DUKE SURGERY 2017 ANNUAL REPORT
CONTENT
2
4
Patient Care
8
Research
14
Education
18
Community Impact
20
Global Initiatives
22
Giving
WELCOME TO DUKE SURGERY Over the last 87 years, the Duke Department of Surgery has dedicated itself to providing unparalleled clinical care, conducting pioneering research, and training the next generation of leaders in clinical and academic surgery. These goals have been approached with a sense of unity: as a department, as a member of the Duke Health System, and increasingly, as a member of a global medical community. We recognize that being “United” does not imply being insular, but rather acknowledges the critical role that surgeons play in the broad tapestry of modern science and healthcare. We are united as a department, so that we can unite collaboratively across the spectrum of care, discovery, insight, and innovation that has defined Duke University’s rich history. In 2017, Duke surgeons performed tens of thousands of surgical procedures across the twelve divisions of the department, maintaining unprecedented quality in the face of increasing patient acuity. Our surgeons are a major driver of Duke’s perennial presence on the U.S. News & World Report honor roll of best hospitals. Outside of the operating room, our faculty and trainees have formed rich collaborations across the University and with institutions across the globe to conduct groundbreaking research, with more than 500 peer-reviewed research articles published each year. In December 2017, the department held 367 active grants, with over $62 million in external clinical and basic research funding. I am pleased to present this annual report, so that you can learn more about our dedication and unity, for all patients: those who come to Duke for care, and through our education, discovery and innovation, future patients around the world.
Allan D. Kirk, MD, PhD, FACS David C. Sabiston, Jr. Distinguished Professor and Chairman Department of Surgery, Duke University School of Medicine Surgeon-in-Chief, Duke University Health System
Allan D. Kirk, MD, PhD, FACS
We l co me to DUKE SURGERY
3
CONTINUING IMPROVEMENTS IN PATIENT CARE With over 31,000 operating room surgeries performed by the Department of Surgery and 72,000 performed by all surgical departments in 2017, the Department’s vision statement remained paramount: United, for all patients. Through expansions, new initiatives, and novel research, Duke Surgery continued to find innovative ways to improve patient care. 4
transdepartmental Hand Division, consolidating faculty expertise. The first hand transplant in North Carolina was performed at Duke in June 2016.
• The Private Diagnostic Clinic formed the APP First Assist Program in December 2016, which includes fulltime, part-time, and per diem APPs with 45 years of combined experience across the following specialties: robotics, orthopedics, neurosurgery, plastics, general surgery, surgical oncology, urology, and trauma.
• Duke Children’s Surgery received Level 1 designation for high-quality pediatric care, one of only 5 centers in the nation.
• Despite an increase in the major metric indicating patient acuity over the last three years, the mortality index decreased over the same period. While serving sicker patients, outcomes have improved.
• The Division of Emergency Medicine enacted several initiatives of care, including a revised upfront process. The division also developed an Emergency General Surgery registry of patients.
• Duke Surgery combined with the Duke Orthopeadic Surgery in May 2017 to form a novel
• The Surgical Intensive Care Unit expanded capacity with the opening of 8 surgical critical care beds.
SURGICAL
OPERATING ROOM 31,394 VOLUME
27,032 2,427
4,163
3,138
Duke Regional Hospital
5,252
Duke Raleigh Hospital
27,197 2,326
4,632 Duke University Hospital
23,004 20,442
FY ‘15
• The liver transplant team performed 98 transplants in one year, the highest on record at Duke. Adult liver transplant patients at Duke have the best outcomes nationwide according to data from the Scientific Registry of Transplant Recipients. • Duke’s cardiothoracic program became the highest performing site in the Cardiothoracic Surgical Trials Network, enrolling the highest number of patients in the LVAD Cell Therapy II Trial and the second highest number in the Tricuspid Valve Repair During Mitral Surgery Study. Photo: Jacob A. Klapper, MD, leads lung transplant team during surgery.
20,239
FY ‘16
FY ‘17
LIVER AND LUNG TRANSPLANT PROGRAMS Duke’s transplant programs continue to receive national recognition for efficiency and best outcomes. Patients at Duke move off of the liver transplant wait list 2.5 times faster than the national average.
