Published in the November 2007 issue of Today’s Hospitalist
Editor’s note: This is the second in a series of profiles on hospitalist groups that have launched new services. In this month’s issue, we highlight a hospitalist practice that has taken on a menu of more than a dozen procedures.
GROUP: Hospitalists at Cedars-Sinai Medical Center
LOCATION: Los Angeles
NEW SERVICES: Bedside procedures and a dedicated procedure center
The hospitalist-staffed procedure center at Cedars- Sinai Medical Center in Los Angeles is hardly new. After all, it has grown in tandem with the academic hospitalist service, which was established in the 1990s.
What is new, however, is the center’s rapid and continual evolution. Starting with only a handful of PICCs a week in 1990, the center now performs more than 5,500 procedures a year.
“Our service almost preceded hospitalists in a sense, but we have added several procedures over the years and our volume is increasing all the time,” says assistant director Bradley Rosen, MD, MBA, who also is medical director of Cedars-Sinai’s non-teaching hospitalist service.
The proceduralists perform more than a dozen different procedures, many of which internists do rarely and specialists do only reluctantly.
The group’s mainstays are PICCs (now 2,200 a year), paracenteses and thoracenteses, but proceduralists also do more than 700 central lines a year and about 300 lumbar punctures. Other frequently performed procedures include peripheral access system ports, percutaneous tracheostomies, tunneled catheters and bone marrow biopsies.
Dr. Rosen ticks off the center’s many benefits. For one, the service is able to schedule and complete procedures much faster than subspecialists typically can. That is a big plus for referring physicians “and for the hospital, because timely procedures translate into earlier discharges.
Dr. Rosen recalls that before the center was launched, patients might wait as long as three days for a PICC.
“If the physician writes the order on Monday but the patient doesn’t get the PICC until Wednesday afternoon, that’s pretty bad,” he says. “We’ll put in the PICC on Monday afternoon, and the patient can go home that day as long as home health is set up.”
Because the proceduralists are dedicated to the work, patients receive safer care: The center’s complication rates across all procedures are an enviable less-than-1%. And for the proceduralists, the center means an expanded set of skills and a wider variety of work.
The business case
The center’s continued growth has been fueled in part by developments in the specialties that have typically performed these medical procedures. Increasingly, specialists gravitate toward more complex, higher reimbursing procedures, leaving them less time “and inclination “to handle simpler ones.
For the proceduralists, Dr. Rosen explains, the center provides only a small boost to revenue because many medical procedures don’t reimburse particularly well.
“They pay a little better than the cognitive work of seeing a patient and writing a note,” he says, “and with a well-oiled machine, the time consumption is comparable. We have achieved an economy of scale, so we have added economic value through volume.”
In addition to contributing to the hospitalists’ bottom line, the center is extremely popular with specialists for whom handling procedures is a revenue drain.
“For the vascular surgeon or interventional radiologist, putting in a PICC line or doing a lumbar puncture is just not worth it,” says Dr. Rosen, particularly when those specialists could be doing a bypass graft or fistula de-clot instead. “A lot of them are relieved to give up the basic procedures.”
That was the case when the proceduralists added lumbar punctures to their procedure menu in 2005. Overwhelmed interventional radiologists called the center and asked, “Can you take this on?” In the same breath, he says, radiology promised to take over in a difficult situation or complex case.
That business dynamic, coupled with reduced wait times for patients and faster results for referring physicians, has spurred the center’s growth.
How it works
Five hospitalists, out of a total of 14 in the group, rotate through the center, with three proceduralists on-service. They either perform the procedures in the center or go to the bedside, bringing in supply carts and using portable equipment such as ultrasound. One nurse practitioner associated with the practice is trained to do PICCs, and one nurse assists each proceduralist.
The proceduralists spend about 75% of their time on the service during the year, Dr. Rosen explains. Those physicians have received advanced training and additional certification in such areas as conscious sedation, ventilator management, fluoroscopy, upper-airway endoscopy and percutaneous tracheostomy, among others. All are proficient in ultrasonography and in setting up wide sterile barriers.
Each procedure is logged and tracked, with details on how patients fared, when the item (if one was inserted) was removed and whether complications occurred. Patients are followed up as needed and “more closely when devices are left in place,” Dr. Rosen says.
Politics and barriers
The proceduralists have experienced little in the way of resistance, largely because the specialists have over time welcomed their help and because the service maintains a stellar reputation. Still, Dr. Rosen admits, establishing such a service is no small feat.
“It’s not just having one or two docs running around doing procedures,” he explains. “You need to have someone taking phone calls and doing scheduling,” along with data management, nursing leadership and infrastructure. Other basics needed at the front end include stocking equipment and kits, purchasing supply carts, and maintaining storage space. Other logistical essentials include providing the requisite training and maintaining long-term competency.
Training new proceduralists on all the procedures that the center does, Dr. Rosen says, takes three to six months “before they can fly independently.” As a result, he adds, a procedure service can’t be started on a shoestring or without careful planning.
“It would be hard to create this de novo at this level of sophistication,” Dr. Rosen explains. “Ours has successfully evolved over a number of years.”
Still, he says, procedures offer many opportunities for hospitalists, even in community hospitals. Groups might initially target procedures done in the ER or on an outpatient basis, such as paracentesis for liver-failure patients. He also suggests that nocturnists can become proficient in a few procedures that could be performed when specialists aren’t in-house.
“You don’t want to compete too directly with your referral base,” he advises, “but when procedural services aren’t being well provided, there are opportunities. It’s a matter of recognizing the bottlenecks, and then doing a thorough evaluation and economic analysis.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Chadds Ford, Pa.
Tips for starting a procedure service
- Don’t promise too much too quickly. “You have to make sure the infrastructure is in place,” says Bradley Rosen, MD, MBA, assistant director of the procedure center at Cedars-Sinai Medical Center in Los Angeles. “You can’t have people think that you’re the go-to service and then run out of supplies or not have the available staff.”
- Ensure competence before starting up. “Be careful about who you hire, and make sure they’re well trained,” Dr. Rosen notes. “Ideally, you want to be as good as “or better than “the subspecialties that have historically performed these procedures.”
- Consult with the “competition” first. Get buy-in from the subspecialists or departments from whom you might be taking away work before you propose a plan, he says. “Look for where there is a need, so you don’t end up having too much political or economic conflict with whoever is providing the service now.”