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Alshumrani Y, Droukas D, Carney BJ, Willim R, Brook A, Wu JS. CT guided versus non-image guided bone marrow aspiration and biopsy: Comparison of indications, specimen quality and cost. Clin Imaging 2024; 113:110236. [PMID: 39106655 DOI: 10.1016/j.clinimag.2024.110236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/09/2024]
Abstract
PURPOSE To compare the indications, specimen quality, and cost of CT versus non-image guided bone marrow aspirate and biopsy (BMAB). METHODS All CT and non-image guided BMAB performed from January 2013-July 2022 were studied. Body-mass-index (BMI), skin-to-bone distance, aspirate, and core specimen quality, and core sample length were documented. Indications for CT guided BMAB were recorded. Categorical variables were compared using chi-squared test and continuous variables using Mann-Whitney test. Analysis of per-biopsy factors used linear mixed-effect models to adjust for clustering. Cost of CT and non-image guided BMAB was taken from patient billing data. RESULTS There were 301 CT and 6535 non-image guided BMABs studied. All CT guided BMAB were studied. A subset of 317 non-image guided BMAB was selected randomly from the top ten CT BMAB referrers. BMI (kg/m2) and skin-to-bone distance (cm) was higher in the CT versus the non-image guided group; 34.4 v 26.8, p < 0.0001; 4.8 v 2.5, p < 0.0001, respectively. Aspirate and core sample quality were not different between groups, p = 0.21 and p = 0.12, respectively. CT guided core marrow samples were longer, p < 0.0001. The most common CT BMAB referral indications were large body habitus (47.7 %), failed attempt (18.8 %) and not stated (17.4 %). Cost of a CT guided BMAB with conscious sedation was $3945 USD versus $310 USD for non-image guided. CONCLUSION CT guided BMAB are commonly performed in patients with large body habitus and failed attempt. However, the cost is 12.7 fold higher with no increase in specimen quality. These findings can help referrers be cost conscious.
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Affiliation(s)
- Yousef Alshumrani
- Department of Internal Medicine - Division of Radiology, King Khalid University, 7887 Alfara street, Abha 62529, Saudi Arabia; Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America
| | - Daniel Droukas
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Brian J Carney
- Department of Medicine, Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Robert Willim
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
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Koh J, Dowlatshahi S, Turner BJ. Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative Inquiry. Dig Dis Sci 2024; 69:2324-2332. [PMID: 38700627 PMCID: PMC11258186 DOI: 10.1007/s10620-024-08358-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/13/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. AIM This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. METHODS The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. RESULTS Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. CONCLUSION This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.
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Affiliation(s)
- Jennifer Koh
- Department of Medicine, Keck Medical Center of University of Southern California, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA
| | - Shadi Dowlatshahi
- Department of Hospital Medicine, Los Angeles General Medical Center, 2051 Marengo St, Los Angeles, CA, 90033, USA
- Department of Medicine, Keck Medical Center of University of Southern California, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA
| | - Barbara J Turner
- Department of Medicine, Keck Medical Center of University of Southern California, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA.
- Gehr Family Center for Health System Science and Innovation, Clinical Sciences Center, Keck School of Medicine of USC, 2250 Alcazar Street Room #261, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA.
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3
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Bergmans C, Tapper EB. Outpatient Management of Symptomatic Ascites: Bypassing the Path of Least Resistance. Dig Dis Sci 2024; 69:2284-2286. [PMID: 38700628 DOI: 10.1007/s10620-024-08403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 07/19/2024]
Affiliation(s)
- Carrie Bergmans
- Division of Gastroenterology and Hepatology, University of Michigan, 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
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Dowlatshahi S, Koh J, Vyas A, Mack WJ, Turner BJ. Disparities in Care for Low-Income Patients with Cirrhosis: Implementing an Innovative Outpatient Clinic for Refractory Ascites in a Safety Net Hospital. J Gen Intern Med 2024; 39:1245-1251. [PMID: 38378980 PMCID: PMC11116333 DOI: 10.1007/s11606-024-08675-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. AIM To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. SETTING A large safety net hospital in Los Angeles. PARTICIPANTS MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. PROGRAM DESCRIPTION According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. PROGRAM EVALUATION After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. DISCUSSION Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care.
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Affiliation(s)
- Shadi Dowlatshahi
- Department of Hospital Medicine, Los Angeles General Medical Center, Los Angeles, CA, USA
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Jennifer Koh
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Annasha Vyas
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Wendy J Mack
- Department of Population and Public Health Sciences, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Barbara J Turner
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA.
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of USC, Clinical Sciences Center, Los Angeles, CA, USA.
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Koh J, Dowlatshahi S, Turner BJ. Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative. RESEARCH SQUARE 2023:rs.3.rs-3793244. [PMID: 38234824 PMCID: PMC10793502 DOI: 10.21203/rs.3.rs-3793244/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Background Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. Aim This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. Methods The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. Results Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. Conclusion This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.
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Affiliation(s)
- Jennifer Koh
- Keck Medical Center of University of Southern California
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Ahmed M, Islam M, Gogokhia L, Borz-Baba C, Wakefield D, Jakab SS. Hospital Utilization for Patients With Cirrhosis and Severe Ascites in a Model of Outpatient Paracentesis by Interventional Radiology. Cureus 2023; 15:e51397. [PMID: 38292997 PMCID: PMC10826452 DOI: 10.7759/cureus.51397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, there is usually no evaluation of patients' renal function or adjustment of their medications at the time of paracentesis. The objectives of this study were to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care. METHODS This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR between October 15, 2015, and October 15, 2018, at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracentesis dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post index paracentesis. Associations between categorical predictors and clinical outcomes were analyzed using the chi-square test. Associations between quantitative predictors and clinical outcomes were analyzed using the Wilcoxon rank sum test. RESULTS Our study included 69 unique patients who had at least one outpatient encounter for paracentesis by IR in the study period. Most patients were men (71%), had alcohol-related cirrhosis as primary etiology (53.6%), an average age of 60 years, and an average Model for End-Stage Liver Disease-sodium (MELDNa) score at baseline of 16. Within six months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient), 43 patients (62.3%) had ER visits (total 118 ER visits, 2.8/patient), 41 patients (59.4%) had hospital admissions (total 88 admissions, 2.2/patient), and 11 patients required ICU admission. Complications of cirrhosis noted during follow-up included hepatic encephalopathy (40.5%), acute kidney injury (38.2%), upper gastrointestinal (UGI) bleeding (16%), and spontaneous bacterial peritonitis (SBP) in 15%. The mortality rate at six months was 20%. On multivariate analysis, the predictive factors for mortality were older age (p = 0.03) and MELDNa score (p = 0.02). Baseline MELDNa was predictive of acute kidney injury (p = 0.02), UGI bleed (p < 0.01), and ICU admission (p < 0.01), but not of SBP, encephalopathy, ED visit, or hospital admissions. Among patients with more than one paracentesis (64%),six patients underwent transjugular portosystemic shunt (TIPS), but there was no documentation of TIPS consideration in 31 patients (70.4%). A total of 20 patients (29%) were waitlisted for liver transplantation. CONCLUSION In this contemporary cohort of patients with cirrhosis undergoing outpatient IR paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data are needed to identify specific gaps in care, but IR paracentesis should be integrated within a multidisciplinary management model, with emphasis on early TIPS in eligible patients, as recommended by the current practice guidelines.
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Affiliation(s)
- Mustajab Ahmed
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Masuma Islam
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Lasha Gogokhia
- Gastroenterology and Hepatology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, USA
| | | | - Dorothy Wakefield
- Statistics, Department of Research, Saint Francis Hospital & Medical Center, Hartford, USA
| | - Sofia S Jakab
- Gastroenterology and Hepatology, Yale School of Medicine, New Haven, USA
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7
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Mohy-ud-din N, Noll A, Jonassaint N. CON: Ascitic fluid cell count should not be routinely sent with every therapeutic paracentesis to assess for spontaneous bacterial peritonitis. Clin Liver Dis (Hoboken) 2023; 22:143-145. [PMID: 37908868 PMCID: PMC10615510 DOI: 10.1097/cld.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/05/2023] [Indexed: 11/02/2023] Open
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8
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Martin R. Growing Pains of Nonphysician Providers in Radiology. Curr Probl Diagn Radiol 2023; 52:149-152. [PMID: 36804418 DOI: 10.1067/j.cpradiol.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 12/04/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
Nonphysician providers (NPPs) place in medicine continues to evolve regardless of controversy. NPPs presence in academic and private practices continues to grow in all fields. Despite their growth, there remains Contention and debate about the capability, safety, efficiency, and aptitude of NPP's abilities for proper image ordering, image interpretation, and performing radiology-related tasks. NNPs role in healthcare across the United States continues to grow in all facets of healthcare, including radiology and radiologist related procedures. The claims submitted by NPPs involving radiology have significantly increased. However, current research suggests that the current scope of practice maintains the levels of capability, safety, efficiency and aptitude of a physician. It is imperative to note that there remains no evidence comparing diagnostic accuracy/errors between NPPs and radiologists. Despite the increased radiology services rendered by NPPs, the output of NPPs is still fractional compared to radiologists but it is mostly fluoroscopy and radiography. As with medical student education, the education for NPPs has continued to grow to encompass more aspects of medicine, including radiology. Evidence-based programs for NPP radiology training offers potential to encourage proper radiology service rendering. 10,15 NPPs are skilled in their ability to provide care for specific common conditions and potential greater ability to follow protocol. All of these factors promote the opportunity to take tedious tasks and/or cases from overworked radiologists to pursue greater generation of profit and work-life balance.