120
2.5
14
DAYS
DAYS
NATIONAL AVERAGE
DUKE
FASTER AT DUKE
Average number of days on wait list prior to lung transplant
Comparison of Duke Liver transplant wait list to national average
U n it e d in PATIENT CARE
5
THE PATIENT EXPERIENCE The Department’s Balanced Scorecard reports data from patient and clinician surveys, including the CAHPSŽ Clinician & Group Survey (CG-CAHPS) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). These metrics showed improvements in several areas during 2017, including appointment scheduling, physician communication, phone calls answered within 30 seconds, and overall hospital rating. 6
Photo: Duke women surgeons participate in the New Yorker Cover Challenge, to raise awareness about women in medicine.
8.3 8.3
The Surgery Access Center worked to avoid abandoned patient calls for appointment scheduling.
Values demonstrate percentage of patient calls not answered
Partnership to elevate performance
7.7
7.6
6.7 7.0
5.8
5.2
3.1 7/16 8/16 9/16 10/16 11/16 12/16 1/17
NSQIP REPORT NATIONAL SURGICAL QUALITY IMPROVEMENT PRORGAM
PECTED
SURGICAL SITE INFECTIONS
AS
EX
PECTED
RENAL FAILURE
PNUEMONIA
EX E MPL
EX
PECTED
Y
AS
PECTED
EX E MPL
PECTED
AR
EX
URINARY TRACT INFECTIONS
EX
Y
Y
MORTALITY
The American College of Surgeons recognized Duke University Hospital in October 2017 as one of 66 ACS NSQIP-participating hospitals nationwide to achieve meritorious outcomes for surgical patient care. The following 8 areas determined the high rankings.
AS
EX
2/17 3/17 4/17 5/17 6/17
AR
AR
AS
EX E MPL
2.5
3.2 3.5
AS
SURGERY ACCESS CENTER
UNPLANNED INTUBATION
VENTILATOR > 48 HOURS
CARDIAC
U n it e d in PATIENT CARE
7
NOVEL SURGICAL PROCEDURES IN 2017 High-Intensity Focused Ultrasound (HIFU) HIFU is a non-invasive outtreatment therapy using ultrasound technology for prostrate ablation. Twenty-seven patients were treated at Duke during a national trial beginning in October 2016.
Left Ventricular Assist Device (LVAD) While LVADs are frequently used as a shortterm solution for heart failure and a bridge to transplant, researchers Carmelo Milano, MD, and Joseph Rogers, MD, found that a new centrifugal-flow device reduces the need for pump replacement due to blood clotting, and could serve as a longer-term solution for patients with advanced heart failure.
Cloud-Based 3D Imaging for Endovascular Aneurysm Repair Duke vascular surgeons introduced novel 3D imaging in a technique that fuses computed tomography (CT) images with live fluoroscopic images taken during a surgical procedure, giving surgeons a visual road map to help guide stentgraft insertion. The technology, developed by CYDAR Medical in the United Kingdom, can be used to treat endovascular aneurysm. X-ray image without a 3D CT overlay.
8
X-ray image with a 3D CT overlay.
Jeffrey Lawson, PhD, left, implants the first bioengineered blood vessel in a patient.
RESEARCH LEADS TO INNOVATION Bioengineered Blood Vessels Partnering with Yale University, Duke researchers created man-made blood vessels that have proven to be safe and more durable than commonly used synthetic versions, and present little risk of rejection from the recipient. Photo: Duke surgeons implant a bioengineered blood vessel in a kidney dialysis patient. Credit: Shawn Rocco, Duke Health News
3-D Imaging Ultrasound Using an inexpensive microchip commonly used to track orientation in cellphones, Joshua Broder, MD, created point-of-care ultrasound devices that can be used to create images similar to those of a CT scan or MRI. Researchers at Duke and Stanford tested the new technology in clinical trials for use in emergency medicine. Photo: Joshua Broder, MD, demonstrates the upgraded ultrasound device. U n it e d in RESEARCH
9
BLUE RIDGE INSTITUTE FOR MEDICAL RESEARCH RANKING OF NIH FUNDING
With $14.2 million in NIH funding in 2015, Duke University Medical Center placed 5th in the rankings, and rose to 3rd in the 2016 rankings The increase is a testament to our faculty’s commitment to research and discovery. Researchers often rely on smaller donations to pave the groundwork needed to begin the process of applying for grants from the NIH. Faculty are supported by the Surgery Research Development team, who provides guidance in development, editing, and submission of grant proposals.
Institution
2016
Funding is an essential component to effective research. The Blue Ridge Institute for Medical Research measures funding from the National Institutes of Health (NIH).
