By Darryl Weiman, M.D., J.D.

Introduction

The model for taking care of the patient who has had a cardiovascular and/or thoracic procedure is changing. Many hospitals now recognize that the physician directing or co-directing the care of the post-operative cardiothoracic surgical patient should have the knowledge, education, training, and experience to understand the anatomic, developmental, physiologic, and pathophysiologic basis for cardiovascular and pulmonary disease processes. Many universities now believe that this person should be a cardiothoracic surgeon.

Most medical center cardiovascular intensive care units (CVICU) use a multi-disciplinary approach for patient management. They use a hybrid ICU format. Members of the team include critical care nurses, surgeons, cardiologists, pulmonary-critical care, pharmacists, respiratory therapists, social workers, and case managers. The goal of this integrated team is to provide high quality care and minimize adverse events. They all strive for efficient resource management and a seamless patient transition out of the intensive care setting. The one thing this approach lacks is a leader who can oversee the overall management of the patient, especially when the surgeons are focused elsewhere.

The physician taking care of the post-operative cardiac patient should have adequate “hands on” experience in the operative management of such diseases so it is reasonable to have a cardiothoracic surgeon with intensive care experience to lead the multidisciplinary team in the Cardiovascular Intensive Care Unit. This should not result in a turf war as there is a recognized need to have one person oversee the overall care of the individual patient.

Benefits for the Patient

There is no debate that cardiothoracic surgery patients are different from other patients in the intensive care unit. They are generally older, sicker, and frail. Their management has become increasingly complex; even non-operative candidates are undergoing high risk procedures such as (T)rans-catheter Aortic valve replacements (TAVR) and endovascular graft placements in the descending aorta (TEVAR).

More complex tools are being used in the CVICU such as left ventricular assist devices (LVAD) (Intra-aortic balloon pump, Impella, and other LVADs) and vascular access now requires knowledge of Doppler Ultrasound. The knowledge and skills needed to manage these devices is increasing at an exponential rate.

Cardiac arrest in the post-operative cardiac surgical patient shows higher survival rates if the chest is reopened in an expeditious manner. Studies affirm that the chest should be reopened for ventricular fibrillation or ventricular tachycardia that has not responded to 3 DC shocks and amiodarone. Studies have also shown increased survival if the chest is reopened for asystole or severe bradycardia that does not respond to atropine. The chest should also be reopened for pulseless electrical activity (PEA). Cardiac surgeons have the knowledge, experience, and skills needed to open the chest; techniques vary as to the type of closure involved—plates, wires, or a combination of plates and wires.

A study done in 2008 showed that 61% (212/347) of post op coronary revascularization deaths were related to events in the ICU. The reasons given were related to failures of

A CVICU Director, who is a trained surgeon, should be able to intervene and save some of these patients.

A study done at Stanford University recently concluded that “[i]n its first 2 years, the surgeon-led cardiovascular intensive care unit demonstrated comparable outcomes to the traditional cardiovascular intensive care unit with significant improvements in total length of stay, postoperative transfusions in the cardiovascular intensive care unit, and vasopressor use.”2

Other studies support having a cardiothoracic surgeon manage the postoperative care in the intensive care unit. For example, Whitman, et al showed a decreased length of stay and decreased cost of drugs used postoperatively in a CVICU managed with a cardiothoracic surgeon.3

In an editorial, Hisham Sherif argued strongly that the CVICU should be run by surgeons.

“Deficiencies in the broad-based education, abbreviated clinical training and limited skill sets of non-surgeons seriously impair their situational/environmental awareness and processing of information, their decision-making process and the implementation of decisions, as in the proposed ‘emergent resternotomy in the ICU’ protocol—an often challenging situation for experienced CTS surgeons. Therefore, non-surgeons are not properly qualified to be the primary decision- maker in the high-risk environment of cardiothoracic surgical critical care.”4

Use of the Society of Thoracic Surgeons Data Base

The Society of Thoracic Surgeons continues to monitor quality performance measures in the areas of adult cardiac and general thoracic surgery. These measures are being used by the Centers for Medicare and Medicaid Services (CMS) in their Merit-Based Payment System. These measures are also endorsed by the National Quality Forum. A surgeon well-versed in

these measures can help in seeing that these measures are being followed. He can also help with the checklists needed to document that these measures are being met.

Anti-platelet medication at discharge, Beta blockade at discharge and perioperatively, anti-lipid treatment at discharge, and selection and duration of antibiotic prophylaxis are just a few of the examples of the measures being used in the STS data base.

For Medical Centers that participate in the STS Data base, a surgeon directing the CVICU can help make sure the quality measures are being met, and the data is being captured appropriately by the coders.

