined private practice groups, they insisted on moving educational programs such as Surgery Grand Rounds to weekdays so they could participate in family activities. They entrusted the care of their patients to their partners, freeing them for entire weekends that could be devoted to family events.

The healthier balance they have brought to a career in surgery is to be admired. Much to the benefit of their senior colleagues, it has become their way of life as well. The trade-off has been some decay of the ideals of patient ownership and continuity of care.

The next and potentially more serious challenge to the cherished concept of continuous care of our patients was the mandate of an 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. As to its effects on graduate surgical education, I believe the 80-hour work week has been a double-edged sword. On the positive side, at a time when interest in general surgery was waning, institution of duty hours restrictions along with the advent of minimally invasive surgery made our specialty more attractive to medical school graduates, including women, who now constitute 50% of most medical school classes. Another plus was that teaching hospitals were forced to hire physician extenders and other personnel to perform some of the noneducational tasks previously carried out by residents.

On the negative side, since many of the lost hours were in the evenings and weekends, residents’ exposure to urgent and emergency cases was diminished. More significantly, surgery residents began to work in shifts to accommodate increasingly inflexible rules. Ownership of their patients could no longer be held as a high priority in surgical education. Several classes of surgery residents who were educated under these fairly restrictive guidelines have now graduated and have brought a "shift mentality" with them to their positions in private practice groups and on academic faculties.

Since work hour restrictions are highly unlikely to disappear from our training programs and may in fact be applied in the future to all working physicians and surgeons, what can be done to preserve the time-honored value of continuous care of our patients? The answer probably lies in seeking reasonable flexibility within the rules rather than elimination of them. A bright light in this regard is an upcoming randomized controlled trial to assess the feasibility of more flexible work hours rules for general surgery residents. This trial is sponsored by the American Board of Surgery and the American College of Surgeons, and has the support of the ACGME. It will be conducted in hospitals that have instituted the National Surgical Quality Improvement Program (NSQIP) and also sponsor general surgery residencies. Beginning in July 2014, these residencies will be randomized to one of two arms – one using the extensive and rigid present duty hour standards and the second utilizing more flexible standards limited to an 80-hour work week, one night in three on call, and one day in seven free of clinical responsibilities, all averaged over a month. Patient outcomes in each arm will be determined from NSQIP data.

The trial will be conducted over 1 year, with residents’ opinions being surveyed at its midpoint. If patient outcomes are similar in the two arms or superior in the arm with more flexible rules and resident opinion is favorable, this would lend strong support for more flexibility in all general surgery residencies. As of this date, more than 100 general surgery programs have agreed to randomization.

The sponsoring agencies are to be congratulated for designing a trial that for the first time will objectively evaluate just how restrictive work rules need to be. Their efforts may effectively preserve a value that is at the core of our profession – the continuous care of our surgical patients.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

The American College of Surgeons (ACS) has published new comprehensive guidelines that define the resources the nation’s surgical facilities need to perform operations effectively and safely in infants and children. The standards – published in the March issue of the Journal of the American College of Surgeons – also have the approval of the American Pediatric Surgical Association and the Society of Pediatric Anesthesia.* Representatives of these organizations as well as invited leaders in other pediatric medical specialties, known as the Task Force for Children’s Surgical Care, developed the consensus recommendations over the past three years.

"The intent of these recommendations is to ensure that all infants and children in the U.S. receive care in a surgical environment matched to their individual medical, emotional, and social needs," said Keith T. Oldham, MD, FACS, task force chair and the surgeon-in-chief at Children’s Hospital of Wisconsin, Milwaukee.

Many studies show better results—including fewer complications and shorter hospital stays—when newborns and children undergo surgical procedures in environments that have expert resources for pediatric patients, compared with non-specialized centers.

In its report, the Task Force for Children’s Surgical Care defined the proper surgical environment for children as one "that offers all of the facilities, equipment, and, most especially, access to the professional providers who have the appropriate background and training to provide optimal care."

