Background: The American Board of Internal Medicine expects all general internists to be competent, at least “with regard to their knowledge and understanding,” in bedside paracentesis, thoracentesis, central venous catheterization, and lumbar puncture, among other less invasive procedures. Unfortunately, increasing patient loads with a focus on efficiency caused a shift away from our hospitalist group performing these bedside procedures and an increase in referrals to interventional radiology. As a result, hospitalist attendings became less facile in performing procedures and thus less comfortable supervising and teaching trainees. This perpetuated a cycle of decreasing procedural experience and increasing procedural discomfort from the top down.
Purpose: Our objective in creating a hospitalist-led Medicine Procedure Service (MPS) was to increase the number of resident-performed, attending-supervised invasive bedside procedures in order to ensure resident competency while keeping patient safety the main priority.
Description: The University of North Carolina Healthcare System is a large academic hospital with two general medicine inpatient services and seven subspecialty medicine services. The MPS was established in January 2014 and consists of a core group of hospitalist attendings that are proficient in ultrasound-guided procedures and an upper level internal medicine resident. The MPS is available to supervise and teach procedures for all inpatient medicine services seven days a week. The MPS also follows up with the patient after the procedure to assess for possible complications and provide appropriate treatment.
We searched current procedural terminology (CPT) codes for paracentesis, thoracentesis, non-tunneled central venous catheterization, and lumbar puncture and compared billing data from 2013 to billing data since the inception of the MPS (January 2014 to September 2015). Even without data from the last quarter of 2015, the total number of supervised procedures increased almost 10 times: from 136 in 2013 to over 1200 since 2014.
Each procedure is reviewed by the director of the MPS for purposes of quality improvement and patient safety. Our complication rates compare favorably to complication rates in the existing literature for resident-performed procedures.
Conclusions: In almost 2 years since the creation of a hospitalist-led Medicine Procedure Service, the number of procedures performed by internal medicine residents and supervised by an attending physician has increased by nearly an order of magnitude. Along with an increase in experience and revenue, the MPS has enhanced resident education by implementing a bedside ultrasound curriculum and standardizing the evaluation of resident procedural competency. Further work and evaluation of the MPS will focus on quality improvement and patient safety, specifically in evaluating and decreasing complication rates.