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Affiliation(s)
- Robert Martin
- Rowan University School of Osteopathic Medicine, 30 Cherry Circle, Blackwood, NJ, 08012.
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9
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Santavicca S, Hughes DR, Rosenkrantz AB, Rubin E, Duszak R. Professional Services Rendered by Nurse Practitioners and Physician Assistants Employed by Radiology Practices: Characteristics and Trends From 2017 Through 2019. J Am Coll Radiol 2023; 20:117-126. [PMID: 36008228 DOI: 10.1016/j.jacr.2022.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE With radiology practices increasingly employing nonphysician practitioners (NPPs), we aimed to characterize specific NPP clinical roles. METHODS Linking 2017 to 2019 Medicare data sets, we identified all claims-submitting nurse practitioners and physician assistants (together NPPs) employed by radiologists. NPP-billed services were identified, weighted by work relative value units, and categorized as (1) clinical evaluation and management (E&M), (2) invasive procedures, and (3) noninvasive imaging interpretation. NPP practice patterns were assessed temporally and using frequency analysis. RESULTS As the number of radiologist-employed NPPs submitting claims increased 16.3% (from 523 in 2017 to 608 in 2019), their aggregate Medicare fee-for-service work relative value units increased 17.3% (+40.0% for E&M [from 79,540 to 111,337]; +5.6% for procedures [from 179,044 to 189,003]; and +74.0% for imaging [from 5,087 to 8,850]). The number performing E&M, invasive procedures, and imaging interpretation increased 7.6% (from 329 to 354), 18.3% (from 387 to 458), and 31.8% (from 85 to 112), with 58.2%, 75.3%, and 18.4% billing those services in 2019. Paracentesis and thoracentesis were the most frequently billed invasive procedures. Fluoroscopic swallowing and bone densitometry examinations were the most frequently billed imaging services. By region, NPPs practicing as majority clinical E&M providers were most common in the Midwest (33.5%) and South (33.0%), majority proceduralists in the South (53.1%), and majority image interpreters in the Midwest (50.0%). CONCLUSIONS As radiology practices employ more NPPs, radiologist-employed NPPs' aggregate services have increased for E&M, invasive procedures, and imaging interpretation. Most radiologist-employed NPPs perform invasive procedures and E&M. Although performed by a small minority, imaging interpretation has shown the largest relative service growth.
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Affiliation(s)
- Stefan Santavicca
- Senior Data Analyst, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
| | - Danny R Hughes
- Professor, School of Economics and Director, Health Economics and Analytics Lab, Georgia Institute of Technology, Atlanta, Georgia; and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Andrew B Rosenkrantz
- Professor, Director of Prostate Imaging, Director of Health Policy, and Section Chief of Abdominal Imaging, Department of Radiology, NYU Langone Medical Center, New York, New York
| | - Eric Rubin
- Chief, CT Scan, Southeast Radiology Limited, Ridley Park, Pennsylvania
| | - Richard Duszak
- Professor and Vice Chair of Radiology, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Seah DS, Wilcock A, Chang S, Sousa MS, Sinnarajah A, Teoh CO, Allan S, Chye R, Doogue M, Hunt J, Agar M, Currow DC. Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study. Palliat Med 2022; 36:1408-1417. [PMID: 36113139 DOI: 10.1177/02692163221122326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Paracentesis is commonly undertaken in patients with cancer-related ascites. AIM To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting. DESIGN Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner. SETTING/PARTICIPANTS Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50. RESULTS At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation. CONCLUSION Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.
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Affiliation(s)
- Davinia Se Seah
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wilcock
- Hayward House Specialist Palliative Care Unit, School of Clinical Oncology, University of Nottingham, Nottingham, England
| | - Sungwon Chang
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mariana S Sousa
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, School of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Richard Chye
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Matthew Doogue
- University of Otago - Christchurch & Canterbury District Health Board, Christchurch, New Zealand
| | - Jane Hunt
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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11
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Stecka AM, Grabczak EM, Michnikowski M, Zielińska-Krawczyk M, Krenke R, Gólczewski T. The impact of spontaneous cough on pleural pressure changes during therapeutic thoracentesis. Sci Rep 2022; 12:11502. [PMID: 35798822 PMCID: PMC9262881 DOI: 10.1038/s41598-022-15480-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 06/24/2022] [Indexed: 11/18/2022] Open
Abstract
Cough during therapeutic thoracentesis (TT) is considered an adverse effect. The study was aimed to evaluate the relationship between cough during TT and pleural pressure (Ppl) changes (∆P). Instantaneous Ppl was measured after withdrawal of predetermined volumes of pleural fluid. Fluid withdrawal (FW) and Ppl measurement (PplM) periods were analyzed separately using the two sample Kolmogorov-Smirnov test and the nonparametric skew to assess differences between ∆P distributions in periods with and without cough. The study involved 59 patients, median age 66 years, median withdrawn fluid volume 1800 mL (1330 ÷ 2400 mL). In total, 1265 cough episodes were recorded in 52 patients, in 24% of FW and 19% of PplM periods, respectively. Cough was associated with significant changes in ∆P distribution (p < 0.001), decreasing the left tail of ∆P distribution for FW periods (the skew = - 0.033 vs. - 0.182) and increasing the right tail for PplM periods (the skew = 0.182 vs. 0.088). Although cough was more frequent in 46 patients with normal pleural elastance (p < 0.0001), it was associated with significantly higher ∆P in patients with elevated elastance (median Ppl increase 2.9 vs. 0.2 cmH2O, respectively). Cough during TT is associated with small but beneficial trend in Ppl changes, particularly in patients with elevated pleural elastance, and should not be considered solely as an adverse event.
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Affiliation(s)
- Anna M Stecka
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 02-109, Warsaw, Poland
| | - Elżbieta M Grabczak
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-097, Warsaw, Poland.
| | - Marcin Michnikowski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 02-109, Warsaw, Poland
| | - Monika Zielińska-Krawczyk
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-097, Warsaw, Poland
| | - Rafał Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-097, Warsaw, Poland
| | - Tomasz Gólczewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 02-109, Warsaw, Poland
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12
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Aby ES, Lall D, Vasdev A, Mayer A, Olson APJ, Lim N. Rates of timely paracentesis for patients admitted to hospital with cirrhosis and ascites remain low but are unaffected by the COVID-19 pandemic. J Hosp Med 2022; 17:276-280. [PMID: 35535925 PMCID: PMC9088316 DOI: 10.1002/jhm.12797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/22/2022] [Indexed: 11/16/2022]
Abstract
For the first 6 months of the novel coronavirus-19 (COVID-19) pandemic, the hospital medicine procedure service at our center was temporarily unavailable. We assessed paracentesis rates and clinical outcomes for patients admitted with cirrhosis and ascites before and during the COVID-19 pandemic. Two hundred and twenty-four and 131 patients with cirrhosis and ascited were admitted to hospital before and during COVID-19 respectively. Approximately 50.9% and 49.6% of patients underwent a paracentesis within 24 h pre- and mid-pandemic, p = .83. No differences were observed for length-of-stay or 30-day readmissions. GI consultation was associated with higher rates of paracentesis in both eras (p < .001 pre-COVID-19, and p = .01 COVID-19). Changes due to the COVID-19 pandemic did not result in changes to rates of timely paracentesis in patients admitted with cirrhosis and ascites. While involvement of gastroenterology may increase rates of paracentesis, further efforts are needed to optimize rates of timely paracentesis to positively impact clinical outcomes.