The task force assigned levels of resources, as the ACS has done for trauma centers for decades. The classification for children’s surgical centers is as follows:

Level I (highest level): Possesses adequate resources to provide comprehensive surgical care and perform both complex and noncomplex surgical procedures in newborns and children of all ages, including those with the most severe health conditions and birth defects. Is staffed 24 hours a day, seven days a week with properly credentialed pediatric specialists, including pediatric and subspecialty surgeons, pediatric anesthesiologists, pediatric diagnostic and interventional radiologists, and pediatric emergency physicians. Has a Level IV neonatal intensive care unit (NICU), the highest level of critical care for newborns.

Level II: Possesses adequate resources to provide advanced surgical care for children of all ages, including those who have accompanying ("comorbid") medical conditions. Operations would typically be performed by a single surgical specialty. Personnel include a board-certified pediatric surgeon, pediatric anesthesiologist, and pediatric radiologist with other pediatric specialists readily available for consultation, and has an emergency physician and an intensive care unit that both have pediatric expertise. Has a Level III or higher NICU.

Level III: Possesses adequate resources to provide basic surgical care and perform common, low-risk surgical procedures in children older than one year who are otherwise healthy. Has a general surgeon, anesthesiologist, radiologist, and emergency physician, all of whom have pediatric expertise. Has a Level I NICU (well-newborn nursery) or higher.

Both Level II and III surgical centers must be able to stabilize and transfer critically ill children to a hospital with higher-level resources. All children’s surgical centers must have at least one pediatric surgical nurse, a pediatric rapid response team of critical care professionals available at all hours, and an in-house physician with Pediatric Advanced Life Support certification or equivalent qualifications. Furthermore, all areas of these centers must have the resources needed to perform pediatric resuscitation.

Additional guidelines for ambulatory, or outpatient, surgical centers include having preoperative and recovery areas dedicated to pediatric patients. Also, according to the task force report, a pediatric anesthesiologist at an ambulatory surgical center should administer or supervise the administration of a general anesthetic or sedative to all infants younger than one year old.

Acknowledging that the standards are high, ACS Executive Director David B. Hoyt, MD, FACS, a member of the Task Force for Children’s Surgical Care, added, "I think many hospitals will rise to these new standards by adding resources."

In designating the resources that children’s surgical centers need, the Task Force for Children’s Surgical Care reportedly relied on published scientific evidence and expert opinion. According to Dr. Oldham, supporting evidence included the success of the ACS’ nationwide classification and verification system for trauma centers. By helping ensure that injured patients receive care at the appropriate level, the trauma system has saved many lives, he noted.

Plans are under way to develop criteria for evaluating existing facilities that perform children’s surgical procedures. The ACS will oversee the site verification process, which Dr. Oldham anticipates will become available sometime this year.

*Optimal resources for children’s surgical care in the United States. J Am Coll Surg. 2014;218(3):479-487.e4.

The American College of Surgeons (ACS) has published new comprehensive guidelines that define the resources the nation’s surgical facilities need to perform operations effectively and safely in infants and children. The standards – published in the March issue of the Journal of the American College of Surgeons – also have the approval of the American Pediatric Surgical Association and the Society of Pediatric Anesthesia.* Representatives of these organizations as well as invited leaders in other pediatric medical specialties, known as the Task Force for Children’s Surgical Care, developed the consensus recommendations over the past three years.

"The intent of these recommendations is to ensure that all infants and children in the U.S. receive care in a surgical environment matched to their individual medical, emotional, and social needs," said Keith T. Oldham, MD, FACS, task force chair and the surgeon-in-chief at Children’s Hospital of Wisconsin, Milwaukee.

Many studies show better results—including fewer complications and shorter hospital stays—when newborns and children undergo surgical procedures in environments that have expert resources for pediatric patients, compared with non-specialized centers.

In its report, the Task Force for Children’s Surgical Care defined the proper surgical environment for children as one "that offers all of the facilities, equipment, and, most especially, access to the professional providers who have the appropriate background and training to provide optimal care."

The task force assigned levels of resources, as the ACS has done for trauma centers for decades. The classification for children’s surgical centers is as follows:

Level I (highest level): Possesses adequate resources to provide comprehensive surgical care and perform both complex and noncomplex surgical procedures in newborns and children of all ages, including those with the most severe health conditions and birth defects. Is staffed 24 hours a day, seven days a week with properly credentialed pediatric specialists, including pediatric and subspecialty surgeons, pediatric anesthesiologists, pediatric diagnostic and interventional radiologists, and pediatric emergency physicians. Has a Level IV neonatal intensive care unit (NICU), the highest level of critical care for newborns.

