Hospitals Launch Bedside Procedure Services

A dedicated procedure team or service can give hospitals needed expertise without requiring a one-size-fits-all approach. In many cases, hospitalists run procedure services, but interventional radiologists and pulmonary critical care specialists also oversee some of them.

At The Johns Hopkins Hospital, the bedside procedure service began in the department of medicine and has since expanded throughout the hospital.

“I think a proceduralist service is as important as the hospitalist service,” says David Lichtman, PA, director of the service. He calls it “essential” for good patient care because it can allow experienced providers to be consistently involved in the process, whether proceduralists, medical students, or new interns perform the procedure.

“Patients have the benefit of expert care, and the trainees have the ability to learn and do without having to worry about working without a safety net,” he says. As a result, the service keeps patients safe while maximizing medical education.

At many institutions, a service or team can also meet a pressing need. In its seven years of existence, for example, the hospitalist-led procedures team at the University of Miami Jackson Memorial Hospital Medical Campus has been called upon to do more than 7,500 procedures.

“The idea behind procedure services is that you consolidate the expertise and training within a few people, be it a few hospitalists or a few proceduralists,” says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California

San Francisco (UCSF). But a successful service can require significant investments in infrastructure and other resources. When they run the numbers, many hospitalist groups are forced to conclude that they simply don’t have sufficient demand to justify the expense of maintaining provider competency.

“People are really struggling with this,” she says.

I derive a tremendous amount of enjoyment from working with my hands, from being able to provide my patients this service, from often giving them relief from excessive fluid buildup, and from being able to do these procedures at the bedside. —Michelle Mourad, MD, associate professor of clinical medicine and director of quality improvement and patient safety, division of hospital medicine, University of California San Francisco
The few studies conducted on procedure services, however, suggest that hospitals can benefit from improved patient satisfaction and a potential reduction in some complications.

“We were worried that that use of trainees and the teaching that went on at the bedside might be a concern for patients,” Dr. Mourad says of the UCSF procedures program. “We found that, instead, patients were reassured by having a designated expert in the room and recognized that it hadn’t always been the case in the past.” Accordingly, she says, a survey of satisfaction recorded “exceptionally high” rates.3

Initial research also suggests a reduction in such complications as thoracentesis-related pneumothorax.

“We have some inkling that perhaps the rigor with which we approach procedures, the high level of experience that we bring to procedures, and the presence of an expert in the room for every procedure may have decreased the complication rate for thoracentesis at our institution,” Dr. Mourad says.

At Boston University, the procedure service is based in the department of pulmonary critical care, and the department’s attending physicians supervise internal medicine residents. It was developed after “identifying some potential patient safety concerns with unsupervised resident procedures,” says Melissa Tukey, MD, MSc, now a pulmonology critical care physician at Lahey Clinic in Burlington, Mass. A major aim of the procedure service, she says, is to provide supervision and teaching to medical house staff performing the procedures.

To test whether the service was delivering on those goals, Dr. Tukey and colleagues studied thoracentesis, paracentesis, central line, and lumbar puncture procedures.4 The study, an 18-month comparison of the procedures performed by the dedicated procedure service versus those done by other providers, found no significant difference in what were already quite low complication rates.

Unexpectedly, the researchers didn’t see higher levels of resident engagement in procedures performed by the procedure team, but they did find improvement in “best practice safety process measures,” such as whether ultrasound use followed established recommendations.

“I think that whenever you’re looking at quality improvement initiatives, you have to have an understanding of what might be the potential benefits,”

Dr. Tukey says. Her study, at least, suggests that launching a procedure service primarily to reduce the number of severe complications may not be the most appropriate goal. On the other hand, she says, the data do support the “very realistic goals” of improving residency education and maintaining procedure quality.

A dedicated service may not be a cure all, in other words. And it’s certainly not for everyone. But given enough resources and buy in, experts say, it could at least help put a hospital’s ailing bedside procedure strategy on the road to recovery without overextending its providers.