Procedural and clinical experiences of Surgical Critical Care and Acute Care Surgery fellows were logged in the ACS Case Log, starting in July 2010. This system was used to capture experiences believed to be relevant to fellow training. Using CPT codes, experiences and cases were entered identically to billable rules and documentation submitted to our electronic medical record. Annually, CPT codes are updated by the ACS Case Log and currently reflect any 2012 CPT changes. When relevant, in the ACS Case Log free-text "Notes" field, specific keywords were entered that specified unique fellow services, resuscitation types (Burn, Blunt, Penetrating), and focused abdominal sonography for trauma (FAST) test characteristics. This data was exported in comma separated value format and de-identified. IRB approval was obtained for the purposes of this publication.
Operative procedures, bedside procedures, and free-text designated resuscitations were parsed using STATA programming (StataCorp. 2009. Stata Statistical Software: Release 11. College Station, TX: StataCorp LP). Coupling the code for evaluation and management of the critically ill (99291) with standardized free-text, we differentiated resuscitations from daily critical care time. Critical care time also captured elements essential for critical care certification such as hemodynamic monitoring, ventilator support, cardiac resuscitation, dialysis/hemofiltration, and nutritional support.
Relevant bedside diagnostic and therapeutic procedures were also captured. Ultrasound modalities measured were FAST examination performance with sensitivity and specificity reporting, in addition to transesophageal, transthoracic, and Doppler mode echocardiography exams. Bedside airway procedures captured included intubation, tracheostomy, and cricothyroidotomy. Bedside Intensive Care Unit (ICU) vascular procedures were subcategorized into placements of central venous catheters, arterial catheters, intraosseous access, inferior vena cava filters, transvenous pacers, Swan-Ganz catheters, and intra-aortic balloon pumps. Other bedside procedures included bronchoscopy, endoscopy, tube thoracostomy, percutaneous endoscopic gastrostomy, application of negative pressure wound therapy, provision of conscious sedation, paracentesis (including peritoneal lavage), thoracentesis, external cardioversion, cardiopulmonary resuscitation, laceration repair, port removal, and urinary system imaging.
For operative procedures with multiple CPT codes, the number of operative cases was kept distinct from the individual intra-operative CPT coded procedures performed. Based on our prior work and proposed curriculum in acute care surgery,(5
) major operative procedures were then structured into six main Acute Care Surgery categories: Cardiothoracic, Vascular, Abdominal Wall, Gastrointestinal and Genitourinary, Solid Organ, and Soft Tissue. Cardiothoracic procedures ranged from exploration of penetrating thoracic wounds, thoracotomy, thoracoscopy, open sternal fixation, open rib fixation, cardiorraphy, pericardial window, lung resection, lung hernia repair, and esophageal repair. Vascular CPTs covered ligation or repair of major vasculature, vein harvest and/or ligation, amputation, and spinal exposures. Abdominal wall CPT codes covered exploratory laparotomy, diagnostic laparoscopy, exploration of penetrating wounds, hernias (ventral, femoral, inguinal, lumbar, laparoscopic), mesh manipulation, and evisceration repair. Gastrointestinal and Genitourinary CPTs covered the hollow viscus organs (stomach, small bowel, large bowel and bladder), endoscopy, and enteral feeding access. Soft tissue CPTs covered skin grafting, escharotomy, burn excision, fasciotomy, débridement, and myofasciocutaneous flap construction.
Orthopedic procedures represented a combination of bedside extremity closed treatment covering splinting, reduction, and external fixation. Neurosurgical CPTs included lumbar puncture, burr hole, ventricular access, craniotomy, and shunt creation and/or revision.