Level II: Possesses adequate resources to provide advanced surgical care for children of all ages, including those who have accompanying ("comorbid") medical conditions. Operations would typically be performed by a single surgical specialty. Personnel include a board-certified pediatric surgeon, pediatric anesthesiologist, and pediatric radiologist with other pediatric specialists readily available for consultation, and has an emergency physician and an intensive care unit that both have pediatric expertise. Has a Level III or higher NICU.

Level III: Possesses adequate resources to provide basic surgical care and perform common, low-risk surgical procedures in children older than one year who are otherwise healthy. Has a general surgeon, anesthesiologist, radiologist, and emergency physician, all of whom have pediatric expertise. Has a Level I NICU (well-newborn nursery) or higher.

Both Level II and III surgical centers must be able to stabilize and transfer critically ill children to a hospital with higher-level resources. All children’s surgical centers must have at least one pediatric surgical nurse, a pediatric rapid response team of critical care professionals available at all hours, and an in-house physician with Pediatric Advanced Life Support certification or equivalent qualifications. Furthermore, all areas of these centers must have the resources needed to perform pediatric resuscitation.

Additional guidelines for ambulatory, or outpatient, surgical centers include having preoperative and recovery areas dedicated to pediatric patients. Also, according to the task force report, a pediatric anesthesiologist at an ambulatory surgical center should administer or supervise the administration of a general anesthetic or sedative to all infants younger than one year old.

Acknowledging that the standards are high, ACS Executive Director David B. Hoyt, MD, FACS, a member of the Task Force for Children’s Surgical Care, added, "I think many hospitals will rise to these new standards by adding resources."

In designating the resources that children’s surgical centers need, the Task Force for Children’s Surgical Care reportedly relied on published scientific evidence and expert opinion. According to Dr. Oldham, supporting evidence included the success of the ACS’ nationwide classification and verification system for trauma centers. By helping ensure that injured patients receive care at the appropriate level, the trauma system has saved many lives, he noted.

Plans are under way to develop criteria for evaluating existing facilities that perform children’s surgical procedures. The ACS will oversee the site verification process, which Dr. Oldham anticipates will become available sometime this year.

*Optimal resources for children’s surgical care in the United States. J Am Coll Surg. 2014;218(3):479-487.e4.

The American College of Surgeons (ACS) has published new comprehensive guidelines that define the resources the nation’s surgical facilities need to perform operations effectively and safely in infants and children. The standards – published in the March issue of the Journal of the American College of Surgeons – also have the approval of the American Pediatric Surgical Association and the Society of Pediatric Anesthesia.* Representatives of these organizations as well as invited leaders in other pediatric medical specialties, known as the Task Force for Children’s Surgical Care, developed the consensus recommendations over the past three years.

"The intent of these recommendations is to ensure that all infants and children in the U.S. receive care in a surgical environment matched to their individual medical, emotional, and social needs," said Keith T. Oldham, MD, FACS, task force chair and the surgeon-in-chief at Children’s Hospital of Wisconsin, Milwaukee.

Many studies show better results—including fewer complications and shorter hospital stays—when newborns and children undergo surgical procedures in environments that have expert resources for pediatric patients, compared with non-specialized centers.

In its report, the Task Force for Children’s Surgical Care defined the proper surgical environment for children as one "that offers all of the facilities, equipment, and, most especially, access to the professional providers who have the appropriate background and training to provide optimal care."

The task force assigned levels of resources, as the ACS has done for trauma centers for decades. The classification for children’s surgical centers is as follows:

Level I (highest level): Possesses adequate resources to provide comprehensive surgical care and perform both complex and noncomplex surgical procedures in newborns and children of all ages, including those with the most severe health conditions and birth defects. Is staffed 24 hours a day, seven days a week with properly credentialed pediatric specialists, including pediatric and subspecialty surgeons, pediatric anesthesiologists, pediatric diagnostic and interventional radiologists, and pediatric emergency physicians. Has a Level IV neonatal intensive care unit (NICU), the highest level of critical care for newborns.

