Background: While many physicians graduate from residency with competency to perform bedside procedures such as lumbar punctures (LPs) and paracentesis, the skillset often wanes after years in practice. Though a dedicated procedure service with full-time equivalent support may be a solution in settings where hospitalists need to perform numerous procedures per day, at our large urban academic institution specialty teams perform most bedside procedures. Our hospitalist group is responsible for LPs and paracenteses at a rate of 2.3 procedures per week. This number of procedures did not create enough demand to establish an entire procedure service and yet many of our hospitalists no longer felt comfortable performing these infrequent procedures. We thus devised an innovative and cost-effective procedure team to handle the smaller volume of procedures and maintain a high degree of competence and safety.
Purpose: Create a cost-effective model to address the need for the low volume of LPs and paracenteses on a hospitalist service.
Description: The needs assessment survey was administered to 50 members in our hospitalist group with 26 responses. Most respondents indicated that during residency, they achieved competency in both LPs (81%) and paracenteses (92%). However, far fewer hospitalists felt comfortable doing these procedures unsupervised at the current time, with only 26% reporting comfort with LPs and 58% with paracenteses. Among 16 hospitalists with 4+ years of experience, 0% felt comfortable completing an unsupervised LP and 56% felt comfortable completing an unsupervised paracentesis, indicating that comfort with LP in particular waned with years from residency.We established an On-call Procedure Team (OPT) comprising five full-time hospitalists to perform LPs and paracenteses. These hospitalists were given a small financial stipend of $10,000 annually to train up expertise in these procedures and be available on an on-call basis to perform these procedures. The OPT members were available while continuing to see their full patient panels. Other members of the hospitalist group contact the OPT when the need for a procedure arises.The OPT was implemented in April 2023. From implementation until November 17th, the team performed a total of 78 procedures, averaging 2.5 procedures per week. Most of the procedures were LPs (74%), consistent with the comfort level reported in the survey. The OPT was successful for 85% of LP attempts and 4% were traumatic; these rates are consistent with those reported in the literature. Most of the procedures (54%) were requested on a resident teaching team. The OPT provided supervision of 27 different residents on the procedures.
Conclusions: For a hospitalist service with a low-volume demand for bedside procedures, an on-call team of trained hospitalist proceduralists is a cost-effective solution. Our team of hospitalists are incentivized through a small annual financial stipend, requiring 80-90% less funding than a dedicated full-time procedure team. The focused group of physicians ensures ongoing competency and provided safe procedures with low complication rates. An on-call team is also capable as serving to augment residency programs in procedural training. As the ACGME no longer requires Medicine residents to graduate with specific procedural competencies and as experience with low-demand procedures wanes over years of clinical experience, the need for dedicated hospitalist procedural experts may arise in other hospitalist groups.