PHYSICIAN ASSISTANTS IN CARDIAC SURGERY

PHYSICIAN ASSISTANTS IN CARDIAC SURGERY Past,, and Future PAST 1965 first class of Physician Assistants graduated from Duke University Research revealed geographic maldistribution of primary care providers Dr. Eugene Stead Medical training was based on US military war time General Medical Officer Training 1965 4 Navy Corpsman began training 1

PAST 1967 Surgeon s Assistant program developed at University of Alabama-Birmingham John W, Kirkland, MD He postulated that PA s could be trained to perform many of the tasks traditionally performed by surgeons First surgical PA s trained in Cardiac Surgery PAST J Thorac Cardiovasc Surg. 1978 Nov;76(5):639-42. Physicians' assistants on a university cardiothoracic surgical service. A five-year update. Miller JI, Hatcher CR. 2

PAST In 1973 two physican assistants (P.A.'s) were employed on a cardiothoracic surgical service at Emory University Hospital 1,700 cardiac cases and 600 thoracic cases per year The P.A. has assumed a position of increasing importance both in operating room assistance and in preoperative and postoperative care. Functions as a junior house officer PAST Emory History and Physical Surgical First Assisting (non-academic centers) Insertion of invasive catheters Insertion of chest tubes Study Chest closures In-house coverage of ICU, step-down, and surgical floors Outpatient follow up Coordination of care 3

PAST Conclusion When properly utilized and supervised, the P.A. can be a vital member of the cardiothoracic team. PAST Ann Surg. 1981 Feb; 193(2): 132 137. The current and future role of surgical physician assistants. Report of a national survey of surgical chairmen in large U.S. hospitals. H B Perry, D E Detmer, and E L Redmond 4

PAST The chairman of departments of surgery in general hospitals with more than 400 beds were surveyed to assess their current and projected use of surgical physician assistants. Of the 552 institutions represented in the survey, surgical physician assistants were working in one-third, providing preoperative, intraoperative, and postoperative care. Two-thirds of the chairmen felt that the introduction of physician assistants had improved surgical patient care in their institutions. Annals of Surgery Conclusions In institutions with surgical housestaff, almost half the chairmen felt that surgical physician assistants had improved the quality of residency training During the next five years an increase of 87% in the number of surgical physician assistants is projected by respondents. Conclusion: That appropriately trained and supervised surgical physician assistants will play an increasingly important role in improving the care of surgical patients and, by functioning as junior housestaff, make it possible to reduce the number of surgeons being trained. 5

PAST Physicians Assistants in Cardiothoracic Surgery: A 30- Year Experience in a University Center ed at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13 15, 2003. Vinod H. Thourani, MD, Joseph I. Miller Jr, MD, Emory University Experience History and Physical Surgical First Assisting (non-academic centers) Insertion of invasive catheters Insertion of chest tubes Chest closures In-house coverage of ICU, step-down, and surgical floors Outpatient follow up Coordination of care 6

Emory University Experience Conclusions The addition of PAs to our CTS university service has allowed us to resolve many problems of work assignment and coverage and enabled us to establish effective and efficient surgical teams without increasing the number of categorical CTS residents. According to NCCPA, 3,634 PA s practicing cardiac and thoracic surgery in the US Germany, Netherlands, and India actively starting CT PA programs Australia and Japan currently developing plans to use PA like professionals in CT surgery Association of PA s in Cardiovascular Surgery 7

Patient Care % Private Practice University Community Hospital H&P/Consults 85.1 84.5 84.0 84.1 ICU/Critical Care Stepdown Care Patient Education All 81.9 60.6 84.5 79.2 83.0 76.1 89.5 85.2 68.1 74.7 74.5 72.9 In-services 28.7 26.8 38.0 33.4 Discharges 76.6 74.7 85.0 80.8 Procedure % Private Practice University Practice Community Hospital Arterial Lines 64.9 57.8 71.0 66.9 Swan Ganz 40.4 32.4 37.5 37.3 CVP Line 53.2 40.9 47.0 47.4 Chest Tubes 68.1 69.0 76.5 72.9 IABP 28.7 43.7 40.5 38.1 All 8