Cardiac Surgeons as Intensivists

The American Board of Thoracic Surgery (ABTS) has recognized that critical care has always been a core component of ABTS certification. “Our (D)iplomats have been trained in critical care management of thoracic surgical patients and they have successfully completed both written and oral examinations which cover the critical care aspects of surgical patient management”5

In fact, the ABTS will write a letter on behalf of the Diplomat requesting ICU privileges to the specific credentials committee…to affirm the Diplomat is trained to take care of patients in the intensive care unit.6

The cardiac surgeon is uniquely qualified to:

(1) Ensure proper surgical care of chest tubes, surgical wounds, vascular access devices, and placement of invasive lines and tubes (arterial lines, Pulmonary Artery catheters, bladder catheters, nasogastric tubes and endotracheal tubes);

(2) Ensure disease diagnosis and treatment for arrhythmias, blood pressure abnormalities, and bleeding disorders;

(3) Order the proper tests for diagnosis;

(4) Refer to the appropriate specialists as necessary (pulmonary, cardiology, endocrine, infectious disease, other surgical subspecialties);

(5) Institute and monitor order sets which have become best practices (ventilator bundles, sepsis protocols, sedation protocols, line placement protocols, enteral feeding protocols, renal protection protocols);

(6) Provide for needed bedside surgical procedures such as placement of arterial lines, placement of central lines, chest tube insertion, placement of bladder catheters, placement of endotracheal tubes or a surgical airway, and bronchoscopy for diagnosis and treatment.

Education of Nonphysician Providers, Residents, and Medical Students

The director of the CVICU must encourage a culture of continuous quality improvement and continuing medical education. The director must maintain his own fund of knowledge that keeps up with the new advances now on the cutting edge of surgical critical care.

The CVICU director should be the educator of those working in the unit. Critical care training can be improved with daily teaching rounds incorporated into multidisciplinary work rounds. Improvements in physical exams, formation of differential diagnoses, order sets, procedures, and medical management can all be realized. An experienced cardiothoracic surgeon leading those rounds has become standard at many universities (Johns Hopkins, University of Michigan) and this would be a significant step for any medical center looking to maintain its leadership in Cardiac care in its community.

The emphasis on education is essential in nurse training and a surgeon committed to education would be important in both recruiting and retaining those nurses interested in cardiovascular intensive care.

Research Activity in the CVICU

The CVICU is an excellent place to conduct research pertinent to the care of the critically ill surgical patient. Models for the study of myocardial dysfunction, post-operative bleeding, transfusion management, end-organ dysfunction and the potential for studying genomic markers, new devices, and the creation of new databases for data extraction are all areas ripe for focused research; this research can be led by a surgeon with a research background.

Financial Justification for a Surgeon CVICU Director

Besides providing optimal care for the post-operative patient, the cardiothoracic CVICU intensivist can be a financial benefit for the hospital.

Any procedures done can be billed so long as the proper documentation is shown.

The intensivist, who is acting within his scope of practice, can independently report his professional services. There are numerous CPT Codes that can come into play. Examples are as follows:

The above are just some of the areas where the surgeon intensivist can help lessen the workload of the main operative cardiothoracic surgeons.

In summary, endoscopic procedures, procedures on the lungs and pleura (VATS), pericardial procedures, temporary pacemakers, implantation of hemodynamic monitors, extracorporeal membrane oxygenation support devices, central venous and arterial access, are examples of procedures that can be done by the surgeon CVICU intensivist.

The generated billings of the CVICU surgeon director who is seeing patients in consultation can easily meet the costs associated with his salary and benefits. Billing accrued from tests ordered, notes written, and procedures done will further justify this position.

Conclusion

In conclusion, a cardiothoracic surgeon helping manage the CVICU is the “right operator, with the right information, making the right decision to use the right tool to perform the right task at the right time in the right manner.”8

“…[A]dvances have not been in improved hemodynamic monitoring, pharmacologic therapy, or understanding of the pathophysiology of the diseases unique to our patients, but rather improvements in the system of medical care delivery such as checklists and improving teamwork” has led to better results.9

Having a Cardiothoracic surgeon directing the CVICU is the national trend, and the time is right for medical centers that do cardiac and thoracic surgery to take this next step in maintaining surgical excellence in cardiovascular and thoracic care.

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1 Guru V et al. Circulation, 117; 2969-2976, (2008). 2 Choi PS, Pines KC, Swaminathan A, et al. Diversifying cardiac intensive care unit models: Successful example of an operating surgeon led unit. (JTCVS Open 2023; 16, 524-31). 3 Whitman GJR, Haddad M, Hirose H, Allen JG, et al. Cardiothoracic Surgeon Management of Postoperative Cardiac Critical Care. Arch Surg/Vol 146 (No. 11) Nov 2011, 1253-60. 4 Sherif HMF: After-hours coverage of cardiothoracic critical care units by non-surgeons: process and value issues. European Journal of Cardio-Thoracic Surgery 46 (2014) 507. 5 Baumgartner W, Calhoon JH, Shemin RJ, Allen MS: Critical care: American Board of Thoracic Surgery update. The Journal of Thoracic and Cardiovascular Surgery, 145(6), 1448-9, (2013). 6 Id. 7 CPT 2024 Professional Edition. 8 Sharif HMF. Developing a curriculum for cardiothoracic surgical critical care: impetus and goals. Journal of Thoracic and Cardiovascular Surgery, 143(4), 804-8, (2012). 9 Shake JG, Pronovost PJ, Whitman G. Cardiac surgical ICU care: eliminating “preventable” complications. Journal of Cardiac Surgery, 28(4), 406-13, (2013).