Scott T. Schmidt

Unnecessary Emergency Transfers for Evaluation by a Plastic Surgeon: A Burden to Patients and the Health Care System.

Background: Plastic surgeons are frequently consulted for hand and facial injuries, and patients are often transferred to trauma centers for evaluation of these problems. The authors sought to identify the frequency and impact of “unnecessary” transfers for emergency evaluation by a plastic surgeon at a Level I trauma center. Methods: The authors reviewed more than 32,000 consecutive emergency department encounters at their institution between April of 2009 and April of 2013 and found 1181 patients transferred for evaluation by plastic surgery. Using a retrospective chart review, necessity of transfer was determined based on the intervention performed at the authors’ institution and the availability of resources at the transferring site. Results: Of all the patients referred for “emergency” evaluation, 860 (74.1 percent) were unnecessary. Transfers for hand-related issues were more likely to be coded as unnecessary compared with referrals for facial trauma and infection (76 percent versus 66 percent; p < 0.001). The average time from referral to discharge from the emergency department was 412 minutes. The expense for these unnecessary transfers exceeded

Duty hours and home call: the experience of plastic surgery residents and fellows.

4.6 million. Conclusions: This is the first intervention-based study evaluating the impact of unnecessary transfer for evaluation of hand and facial emergencies. Using a framework based on objective outcomes, the authors found that fewer than one-third of patients required emergent transfer for evaluation by a plastic surgeon, and almost half did not receive an intervention following transfer. Based on patient time and financial expenses for these unnecessary evaluations, improvements could be made in both quality and cost of care by limiting inappropriate emergency department referrals.

Coding and Billing in Surgical Education: A Systems-Based Practice Education Program.

Background: Although resident duty hours are strictly regulated by the Accreditation Council for Graduate Medical Education, there are fewer restrictions on at-home call for residents. To date, no studies have examined the experience of home call for plastic surgery trainees or the impact of home call on patient care and education in plastic surgery. Methods: The authors distributed an anonymous electronic survey to plastic surgery trainees at 41 accredited programs. They sought to produce a descriptive assessment of home call and to evaluate the perceived impact of home call on training and patient care. Results: A total of 214 responses were obtained (58.3 percent completion rate). Nearly all trainees reported taking home call (98.6 percent), with 66.7 percent reporting call frequency every third or fourth night. Most respondents (63.3 percent) felt that home call regulations are vague but that Council regulation (44.9 percent) and programmatic oversight (56.5 percent) are adequate. Most (91.2 percent) believe their program could not function without home call and that home call helps to avoid strict duty hour restrictions (71.5 percent). Nearly all respondents (92.3 percent) preferred home call to in-house call. Conclusions: This is the first study to examine how plastic surgery residents experience and perceive home call within the framework of Accreditation Council for Graduate Medical Education duty hour regulations. Most trainees feel the impact of home call is positive for education (50.2 percent) and quality of life (56.5 percent), with a neutral impact on patient care (66.7 percent). Under the Council’s increasing regulations, home call provides a balance of education and patient care appropriate for training in plastic and reconstructive surgery.

Methods and Pitfalls in Treatment of Fractures in the Digits

OBJECTIVE Despite increased emphasis on systems-based practice through the Accreditation Council for Graduate Medical Education core competencies, few studies have examined what surgical residents know about coding and billing. We sought to create and measure the effectiveness of a multifaceted approach to improving resident knowledge and performance of documenting and coding outpatient encounters. DESIGN We identified knowledge gaps and barriers to documentation and coding in the outpatient setting. We implemented a series of educational and workflow interventions with a group of 12 residents in a surgical clinic at a tertiary care center. To measure the effect of this program, we compared billing codes for 1 year before intervention (FY2012) to prospectively collected data from the postintervention period (FY2013). All related documentation and coding were verified by study-blinded auditors. SETTING Interventions took place at the outpatient surgical clinic at Rhode Island Hospital, a tertiary-care center. PARTICIPANTS A cohort of 12 plastic surgery residents ranging from postgraduate year 2 through postgraduate year 6 participated in the interventional sequence. RESULTS A total of 1285 patient encounters in the preintervention group were compared with 1170 encounters in the postintervention group. Using evaluation and management codes (E&M) as a measure of documentation and coding, we demonstrated a significant and durable increase in billing with supporting clinical documentation after the intervention. For established patient visits, the monthly average E&M code level increased from 2.14 to 3.05 (p < 0.01); for new patients the monthly average E&M level increased from 2.61 to 3.19 (p < 0.01). CONCLUSIONS This study describes a series of educational and workflow interventions, which improved resident coding and billing of outpatient clinic encounters. Using externally audited coding data, we demonstrate significantly increased rates of higher complexity E&M coding in a stable patient population based on improved documentation and billing awareness by the residents.

Improving Pressure Ulcer Reconstruction: Our Protocol and the COP (Cone of Pressure) Flap

This article describes the indications for and methods of managing phalangeal fractures. The fractures around the finger joints are particularly difficult to treat. The technical details and pitfalls for these cases are discussed in detail. The problems associated with the phalangeal fractures such as articular destruction, nonunion, and postoperative care are also discussed. The authors present their preferred surgical treatment, with review of recent advancement regarding the treatment of phalangeal fractures.