Funding
1
University of Pennsylvania
$19,621,244
2
Washington University
$19,280,840
3
Duke University
4
University of Michigan
$16,531,254
5
University of Pittsburgh
$15,586,617
6
University of California, SF
$14,299,884
$16,546,762
DECADES OF MILESTONES
1956
Duke becomes first institution to use systemic hypothermia during cardiac surgery.
J. Deryl Hart, MD, introduces sterile lamps into operating rooms to kill airborne germs.
Duke becomes one of the first institutions in the country to perform a kidney transplant.
1936
1965
10
TOTAL AWARDS FOR PRIMARY APPOINTMENT 2012 – 2017
$60m
Total external funding in FY’ 17 totaled over $62 million dollars, combining federal and nonfederal dollars.
$50m
Duke Surgery researchers remain at the forefront of national clinical trials, offering advanced treatment options to patients and using the latest technology.
$40m $30m
Federal Dollars
$20m
Non-Federal Dollars
$10m
FY ‘12
FY ‘13
FY ‘14
1969
FY ‘15
FY ‘16
FY ‘17
1984
Duke orthopedic surgeon performs first total hip replacement in the South.
Duke physicians perform first liver transplant in the state of North Carolina.
Duke surgeons are first to reattach a severed thumb more than 8 hours after injury.
1972 U n it e d in RESEARCH
11
CLINICAL TRIAL ENROLLMENT BY FISCAL YEAR
434
TOTAL NUMBER OF PATIENTS
279 248
Clinical trial enrollment in the department has continued to increase over the last three years. Several trials received recognition for being the highest enrolling sites in the nation, including the OrganOX Liver Transplant trial, which used a perfusion device to keep a donor’s liver functioning before being transplanted.
200 171 153
140
2017
115
164
172
122
92
2016 2015 JULY – SEPT
OCT – DEC
JAN – MAR
APR – JUN
MAJOR RESEARCH PROJECTS RANKED BY PROJECT COST Faculty
Research Project
Project Cost
David Montefiori, PhD
“Comprehensive Antibody Vaccine Immune Monitoring Consortium” HIV Vaccine Research
$32.6m
Charles Scales Jr., MD
“Urinary Stone Disease Research Network: Scientific Data Research Center” (NIH U01)
$5.6m
“Breast Cancer Detection Consortium” (NIH U01)
$3.1m
“Translational Research in Surgical Oncology” (NIH T32)
$2.1m
Jeffrey Marks, PhD H Kim Lyerly, MD Shelley Hwang, MD David Harpole Jr., MD John Stewart IV, MD 12
DUKE SURGERY RESEARCH • An internationally recognized leader in laboratory and clinical investigation, the Duke Department of Surgery has been among the top 10 institutions in NIH funding for 25 consecutive years. • The Department currently has 367 active grants and contracts with $62,600,000 in external funding. • The Department sponsors several Shared Resources for the Duke research community, including the Core for Microsurgery, the Duke Human Heart Repository, the Duke Immune Profiling Core, the Large Animal Resources Division of Animal Research and Training Core, and the Substrate Services Core Research Support. • In FY ‘17, faculty published 516 articles in peer-reviewed journals, including 33 (6.4%) in high-impact factor journals. • The Surgical Center for Outcomes Research (SCORES) team is a novel, transdisciplinary effort that promotes excellence in research for various surgical patient populations. Duke SCORES serves as a hub for education, research, mentorship, and resources for trainees and faculty. • Two Duke Surgery faculty members, Georgia Tomaras, PhD, and David Montefiori, PhD, made the list of the top 1% of the world’s most cited researchers, data provided by Clarivate Analytics.
Julie Thacker, MD
U n it e d in RESEARCH
13
EDUCATION
BY THE NUMBERS GENERAL SURGERY RESIDENTS
64
GENERAL SURGERY FELLOWS
16
FACULTY IN ALL DIVISIONS
RATIO OF FULL-TIME FACULTY TO RESIDENTS AND FELLOWS
PERCENT OF FACULTY TRAINED AT DUKE 14
249
2.1:1
__
CONTINUAL IMPROVEMENT IN ABSITE ® SCORES The American Board of Surgery offers an Annual In-Training Examination (ABSITE®), a multiple-choice exam measuring residents’ progress in knowledge of applied science and management of clinical problems related to surgery. Duke Surgery resident’s average scaled scores have increased on the exam for the last 4 years.