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Affiliation(s)
- Elizabeth S. Aby
- Division of Gastroenterology, Hepatology, and NutritionUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Drishti Lall
- University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Amrit Vasdev
- University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Adam Mayer
- University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Andrew P. J. Olson
- Division of General Internal Medicine, Section of Hospital MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
- Division of Pediatric Hospital MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, and NutritionUniversity of MinnesotaMinneapolisMinnesotaUSA
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13
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Growth in Thoracentesis and Paracentesis Performed by Radiology and Advanced Practice Providers: Medicare Volume and Reimbursement Trends From 2012 to 2018. J Am Coll Radiol 2022; 19:597-603. [PMID: 35341699 DOI: 10.1016/j.jacr.2022.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To study trends in volume and reimbursement for paracentesis and thoracentesis by physicians and advanced practice providers (APPs) after the introduction of discreet Current Procedural Terminology codes for image-guidance. METHODS Medicare claims for 2012 to 2018 (paracentesis) and 2013 to 2018 (thoracentesis) were extracted using Current Procedural Terminology codes for blind and image-guided paracentesis and thoracentesis. Total volumes were analyzed by provider specialty. Nonfacility reimbursement and relative value units were compared. RESULTS For blind paracentesis, volume decreased from 17,393 to 12,226 procedures from 2012 to 2018. Conversely, volume of image-guided paracentesis increased from 171,631 to 253,834 procedures. Radiology performed the majority of image-guide paracentesis (83.9% in 2012 and 77.1% in 2018). Volume and relative share for APPs dramatically increased (from 10.2% to 15.8%). For blind thoracentesis, volume decreased from 26,716 to 15,075 procedures from 2013 to 2018. Conversely, volume of image-guided thoracentesis increased from 187,168 to 222,673 procedures. Radiology performed the majority of image-guided thoracentesis (73.6% in 2013 and 66.2% in 2018). Volume and relative share for APPs dramatically increased (from 7.7% to 12.9%). Although reimbursement for both image-guided paracentesis and thoracentesis decreased, their reimbursement remained higher than that of blind paracentesis and thoracentesis throughout the study period. CONCLUSION A higher percentage of these procedures are being performed using image guidance; radiologists performed a growing number but declining percentage of image-guided paracentesis and thoracentesis. APPs are playing an increasing role, particularly using image-guidance. Given decreasing reimbursement for these procedures, APPs can provide a large cost advantage in procedural radiology practices.
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14
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Hanna C, Montague S, Hanna NM. The power of Doppler in ultrasound-guided paracentesis. CAN J EMERG MED 2022; 24:447-449. [PMID: 35312987 DOI: 10.1007/s43678-022-00292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Christine Hanna
- Department of Family Medicine, Queen's University, Kingston, ON, Canada.,Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Steven Montague
- Department of Internal Medicine, Queen's University, Kingston, ON, Canada
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston Health Sciences Centre, Victory 3, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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15
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Bibliometric analysis of interventional radiology studies in PubMed-indexed literature from 1991 to 2020. Clin Imaging 2022; 85:43-47. [DOI: 10.1016/j.clinimag.2022.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 11/17/2022]
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16
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Godfrey M, Puchalski J. Pleural Effusions in the Critically Ill and "At-Bleeding-Risk" Population. Clin Chest Med 2021; 42:677-686. [PMID: 34774174 DOI: 10.1016/j.ccm.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Thoracentesis is a common bedside procedure, which has a low risk of complications when performed with thoracic ultrasound and by experienced operators. In critically ill or mechanically ventilated patients, or in patients with bleeding risks due to medications or other coagulopathies, the complication rate remains low. Drainage of pleural effusion in the intensive care unit has diagnostic and therapeutic utility, and perceived bleeding risks should be one part of an individualized and comprehensive risk-benefit analysis.
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Affiliation(s)
- Mark Godfrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 15 York Street, LCI 100, New Haven, CT 06510, USA
| | - Jonathan Puchalski
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 15 York Street, LCI 100, New Haven, CT 06510, USA.
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17
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Feldman AG, Squires JE, Hsu EK, Lobritto S, Mohammad S. The current state of pediatric transplant hepatology fellowships: A survey of recent graduates. Pediatr Transplant 2021; 25:e14065. [PMID: 34120405 PMCID: PMC10155256 DOI: 10.1111/petr.14065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/03/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The number of programs offering a PTH fellowship has grown rapidly over the last 10 years. This study aimed to describe the clinical, didactic, procedural, and research experiences of recent PTH fellowship graduates. In addition, we sought to understand graduates' post-fellowship professional responsibilities and their perception about the utility of the PTH fellowship. METHODS An anonymous survey was distributed from February to October 2020 through REDCap to all recent graduates (2015-2019) of an ACGME-approved PTH fellowship program. The survey consisted of 49 questions focused on the PTH fellowship experience. Results were summarized using descriptive statistics. RESULTS Thirty-eight of 43 graduates (88%) responded to the survey representing 12 PTH fellowship programs. The didactic experience varied; 97% received pathology lectures, 81% radiology lectures, 54% organ allocation lectures, 54% procedural lectures, 57% immunology lectures, and 43% live donation lectures. During the PTH fellowship, the majority of fellows performed >10 liver biopsies (82%) and >5 variceal bandings (58%); however, 63%, 32%, 8%, and 8% never performed paracentesis, variceal sclerotherapy, variceal banding, and liver biopsies, respectively. The majority of fellows (95%) completed a research project during PTH fellowship. Currently, 84% of graduates are employed at a transplant academic institution. All graduates recommended the fellowship. CONCLUSIONS There is variability in the didactic, clinical, and procedural training among PTH fellowship programs. Although uniformly viewed as a beneficial fellowship year, there is an opportunity to collaborate to create a more standardized training experience.
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Affiliation(s)
- Amy G Feldman
- Section of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Steven Lobritto
- Center for Liver Disease and Transplantation, NY Presbyterian-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Sgro G, Kelly M, Preisner R. Comparison of Simulation-Only vs. Simulation + Live Training in Paracentesis. PATIENT SAFETY 2021. [DOI: 10.33940/med/2021.9.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background
Several studies have examined the effects of simulation and live training experiences on abdominal paracentesis skills, but no study has examined the durability of such training or compared skills retention between the simulation-only and hybrid training approaches.
Methods
A subset of internal medicine residents who participated in simulation-based training in abdominal paracentesis were assigned to an additional, live training experience. Procedural knowledge and skill were assessed following initial training and at six months, and compared between groups.
Results
Complete data was available for 29 out of 37 residents who received simulation-only training and 18 out of 23 who received simulation plus live training. There were no statistical differences in procedural skills scores at either point in time. The simulation plus live training group achieved a higher mean score on the knowledge test at six months (p=0.006).
Conclusions
Simulation-based training is sufficient for achieving initial mastery in abdominal paracentesis, but not for maintaining paracentesis skills at six months in the absence of structured, maintenance training. The addition of a live training experience to complement the simulation training was not sufficient to prevent skills decline.
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19
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Can procedure time for paracentesis be optimized based on bottle selection? Abdom Radiol (NY) 2021; 46:4062-4067. [PMID: 33783568 DOI: 10.1007/s00261-021-03033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of our study was to assess if plastic containers could decrease the overall procedure time for paracentesis relative to more commonly used glass containers. METHODS In this IRB exempt study, initial pilot data comparing filling time of glass and plastic containers in an ex vivo setting under identical conditions revealed power calculations that n = 37 patients per group would be needed to achieve standard deviation (SD) = 60 s, difference (diff) = 40 s, two-tailed alpha-level 0.05, and power 80%. Total of 43 patients (93 containers) were enrolled and randomized to glass or plastic bottles at enrollment. Timing of bottle filling was assessed using standardized sonographic screen captures. RESULTS An interim look at statistics at n = 20 patients indicated that original conjectures from pilot data were conservative and smaller sample size was sufficient to stop the study and conduct the analyses. Specifically, SD = 54 s, diff = 49 s, two-tailed alpha-level 0.05, and power 80% required n = 21 patients per group. Plastic containers had a statistically significantly lower average filling time per bottle (162.7 ± 53.3 s) compared to glass (212.2 ± 50.4 s) (p = 0.003). Viscosity was calculated for each specimen and did not affect the statistical significance of the results (p = 0.32). CONCLUSION Plastic containers have 50 s time savings of per bottle filling time as compared to glass bottles as theorized based on their faster flow rate. This holds true in both an ex vivo setting and in patients and can have important downstream impacts on patient throughput, provider efficiency and system wide cost savings.
