Published in the July 2007 issue of Today’s Hospitalist.
Faced with problems getting help inserting PICCs, the medical department at Chicago’s Cook County Hospital decided to take a relatively unorthodox approach: It created a medical procedures service staffed by a hospitalist.
While other hospitals have looked to specially trained nursing services to handle PICCs, Cook County wanted a team that could administer other procedures, like thorocentesis, abdominal paracentesis and lumbar punctures. The hospital decided that no one was better equipped to man that team than a hospitalist.
The new service turned out to be the right solution for a number of reasons. Not only did it reduce the overall waiting time for PICC consults, helping reduce length of stay on a subgroup of patients, but it eliminated communication problems between departments.
A waiting game
For years, Cook County has had a nursing service that handles PICCs, but it often shies away from the more difficult patients because it doesn’t use ultrasound guidance. According to Joseph K. Asbury, MD, a hospitalist at Cook, most physicians would instead call interventional radiology “and then wait for one, two and even three days for help.
The interventional radiology service’s three physicians were not only busy, but they would not make PICC insertions a priority. "There’s little teaching in it for their residents," Dr. Asbury explains. "And because Cook County is a level 1 trauma center, more urgent cases were continually taking precedence. The PICCs would always end up on the back burner."
According to Dr. Asbury, waits for PICC consults were causing problems with length of stay. "You would be told, ‘We’ll do it tomorrow,’ only to end up having to wait another day and then another," he recalls. "Patients were waiting around with endocarditis or osteomyelitis to have a line inserted before they could go to another facility or go home."
Reduced length of stay
Just under two years ago, when Dr. Asbury arrived at Cook County fresh from residency training, he created a medical procedures service to help teach internal medicine residents how to do bedside procedures. (He notes that a survey had shown that housestaff were not comfortable performing procedures with only resident supervision.) The service covers the medical wards, as well as the medical and cardiac ICUs, and is available on weekday afternoons.
The procedures service has produced many benefits, most notably better timing of PICC insertions. Preliminary data found that the service has reduced the waiting time for PICCs by at least a day. Dr. Asbury, however, suspects it has made an even greater impact.
While it typically takes one or more days for an interventional radiologist to insert a PICC, Dr. Asbury’s service usually performs the procedure on the same day, often within hours of receiving a request. Patients who need a PICC aren’t languishing in the hospital for an additional day because they’re waiting for a simple procedure.
"They know that if they want to get a patient out in a day or so and all that patient needs is a PICC," Dr. Asbury says, "there’s not going to be any holdup."
But the reduction in waiting times is only one measure of the service’s success. Dr. Asbury says that attendings and housestaff alike have come to embrace the timely help it provides.
"The housestaff are more comfortable having someone they view as an expert around to help out with risky procedures," he explains, "such as putting in central lines or temporary dialysis catheters on patients who have a degree of coagulopathy or thrombocytopenia. We have found that medical teams are more likely to perform certain procedures with therapeutic benefit when the procedure service is available to supervise and assist."
Mastering a difficult procedure
While the procedures service was set up as a teaching unit, it has done most of the PICCs with no participation from residents. Because PICC insertions can be surprisingly difficult, Dr. Asbury offers training on them only to residents who can devote a couple of weeks to learning to do the procedure. He expects to establish an elective rotation with the procedures service soon.
He notes that he was surprised by how challenging PICC insertions can be. "I would have guessed that after doing 10 of them, I would have been as good as I was going to get," Dr. Asbury explains. "But it took more like 50 or 100, and there are still things that I encounter in terms of anatomy that make them more challenging than I would have expected."
Some of the challenge in inserting PICCs may stem from the fact that Dr. Asbury operates as a one-man show. He locates and marks the patient’s vein, then sets up the PICC kit and preps the skin himself. He gloves out, sets up the tourniquet and ultrasound probe, then gloves back in to complete the procedure.
While most teams use more than one person to insert a PICC, he says the procedure can be done relatively easily alone, although it takes a few extra minutes.
The key, Dr. Asbury explains, is patience and a lot of practice. "You need to accept that you’re not going to be great at PICCs from the outset," he says, "that you’ll get better as you keep doing them."
Getting hospitalists on board
Dr. Asbury has a special fondness for medical procedures, in part because he says they provide a nice change from the day-today duties of an internist. "I enjoy working with my hands, and I like the discrete nature of the procedures. There’s a beginning, middle and end."
But he realizes that his interest in medical procedures makes him unique among hospitalists. In fact, he says he knows of only a handful of hospitals that have similar medical procedure services.
While Cook County’s approach may not work at every hospital, Dr. Asbury says there are some big benefits to keeping hospitalists involved in medical procedures. One is that doing procedures takes advantage of the collaborative relationship that exists on the medical wards, something that can be absent when working with other departments.
In the past, for example, interventional radiologists have refused to insert a PICC in patients with a PTT of greater than 40, stating that the risk was too great. "I understand that giving someone who’s already on the verge of fluid overload a colloid when you’re not changing their risk appreciably is not the best way to practice medicine," Dr. Asbury says. "I know when a procedure needs to be done urgently and when it doesn’t, and I am always available to collaborate with the teams."
A victim of its own success?
While Cook County’s medical procedures service has worked well, Dr. Asbury says he is keeping a close eye on the number of PICC consults he performs. Demand for PICCs is going up, both at Cook County and across the country, in part because people are realizing that it’s a safer way to administer medicines than using a central line.
Dr. Asbury also admits that in some ways, the service may be a victim of its own success. One likely reason for at least some of the increased demand for PICCs on the wards is that the service makes it so easy to get a line placed.
He does note that if demand for PICCs continues to climb, he’ll have to get help. Dr. Asbury is currently working on gathering support for training a small group of nurses in ultrasound-guided PICC insertions. If that strategy doesn’t work, and the volume of PICCs rises too much, he may have to farm some out to interventional radiology again.
But that’s clearly not his preference. "It makes sense to have a few internists specializing in bedside procedures and doing all of the medical procedures for their patients," Dr. Asbury says. "Especially with the advent of portable ultrasound, you can do even technically challenging procedures safely."
Edward Doyle is Editor of Today’s Hospitalist.