DUKE SURGERY EDUCATION As an academic and research-oriented institution, Duke Surgery continues to create an environment promotive of learning. Through its 9 residency programs and 12 fellowship programs, trainees are offered opportunities for advanced training and research. Endowed Professorships Professorships allow the department to recruit, retain, and reward exceptional faculty members by offering resources, recognition, and prestige, while providing the support that will allow the completion of cutting-edge research, provision of excellent patient care, and mentorship of surgical residents and fellows. Duke Surgery currently holds 14 endowed professorships and relies on donor support to fund the program. Surgery Technique and Review (STAR) Course
STAR Course Interns practice in the Human Fresh Tissue Laboratory.
2014 2015 2016 2017
A new 2-week elective for third- and fourth-year medical students offers hands-on medical training. Studies indicate that graduating medical students often feel that they lack the confidence that comes from experience as they start their residency. While problem solving and responding to mock scenarios, the students also train in the Human Fresh Tissue Laboratory.
60.48 63.85 65.62 71.60 U n it e d in EDUCATION
15
EDUCATIONAL LABORATORIES Duke Surgery offers a world-class educational experience for its trainees through use of its educational laboratories. All feature state-of-the-art technology used in a variety of disciplines. Surgical Education and Activities Lab (SEAL)
Human Fresh Tissue Laboratory
A simulation center designed to provide advanced and innovative training in a risk-free environment. Simulation training provides learners the opportunity to develop skills and practice minimally invasive procedures without the pressures of the operating room to advance medical education and improve patient safety.
The Duke Human Fresh Tissue Laboratory is a medical skills lab where residents, attending physicians, and medical students can perform advanced surgical training on fresh tissue. The lab has been used to provide training to medical professionals from Duke and throughout the country since 1997.
Duke Vivarium A key component of the Duke Animal Care and Use Program is the Surgical Pavilion that consists of four operating rooms as well as rooms for surgical preparation, anesthetic monitoring, post-operative recovery and surgical instrument processing.
3D Printing Lab The Duke 3D Printing Lab offers unique research and educational experiences for surgical trainees. Printers can be accessed remotely via an online project queue. Physicians can use the access an ordering system to have models printed in the studio.
DECADES OF MILESTONES
1993
The first antiretroviral drug therapy for HIV is developed by a research team at Duke.
Duke physicians perform the first lung transplant and first heart/ lung transplant in hospital history.
Duke Urology surgeons perform the first robotic prostatectomy in the state of North Carolina.
1992
2003
16
PHYSICIAN ASSISTANT SURGICAL RESIDENCY PROGRAM
CELEBRATING
50
YRS
OF TRAINING
Patient care Practice-based learning Communication skills Medical knowledge Systems-based practice Professionalism
Duke’s 3D Printing Lab
2013
2016
Duke surgeons begin first-ever trial utilizing a bioengineered blood vessel.
Duke surgeons perform first hand transplant in the state of North Carolina.
Duke Heart Transplant team performs 1000 th heart transplant at Duke.
2014 U n it e d in EDUCATION
17
COMMUNITY PARTNERSHIPS Through partnerships across Duke University Medical Center, in Durham, and across the state of North Carolina, the Department seeks to impact its local community through several focused initiatives.
ASSET Program and Durham Nativity School The Department of Surgery has partnered with the Durham Nativity School to provide surgical skills and simluation workshops as part of the Academic Success Through Surgical Education and Training (ASSET) program. This program aims to foster high achievement in science through surgical education for financially disadvantaged students at the school. In November 2017, the students participated in a “Be a Surgeon” workshop, pictured above. Pretty in Pink Foundation Started by Lisa Tolnitch, MD, the Pretty in Pink Foundation was founded with the mission to provide financial assistance for quality, life-saving treatment to uninsured and under-insured breast cancer patients in North Carolina. In 2017, the foundation awarded grants to 88 breast cancer patients, 20% with no insurance coverage. Health Career Academy The City of Medicine Academy in Durham is a magnet school for 400 high school students committed to careers in the medical field, many of low socioeconomic status. Duke Surgery medical students and faculty partner with the academy to teach weekly classes.
STRENGHTENING INTERNAL & EXTERNAL COMMUNCIATIONS
18
The Department worked to improve internal and external communications through several initiatives in 2016–2017, including a redesign of the website and the expansion of the Department’s Office of Publications & Communications, which provides faculty and staff support and furthers the Duke Surgery brand.
The newly designed Duke Surgery website saw a 220% increase in traffic in 2017 compared to 2016, offering the public a clearer picture of what happens inside the Department.