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Pleural Manometry—Basics for Clinical Practice. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-021-00277-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose of Review
The aim of this paper is to present basic data on pleural manometry and to outline the advances in its use as both a research tool enabling a better understanding of pleural pathophysiology and as a clinical tool useful in management strategy planning in patients with pleural diseases. To discuss updates and current trends in the development of pleural manometry, a search of the literature on pleural manometry published in recent years was performed.
Recent Findings
The technique of pleural manometry has significantly evolved over the last 40 years from simple water manometers to electronic or digital devices which enable the measurement and recording of instantaneous pleural pressure. Although to date it is mainly used as a research tool, pleural manometry has the potential to be applied in clinical practice. Recent studies demonstrated that monitoring of pleural pressure changes during therapeutic thoracentesis does not seem to be helpful in predicting re-expansion pulmonary edema and procedure-related chest discomfort. On the other hand, measurement of pleural elastance plays an important role in the diagnosis of unexpandable lung in patients with malignant pleural effusion facilitating determination of the optimal management strategy. Additionally, it allows for study of newly discovered phenomena, including pleural pressure pulse assessment and the impact of continuous positive airway pressure and cough on pleural pressure.
Summary
Pleural manometry is an established technique of pleural pressure measurement. Despite recent advances, its role in clinical practice remains undetermined.
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21
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Cool JA, Huang GC. Procedural Competency Among Hospitalists: A Literature Review and Future Considerations. J Hosp Med 2021; 16:230-235. [PMID: 33734979 DOI: 10.12788/jhm.3590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/11/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience. METHODS We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures. RESULTS Our synthesis of the literature characterizes contributors to hospitalists' procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists. CONCLUSION We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.
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Affiliation(s)
- Joséphine A Cool
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Grace C Huang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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22
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Trunz LM, Gandhi AV, Karambelkar AD, Lange SM, Rao VM, Flanders AE. National Trends in Lumbar Puncture from 2010 to 2018: A Shift Reversal from the Emergency Department to the Hospital Setting for Radiologists and Advanced Practice Providers. AJNR Am J Neuroradiol 2021; 42:206-210. [PMID: 33184070 DOI: 10.3174/ajnr.a6870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/11/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prior research has shown substantial shifts in procedure shares between specialty groups providing lumbar punctures. Our aim was to analyze national trends in lumbar punctures among the Medicare population from 2010 to 2018. MATERIALS AND METHODS Medicare Part B Physician/Supplier Procedure Summary Master Files from 2010 to 2018 were analyzed for all Current Procedural Terminology, Version 4 codes related to lumbar punctures (62270 and 62272). Lumbar puncture procedure volume and utilization rates were assessed and stratified by place of service and specialty background of the providers. RESULTS From 2010 to 2018, the overall number of lumbar puncture procedures essentially has not changed (92,579 versus 92,533). Radiologists hold the largest and an increasing procedure share of diagnostic and overall lumbar punctures (overall share, 45.7% in 2010 [n = 42,296] versus 52.3% in 2018 [n = 48,414]). Advanced practice providers have increased their procedure share (3.7% in 2010 [n = 3388] versus 8.4% in 2018 [n = 7785], + 129.8% procedure volume). Emergency medicine physicians and neurologists have a decreasing procedure share (21.8% versus 15.3% and 12.5% versus 8.8%, respectively). The inpatient hospital setting remains the largest place of service for lumbar punctures, recording a 5.3% increase in procedure share. The emergency department lumbar puncture volume has declined, with a 7.4% decrease in the overall procedure share. Similarly, the hospital outpatient department procedure volume has increased (+4%), while the private office volume has decreased (-1.7%). CONCLUSIONS During the past decade, lumbar puncture procedures among the Medicare population have remained stable, with a shift in procedure volume from the emergency department and private offices to the hospital setting, which has mainly affected radiologists and advanced practice providers.
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Affiliation(s)
- L M Trunz
- From the Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - A V Gandhi
- From the Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - A D Karambelkar
- From the Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - S M Lange
- From the Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - V M Rao
- From the Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - A E Flanders
- From the Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
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Abdu B, Akolkar S, Picking C, Boura J, Piper M. Factors Associated with Delayed Paracentesis in Patients with Spontaneous Bacterial Peritonitis. Dig Dis Sci 2021; 66:4035-4045. [PMID: 33274417 PMCID: PMC8510927 DOI: 10.1007/s10620-020-06750-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM In patients with spontaneous bacterial peritonitis (SBP), studies show that delayed paracentesis (DP) is associated with worse outcomes and mortality. We aimed to assess the rate of DP in the community setting and associated factors with early versus delayed paracentesis. METHODS Patients hospitalized with SBP were retrospectively studied between 12/2013 and 12/2018. DP was defined as paracentesis performed > 12 h from initial encounter. Data collected included: patient factors (i.e., age, race, symptoms, history of SBP, MELD) and physician factors (i.e., admission service, shift times, providers ordering and performing paracentesis). Logistic regression analysis was performed to assess for factors associated with DP. RESULTS DP occurred 82% of the time (n = 97). The most significant factors in predicting timing of paracentesis were ordering physician [emergency department (ED) physician was associated with early paracentesis (57% vs 8%, p < 0.001) and specialty of physician performing paracentesis (interventional radiology was associated with DP (88% vs 48%, p < 0.001)]. Younger patients were more likely to receive early paracentesis. In regression analysis, the factor most associated with early paracentesis was when the order was made by the ED provider (OR 0.07, 95% CI 0.02-0.22). No differences were observed in patients with prior history of SBP, abdominal pain, encephalopathy, or creatinine level. CONCLUSIONS Studies have suggested that DP is associated with increased mortality in patients with SBP. Despite this, DP is common in the community setting and is influenced by ordering physician and specialty of physician performing paracentesis. Future efforts should assess interventions to improve this important quality indicator.
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Affiliation(s)
- Backer Abdu
- Department of Gastroenterology and Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI 48075 USA
| | - Shalaka Akolkar
- Department of Gastroenterology and Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI 48075 USA
| | - Christopher Picking
- Department of Gastroenterology and Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI 48075 USA
| | - Judith Boura
- Department of Gastroenterology and Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI 48075 USA
| | - Marc Piper
- Department of Gastroenterology and Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI 48075 USA
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Gorgone M, McNichols B, Li D, Quill C. Resident-Driven Procedure Team and Speed of Obtaining Diagnostic Paracentesis. Jt Comm J Qual Patient Saf 2020; 47:137-139. [PMID: 33121890 DOI: 10.1016/j.jcjq.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
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Singh K, Balthazar P, Duszak R, Horný M, Hanna TN. Clinical Yield of Routine Chest Radiography after Ultrasound-Guided Thoracentesis. Acad Radiol 2020; 27:1379-1384. [PMID: 31831265 DOI: 10.1016/j.acra.2019.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate the clinical yield of routine chest radiography in identifying pneumothorax warranting chest tube decompression in patients undergoing ultrasound-guided thoracentesis. MATERIALS AND METHODS All adult patients without pre-existing pneumothorax who underwent ultrasound-guided thoracentesis by a radiologist within a four-hospital large metropolitan academic health system over a 10-year period were identified. Demographic, clinical, and radiographic report information were obtained. Chest radiographic reports were assessed for the presence of pneumothorax and, if positive, manual image and chart review were performed. RESULTS Of 2541 consecutive ultrasound-guided thoracentesis procedures, 12 were excluded due to pre-existing pneumothorax, yielding 2529 cases. Mean patient age was 67.7 years; 54.5% were male. Overall, 89 procedures (3.5%) resulted in a postprocedural pneumothorax. Of those, only six (6.7%) had documented changes in patient symptoms. Chest tubes were placed in 15, representing 16.9% (15/89) of cases with postprocedural pneumothoraces and 0.59% (15/2,529) of all procedures. Of these 15, 5 (33.3%) had symptomatic pneumothoraces, most commonly shortness of breath. CONCLUSION Following ultrasound-guided thoracentesis, the incidence of pneumothorax requiring chest tube decompression is only 1 in 170. Of the 1 in 30 patients who develop a pneumothorax, only 1 in 6 require a chest tube. This information can inform procedural consent discussions as well as future guidelines about the necessity of routine postprocedural chest radiography.
