Background: Procedures are often an integral component of a patient’s care plan. Delays in procedures may lead to increased length of stay and decreased quality of care. For instance, prompt paracenteses in hospitalized patients with ascites is associated with a 24% decreased mortality in one study. At our institution, hospital throughput is essential given a consistently high patient census. Poor access to procedures in the outpatient setting can lead to increased hospital visits in an already saturated setting. Interventional radiology is a valuable but highly utilized resource with scheduling constraints. Hospitalists are uniquely positioned to understand the factors that cause delays in transitions of care and those that lead to readmissions.
Purpose: At the outset in 2015, the procedure service was developed for educational purposes in response to fewer resident procedures and decreased attending comfort with supervision. After recognition of the procedure service as a vehicle to bridge gaps in transitions of care, we expanded to the outpatient setting in 2018. Our focus now encompasses efficiency of care, prevention of readmissions, and appropriate utilization of vascular devices.
Description: The procedure service is typically comprised of 1 hospitalist and 1 intern who are available on pager for paracenteses, lumbar punctures, central lines, and ultrasound-guided peripheral IVs. With new availability in the outpatient setting, providers can either schedule an appointment for routine procedures such as a therapeutic paracenteses or use the pager for more time-sensitive matters. For instance, an elderly woman presented to clinic with dehydration without other concerning factors. Her outpatient provider ordered normal saline to be infused in clinic; however, the nurses could not secure an IV. The procedure service was called and placed an ultrasound-guided IV. The patient avoided an emergency room visit and likely admission, returning home an hour later feeling better.
The other arena that has seen more appropriate utilization is decreased use of PICC lines. The procedure service places ultrasound-guided peripheral IVs that can last up to 2 weeks and have lower rates of infection and blood clots. In a survey of 27 hospitalist attendings at our medical center, two-thirds endorsed that the availability of the procedure service prevented at least one PICC line placement in their patients. Seventy-eight percent have recently discharged patients with a peripheral IV for medications.
Conclusions: A hospitalist-run procedure service has multiple advantages for the health care system. It can expedite procedures in the inpatient setting, which may lead to decreased length of stay. In the outpatient setting, it can also prevent delays in care and decrease hospital admissions. In both arenas, it has the potential to increase patient satisfaction and safety by having experienced procedure operators and minimizing delays.