DUKE SURGERY CLINICS EXPANDING OUR REGIONAL REACH New expansions since 2012 Planned expansions by 2022
Duke Surgery maintains an open line of communication with patients and the public through its social media accounts. Active posting increased audience by 29% in 2017. Patients use the site to write reviews and to receive news alerts related to the Department.
Twitter holds a stronger academic audience of alumni and other medical professionals. A measurement of “impressions� (the number of post views on Twitter) showed a monthly audience increase of 21% in 2017.
In 2017, the communications team assisted faculty and staff with over 200 major projects, including medical illustration, news reporting, graphic design, and publications.
U n it e d w it h o ur LOCAL COMMUNITY
19
ALASKA Susan Emmett, MD, studies hearing loss in remote Alaskan villages, and uses new cellphone-based technology for screening of hearing loss.
GLOBAL INITIATIVES Across the globe, the Department of Surgery continues its mission of learning about patient health and disease, empowering patients and physicians with knowledge, and providing safe and high-quality care. Starting in Durham at Duke, fellowship and training programs help to bridge the gap for physicians and trainees from other countries where specialty and advanced training is not always available. These programs have offered Safety and Quality training to physicians from Guatemala, otolaryngology training for specialists from Israel, and training in advanced thoracic surgery techniques for physicians from China, to name a few. Exchange programs, such as the partnership between Duke and Singapore Medical Center, allow Duke physicians to train with a global mindset and work with different patient populations.
20
GUATEMALA Henry Rice, MD, works with physicians at Roosevelt Hospital to begin a Safety and Quality Training Fellowship. The first two fellows are trained at Duke in September 2017.
BRAZIL Catherine Staton, MD, analyzes public data sets in order to develop an understanding of health disparates between different socioeconomic settings, and how public policy impacts health.
JERUSALEM Duke co-sponsors first ENT Global Health Symposium with Hadassah Medical Center in July 2017, the first medical conference organized by two hospitals in separate countries. David M. Kaylie, MD, began the initial partnership.
CHINA Thomas D’Amico, MD, teaches minimally invasive thoracic surgery techniques to treat lung and esophageal cancer to surgeons at universities throughout the country. Dana Portenier, MD, and the Weight Loss Division begins partnership with Shanghai Pudong Hospital to create a weight loss center providing bariatric surgery to patients.
UGANDA Tamara Fitzgerald, MD, works to improve pediatric surgical care in an area where in 2013 there was only 1 pediatric surgeon for 39 million people.
SINGAPORE Duke partners with Singapore General Hospital to form the Duke–National University of Singapore Medical School, along with a resident exchange program.
U n it e d w it h o ur GLOBAL COMMUNITY
21
GIVING TO DUKE SURGERY A gift to the Department of Surgery is a gift of knowledge, discovery, and life.
Division of Surgery
The continued success of Duke Surgery is highly dependent upon the generous support of its alumni and friends.
Abdominal Transplant Surgery
3
Advanced Oncologic and Gastrointestinal Surgery
17
Your gifts benefit the department’s tripartite mission of providing world-class patient care, training the world’s best and brightest surgeons to serve future generations, and the discovery of new techniques, technology, and treatments to improve the health of all through creative innovation and cutting-edge research.
Cardiovascular and Thoracic Surgery
13
Emergency Medicine
12
Head and Neck Surgery & Communication Sciences
20
Metabolic and Weight Loss Surgery
4
Pediatric General Surgery
1
Plastic, Maxillofacial, and Oral Surgery
71
Surgical Sciences
1
Trauma and Critical Care Surgery
12
Urology
65
Vascular and Endovascular Surgery
1
Your gift to the Department of Surgery will support: • Novel Advances in Patient Care • Endowed Professorships • Resident and Fellow Education • Cutting-Edge Research
Your gift, no matter the size, will make an immediate difference.
Total
To donate to Duke Surgery or for more information, please contact: Marcia Romary Senior Director of Development Department of Surgery 710 W. Main St., Suite 200 Durham, NC 27701 919-385-0051 office marcia.romary@duke.edu 22
Donors in 2017
283
Thank you to all of our previous donors for supporting our mission.
MISSION
VISION
Through sustainable, multidisciplinary teams we:
Duke Surgery: United, for All Patients
1 2 3
Provide insight regarding the fundamental nature of patient health and disease
Empower all patients, trainees, and colleagues with knowledge
Provide safe and high-quality care based on an advanced understanding of and respect for our patients’ needs and guided by best practices
Department of Surgery DUMC 3704 Durham, NC 27710 4017669
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