Level II: Possesses adequate resources to provide advanced surgical care for children of all ages, including those who have accompanying ("comorbid") medical conditions. Operations would typically be performed by a single surgical specialty. Personnel include a board-certified pediatric surgeon, pediatric anesthesiologist, and pediatric radiologist with other pediatric specialists readily available for consultation, and has an emergency physician and an intensive care unit that both have pediatric expertise. Has a Level III or higher NICU.

Level III: Possesses adequate resources to provide basic surgical care and perform common, low-risk surgical procedures in children older than one year who are otherwise healthy. Has a general surgeon, anesthesiologist, radiologist, and emergency physician, all of whom have pediatric expertise. Has a Level I NICU (well-newborn nursery) or higher.

Both Level II and III surgical centers must be able to stabilize and transfer critically ill children to a hospital with higher-level resources. All children’s surgical centers must have at least one pediatric surgical nurse, a pediatric rapid response team of critical care professionals available at all hours, and an in-house physician with Pediatric Advanced Life Support certification or equivalent qualifications. Furthermore, all areas of these centers must have the resources needed to perform pediatric resuscitation.

Additional guidelines for ambulatory, or outpatient, surgical centers include having preoperative and recovery areas dedicated to pediatric patients. Also, according to the task force report, a pediatric anesthesiologist at an ambulatory surgical center should administer or supervise the administration of a general anesthetic or sedative to all infants younger than one year old.

Acknowledging that the standards are high, ACS Executive Director David B. Hoyt, MD, FACS, a member of the Task Force for Children’s Surgical Care, added, "I think many hospitals will rise to these new standards by adding resources."

In designating the resources that children’s surgical centers need, the Task Force for Children’s Surgical Care reportedly relied on published scientific evidence and expert opinion. According to Dr. Oldham, supporting evidence included the success of the ACS’ nationwide classification and verification system for trauma centers. By helping ensure that injured patients receive care at the appropriate level, the trauma system has saved many lives, he noted.

Plans are under way to develop criteria for evaluating existing facilities that perform children’s surgical procedures. The ACS will oversee the site verification process, which Dr. Oldham anticipates will become available sometime this year.

*Optimal resources for children’s surgical care in the United States. J Am Coll Surg. 2014;218(3):479-487.e4.

For almost a year, trauma surgeons, federal law enforcement personnel, and emergency responders have led an effort aimed at increasing the number of survivors of active shooter or mass-casualty incidents. An important part of this initiative calls for all law enforcement officers to be trained and equipped to control bleeding, a goal set forth by the Hartford Consensus, a collaborative group composed of leaders from the American College of Surgeons (ACS), the Federal Bureau of Investigation (FBI), the Major Cities Chiefs Association (MCCA), and the Prehospital Trauma Life Support program.

THREAT response

The principle of more training and equipment is central to the findings of the Hartford Consensus, according to "The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept," an article published in the March issue of the Journal of the American College of Surgeons (JACS). A companion piece, "Joint Committee to Create a National Policy to Enhance Survivability from Mass-Casualty Shooting Events: Hartford Consensus II," calls for a broad educational strategy and a robust evaluation of the implementation of THREAT in order to quantify its benefits in the management of active shooter and mass-casualty events. THREAT is an acronym for the needed response to mass shooting events developed by the Hartford Consensus: T–Threat suppression, H–Hemorrhage control, RE–Rapid Extrication to safety, A–Assessment by medical providers, and T–Transport to definitive care. 

Driving the recommendations of the Hartford Consensus is the fact that victims of active shooter and mass-casualty events often bleed to death before medically trained emergency responders can reach the scene. Law enforcement officers are typically the first to arrive at the scene of such an incident, but they often lack the medical training and equipment to treat the victims. Filling that need has become one of the central calls to action of the Hartford Consensus, which is led by the ACS Committee on Trauma and builds on guidelines developed by the U.S. military to advance battlefield trauma care.

"Controlling hemorrhage has to be a core law enforcement tactic," said Alexander Eastman, MD, MPH, FACS, chief of trauma at the University of Texas (UT) Southwestern/Parkland Memorial Hospital, Dallas, and a Dallas Police Department Lieutenant. "We saw the dramatic impact of this tactic in the Tucson, AZ, shooting in 2011. With training and tourniquets, law enforcement officers will save lives—many lives."