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Affiliation(s)
- Kush Singh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Patricia Balthazar
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States; Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA 30322, United States
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
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Diagnostic Imaging Examinations Interpreted by Nurse Practitioners and Physician Assistants: A National and State-Level Medicare Claims Analysis. AJR Am J Roentgenol 2019; 213:992-997. [DOI: 10.2214/ajr.19.21306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gottumukkala RV, Prabhakar AM, Hemingway J, Hughes DR, Duszak R. Disparities over Time in Volume, Day of the Week, and Patient Complexity between Paracentesis and Thoracentesis Procedures Performed by Radiologists versus Those Performed by Nonradiologists. J Vasc Interv Radiol 2019; 30:1769-1778.e1. [PMID: 31422023 DOI: 10.1016/j.jvir.2019.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/01/2019] [Accepted: 04/11/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To compare the disparities between the paracenteses and thoracenteses performed by radiologists with those performed by nonradiologists over time. Variables included the volume of procedures, the days of the week, and the complexity of the patient's condition. MATERIALS AND METHODS Using carrier claims files for a 5% national sample of Medicare beneficiaries from 2004 to 2016, paracentesis and thoracentesis examinations were retrospectively classified by physician specialty (radiologist vs nonradiologist), day of the week (weekday vs weekend), and the complexity of the patient's condition (using Charlson comorbidity index scores). The Pearson chi-square and independent samples t-test were used for statistical analysis. RESULTS Between 2004 and 2016, the proportion of all paracentesis and thoracentesis procedures performed by radiologists increased from 70% to 80% and from 47% to 66%, respectively. Although radiologists increasingly performed more of both services on both weekends and weekdays, the share performed by radiologists was lower on weekends. For most of the first 9 years across the study period, radiologists performed paracentesis in patients with more complex conditions than those treated by nonradiologists, but the complexity of patients' conditions was similar during recent years. For thoracentesis, the complexity of patients' conditions was similar for both specialty groups across the study period. CONCLUSIONS The proportion of paracentesis and thoracentesis procedures performed in Medicare beneficiaries by radiologists continues to increase, with radiologists increasingly performing most of both services on weekends. Nonetheless, radiologists perform disproportionately more on weekdays than on weekends. Presently, radiologists and nonradiologists perform paracentesis and thoracentesis procedures in patients with similarly complex conditions. These interspecialty differences in timing and complexity of the patient's condition differ from those recently described for several diagnostic imaging services, reflecting the unique clinical and referral patterns for invasive versus diagnostic imaging services.
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Affiliation(s)
- Ravi V Gottumukkala
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.
| | - Anand M Prabhakar
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | | | - Danny R Hughes
- Harvey L. Neiman Health Policy Institute, Reston, Virginia; School of Economics, Georgia Institute of Technology, Atlanta, Georgia; Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Rosenkrantz AB, Hawkins CM, Deitte LA, Hemingway J, Hughes DR, Duszak R. Invasive Procedural Versus Diagnostic Imaging and Clinical Services Rendered by Radiology Trainees Over Two Decades. J Am Coll Radiol 2019; 16:845-855. [DOI: 10.1016/j.jacr.2018.11.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 11/25/2022]
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Heraganahally S, Mehra S, Veitch D, Sajkov D, Falhammar H, Morton S. New cost-effective pleural procedure training: manikin-based model to increase the confidence and competency in trainee medical officers. Postgrad Med J 2019; 95:245-250. [PMID: 30992415 DOI: 10.1136/postgradmedj-2018-136380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 01/21/2019] [Accepted: 03/16/2019] [Indexed: 11/04/2022]
Abstract
PURPOSE OF THE STUDY Pleural diseases are common in clinical practice. Doctors in training often encounter these patients and are expected to perform diagnostic and therapeutic pleural procedures with confidence and safely. However, pleural procedures can be associated with significant complications, especially when performed by less experienced. Structured training such as use of training manikin and procedural skills workshop may help trainee doctors to achieve competence. However, high costs involved in acquiring simulation technology or attending a workshop may be a hurdle. We hereby describe a training model using a simple manikin developed in our institution and provide an effective way to document skill acquisition and assessment among trainee medical officers. STUDY DESIGN This was a prospective observational study. The need for training, competence and confidence of trainees in performing pleural procedures was assessed through an online survey. Trainees underwent structured simulation training through a simple manikin developed at our institute. Follow-up survey after the training was then performed to access confidence and competence in performing pleural procedures. RESULTS Forty-seven trainees responded to an online survey and 91% of those expressed that they would like further training in pleural procedure skills. 81% and 85% of responders, respectively, indicated preferred method of training is either practising on manikin or performing the procedure under supervision. Follow-up survey showed improvement in the confidence and competence. CONCLUSION Our pleural procedure training manikin model is a reliable, novel and cost-effective method for acquiring competences in pleural procedures.
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Affiliation(s)
- Subash Heraganahally
- Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia .,Respiratory and Sleep Medicine, Royal Darwin Hospital, Casuarina, Northern Territory, Australia
| | - Sumit Mehra
- Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Daisy Veitch
- SHARP Dummies Pty Ltd, Adelaide, South Australia, Australia.,Industrial Design Engineering, Delft University of Technology, TU Delft, The Netherlands
| | - Dimitar Sajkov
- Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Medicine, Royal Darwin Hospital, Casuarina, Northern Territory, Australia
| | - Sharon Morton
- Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
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Morrison JJ. Evolution in Private Practice Interventional Radiology: Data Mining Trends in Procedure Volumes. Semin Intervent Radiol 2019; 36:17-22. [PMID: 30936611 DOI: 10.1055/s-0039-1683358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Diversity of procedures is a mainstay of interventional radiology (IR) and the ability to adapt and acquire new procedural skills is a benefit in a constantly changing medical environment. Strategies for success include building direct referral patterns from primary care providers, fostering strong interpersonal relationships with referring services, and providing efficient care coordinated through a dedicated IR clinic. In this study, retrospective analysis of procedural volumes over 16 years within a single large private IR practice was performed to examine the evolution of private practice IR. Primary data are presented, with analysis of the internal and external factors that have determined current procedural scope.
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Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E7-E15. [PMID: 30604780 PMCID: PMC8021127 DOI: 10.12788/jhm.3095] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.
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Affiliation(s)
- Joel Cho
- Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA.
| | - Trevor P Jensen
- Division of Hospital Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
| | - Kreegan Reierson
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
| | - Benji K Mathews
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Anjali Bhagra
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ricardo Franco-Sadud
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Michael Mader
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Ria Dancel
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brian P Lucas
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | | | - Nilam J Soni
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
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Gorgone M. The Procedure Coordinator: A Resident-Driven Initiative to Increase Opportunity for Inpatient Procedures. J Grad Med Educ 2018; 10:583-586. [PMID: 30386486 PMCID: PMC6194897 DOI: 10.4300/jgme-d-18-00399.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/10/2018] [Accepted: 07/17/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Training residents to become competent in common bedside procedures can be challenging. Some hospitals have attending physician-led procedure teams with oversight of all procedures to improve procedural training, but these teams require significant resources to establish and maintain. OBJECTIVE We sought to improve resident procedural training by implementing a resident-run procedure team without routine attending involvement. METHODS We created the role of a resident procedure coordinator (RPC). Interested residents on less time-intensive rotations voluntarily served as RPC. Medical providers in the hospital contacted the RPC through a designated pager when a bedside procedure was needed. A structured credentialing process, using direct observation and a procedure-specific checklist, was developed to determine residents' competence for completing procedures independently. Checklists were developed by the residency program and approved by institutional subspecialists. The service was implemented in June 2016 at an 850-bed academic medical center with 70 internal medicine and 32 medicine-pediatrics residents. The procedure service functioned without routine attending involvement. The impact was evaluated through resident procedure logs and surveys of residents and attending physicians. RESULTS Compared with preimplementation procedure logs, there were substantial increases postimplementation in resident-performed procedures and the number of residents credentialed in paracenteses, thoracenteses, and lumbar punctures. Fifty-nine of 102 (58%) residents responded to the survey, with 42 (71%) reporting the initiative increased their ability to obtain procedural experience. Thirty-one of 36 (86%) attending respondents reported preferentially using the service. CONCLUSIONS The RPC model increased resident procedural training opportunities using a structured sign-off process and an operationalized service.
