Hospitalists Perform Well on Fluid Retrieval Procedures

GRAPEVINE, TEX. – Hospitalists can safely perform fluid retrieval procedures with a high rate of success and no patient complications, according to the findings of a retrospective study.

A hospitalist procedure team had an overall success rate of 92% among 977 thoracenteses, paracenteses, and lumbar punctures that were performed over a 2-year period, Dr. Michelle Mourad reported at the annual meeting of the Society of Hospital Medicine. The results suggest that additional training can boost hospitalists’ success rates to nearly that of the subspecialists who routinely perform these procedures.

"Unfortunately, many hospitalists lack formal training in procedure skills because training during residency is decreasing," said Dr. Mourad, a hospitalist at the University of California, San Francisco. "We are graduating hospitalists without these skills and having to refer procedures to subspecialties and interventional radiology."

Having hospitalists who are competent in procedures "is becoming more important because advanced technologies like bedside ultrasounds are rapidly becoming the standard of care."

Dr. Mourad and her colleagues examined their database over a 2-year period to determine the success rate of the three common procedures. Aside from success or failure, the outcomes took into account patient characteristics that might contribute to the lack of success and any patient outcomes that were related to unsuccessful procedures.

The hospitalist procedure service at Dr. Mourad’s institution began in 2008 and includes five physicians who obtained additional procedure skills from emergency physicians and interventional radiologists.

Over the 2-year period, the team performed 977 of these procedures (408 paracenteses, 279 thoracenteses, and 290 lumbar punctures). Nonsuccess was defined as the failure to obtain adequate fluid despite several needle passes.

The failure rate among paracenteses was 1%. All four of the unsuccessful procedures had ultrasound corroboration of fluid. "All of these patients also had an abdominal wall greater than 5 cm," Dr. Mourad said. "None sustained any complications," nor were any of these patients referred to another provider. All were treated empirically for spontaneous bacterial peritonitis.

Among the thoracenteses, 6% were unsuccessful. A CT scan corroborated the presence of more than 2 cm of fluid in each of the 16 cases. In all, 10 of the 16 patients had malignant effusions and 50% had pleural thickening. "We suspect that the pleural thickening" may have caused the procedures to be prematurely aborted "because the fluid was deeper than anticipated," Dr. Mourad said.

Nine patients were referred to interventional radiology and, although all radiologists agreed that the procedure was possible, they were unable to obtain fluid in three patients. "Of the six that were completed, three were more complicated than initially thought. Interventional radiology had to use CT guidance to complete the procedure." None of the failures resulted in any patient complications.

The largest failure rate occurred among the lumbar punctures, in which 19% (56) were unsuccessful. Most of the patients with unsuccessful procedures were overweight or obese, Dr. Mourad said; 53% had a body mass index of more than 25 kg/m² and 36% had a BMI of more than 30. "We need to compare this to our total population of procedures to determine if BMI is a true risk factor or not," she said.

Of the unsuccessful procedures, 28 were referred to neuroradiology, where they were all successfully completed, although some required CT guidance. There were no complications among any of the patients with a failed procedure.

The findings have prompted some changes in the way procedures are managed, Dr. Mourad said. "For instance, for paracentesis we now routinely measure the abdominal wall thickness, and we have [a larger] range of needles available because we know that the problems of not getting fluid are often a problem of needle length."

Dr. Mourad reported having no conflicts of interest.

GRAPEVINE, TEX. – Hospitalists can safely perform fluid retrieval procedures with a high rate of success and no patient complications, according to the findings of a retrospective study.

A hospitalist procedure team had an overall success rate of 92% among 977 thoracenteses, paracenteses, and lumbar punctures that were performed over a 2-year period, Dr. Michelle Mourad reported at the annual meeting of the Society of Hospital Medicine. The results suggest that additional training can boost hospitalists’ success rates to nearly that of the subspecialists who routinely perform these procedures.

"Unfortunately, many hospitalists lack formal training in procedure skills because training during residency is decreasing," said Dr. Mourad, a hospitalist at the University of California, San Francisco. "We are graduating hospitalists without these skills and having to refer procedures to subspecialties and interventional radiology."

Having hospitalists who are competent in procedures "is becoming more important because advanced technologies like bedside ultrasounds are rapidly becoming the standard of care."

Dr. Mourad and her colleagues examined their database over a 2-year period to determine the success rate of the three common procedures. Aside from success or failure, the outcomes took into account patient characteristics that might contribute to the lack of success and any patient outcomes that were related to unsuccessful procedures.

The hospitalist procedure service at Dr. Mourad’s institution began in 2008 and includes five physicians who obtained additional procedure skills from emergency physicians and interventional radiologists.

Over the 2-year period, the team performed 977 of these procedures (408 paracenteses, 279 thoracenteses, and 290 lumbar punctures). Nonsuccess was defined as the failure to obtain adequate fluid despite several needle passes.

