Procedures

Medicine Procedure Service (MPS):

The Medicine Procedure Service was started in 2014 to improve the care of patients requiring bedside procedures at UNC Hospital while standardizing the education of learners in proper, ultrasound-guided techniques. The service provides a one-on-one learning experience to achieve this mission.

Basic Expectations: - Faculty will be on-boarded onto the Medicine Procedure Service (MPS) by the director or associate director for 10 shifts prior to independently attending on the MPS. - All central lines, paracentesis, and thoracentesis performed by MPS are to be ultrasound guided. Ultrasound guidance for lumbar punctures results in a more successful procedure and is highly recommended. - We follow standard guidelines and contraindications for our procedures. There are specific guidelines for pleural effusions and whether they should be tapped by MPS or referred to Interventional Pulmonology. - Complications are rare but they do happen – please discuss them with the Director of the MPS. The purpose is never to assign blame but to collect data and debrief so that we might all learn. A formal M&M may be important to investigate whether systematic changes should be made to keep our patients safe. - The MPS is a separate entity from the Medicine Consult Service (MCS) and has a dedicated intern and elective residents. Resident will sign onto the procedure pager (123-7077) and fill out the .MPSNEWTRIAGE treatment plan note when a procedure consult is received. dot phrase will step them through the following: - Have team place order for the Medicine Procedure Service (not the Medicine Consult order). - Discuss bleeding risks and contraindications – see peri-procedural management below. - Ensure the patient has capacity for consent. - Consider dose of anxiolytic if no contraindications. Lorazepam is readily available. Midazolam must be sent from pharmacy but is a reasonable short-acting option. BDZ and opioids cannot be given together on the floor or stepdown since this is considered conscious sedation. - Ask the primary team to order appropriate labs and tests. - Coordinate timing with other tests / procedures. - The MPS also performs procedures for hospital-based clinics (Oncology, Hepatology) and the ED. The clinics are asked to provide advanced notice of at least 24 hours when possible. Sometimes patients will have urgent same-day needs that we will try to accommodate. - Outpatient IT chemo: we have asked the clinic to schedule these appointments in the morning and that our inpatient service cannot accommodate more than 2 per week. Defer all non-IT chemo questions and concerns to the outpatient APPs. The clinic has been instructed to give us at least 24 hours' notice and to page when 1) platelets are > 30K and 2) chemo and kit are at bedside. Urgent inpatient procedures take precedence. - Supplies for each procedure are charged to the unit on which the patient resides. Try to anticipate and ask HUC to order supplies for procedures that are off medicine units. Many medicine units have a procedure cart for our use. On 4 Onc, the HUCs have locked kits in a cabinet and will hand you what you need. If you take things out of the procedure cart, fill out the supply form so that the HUC can resupply the cart. If you take supplies from one unit to another, ask the HUC from the recipient unit to order supplies and send them to the donor unit. Typically, asking the HUCs to call each other reduces confusion. - You are expected to attend resident AM report MWF 8:00-8:30. Residents are expected to attend AM report and noon conferences. - https://www.med.unc.edu/medicine/education/residency/ - Residents are not expected to return to the hospital following pm clinics. - Elective residents are not expected to work on the weekends. The non-elective resident will work 1 weekend day. - Attending will carry procedure pager on resident-free days. - Residents may leave at 4:00 unless they wish to stay and complete procedures later than that cut-off time.

Documentation: - Have the residents use the .medres procedure notes that were adapted from Leo Marucci’s procedure note templates. His notes have information needed for auditing (team requesting procedure, time of request, time procedure was done, resident doing procedure, etc) and ensure correct billing. - An ultrasound image is a required part of documentation. - Write a procedure note even if the procedure was unsuccessful. (Ex – an LP that did not yield CSF) for documentation and billing reasons. - For clinic procedures, send an email to Rachel Knight to ensure appropriate billing. - In order to provide excellent patient care and for QA of procedure complications, see and write a follow up consult note on all patients 24-48 hours after performing a procedure.

Other resources: - Service Leader – Ria Dancel MD. 919-260-8465

Procedure Specific Guidelines and Contraindications: