It's time for internal medicine to think about taking back bedside procedures, Joshua D. Lenchus, DO, FACP, told attendees at Hospital Medicine 2015, held in National Harbor, Md., in March.
“A lot of us have decided that it's probably not viable anymore to give it to other people, but for us to reclaim the territory that we once abdicated,” he said. “Sending somebody to IR [interventional radiology] may get the procedure done, but that's an incredible waste of resources. We waste their technical skill and expertise and add an additional facility fee, and ... may increase a patient's length of stay.”
During the session, Dr. Lenchus and some of his colleagues explained how they've launched procedure services staffed by hospitalists and/or medicine trainees at different hospitals around the country.
The services perform a variety of procedures, with paracentesis, thoracentesis, and placement of central lines being among the most common, in addition to lumbar puncture, chest tube placement, and arthrocentesis.
The procedure service leaders also cited varying motivations for starting their services, not just the efficiency reasons listed by Dr. Lenchus, but also patient safety, education of trainees, prevention of admissions, and even profit.
Clarifying why to have a procedure service is the first step toward getting one, advised Nilam J. Soni, MD, FACP, who co-led the session and is an associate professor of medicine at the University of Texas Health Science Center at San Antonio.
“Is the mission to educate the residents? Is the mission to expedite care of hospitalized patients? Is the mission to offload IR?” he asked. “You'll definitely want to establish these goals and have them written out before you start.”
The goals should also be measurable, in both the short and long term. For example, it might not take long to show that you're expediting procedures, but proving that a service made procedures safer would require longer-term data. “With ultrasound guidance, in the hands of competent faculty, complication rates are less than 1% or 2% for paracentesis. It's going to take you several thousand patients to show that you have reduced that,” said Dr. Soni.
Proving the service's value will also be easier down the road if you can gather some statistics on procedures before implementation. “If you're not under pressure to launch this immediately and you can gather some baseline data, that would be the best,” Dr. Soni said. “That way at the end of the year, or the end of 2 years, you can show we reduced this by x%.”
A new procedure service may also have to work with hospital administration on credentialing. “They may say, ‘We want you to show us 5 [procedures]. We want you to attend this course,’” said Dr. Soni.
Such courses are offered at medical society meetings and workshops, such as ACP's Internal Medicine Meeting and events held by the Society of Hospital Medicine, the American College of Chest Physicians, and the Society of Critical Care Medicine, among others. “This is a great starter, but then you need to go home and practice,” said Dr. Soni.
Back at your hospital, it'd be ideal to get colleagues with procedure expertise, possibly from critical care or IR, to help. “The best training you're going to get is going to be hands-on at home using the kits and ultrasound machine you have in your home environment,” said Dr. Soni.
Hospitalists might expect the physicians who currently do these procedures to be opposed to a new service, but specialists could be receptive, if they're very busy and you broach the idea carefully. “See what kind of procedures they're more interested in doing and entice them, saying, ‘Hey, we can take the easy stuff from you and let you focus on the more fun stuff that you guys like to do,’” said Gerard Salame, MD, director of the procedure team at Denver Health and one of the session's panelists.
Finding training, equipment
Private education companies and equipment manufacturers may also offer training, although it's wise to get experienced participants' evaluations of these offerings before signing up, Dr. Soni advised.
Procedure training should involve simulation and direct supervision, and programs should further ensure patient safety by use of ultrasounds and checklists, Dr. Lenchus noted.
Every procedure service will have to acquire a portable ultrasound. “The cost is going to be somewhere between $30,000 to $60,000,” said Dr. Soni. “That should be bought and maintained by the hospital. It shouldn't be bought by you or your group.”
The procedure service cart should also have a portable computer and supply kits. Make sure the supplies are optimal, not just the default. “Atraumatic needles are a great example,” said Dr. Soni. “In our procedure kits for lumbar punctures, they mostly have traumatic needles. You have to go and find those [atraumatic] needles. Your hospital definitely carries them.”
The capability to archive ultrasound images is also important, especially for reimbursement. “It's good just from a clinical practice standpoint to have the images ..., but if you're billing you definitely need to have those images archived,” Dr. Soni said.
Paying for it
Understanding the financial complexities of performing procedures is critical to making a service successful.
The procedures themselves are not that highly reimbursed, but performing them safely can be a big money saver for hospitals, according to Dr. Soni. “On the pro fee side, you might get $20, $30, $60, $120, maybe $200, but if you reduce 1 complication, now you're talking $20,000 to $50,000,” he said.
At the University of Miami, where Dr. Lenchus is an associate professor of medicine and anesthesiology, the procedure service recently evaluated its value by tallying pneumothoraxes during thoracentesis.
“The hospital was on par with the national average of about 6%. Our rate was under 2%,” said Dr. Lenchus. “You're talking about saving the hospital over a million dollars if the procedure team had done all of those thoracenteses, just in terms of saving money from hospitalization, increased length of stay, and morbidity or mortality costs.” Hospitalists who perform procedures in the emergency department can also save costs by preventing admissions, the speakers noted.
These benefits could inspire hospital administration to financially support a procedure service. There are also grants available, from private foundations or government agencies. “Our program was funded through the VA [Veterans Affairs]. The VA has a lot of interest in this,” said Dr. Soni.
Providing a consult at the time of the procedure can increase the profitability of the service. “Many times we go to see a patient and we actually don't do a procedure, but we did spend an hour of time, seeing them, reviewing the labs, doing an ultrasound, and we go back to the team and say, ‘Hey, there's not enough fluid or there's no fluid,’” said Dr. Soni. “If we don't bill for a consult, we'd lose that reimbursement.”
Hospitalists can also bill for a consult when they perform a procedure, as long as the patient has not already been seen by a clinician from the same practice. “A consult is something you can legitimately do,” said Dr. Lenchus. “You do the whole history and physical. You look at the chart. You look at the labs and all this stuff, medical decision making, and then you're going to assess whether or not to do the procedure.”
Adding a consult significantly increases the relative value units and the Medicare allowable charges for a procedure, he added. Patients referred to a hospital medicine department's procedure service from any other department—not just surgery, for example, but general medicine—are eligible for a consult. “We could create a division of procedural medicine and then I could consult on everybody,” Dr. Lenchus said.
Once a procedure service opens for business, prepare to be busy, the experts advised. “If you build it, they will call,” said Dr. Soni.
Panelists during the session described a variety of different tasks that had come to their services. “Our procedure service started back in 2007 after a sentinel event,” said David Lichtman, PA, director of the service at Johns Hopkins in Baltimore. The service is now called to inpatient and outpatient departments for routine procedures and tricky tasks like treating thrombocytopenic patients or ICU patients who are too sick to be moved.
In Miami, the service has taken on a major role in procedure education. “Believe it or not, we teach the neurologists how to do lumbar punctures. We teach anesthesiologists and surgeons how to put lines in, nephrologists how to put hemodialysis catheters in,” said Dr. Lenchus.
Expansion is a good thing, but keep an eye on your service's capacity, advised Dr. Soni. “You have to be very realistic about what you can do and how much time you're being given to do this,” he said.
If a procedure service is very busy and has been successfully meeting the goals set at the start, it may be possible to gain additional funding and staff. “Go back and look at the numbers, make sure you're on track,” said Dr. Soni. “You may achieve your goals at 6 months, and that may give you enough power to go back to your hospital to ask for more resources, more faculty time, another ultrasound machine, whatever you need.”