Anesthesia for TEE’s

[circleK]

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Wanted to take an informal poll here. We have a slew of new cardiologists who are apparently not certified to give concious sedation, so we are having to utilize an anesthesiologist for 2-4 TEEs a day now. Curious how prevalent this is at all of your places as it seems to be a poor use of our high in demand services.

 

[GassYous]

Tell them to consolidate days

 

[abolt18]

Wanted to take an informal poll here. We have a slew of new cardiologists who are apparently not certified to give concious sedation, so we are having to utilize an anesthesiologist for 2-4 TEEs a day now. Curious how prevalent this is at all of your places as it seems to be a poor use of our high in demand services.

We only do them for select cases typically (sick patient, super morbid obese, failed previous attempt, etc). Our cardiologists are comfortable sedating most patients. Most use methohexital (which had a shortage last I heard?), but some will just give midazolam/fentanyl to their heart's content. I feel like we commonly have 1-2 TEEs or cardioversions every other day.

 

[Arch Guillotti]

Wanted to take an informal poll here. We have a slew of new cardiologists who are apparently not certified to give concious sedation, so we are having to utilize an anesthesiologist for 2-4 TEEs a day now. Curious how prevalent this is at all of your places as it seems to be a poor use of our high in demand services.

Inundated with these as well as cardioversions.

 

[rowsdower88]

Becoming more common unfortunately. My group has similar utilization.

 

[TheLoneWolf]

Near daily, I think they want us present for each TEE. We usually have to pull someone from a room to cover these as they arise.

Previous hospital in the same city had 8-14 cardioversions and TEEs daily, always done with anesthesia.

 

[coffeebythelake]

Wanted to take an informal poll here. We have a slew of new cardiologists who are apparently not certified to give concious sedation, so we are having to utilize an anesthesiologist for 2-4 TEEs a day now. Curious how prevalent this is at all of your places as it seems to be a poor use of our high in demand services.

The cardiologists don't have certification to give conscious sedation? I thought they use a sedation nurse who has the certification.. non-crna

 

[jwk]

We have a non-invasive cardiology anesthetist each day. They do all the cardioversions and TEEs. Typically propofol only or prop and a little lido. Our cardiologists are spoiled and pretty much never do conscious sedation anymore - probably safer all around with us doing it anyway.

 

[caligas]

we have them consolidate to 3 days per week, 8-10 TEE and/or cardioversions. We use a CRNA, supervised by the anesthesiologist covering our EP lab (2 rooms).

**** goes down occasionally with a cardioversion or aortic stenosis TEE, not a bad place for real anesthesia care.

 

[Shimmy8]

We do them all. It sucks.

 

[Simba1711]

We do them too. Previous practice we would do only high risk patients. The nurse would give conscious sedation for the lower risk patients.

Current practice we do all the tees.

 

[IMGASMD]

Someone is not getting paid enough to take on the risk..... we are the default... =D

 

[Remxed]

We do them all as well as cardioversions. They are very quick, and we work them into our daily schedule. If there is an add on, our board runner can go down and do one really quickly.

 

[AppTrail]

what is the contract between your group and the hospital? TEE should fit within the footprint of your agreed staffing locations, otherwise hospital should understand you will need to hold up/close an OR/anesthetizing location for TEEs. We usually try and do them early AM like 7/730 before endoscopy.

 

[Arch Guillotti]

We do them all as well as cardioversions. They are very quick, and we work them into our daily schedule. If there is an add on, our board runner can go down and do one really quickly.

Yeah just work them in since they just get added on randomly a lot of times and the cardiologists availabilty is variable.

 

[DesiredMemberName?]

Our utilization for these has increased after a few esophageal perforations where we weren’t involved.

 

[sevoflurane]

Have the hospital stipend that NORA line.

Bang them out. 6/u start up plus chair time if i remember correctly.
Do 6 a day= 48 u.

 

[nimbus]

We have long turnovers. Can usually find somebody free between cases to do them. Often that person is doing ablations and ICDs in Cath lab.

 

[thinkorswim]

All of our TEE and cardioversions are performed under anesthesia. They key is working with your cath lab to schedule them appropriately.

The EP cardiologists are usually doing procedures so their TEE/CVs are scheduled in between cases and the same anesthesiologist doing the lineup does them (this also helps with turnover and breaks for staff in the cath lab rooms). If it’s a cardiologist with a single TEE/CV and nothing else, then they are required to schedule the procedure in a short block in the morning and are placed in a lineup with others. This means only one anesthesiologist is needed for a short period and can then go do cases elsewhere afterwards.

