AP-Led Team Reduces Procedural Time for Ultrasound-Guided Paracenteses and Thoracenteses

Implementing an advanced practitioner (AP)–led team to perform ultrasound-guided paracentesis and thoracentesis at the bedside decreased patient wait time and use of interventional radiology (IR) suites, according to findings presented at JADPRO Live Virtual 2021. The initiative also allowed APs to practice to their full scope of practice, the authors noted.

“Due to the increased complexity of the inpatient cancer population and lack of adequately trained clinicians, the number of IR referrals for [these procedures] has increased,” explained lead author and presenter Caitlin Treacy, MS, AGACNP-BC, from Memorial Sloan Kettering Cancer Center (MSKCC). Given the limited availability of time in the IR suite, thoracentesis and paracentesis could be delayed when higher acuity cases take precedence, potentially resulting in longer hospitalizations for patients.

To help manage procedure turnaround time, the IR service at MSKCC pioneered an initiative to train APs to perform ultrasound-guided paracentesis and thoracentesis procedures at the bedside.

The “Mobile IR Team” consisted of four APs (two nurse practitioners and two physician assistants), all of whom had minimal or no ultrasound-guided procedural skills. Through the program, each AP received a combination of didactic learning, simulation, and hands-on skills training in the IR suites to achieve procedural competencies. After performing an average of 25 supervised procedures, the APs achieved baseline competency and began practicing independently.

A multidisciplinary team of IR attendings and APs then established and standardized a new bedside procedural workflow: After referral, IR attendings approved the Mobile IR Team to perform the procedures and the Mobile IR Team performed the bedside procedures and coordinated care with nursing staff. In addition, an AP data analyst used nursing informatics data to develop a dashboard to track key data metrics including referral time and procedural start and end times. From these metrics, the team calculated the percent of IR referrals for paracentesis and thoracentesis completed within 24 hours.

The AP-led bedside procedural team was implemented in January 2020. Through June 2021, the team performed a total of 661 ultrasound-guided paracenteses and 62 ultrasound-guided thoracenteses. Overall, 88% of paracenteses and 82% of thoracenteses were completed within 24 hours of referral. For comparison, in the year prior to the implementation of this AP-led bedside procedural team, 53% of paracenteses and 32% of thoracenteses were completed within 24 hours.

Regarding complication rates, Ms. Treacy reported that, to date, the Mobile IR Team has completed 878 ultrasound-guided cases and only two paracenteses resulted in bleeding complications that required embolization and/or surgical intervention, for a complication rate of 0.23%.

Overall, these findings suggest that procedures performed by a dedicated Mobile IR Team are safe and equally satisfactory to patients. The initiative also improved availability to the IR suite for acute cases, possibly leading to increased revenue for these procedures. In addition, the initiative decreased pre-procedural wait time, unnecessary bedside-to-suite transportation, and length of stay.

“Areas for future research include determining the AP-led procedural team’s impact on patient length of stay and patient satisfaction as well as financial impact,” Ms. Treacy and coauthors concluded. They also noted that this model could be expanded to other bedside procedures and the outpatient setting.

The authors report no relevant conflicts of interest.

Reference

Treacy C, Kit Y, Kounev LC, Marte MK. Implementation and impact of an advanced practice provider-led bedside procedural team at a major cancer institution. Poster JL910. Presented at JADPRO Live Virtual, October 7-17, 2021.