Procedure % SVG Harvesting Radial Artery Harvesting IMA Harvesting Sternal Closure Private Practice University Practice Community Hospital All 96.8 81.7 92.0 91.2 58.5 50.7 67.0 61.6 6.4 5.6 4.0 4.9 59.6 62.0 60.5 60.6 First Assisting 96.8 91.6 92.5 93.4 Sternotomy 16.0 31.0 18.0 20.0 The safety and efficacy of physician assistants as first assistant surgeons in cardiac surgery RANZENBACH, EDWARD A. PA C, MPAS, FAPACVS, DFAAPA; POA, LI MD, FACS Journal of the American Academy of Physician Assistants: August 2012 - Volume 25 - Issue 8 - p 52, e53 e55 9

ABSTRACT: This study is a retrospective review of 956 patients comparing cases first assisted by physician assistants (PAs) to those first assisted by surgeons, examining whether PAs can function safely and efficiently in the role of first assistant surgeon for cardiac surgery. No differences were found between the two cohorts. Incidence of cases was insignificant between the two cohorts PAs first assisted on significantly more off-pump cases than MDs EuroScores and EuroMortality for the two cohorts was virtually identical Complication rates were similar Demonstrates surgeon confidence in PAs to do complex cases PAs are safe and efficacious first assistants for all types of cardiac surgery cases 10

A randomized trial of endoscopic versus open saphenous vein harvest in coronary bypass surgery. Puskas JD1, Wright CE, Miller PK, Anderson TE, Gott JP, Brown WM 3rd, Guyton RA Ann Thorac Surg. 1999 Oct;68(4):1509-12 There was no difference between groups in mortality, perioperative myocardial infarction, intensive care unit or postoperative length of stay, blood product utilization, or discharge laboratory measures. There was more drainage noted from leg incisions at hospital discharge in the OVH (34%) versus EVH group (8%; p = 0.001), but more ecchymosis in the EVH group. Although there was a trend towards reduced leg incision pain in the EVH group, there was no statistically significant difference in pain or in the quality of life measure at any point in time. There was no difference between groups in readmission to hospital, administration of antibiotics, or incidence of leg infection. 11

CONCLUSIONS: EVH is a safe, reliable, and cost-neutral method for saphenous vein harvest. The best indication for EVH may be in patients who are at increased risk for wound infection and in those for whom cosmesis is a major concern. A Study of Pneumothorax Rates for Physician Assistants Inserting Central Venous Catheters at a Large Urban Hospital Theresa Cox, Thomas Parash, Robert Zane Reasoner The Internet Journal of Allied Health Sciences and Practice. 2005 Jul 01;3(3), Article 7. 12

Prospective study followed 9 PAs inserting central venous catheter (CVC) lines in pulmonary critical care and cardiothoracic surgery settings in a large urban hospital from June 1, 2002 through December 1, 2002. Each PA required general supervision for the procedures. The most common complication of CVC placement is pneumothorax. Published complication rate varies from 0.5-1.8% None of these occurred during the study period in 233 CVC lines inserted by PAs This group of PAs inserted 75 Swan-Ganz catheters, performed 25 thoracenteses, 30 endotracheal intubations, and 10 chest tube placements Complications were noted and recorded via the on site researcher Only complication was one pneumothorax during a thoracientesis 13

This research study demonstrates that with the proper training and supervision from a physician, PAs can perform invasive medical procedures with a complication rate comparable to that of physicians in a similar setting. Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review Kleinpell, Ruth M. PhD, RN, ACNP, FCCM; Ely, E Wesley MD, MPH, FCCM; Grabenkort, Robert PA, MMSc, FCCM Critical Care Medicine Issue: Volume 36(10), October 2008, pp 2888-2897 14

Objectives: To identify published literature on the role of nurse practitioners and physician assistants in acute and critical care settings Methods: We conducted a systematic search of the English-language literature of publications on nurse practitioners and physician assistants utilizing Ovid MEDLINE, PubMed, and the Cumulative Index of Nursing and Allied Health Literature databases from 1996 through August 2007. NP and PA care was associated with improved Clinical and financial outcomes for mechanically ventilated Improved management of patients with chronic heart failure Reduction in LOS and costs of care for cardiac surgery patients Reduction in LOS for vascular medicine patients Proficiency in skills such as intracranial pressure monitor placement, surgical assistant skills, invasive procedures including arterial lines, central venous catheters, pleural taps, lumbar puncture and thoracentesis, and diagnostic cardiac catheterization. 15