The Hartford Consensus is already having an impact. In concert with ACS and the MCCA, more than 36,000 police officers in Los Angeles, CA; Philadelphia, PA; Houston, TX; Phoenix, AZ; Dallas; New Orleans, LA; Tampa, FL; and Washington, DC, will receive bleeding control kits and training this year. The Hartford Consensus also urges cities to develop an integrated response system customized to the needs of their community and focused on the importance of initial actions to control hemorrhage.

We can no longer wait until casualties are brought out to the perimeter," said ACS Regent Lenworth M. Jacobs, MD, MPH, FACS, vice-president of academic affairs and chief academic officer and director, Trauma Institute at Hartford Hospital, CT. "We must prepare responders to safely intervene, control bleeding, and save lives."

Another recommendation of the Hartford Consensus is to educate and equip the public to respond to the needs of victims. However, activating that type of response effort means that tourniquets and other equipment need to be broadly available in schools, offices, shopping centers, churches, and other public places.

"Just as automatic external defibrillators are easily usable and quickly available to the public, so should easily applied tourniquets be available in a similar manner and locations," said Norman McSwain, Jr., MD, FACS, medical director, pre-hospital trauma life support, Tulane University School of Medicine, New Orleans. "It’s not a complicated process, and it will save lives."

"We need to expand the pool of first responders," added Michael F. Rotondo, MD, FACS, Chair, ACS Committee on Trauma. "With proper training, under the right circumstances anyone can act as a rescuer."

For almost a year, trauma surgeons, federal law enforcement personnel, and emergency responders have led an effort aimed at increasing the number of survivors of active shooter or mass-casualty incidents. An important part of this initiative calls for all law enforcement officers to be trained and equipped to control bleeding, a goal set forth by the Hartford Consensus, a collaborative group composed of leaders from the American College of Surgeons (ACS), the Federal Bureau of Investigation (FBI), the Major Cities Chiefs Association (MCCA), and the Prehospital Trauma Life Support program.

THREAT response

The principle of more training and equipment is central to the findings of the Hartford Consensus, according to "The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept," an article published in the March issue of the Journal of the American College of Surgeons (JACS). A companion piece, "Joint Committee to Create a National Policy to Enhance Survivability from Mass-Casualty Shooting Events: Hartford Consensus II," calls for a broad educational strategy and a robust evaluation of the implementation of THREAT in order to quantify its benefits in the management of active shooter and mass-casualty events. THREAT is an acronym for the needed response to mass shooting events developed by the Hartford Consensus: T–Threat suppression, H–Hemorrhage control, RE–Rapid Extrication to safety, A–Assessment by medical providers, and T–Transport to definitive care. 

Driving the recommendations of the Hartford Consensus is the fact that victims of active shooter and mass-casualty events often bleed to death before medically trained emergency responders can reach the scene. Law enforcement officers are typically the first to arrive at the scene of such an incident, but they often lack the medical training and equipment to treat the victims. Filling that need has become one of the central calls to action of the Hartford Consensus, which is led by the ACS Committee on Trauma and builds on guidelines developed by the U.S. military to advance battlefield trauma care.

"Controlling hemorrhage has to be a core law enforcement tactic," said Alexander Eastman, MD, MPH, FACS, chief of trauma at the University of Texas (UT) Southwestern/Parkland Memorial Hospital, Dallas, and a Dallas Police Department Lieutenant. "We saw the dramatic impact of this tactic in the Tucson, AZ, shooting in 2011. With training and tourniquets, law enforcement officers will save lives—many lives."

The Hartford Consensus is already having an impact. In concert with ACS and the MCCA, more than 36,000 police officers in Los Angeles, CA; Philadelphia, PA; Houston, TX; Phoenix, AZ; Dallas; New Orleans, LA; Tampa, FL; and Washington, DC, will receive bleeding control kits and training this year. The Hartford Consensus also urges cities to develop an integrated response system customized to the needs of their community and focused on the importance of initial actions to control hemorrhage.

We can no longer wait until casualties are brought out to the perimeter," said ACS Regent Lenworth M. Jacobs, MD, MPH, FACS, vice-president of academic affairs and chief academic officer and director, Trauma Institute at Hartford Hospital, CT. "We must prepare responders to safely intervene, control bleeding, and save lives."