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Rosenkrantz AB, Friedberg EB, Prologo JD, Everett C, Duszak R. Generalist versus Subspecialist Workforce Characteristics of Invasive Procedures Performed by Radiologists. Radiology 2018; 289:140-147. [DOI: 10.1148/radiol.2018180761] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew B. Rosenkrantz
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Health, 660 First Ave, New York, NY 10016 (A.B.R.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (E.B.F., J.D.P., R.D.); and Coastal Radiology Associates, PLLC, New Bern, NC (C.E.)
| | - Eric B. Friedberg
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Health, 660 First Ave, New York, NY 10016 (A.B.R.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (E.B.F., J.D.P., R.D.); and Coastal Radiology Associates, PLLC, New Bern, NC (C.E.)
| | - J. David Prologo
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Health, 660 First Ave, New York, NY 10016 (A.B.R.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (E.B.F., J.D.P., R.D.); and Coastal Radiology Associates, PLLC, New Bern, NC (C.E.)
| | - Catherine Everett
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Health, 660 First Ave, New York, NY 10016 (A.B.R.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (E.B.F., J.D.P., R.D.); and Coastal Radiology Associates, PLLC, New Bern, NC (C.E.)
| | - Richard Duszak
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Health, 660 First Ave, New York, NY 10016 (A.B.R.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (E.B.F., J.D.P., R.D.); and Coastal Radiology Associates, PLLC, New Bern, NC (C.E.)
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Hawkins CM. Rules and Regulations Relating to Roles of Nonphysician Providers in Radiology Practices. Radiographics 2018; 38:1609-1616. [DOI: 10.1148/rg.2018180031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- C. Matthew Hawkins
- From the Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-guided Medicine, Emory University School of Medicine, 1364 Clifton Rd NE, Suite D112, Atlanta, GA 30322; and Department of Radiology and Imaging Sciences, Division of Pediatric Radiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Ga
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Barsuk JH, Cohen ER, Williams MV, Scher J, Jones SF, Feinglass J, McGaghie WC, O'Hara K, Wayne DB. Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:729-735. [PMID: 29068818 DOI: 10.1097/acm.0000000000001965] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Physicians-in-training often perform bedside thoracenteses in academic medical centers, and complications are more common among less experienced clinicians. Simulation-based mastery learning (SBML) is one potential solution to this problem. This study evaluated the effects of a randomized trial of thoracentesis SBML on patient complications: iatrogenic pneumothorax (IP), hemothorax, and reexpansion pulmonary edema (REPE). METHOD The authors randomized internal medicine residents to undergo thoracentesis SBML at a tertiary care academic center from December 2012 to May 2016. They subsequently compared thoracentesis complications from procedures performed by SBML-trained residents, traditionally trained residents (no simulation training), and those referred to pulmonary medicine or interventional radiology (IR). RESULTS During the study period, 917 thoracenteses were performed on 709 patients. IP occurred in 60 (6.5%) procedures, of which 7 (11.6%) were clinically meaningful. SBML-trained residents performed procedures with a trend toward lower combined clinically meaningful complications (IP, hemothorax, REPE) compared with traditionally trained residents (7.9% vs. 0%; P = .06). SBML-trained residents caused fewer clinically meaningful IPs compared with traditionally trained residents, pulmonary, and IR referrals (P = .02). Hemothorax occurred after 4 (0.4%) thoracenteses, and SBML-trained residents had a trend toward lower hemothorax (0) compared with other groups (P = .07). REPE occurred after 3 (0.3%) procedures, with no differences between groups. SBML-trained residents performed procedures with lower combined clinically meaningful complications compared with other groups (P = .008). CONCLUSIONS Residents randomized to an SBML intervention performed thoracenteses with low rates of clinically meaningful complications. Rigorous education represents a successful quality improvement strategy.
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Affiliation(s)
- Jeffrey H Barsuk
- J.H. Barsuk is professor of medicine, Departments of Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois. E.R. Cohen is a research associate, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. M.V. Williams is professor of medicine, director, Center for Health Services Research, and vice chair, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky. J. Scher is research coordinator, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. S.F. Jones is research coordinator, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. J. Feinglass is research professor of medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. W.C. McGaghie is professor of medical education, Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois. K. O'Hara is instructor, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. D.B. Wayne is vice dean for education and Dr. John Sherman Appleman Professor of Medicine, Departments of Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Zielinska-Krawczyk M, Grabczak EM, Michnikowski M, Zielinski K, Korczynski P, Stecka A, Golczewski T, Krenke R. Patterns of pleural pressure amplitude and respiratory rate changes during therapeutic thoracentesis. BMC Pulm Med 2018; 18:36. [PMID: 29444649 PMCID: PMC5813371 DOI: 10.1186/s12890-018-0595-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the impact of therapeutic thoracentesis on lung function and blood gases has been evaluated in several studies, some physiological aspects of pleural fluid withdrawal remain unknown. The aim of the study was to assess the changes in pleural pressure amplitude (Pplampl) during the respiratory cycle and respiratory rate (RR) in patients undergoing pleural fluid withdrawal. METHODS The study included 23 patients with symptomatic pleural effusion. Baseline pleural pressure curves were registered with a digital electronic manometer. Then, the registrations were repeated after the withdrawal of consecutive portions of pleural fluid (200 ml up to 1000 ml and 100 ml above 1000 ml). In all patients the pleural pressure curves were analyzed in five points, at 0, 25%, 50%, 75% and 100% of the relative volume of pleural effusion withdrawn in particular patients. RESULTS There were 11 and 12 patients with right sided and left sided pleural effusion, respectively (14 M, 9F, median age 68, range 46-85 years). The most common cause of pleural effusion were malignancies (20 pts., 87%). The median total volume of withdrawn pleural fluid was 1800 (IQR 1500-2400) ml. After termination of pleural fluid withdrawal Pplampl increased in 22/23 patients compared to baseline. The median Pplampl increased from 3.4 (2.4-5.9) cmH2O to 10.7 (8.1-15.6) cmH2O (p < 0.0001). Three patterns of Pplampl changes were identified. Although the patterns of RR changes were more diversified, a significant increase between RR at baseline and the last measurement point was found (p = 0.0097). CONCLUSIONS In conclusion, therapeutic thoracentesis is associated with significant changes in Pplampl during the respiratory cycle. In the vast majority of patients Pplampl increased steadily during pleural fluid withdrawal. There was also an increase in RR. The significance of these changes should be elucidated in further studies. TRIAL REGISTRATION ClinicalTrial.gov, registration number: NCT02192138 , registration date: July 1st, 2014.
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Affiliation(s)
- Monika Zielinska-Krawczyk
- Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw, Banacha 1a, 02-097, Warsaw, Poland
| | - Elzbieta M Grabczak
- Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw, Banacha 1a, 02-097, Warsaw, Poland
| | - Marcin Michnikowski
- Nalęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109, Warsaw, Poland
| | - Krzysztof Zielinski
- Nalęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109, Warsaw, Poland
| | - Piotr Korczynski
- Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw, Banacha 1a, 02-097, Warsaw, Poland
| | - Anna Stecka
- Nalęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109, Warsaw, Poland
| | - Tomasz Golczewski
- Nalęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109, Warsaw, Poland
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw, Banacha 1a, 02-097, Warsaw, Poland.
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Zielinska-Krawczyk M, Krenke R, Grabczak EM, Light RW. Pleural manometry-historical background, rationale for use and methods of measurement. Respir Med 2018; 136:21-28. [PMID: 29501243 DOI: 10.1016/j.rmed.2018.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 01/14/2018] [Accepted: 01/27/2018] [Indexed: 10/18/2022]
Abstract
Subatmospheric pleural pressure (Ppl), which is approximately -3 to -5 cmH2O at functional residual capacity (FRC) makes pleura a unique organ in the human body. The negative Ppl is critical for maintaining the lungs in a properly inflated state and for proper blood circulation within the thorax. Significant and sudden pleural pressure changes associated with major pleural pathologies, as well as therapeutic interventions may be associated with life-threatening complications. The pleural pressure may show two different values depending on the measurement method applied. These are called pleural liquid pressure and pleural surface pressure. It should also be realized that there are significant differences in pleural pressure distribution in pneumothorax and pleural effusion. In pneumothorax, the pressure is the same throughout the pleural space, while in pleural effusion there is a vertical gradient of approximately 1 cm H2O/cm in the pleural pressure associated with the hydrostatic pressure of the fluid column. Currently, two main methods of pleural pressure measurement are used: simple water manometers and electronic systems. The water manometers are conceptually simple, cheap and user-friendly but they only allow the estimation of the mean values of pleural pressure. The electronic systems for pleural pressure measurement are based on pressure transducers. Their major advantages include precise measurements of instantaneous pleural pressure and the ability to display and to store a large amount of data. The paper presents principles and details of pleural pressure measurement as well as the rationale for its use.