Physician assistant home visit program to reduce hospital readmissions Read at the 38th Annual Meeting of The Western Thoracic Surgical Association, Maui, Hawaii, June 27-30, 2012. John P. Nabagiez, MD, Masood A. Shariff, MD, Muhammad A. Khan, MD, William J. Molloy, PA-C, Joseph T. McGinn Jr., MD A physician assistant home care (PAHC) program providing house calls was initiated to decrease hospital readmission rates. We evaluated the 30-day readmission rates and diagnoses before and during PAHC to identify determinants of readmission and interventions to reduce readmissions. All patients underwent Cardiac Surgery 16

Patients who underwent cardiac surgery were evaluated postoperatively for 13 months as pre-pahc (control group) and 13 months with PAHC. Physician assistants made house calls on days 2 and 5 following hospital discharge for the PAHC group. Both groups were seen in the office postoperatively. Readmission rates for the control and PAHC groups were compared, as were the reasons for readmissions. Readmission diagnoses were categorized as infectious, cardiac, gastrointestinal, vascular, pulmonary, neurologic, and other. Also noted were the interventions made during the home visits. There were 361 patients (51%) in the control group and 340 patients (49%) in the PAHC group. Readmission rate for the control group was 16% (59 patients) and 12% (42 patients) for the PAHC group, a 25% reduction in the rate of readmissions (P =.161). The rate of infection-related readmissions was reduced from 44% (26 patients) to 19% (8 patients) (P =.010). Home interventions included adjustment of medications (90%), ordering of imaging studies (7%), and administering direct wound care (2%). 17

Conclusions The 30-day readmission rate was reduced by 25% in patients receiving PAHC visits. The most common home intervention was medication adjustment, most commonly to diuretic agents, medications for hypoglycemia, and antibiotics Future Physician assistant model for lung procurements: a paradigm worth considering. Costa J1, D'Ovidio F, Bacchetta M, Lavelle M, Singh G, Sonett JR. Ann Thorac Surg. 2013 Dec;96(6):2033-7. doi: 10.1016/j.athoracsur.2013.07.094. Epub 2013 Oct 1 18

Future Over the past 5 years, lung procurements have been performed by a specifically trained physician assistant; as the lead donor surgeon. Future This is a single institution review of 287 consecutive lung procurements performed by either a physician assistant or fellow over 5 years From 2008 to 2012, fellows served as senior surgeon in 90 cases (31.4%) versus 197 cases (68.6%) by the physician assistant, 19

Future Injury rate was significantly lower for the physician assistant compared with the resident cohort (1 of 197 [0.5%] vs 22 of 90 [24%], respectively). Rates for pulmonary graft dysfunction grade 2 and 3 were found to be significantly lower in cases where the physician assistant served as senior surgeon (combined rates of 32.2% [29 of 90] vs 9.6% [19 of 197] in the physician assistant group) (p < 0.01 Future Conclusions Use of experienced physician assistants in donor lung procurements is a safe and viable alternative offering continuity of technical expertise and evaluation of lung allografts. 20

Future Training Assistants Improves the Process of Adoption of Video-Assisted Thoracic Surgery Lobectomy. Meyerson SL1, Balderson SS2, D'Amico TA2. Ann Thorac Surg. 2015 Aug;100(2):401-6. doi: 10.1016/j.athoracsur.2015.03.087. Epub 2015 Jun 23. Future CONCLUSIONS: Specific training directed at surgical assistants may improve the adoption of new technology by mechanisms including improved visualization and better understanding of methods to facilitate the operation and avoid frustration. This type of training should be made available to assistants of surgeons learning new operations. 21

Future The role of physician assistant (PA) in cardiothoracic surgery at Emory University Hospital. [Article in Japanese] Takebe M, Adachi H. Physician assistants: trialing a new surgical health professional in Australia. Ho P1, Pesicka D, Schafer A, Maddern G. Future Increasing age and complexity of patients requiring cardiac surgical procedures Decreasing surgical residents and fellows leading to a shortage of Cardiac Surgeons Emphasis on quality of care and cost of care Increasing technology allowing minimally invasive techniques 22

Future PA s are well qualified to fit the roles as a surgeon extender and provide pre, peri, and post-operative care in a cost efficient manner Studies reveal better outcomes with a multi-disciplinary approach and PA s are leaders within this concept We are also early adopters of new technologies and have lead the way in the development of endoscopic vessel harvesting and ease early surgeon acceptance of other types of endoscopic/minimally invasive therapies The concept has caught the attention of the rest of the world and interest is extremely high Thank You 23