Additional Capacity Management Programs

Proceduralist Program

Another program that a hospital can consider is a Proceduralist program. The concept of this program is to provide a trained team of APPs (NPs and PAs) to provide a flexible and efficient method to have various vascular lines placed or certain procedures done. The current method of acquiring the placement of vascular lines and procedures is to use a combination of resources whose availability may be spotty at best. Having an identified trained individual available for this purpose could have a significant impact on patient length of stay, efficiency of procedure acquisition or vascular line placement, improved patient safety and improved patient, and staff satisfaction.

I can remember when I was in training for my Internal Medicine residency, we were required to perform all the procedures and line placements in the hospital. This included the following:

  • (1) Central line placement
  • (2) Difficult peripheral line placement
  • (3) Arterial line placement
  • (4) Thoracentesis
  • (5) Paracentesis
  • (6) Lumbar puncture

There was limited ability of radiology, phlebotomy, or surgery to provide these services. Things have changed dramatically over the last 34 years. Rarely do residents perform procedures or place lines and the result is to schedule a patient through interventional radiology or perhaps get an intensivist, neurologist, or surgeon to assist in some of the procedures. The result can be significant delays in the line being placed or the procedure being performed. This adds to the patients’ LOS on many occasions or at a minimum, less satisfied patients who may have to wait for extended periods to get the procedure done. The implementation of a proce- duralist program could mitigate those issues. The program would pay for the APP by billing professional fees for the procedures performed.

The following benefits to the program could be experienced:

Efficiency—Patients would have procedures done in a more efficient manner by having specific staff trained in invasive procedures. The more procedures a provider undertakes, the more skilled and efficient the provider becomes.

Utilization management—Patients many times may have the wrong type of line placed. By having trained proce- duralists, patients would get the right line the first time. Inappropriate use of PICC lines would decrease. Trying to manage patients with inadequate peripheral lines would be resolved.

Revenue generation—Currently, many of the invasive procedures are not billed by providers. Each procedure has a separate CPT code and an associated professional fee and facility fee attached to it. By properly billing for procedures, many hospitals have found that the cost for the proceduralist group can be adequately covered by professional fee billing.

Patient safety—By having a trained team of proceduralists, the complication rate for invasive procedures has been found to be less than 1% compared with 2%-5% nationally. Strict adherence to infection control techniques would be standardized with a proceduralist team.

Reduced length of stay—Since the proceduralist group would be available 24/7, patients would no longer be awaiting a procedure, for example, in interventional radiology. Such patients may have a shorted length of stay by getting procedures done in a timely fashion.

Medical staff satisfaction—Clearly, medical staff members whose skill sets are no longer adequately maintained for invasive procedures would have a defined team to provide the services necessary for the care of their patients in a timely fashion which will significantly improve physician satisfaction.

Additional types of services could be rendered to provide sufficient procedure volume for the APP. This could include:

  • (1) PICC lines
  • (2) Dialysis catheters
  • (3) Tunnel catheters
  • (4) G-tube replacement
  • (5) Suprapubic catheters

There are likely additional procedures that could be performed. The APP would be under the supervision of an attending physician in the main hospital. Impact on overall LOS would vary depending on the overall volume of procedures done, the current procedure wait time, and the impact a proceduralist would have. The impact would be most evident on the weekends when many times, a patient will wait the entire weekend for a procedure on Monday because the procedure was not deemed to be emergent.

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