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Affiliation(s)
- Monika Zielinska-Krawczyk
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland.
| | - Elzbieta M Grabczak
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland
| | - Richard W Light
- Department of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical School, Nashville, TN, USA
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Barsuk JH, Rosen BT, Cohen ER, Feinglass J, Ault MJ. Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding. J Hosp Med 2018; 13:30-33. [PMID: 29073312 DOI: 10.12788/jhm.2863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a "2-probe technique, " which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding.
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Affiliation(s)
- Jeffrey H Barsuk
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Bradley T Rosen
- Division of General Internal Medicine, Cedars- Sinai Medical Center, Los Angeles, California, USA
| | - Elaine R Cohen
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joe Feinglass
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark J Ault
- Division of General Internal Medicine, Cedars- Sinai Medical Center, Los Angeles, California, USA
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Wall suction-assisted image-guided thoracentesis: a safe alternative to evacuated bottles. Clin Radiol 2017; 72:898.e1-898.e5. [DOI: 10.1016/j.crad.2017.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/13/2017] [Accepted: 05/02/2017] [Indexed: 11/21/2022]
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The use of a virtual patient to follow pleural pressure changes associated with therapeutic thoracentesis. Int J Artif Organs 2017; 40:690-695. [PMID: 28799625 PMCID: PMC6161568 DOI: 10.5301/ijao.5000636] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2017] [Indexed: 01/22/2023]
Abstract
Purpose Influence of therapeutic thoracentesis on the pleural pressure (Pp) has been discussed in many clinical studies, however reasons of Pp changes are not precisely established. The aim of the study was to use a previously elaborated virtual cardiopulmonary patient (VP) in analysis of impact of physiological factors on Pp during the procedure. Methods Simulations were performed on VP with default values of parameters for which VP simulated the respiratory system of the average 50-year-old healthy Polish woman according to spirometric examination. Alterations of Pp and the amplitude of Pp changes related to breathing (AP) were analyzed. Model parameters related to chosen factors were deviated from their default values to analyze the degree of their impact on Pp and AP. The analysis was based on and supported by our own clinical data. Results The Pp and AP alteration intensity appeared to be most sensitive to the compliances of the rib cage and mediastinum, and the nonlinearity of the dependence between the recoil pressure and the lung volume: the lower the compliances and the higher the nonlinearity were, the deeper the Pp fall during the procedure and the bigger the AP increase were observed. Conclusions Experiments in silico are very useful in analyzing sophisticated physiological and medical problems. They made it possible to show which factors are particularly responsible for changes in Pp during thoracentesis. In the future, they may be useful in establishing objective conditions under which thoracentesis needs to be stopped.
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Kay C, Wozniak EM, Szabo A, Jackson JL. Examining Invasive Bedside Procedure Performance at an Academic Medical Center. South Med J 2017; 109:402-7. [PMID: 27364022 DOI: 10.14423/smj.0000000000000485] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Explore the performance patterns of invasive bedside procedures at an academic medical center, evaluate whether patient characteristics predict referral, and examine procedure outcomes. METHODS This was a prospective, observational, and retrospective chart review of adults admitted to a general medicine service who had a paracentesis, thoracentesis, or lumbar puncture between February 22, 2013 and February 21, 2014. RESULTS Of a total of 399 procedures, 335 (84%) were referred to a service other than the primary team for completion. Patient characteristics did not predict referral status. Complication rates were low overall and did not differ, either by referral status or location of procedure. Model-based results showed a 41% increase in the average length of time until procedure completion for those referred to the hospital procedure service or radiology (7.9 vs 5.8 hours; P < 0.05) or done in radiology instead of at the bedside (9.0 vs 5.8 hours; P < 0.001). The average procedure cost increased 38% ($1489.70 vs $1023.30; P < 0.001) for referred procedures and 56% ($1625.77 vs $1150.98; P < 0.001) for radiology-performed procedures. CONCLUSIONS Although referral often is the easier option, our study shows its shortcomings, specifically pertaining to cost and time until completion. Procedure performance remains an important skill for residents and hospitalists to learn and use as a part of patient care.
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Affiliation(s)
- Cynthia Kay
- From the Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Erica M Wozniak
- From the Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Aniko Szabo
- From the Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Jeffrey L Jackson
- From the Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
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Shrum J, Hallihan G, Jones J, Tesorero L, Gregson G, Kaba A, Holroyd-Leduc JM, Borkenhagen D, Lambert LA, Ma IWY. Impact of a Procedural Cart on Procedural Efficiency. Am J Med Qual 2017; 32:342-343. [PMID: 28467863 DOI: 10.1177/1062860617691355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Barsuk JH, Cohen ER, Williams MV, Scher J, Feinglass J, McGaghie WC, O'Hara K, Wayne DB. The effect of simulation-based mastery learning on thoracentesis referral patterns. J Hosp Med 2016; 11:792-795. [PMID: 27273066 DOI: 10.1002/jhm.2623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/28/2016] [Accepted: 05/08/2016] [Indexed: 11/10/2022]
Abstract
Internal medicine (IM) residents and hospitalist physicians commonly perform thoracenteses. National data show that thoracenteses are also frequently referred to other services such as interventional radiology (IR), increasing healthcare costs. Simulation-based mastery learning (SBML) is an effective method to boost physicians' procedural skills and self-confidence. This study aimed to (1) assess the effect of SBML on IM residents' simulated thoracentesis skills and (2) compare thoracentesis referral patterns, self-confidence, and reasons for referral between traditionally trained residents (non-SBML-trained), SBML-trained residents, and hospitalist physicians. A random sample of 112 IM residents at an academic medical center completed thoracentesis SBML from December 2012 to May 2015. We surveyed physicians caring for hospitalized patients with thoracenteses during the same time period and compared referral patterns, self-confidence, and reasons for referral. SBML-trained resident thoracentesis skills improved from a median of 57.6% (interquartile range [IQR] 43.3-76.9) at pretest to 96.2% (IQR 96.2-100.0) at post-test (P < 0.001). Surveys demonstrated that traditionally trained residents were more likely to refer to IR and cited lower confidence as reasons. SBML-trained residents were more likely to perform bedside thoracenteses. Hospitalist physicians were most likely to refer to pulmonary medicine and cited lack of time to perform the procedure as the main reason. SBML-trained residents were most confident about their thoracentesis skills, despite hospitalist physicians having more experience. This study identifies confidence and time as reasons physicians refer thoracenteses rather than perform them at the bedside. Thoracentesis SBML boosts skills and promotes bedside procedures that are safe and less expensive than referrals. Journal of Hospital Medicine 2016;11:792-795. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Jeffrey H Barsuk
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Elaine R Cohen
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark V Williams
- Department of Medicine, University of Kentucky School of Medicine, Lexington, Kentucky
| | - Jordan Scher
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joe Feinglass
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William C McGaghie
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly O'Hara
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Diane B Wayne
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Abstract
With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify "complex" are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.
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Barr J, Graffeo CS. Procedural Experience and Confidence Among Graduating Medical Students. JOURNAL OF SURGICAL EDUCATION 2016; 73:466-73. [PMID: 26778743 DOI: 10.1016/j.jsurg.2015.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/25/2015] [Accepted: 11/24/2015] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Bedside procedures are a vital component of patient care-particularly for surgeons. Anecdotal evidence and previous studies from individual institutions reveal a lack of exposure to these interventions in medical school. Our objective was to ascertain medical students' experience and confidence in performing bedside procedures. DESIGN Our study included a multi-institutional, anonymous, Health Insurance Portability and Accountability Act-compliant electronic survey. Using a 4-point Likert scale, students were asked how many times they had performed each of 18 common bedside procedures and their anticipated confidence in completing it independently. Statistical analysis included student t test, Chi-square test, analysis of means, linear regression, and Bonferroni correction for multiple comparisons. PARTICIPANTS In total, participants included 2260 4th year medical students at 17 allopathic medical schools. RESULTS Overall, 644 students replied (28.5% response rate). Most respondents had never placed an arterial line (71%), central venous line (81%), chest tube (89%), intraosseous line (95%), injected a joint (63%), or had performed cardiopulmonary resuscitation (50%), a lumbar puncture (57%), paracentesis (66%), or thoracentesis (92%). Venipuncture, suturing, and Foley catheter placement were the only procedures which greater than 50% of students had performed more than 5 times. Significant correlation was observed (r = 0.7) between experience and confidence, with men being reported significantly higher experience and confidence than women (p < 0.0001). Students entering anesthesia and emergency medicine residencies reported significantly higher experience than those matriculating into other specialties (α = 0.003); students entering emergency medicine and surgery reported significantly higher confidence levels (α = 0.003). CONCLUSION The largest survey of its kind, the present study demonstrates that medical students are underexposed to essential bedside procedures and feel uncomfortable performing them-a trend that has worsened over 25 years. Students entering surgical specialties have significantly higher levels of confidence, although a corresponding difference in experience was not observed.