The failure rate among paracenteses was 1%. All four of the unsuccessful procedures had ultrasound corroboration of fluid. "All of these patients also had an abdominal wall greater than 5 cm," Dr. Mourad said. "None sustained any complications," nor were any of these patients referred to another provider. All were treated empirically for spontaneous bacterial peritonitis.

Among the thoracenteses, 6% were unsuccessful. A CT scan corroborated the presence of more than 2 cm of fluid in each of the 16 cases. In all, 10 of the 16 patients had malignant effusions and 50% had pleural thickening. "We suspect that the pleural thickening" may have caused the procedures to be prematurely aborted "because the fluid was deeper than anticipated," Dr. Mourad said.

Nine patients were referred to interventional radiology and, although all radiologists agreed that the procedure was possible, they were unable to obtain fluid in three patients. "Of the six that were completed, three were more complicated than initially thought. Interventional radiology had to use CT guidance to complete the procedure." None of the failures resulted in any patient complications.

The largest failure rate occurred among the lumbar punctures, in which 19% (56) were unsuccessful. Most of the patients with unsuccessful procedures were overweight or obese, Dr. Mourad said; 53% had a body mass index of more than 25 kg/m² and 36% had a BMI of more than 30. "We need to compare this to our total population of procedures to determine if BMI is a true risk factor or not," she said.

Of the unsuccessful procedures, 28 were referred to neuroradiology, where they were all successfully completed, although some required CT guidance. There were no complications among any of the patients with a failed procedure.

The findings have prompted some changes in the way procedures are managed, Dr. Mourad said. "For instance, for paracentesis we now routinely measure the abdominal wall thickness, and we have [a larger] range of needles available because we know that the problems of not getting fluid are often a problem of needle length."

Dr. Mourad reported having no conflicts of interest.

GRAPEVINE, TEX. – Hospitalists can safely perform fluid retrieval procedures with a high rate of success and no patient complications, according to the findings of a retrospective study.

A hospitalist procedure team had an overall success rate of 92% among 977 thoracenteses, paracenteses, and lumbar punctures that were performed over a 2-year period, Dr. Michelle Mourad reported at the annual meeting of the Society of Hospital Medicine. The results suggest that additional training can boost hospitalists’ success rates to nearly that of the subspecialists who routinely perform these procedures.

"Unfortunately, many hospitalists lack formal training in procedure skills because training during residency is decreasing," said Dr. Mourad, a hospitalist at the University of California, San Francisco. "We are graduating hospitalists without these skills and having to refer procedures to subspecialties and interventional radiology."

Having hospitalists who are competent in procedures "is becoming more important because advanced technologies like bedside ultrasounds are rapidly becoming the standard of care."

Dr. Mourad and her colleagues examined their database over a 2-year period to determine the success rate of the three common procedures. Aside from success or failure, the outcomes took into account patient characteristics that might contribute to the lack of success and any patient outcomes that were related to unsuccessful procedures.

The hospitalist procedure service at Dr. Mourad’s institution began in 2008 and includes five physicians who obtained additional procedure skills from emergency physicians and interventional radiologists.

Over the 2-year period, the team performed 977 of these procedures (408 paracenteses, 279 thoracenteses, and 290 lumbar punctures). Nonsuccess was defined as the failure to obtain adequate fluid despite several needle passes.

The failure rate among paracenteses was 1%. All four of the unsuccessful procedures had ultrasound corroboration of fluid. "All of these patients also had an abdominal wall greater than 5 cm," Dr. Mourad said. "None sustained any complications," nor were any of these patients referred to another provider. All were treated empirically for spontaneous bacterial peritonitis.

Among the thoracenteses, 6% were unsuccessful. A CT scan corroborated the presence of more than 2 cm of fluid in each of the 16 cases. In all, 10 of the 16 patients had malignant effusions and 50% had pleural thickening. "We suspect that the pleural thickening" may have caused the procedures to be prematurely aborted "because the fluid was deeper than anticipated," Dr. Mourad said.

Nine patients were referred to interventional radiology and, although all radiologists agreed that the procedure was possible, they were unable to obtain fluid in three patients. "Of the six that were completed, three were more complicated than initially thought. Interventional radiology had to use CT guidance to complete the procedure." None of the failures resulted in any patient complications.

The largest failure rate occurred among the lumbar punctures, in which 19% (56) were unsuccessful. Most of the patients with unsuccessful procedures were overweight or obese, Dr. Mourad said; 53% had a body mass index of more than 25 kg/m² and 36% had a BMI of more than 30. "We need to compare this to our total population of procedures to determine if BMI is a true risk factor or not," she said.

Of the unsuccessful procedures, 28 were referred to neuroradiology, where they were all successfully completed, although some required CT guidance. There were no complications among any of the patients with a failed procedure.

The findings have prompted some changes in the way procedures are managed, Dr. Mourad said. "For instance, for paracentesis we now routinely measure the abdominal wall thickness, and we have [a larger] range of needles available because we know that the problems of not getting fluid are often a problem of needle length."

Dr. Mourad reported having no conflicts of interest.