Published in the April 2019 issue of Today’s Hospitalist
AS HOSPITAL MEDICINE has evolved, hospitalists and residents have moved away from doing procedures, ceding them instead to radiology.
Why? “Hospital medicine became much more busy,” explains Matthew Gorgone, DO, a hospitalist at New York’s University of Rochester Medical Center. “And from a billing and RVU standpoint, it’s more efficient for us to see patients than do bedside procedures.”
But Dr. Gorgone believes that hospitalists and residents need to take back that ground. He heads up a procedure service that does ultrasound-guided paracentesis, thoracentesis, non-tunneled central/dialysis/ apheresis lines and IVs, as well as lumbar punctures.
“Procedures give you a different type of bedside interaction with patients.”
~ Matthew Gorgone, DO
University of Rochester Medical Center
He admits that it’s hard to sustain a certain number of RVUs with a hospitalist-run or -supervised procedure service. Instead, such a service feeds the bottom line indirectly: freeing up radiology, expediting care with potentially lower lengths of stay, improving patient experience and cutting down on the number of care transitions.
There are also major educational benefits. Residents and attendings who can do procedures, he argues, end up being much more knowledgeable about when and if to order them.
And there’s the issue of on-the-job satisfaction. “We can do very few things in medicine that make someone feel better quickly, and procedures is one of them,” Dr. Gorgone says. Plus, “procedures give you a different type of bedside interaction with patients—and take the potential monotony out of the usual hospitalist job.”
The service evolution
Dr. Gorgone launched the procedure service at the University of Rochester in June 2016 when he was still a resident, developing the role of resident procedure coordinator. Volunteer residents who wanted to learn procedures staffed the service. Each became credentialed—after performing five procedures under supervision—to perform them independently.
The service was well-received by the hospitalists and subspecialists, who requested a growing number of bedside procedures. Dr. Gorgone published results of that resident-driven initiative in the October 2018 issue of the Journal of Graduate Medical Education.
But within two years, it was clear the service needed to be restructured. “It wasn’t 100% reliable,” he says. “Every once in a while, the resident on call for procedures would be on a really busy service and couldn’t get to them.” That’s when he and the hospital decided to formalize the service and include hospitalists.
First, the hospital agreed to buy the service its own ultrasound machine and procedure cart, as well as give Dr. Gorgone a place to store supplies. He then worked with his hospital’s e-record building team to create an electronic procedure order set tied to a secure e-mail and pager.
The pulmonary/critical care division agreed to staff the service during the weeks that Dr. Gorgone couldn’t cover it. And the hospital approved the hiring of three advanced practice providers (APPs) for the service, giving Dr. Gorgone protected time to train them and do procedures.
“It was supposed to be 50%, but it’s fallen to 40% because work is so busy,” he says. “I see a handful of patients to help meet the bottom line, then the rest of my time is performing procedures, teaching interested residents and training the APPs.”
The move away from a resident-staffed service occurred in June 2018, and Dr. Gorgone says his plans for this next year broke down neatly into quarters. In the first quarter, he would hire the APPs and establish the service, “building our reputation around the hospital as a formal team.”
He then planned to use the next three months to train the APPs so he’d take only a supervisory role. “But that dragged on longer than expected, taking five to six months instead.” (More on that, below.)
He then planned to get more hospitalists involved, the phase the service is in now. Out of several dozen physicians, five or six are interested and have been given some protected time to do procedures with the team.”
A different hospitalist helps staff the service every week and is given two or three fewer patients to round on a day to be able to do one or two procedures,” Dr. Gorgone points out. He continues to be present for all procedures “to offer tips as the training hospitalists continue to learn and to make sure we’re doing procedures in a relatively standardized way.”
That’s all changing because Dr. Gorgone is headed to a pulmonary/critical care fellowship at Pittsburgh’s UPMC, starting this July. From April 1 on, he won’t have any protected service time, while the hospitalists who’ve trained will receive that time instead during their weeks rotating through the service.
Meanwhile, service volume has shot up from an average of 40 requests a month to about 120 procedures a month now. To boost its number of procedures even more, the service also provides adjunct outpatient oncology paracentesis in the cancer center next to the main building, as well as lumbar punctures there and an occasional chemotherapy installation when an oncologist or oncology APP is available.
“That’s allowed oncology patients to avoid ED visits, and it’s unclogged radiology from the outpatient side,” he says. The procedure team also plans to staff an outpatient hepatology clinic in the coming weeks.
A new service configuration
The goal now is to have two APPs be the backbone of the service going forward, with rotating hospitalists supervising. (The pulmonary/critical care division no longer needs to provide coverage.) In this next academic year, APPs will also teach procedures to second-year residents.
Part of the reason it took longer than expected to train the APPs was that Dr. Gorgone (and the hospital) originally planned on having two of the three APPs alternate between three weeks on the procedure service, then three weeks on the hospitalist service. But he needed to scrap that plan. “Maybe down the road, you could divide an APP’s time 50-50,” he says.
“But during orientation, they have to be doing procedures full time, with as much exposure as possible.” One of the three APPs has since returned to doing full-time hospital medicine.
He also didn’t anticipate how long it would take to get the APPs up to speed with ultrasound performance and interpretation. And he needed to make sure the APPs were allowed to teach residents. “We initially thought it would be OK, but the guidelines are iffy.” After many meetings, it was decided that APPs can teach residents either individually or with an attending present.
“That will be the structure starting in July,” says Dr. Gorgone. “Each second-year resident will spend two weeks rotating on the team, providing both a service line and educational resource.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.