Background: The advent of internal medicine procedure services within academic medical centers has had a profoundly positive impact on patient care, patient safety, and resident training (1-4). In general, these teams focus on performing invasive bedside procedures, including paracenteses, lumbar punctures, central venous catheter placements, thoracenteses, and ultrasound-guided peripheral intravenous catheter placements. Recently, the procedure service at our large academic medical center expanded to the outpatient setting and began collaborating with the hematology oncology department. Through this innovative, multi-disciplinary partnership, the procedure service is now securing appropriate vascular access for a wide variety of patients including those undergoing Chimeric Antigen Receptor (CAR) T-cell therapy, stem cell transplantation, and stem cell donation.

Purpose: The procedure team receives new inpatient consults daily via a pager system, which allows for more flexible scheduling. With the expansion of the procedure service to assist outpatients with temporary apheresis catheter placements for CAR T-cell therapy, the goal was to expedite care for patients while also increasing the training and supervision of central venous catheter placements for residents.  The purpose of this study was to assess the safety and efficiency of femoral apheresis catheter procedures performed by the procedure service in outpatients undergoing apheresis for CAR T-cell therapy or stem cell donation.

Description: The primary endpoint was procedure service complication rate, and the secondary endpoint was procedure wait times. Forty-three consecutive patients undergoing procedures by the procedure team were compared with 17 patients referred to interventional radiology before this partnership took place (Figure 1). At 30 days post-procedure, there were no major complications, and only 1 minor complication, a small hematoma at the access site, in the procedure team cohort. The mean wait time for a procedure was decreased compared with patients referred to interventional radiology (7.6 versus 14.8 days, p=0.041).

Conclusions: The primary aim of our quality improvement study was to examine the safety of placement of temporary non-tunneled apheresis catheters under the supervision of trained hospitalists at a teaching hospital. Apheresis catheters are larger caliber than triple lumen catheters and thus theoretically more prone to complications, although there is not robust literature to support this. One meta-analysis that included large bore catheters used for hemodialysis, not apheresis, revealed a higher rate of catheter-associated blood stream infections in non-tunneled hemodialysis catheter group when compared to the non-tunneled non-hemodialysis central line group (5). Given the possible increased risk for complications with the larger hemodialysis catheter, our medical center recently separated central line from hemodialysis line privileges for both internal medicine attendings and residents. Our study revealed a minimal complication rate for apheresis line placements by a hospitalist-run procedure team. A limitation of our study is a small sample size, but our initial data is encouraging.

IMAGE 1: Figure 1. Workflow for patients undergoing apheresis catheter placement and removal. Those referred to interventional radiology had longer wait times compared with those referred to the procedure service (7.6 versus 14.8 days, p=0.041).