Another recommendation of the Hartford Consensus is to educate and equip the public to respond to the needs of victims. However, activating that type of response effort means that tourniquets and other equipment need to be broadly available in schools, offices, shopping centers, churches, and other public places.

"Just as automatic external defibrillators are easily usable and quickly available to the public, so should easily applied tourniquets be available in a similar manner and locations," said Norman McSwain, Jr., MD, FACS, medical director, pre-hospital trauma life support, Tulane University School of Medicine, New Orleans. "It’s not a complicated process, and it will save lives."

"We need to expand the pool of first responders," added Michael F. Rotondo, MD, FACS, Chair, ACS Committee on Trauma. "With proper training, under the right circumstances anyone can act as a rescuer."

For almost a year, trauma surgeons, federal law enforcement personnel, and emergency responders have led an effort aimed at increasing the number of survivors of active shooter or mass-casualty incidents. An important part of this initiative calls for all law enforcement officers to be trained and equipped to control bleeding, a goal set forth by the Hartford Consensus, a collaborative group composed of leaders from the American College of Surgeons (ACS), the Federal Bureau of Investigation (FBI), the Major Cities Chiefs Association (MCCA), and the Prehospital Trauma Life Support program.

THREAT response

The principle of more training and equipment is central to the findings of the Hartford Consensus, according to "The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept," an article published in the March issue of the Journal of the American College of Surgeons (JACS). A companion piece, "Joint Committee to Create a National Policy to Enhance Survivability from Mass-Casualty Shooting Events: Hartford Consensus II," calls for a broad educational strategy and a robust evaluation of the implementation of THREAT in order to quantify its benefits in the management of active shooter and mass-casualty events. THREAT is an acronym for the needed response to mass shooting events developed by the Hartford Consensus: T–Threat suppression, H–Hemorrhage control, RE–Rapid Extrication to safety, A–Assessment by medical providers, and T–Transport to definitive care. 

Driving the recommendations of the Hartford Consensus is the fact that victims of active shooter and mass-casualty events often bleed to death before medically trained emergency responders can reach the scene. Law enforcement officers are typically the first to arrive at the scene of such an incident, but they often lack the medical training and equipment to treat the victims. Filling that need has become one of the central calls to action of the Hartford Consensus, which is led by the ACS Committee on Trauma and builds on guidelines developed by the U.S. military to advance battlefield trauma care.

"Controlling hemorrhage has to be a core law enforcement tactic," said Alexander Eastman, MD, MPH, FACS, chief of trauma at the University of Texas (UT) Southwestern/Parkland Memorial Hospital, Dallas, and a Dallas Police Department Lieutenant. "We saw the dramatic impact of this tactic in the Tucson, AZ, shooting in 2011. With training and tourniquets, law enforcement officers will save lives—many lives."

The Hartford Consensus is already having an impact. In concert with ACS and the MCCA, more than 36,000 police officers in Los Angeles, CA; Philadelphia, PA; Houston, TX; Phoenix, AZ; Dallas; New Orleans, LA; Tampa, FL; and Washington, DC, will receive bleeding control kits and training this year. The Hartford Consensus also urges cities to develop an integrated response system customized to the needs of their community and focused on the importance of initial actions to control hemorrhage.

We can no longer wait until casualties are brought out to the perimeter," said ACS Regent Lenworth M. Jacobs, MD, MPH, FACS, vice-president of academic affairs and chief academic officer and director, Trauma Institute at Hartford Hospital, CT. "We must prepare responders to safely intervene, control bleeding, and save lives."

Another recommendation of the Hartford Consensus is to educate and equip the public to respond to the needs of victims. However, activating that type of response effort means that tourniquets and other equipment need to be broadly available in schools, offices, shopping centers, churches, and other public places.

"Just as automatic external defibrillators are easily usable and quickly available to the public, so should easily applied tourniquets be available in a similar manner and locations," said Norman McSwain, Jr., MD, FACS, medical director, pre-hospital trauma life support, Tulane University School of Medicine, New Orleans. "It’s not a complicated process, and it will save lives."

"We need to expand the pool of first responders," added Michael F. Rotondo, MD, FACS, Chair, ACS Committee on Trauma. "With proper training, under the right circumstances anyone can act as a rescuer."