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Re-Thinking Robotic Privileges for Major Lung Resection: Departmental Quality Improvement Process Prompting Credentialing Reorganization
Cliff P. Connery1, Faiz Y. Bhora2, Scott Belsley3, Martin Karpeh4.
1St Lukes Roosevelt, Beth Israel, NY, NY, USA, 2St Lukes Roosevelt,, NY, NY, USA, 3St Lukes Roosevelt, NY, NY, USA, 4Beth Israel, NY, NY, USA.
OBJECTIVE:
Robotic assisted thoracic surgery is evolving as an effective modality to employ for thoracic surgery. The robotic system may increase the limited penetrance of video assisted major lung resection for a larger number of surgeons. Optimal patient outcomes demand a close scrutiny of the credentialing process and on-going monitoring of outcomes including potentially important “near misses’ that are sometimes missed by commonly applied database parameters.
METHODS:
A retrospective analysis of our prospectively maintained database patterned on the Society of Thoracic Surgeons (STS) and used for hospital quality improvement (QI) was analyzed. This was compared with data from Morbidity and Mortality conference and other hospital sources. A departmental QI team review with referees from outside the division reviewed 75 cases over approximately 24 months and compared the results to the outcomes of 136 cases performed at the other system site since initiation of the program as well as the relevant outcomes in the published literature
RESULTS:
Our system QI process utilizing STS database parameters identified disparity in lobectomy outcomes between two sites in a major academic medical center. Focused review suggested a higher than average incidence of perioperative bleeding and conversion at one of the two sites using the robot. Results of further intensive review demonstrated that the ability to successfully perform uncomplicated basic robotic assisted procedures did not always translate to safe performance of major lung resection. It was recognized that there are drawbacks to the STS database, other hospital data sources and the surgical morbidity and mortality process in being able to identify potentially important “near misses.”
CONCLUSIONS:
Recommendation was made to revise our previously robust credentialing process to separately privilege major anatomic resection and advanced procedures after successful completion of the basic robotic credentialing, proctoring and supervision process. While patient safety was paramount, sensitivity to the surgical team, concerns regarding the appearance of restraint of trade and state reporting requirements were addressed. An extended period of provisional approval was proposed designed with review of volume, outcomes and appropriateness of robotic usage.
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