Abstract 21: frequency and impact of inappropriate emergent transfer for hand surgical consultation.

Background: Surgical treatment of pressure ulcers is challenging for high recurrence rates. Deepithelialized flaps have been used previously with the aim to eliminate shearing forces and the cone of pressure (COP) effect. The goal of this study is to adopt a standardized protocol and evaluate if 2 different flap techniques affect outcomes. Methods: The novel COP flap is illustrated. Twenty patients were prospectively treated with flap coverage over a 36-month period. According to the flap type, patients were assigned to 2 groups: group 1 with 11 patients treated with the COP flap and group 2 with 9 patients treated with conventional flap without anchoring technique. We adopted a standardized protocol of debridement, tissue cultures, and negative-pressure wound therapy. Rotation fasciocutaneous flaps were used for both groups and mean follow-up was 19 months. The COP flap is a large deepithelialized rotation flap inset with transcutaneous nonabsorbable bolster sutures. The 2 groups were comparable for demographics and ulcer location and size (P < 0.05). Five patients showed positive cultures and were treated with antibiotics and negative-pressure therapy before surgery. Results: Recurrence rates were 12% in the COP flap group and 60% in the conventional flap coverage group (P < 0.001). Results were compared at 16-month follow-up. Conclusions: The COP flap significantly reduces recurrences and eliminates shearing forces, suture ripping, and tension on superficial soft-tissue layers. The technique can be applied to both ischial and sacral pressure sores. The flap provides padding over bony prominence without jeopardizing flap vascularity.

Local and Regional Flaps

PurPose: Approximately one in five Americans presents to an emergency department (ED) each year. With a total of 130 million visits in 2010, ED encounters made up 4% of all healthcare spending. Evaluation of hand and upper extremity diagnoses has been reported for up to 15% of ED visits. Previous studies have demonstrated that “hand surgery” evaluation is a common reason for patient transfers. We sought to identify the frequency and impact of “unnecessary” transfers for emergency evaluation by a hand surgeon.

The Use of a Magnetic Port Finder in the Retrieval of Air Rifle BBs to the Upper Extremity

In a rapidly advancing field of reconstructive surgery, wound healing is one of the most important areas. Major advances in wound care have resulted in the ability to heal small- and medium-sized defects without significant sequela. Wound healing could be complex, especially in patients with multiple comorbidities. Complex defects involving the bones, joint, and tendon could lead to major complications if management and coverage are delayed. Consequently, rapid wound coverage may be may be favored over healing by secondary intention. Technical means for coverage of complex defects include flaps or grafts. A flap is tissue that is transferred from a donor site to a recipient site with its included blood supply. This differs from a graft, which involves tissue transfer without consideration for its native perfusion. Flaps are used in situations where wounds are more complicated and secondary healing is not a sustainable treatment modality. In this chapter, we provide detailed information about local and regional flaps and also recent advances in this field.

Burn scar regeneration with the “SUFA” (Subcision and Fat Grafting) technique. A prospective clinical study

Air-powered rifles shoot ball bearings with enough kinetic energy to penetrate skin and fracture underlying bones. In addition, there are reports of these ball bearings embolizing within the vascular network, causing serious injuries such as ischemic stroke with resultant blindness. The severity of these complications warrants occasional removal of these foreign bodies; however, they can be difficult to localize. In this case report, we describe the use of a magnetic port finder, a sterilizable tool used in breast reconstruction, to localize the foreign body in situ. We believe that this tool is effective at locating ferrous foreign bodies precisely, allowing for surgical retrieval while minimizing damage to surrounding tissue.

Surgical management of digital ischemia caused by constriction band formation in a patient with ichthyosis vulgaris

Summary Background Treatment of burn scars with traditional surgical techniques is challenging due to recurrent contractures. Fat grafting has been previously used in small clinical series and results are often biased by lack of scientific validating methods. Fat grafting in clinical practice is often evaluated for its filler properties and rarely scientifically validated for its potential in dermal regeneration. Animal studies have shown dermal regeneration with new deposition and reorientation of the collagen fiber. Our study aims to apply the validity of in vitro studies to clinical practice. Methods Our study prospectively evaluated outcomes in 12 patients treated with the “SUFA” technique (Subcision and Fat Grafting) for debilitating contracted burns scars limiting range of motion. Results were evaluated clinically with the Vancouver scale and by range of motion at 1, 3, 6 and 12 months. Dermal regeneration was evaluated by looking at dermis thickening using high definition ultrasound and scar remodeling looking at reorientation and new deposition of collagen fibers with hematoxylin-eosin histology and monoclonal antibodies against collagen type 1 and 3. Results Statistically significant clinical improvements in range of motion of the affected joints was observed (P<0.05). Fat reabsorption occurred with a mean of 40%. Thickening of dermis and redistribution and reorientation of the collagen fibers within the dermis was also demonstrated. Conclusions Our results present the first clinical scientific evidence of dermal regeneration in fat grafting. Using monoclonal antibodies and high definition ultrasounds, we demonstrate the first evidence of dermis regeneration in a clinical scenario.