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Affiliation(s)
- Justin Barr
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Christopher S Graffeo
- Department of Neurologic Surgery, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota.
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Kozmic SE, Wayne DB, Feinglass J, Hohmann SF, Barsuk JH. Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals. Jt Comm J Qual Patient Saf 2016; 42:34-40. [PMID: 26685932 DOI: 10.1016/s1553-7250(16)42004-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than performing them at the bedside. Factors associated with thoracentesis procedures at university hospitals were studied to determine clinical outcomes by provider specialty. METHODS An administrative database review was performed of patients who underwent an inpatient thoracentesis procedure in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through September 2013. The incidence of iatrogenic pneumothorax, mean total hospital costs, and mean length of stay (LOS) were compared by clinical specialty. RESULTS There were 113,860 admissions with 132,472 thoracentesis procedures performed on 99,509 patients at 234 UHC hospitals. IR performed 43,783 (33%) thoracentesis procedures; medicine, 22,243 (17%); and pulmonary, 26,887 (20%). The incidence of iatrogenic pneumothorax was 2.8% for IR, 2.9% for medicine, and 3.1% for pulmonary. Medicine and pulmonary had equivalent risk of iatrogenic pneumothorax compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs compared to IR admissions (p < 0.001) after controlling for clinical covariates. Admissions with IR procedures had a mean LOS of 14.1 days; medicine, 13.2 days; and pulmonary, 15.9 days. Admissions with medicine and pulmonary procedures were associated with fewer hospital days when compared to IR in the controlled model (p < 0.001). CONCLUSION Admissions with medicine and pulmonary bedside thoracentesis procedures are as safe and less costly than IR procedures. Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.
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Affiliation(s)
- Sarah E Kozmic
- Northwestern University Feinberg School of Medicine, Chicago, USA
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Hoyer R, Means R, Robertson J, Rappaport D, Schmier C, Jones T, Stolz LA, Kaplan SJ, Adamas-Rappaport WJ, Amini R. Ultrasound-guided procedures in medical education: a fresh look at cadavers. Intern Emerg Med 2016; 11:431-6. [PMID: 26276229 DOI: 10.1007/s11739-015-1292-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
Abstract
Demand for bedside ultrasound in medicine has created a need for earlier exposure to ultrasound education during the clinical years of undergraduate medical education. Although bedside ultrasound is often used for invasive medical procedures, there is no standardized educational model for procedural skills that can provide the learner a real-life simulated experience. The objective of our study was to describe a unique fresh cadaver preparation model, and to determine the impact of a procedure-focused ultrasound training session. This study was a cross-sectional study at an urban academic medical center. A sixteen-item questionnaire was administered at the beginning and end of the session. Fifty-five third year medical students participated in this 1-day event during their surgical clerkship. Students were trained to perform the following ultrasound-guided procedures: internal jugular vein cannulation, femoral vein cannulation femoral artery cannulation and pericardiocentesis. Preparation of the fresh cadaver is easily replicated and requires minor manipulation of cadaver vessels and pericardial space. Fifty-five medical students in their third year participated in this study. All of the medical students agreed that US could help increase their confidence in performing procedures in the future. Eighty percent (95 % CI 70-91 %) of students felt that there was a benefit of learning ultrasound-based anatomy in addition to traditional methods. Student confidence was self-rated on a five-point Likert scale. Student confidence increased with statistical significance in all of the skills taught. The most dramatic increase was noted in central venous line placement, which improved from 1.95 (SD = 0.11) to 4.2 (SD = 0.09) (p < 0.001). The use of fresh cadavers for procedure-focused US education is a realistic method that improves the confidence of third year medical students in performing complex but critical procedures.
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Affiliation(s)
- Riley Hoyer
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Russel Means
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | | | | | - Charles Schmier
- Department of Emergency Medicine, University of Arizona Medical Center, PO Box 245057, Tucson, AZ, 85724-5057, USA
| | - Travis Jones
- Department of Emergency Medicine, University of Arizona Medical Center, PO Box 245057, Tucson, AZ, 85724-5057, USA
| | - Lori Ann Stolz
- Department of Emergency Medicine, University of Arizona Medical Center, PO Box 245057, Tucson, AZ, 85724-5057, USA
| | | | | | - Richard Amini
- Department of Emergency Medicine, University of Arizona Medical Center, PO Box 245057, Tucson, AZ, 85724-5057, USA.
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Wolfe KS, Kress JP. Risk of Procedural Hemorrhage. Chest 2016; 150:237-46. [PMID: 26836937 DOI: 10.1016/j.chest.2016.01.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 01/04/2016] [Accepted: 01/19/2016] [Indexed: 12/17/2022] Open
Abstract
Patients who are critically ill and hospitalized often require invasive procedures as a part of their medical care. Each procedure carries a unique set of risks and associated complications, but common to all of them is the risk of hemorrhage. Central venous catheterization, arterial catheterization, paracentesis, thoracentesis, tube thoracostomy, and lumbar puncture constitute a majority of the procedures performed in patients who are hospitalized. In this article, the authors will discuss the risk factors for bleeding complications from each of these procedures and methods to minimize risk. Physicians often correct coagulopathy prior to procedures to decrease bleeding risk, but there is minimal evidence to support this practice.
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Affiliation(s)
- Krysta S Wolfe
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - John P Kress
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
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McQuillan RF, Clark E, Zahirieh A, Cohen ER, Paparello JJ, Wayne DB, Barsuk JH. Performance of Temporary Hemodialysis Catheter Insertion by Nephrology Fellows and Attending Nephrologists. Clin J Am Soc Nephrol 2015; 10:1767-72. [PMID: 26408550 DOI: 10.2215/cjn.01720215] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 06/17/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Concerns have been raised about nephrology fellows' skills in inserting temporary hemodialysis catheters. Less is known about temporary hemodialysis catheter insertion skills of attending nephrologists supervising these procedures. The aim of this study was to compare baseline temporary hemodialysis catheter insertion skills of attending nephrologists with the skills of nephrology fellows before and after a simulation-based mastery learning (SBML) intervention. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This pre- post-intervention study with a pretest-only comparison group was conducted at the University of Toronto in September of 2014. Participants were nephrology fellows and attending nephrologists from three university-affiliated academic hospitals who underwent baseline assessment of internal jugular temporary hemodialysis catheter insertion skills using a central venous catheter simulator. Fellows subsequently completed an SBML intervention, including deliberate practice with the central venous catheter simulator. Fellows were expected to meet or exceed a minimum passing score at post-test. Fellows who did not meet the minimum passing score completed additional deliberate practice. Attending nephrologist and fellow baseline performance on the temporary hemodialysis catheter skills assessment was compared. Fellows' pre- and post-test temporary hemodialysis catheter insertion performance was compared to assess the effectiveness of SBML. The skills assessment was scored using a previously published 28-item checklist. The minimum passing score was set at 79% of checklist items correct. RESULTS In total, 19 attending nephrologists and 20 nephrology fellows participated in the study. Mean attending nephrologist checklist scores (46.1%; SD=29.5%) were similar to baseline scores of fellows (41.1% items correct; SD=21.4%; P=0.55). Only two of 19 attending nephrologists (11%) met the minimum passing score at baseline. After SBML, fellows' mean post-test score improved to 91.3% (SD=6.9%; P<0.001). Median time between pre- and post-test was 24 hours. CONCLUSIONS Attending nephrologists' baseline temporary hemodialysis catheter insertion skills were highly variable and similar to nephrology fellows' skills, with only a small minority able to competently insert a temporary hemodialysis catheter. SBML was extremely effective for training fellows and should be considered for attending nephrologists who supervise temporary hemodialysis catheter insertions.
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Affiliation(s)
| | - Edward Clark
- Division of Nephrology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; and
| | - Alireza Zahirieh
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Diane B Wayne
- Departments of Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey H Barsuk
- Departments of Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Hawkins CM, Bowen MA, Gilliland CA, Walls DG, Duszak R. The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Operational and Educational Implications. J Am Coll Radiol 2015; 12:898-904. [DOI: 10.1016/j.jacr.2015.03.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 03/23/2015] [Indexed: 01/05/2023]
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