As mentioned above, they can be quite lucrative. We average around 5 units per cardioversion and 8-9 units per TEE.

 

[circleK]

Thanks for all the replies. Was more just curious at how it is elsewhere since for years our cardiologists just did their own sedation unless pt high risk but the new bunch do not sedate anyone themselves. We are employed.

 

[Radar26]

Have the hospital stipend that NORA line.

Bang them out. 6/u start up plus chair time if i remember correctly.
Do 6 a day= 48 u.

We do this. I did 10 TEEs today and wrapped up around 2pm. Plus a stipend. Nice day.

 

[nimbus]

Have the hospital stipend that NORA line.

Bang them out. 6/u start up plus chair time if i remember correctly.
Do 6 a day= 48 u.

I thought TEE (93312) was 7 startup units.

That’s why like it when the patient missed a dose of eliquis before their 4 unit cardioversion (92960) 😉

 

[cchoukal]

I thought TEE (93312) was 7 startup units.

That’s why like it when the patient missed a dose of eliquis before their 4 unit cardioversion (92960) 😉

We get 6+time.

We do them all. 0-5 per day. It's one of our contracted locations per day, and we're generally able to combine it with something else (ECT, endo, eyeballs), and it works out well.

 

[nimbus]

We get 6+time.

We do them all. 0-5 per day. It's one of our contracted locations per day, and we're generally able to combine it with something else (ECT, endo, eyeballs), and it works out well.

Interesting. AbeoCoder says 7 and that’s what I’m credited on my charge reports.

Anyway they are good cases.

 

[cchoukal]

Will have to talk to our billers!

 

[sevoflurane]

I thought TEE (93312) was 7 startup units.

That’s why like it when the patient missed a dose of eliquis before their 4 unit cardioversion (92960) 😉

Yup. 👍🏽

Couldn’t remember, but know it’s a good unit day when you are efficient. Personally, I like TEE days, except for this one cardiologist who thinks it’s ok to do a 45+ minute exam.

 

[medicine2wallstreet]

Wanted to take an informal poll here. We have a slew of new cardiologists who are apparently not certified to give concious sedation, so we are having to utilize an anesthesiologist for 2-4 TEEs a day now. Curious how prevalent this is at all of your places as it seems to be a poor use of our high in demand services.

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

 

[cchoukal]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

It’s only a good deal if it’s a good deal…

 

[cchoukal]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

It’s only a good deal if it’s a good deal…

 

[DesiredMemberName?]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

He said they are employed. It could be more work with no more increase in pay.

 

[teacher2md]

these are not “lucrative” cases— they’re almost universally Medicare with rare exceptions. Even with 7 start base units and q30 min cases, they’re good but certainly not lucrative like a peds ENT or ortho room with good payor mix.

18 units an hour x $20/unit—$360/hour. That’s if the cardiologist agrees to not go do rounds between cases or whatever other BS they tend to do…

 

[ucladoc2b]

It’s only a good deal if it’s a good deal…

Very true.

Well scheduled, well insured are fine. Best when they are lined up en bloc. Easy to assign

What happens in practice at my hospital is that they will schedule them non-contiguously, at random times, insist on doing them “bedside” for whatever reason. It’s often not ideal.

 

[circleK]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

Read much? I stated we are employed 🙄

 

[Arch Guillotti]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

lol the patients are all terrible, bad or no insurance. Cardiologists terrible about being on time, screws up the rest of the schedule etc etc etc

 

[GassYous]

Also they tend to be sick fat smokers so you either give too much and they're apneic or you don't give enough so they are coughing and getting tachy

 

[okayplayer]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

You are the human embodiment of the Dunning-Kruger Effect.

 

[chessknt]

It is telling that the medical specialty who most commonly believes themselves capable of all fields of medicine has decided to turn this over. Cardiology manages endocrine, vascular, and lung issues routinely with supplemental incomes associated with each of those service lines in addition to their primary cash cow of cardiology. I have seen so many patients who basically have their cardiologist acting like their PCP where I am.

The real reason they wont do sedation--reimbursement is horrible if you are also doing the procedure. Reimbursement for conscious sedation from CMS is less than a happy meal at mcdonalds. If they were allowed to bill the same as anesthesiology does I guarantee they would not be asking for you to do these cases.

 

[Hoya11]

It is telling that the medical specialty who most commonly believes themselves capable of all fields of medicine has decided to turn this over. Cardiology manages endocrine, vascular, and lung issues routinely with supplemental incomes associated with each of those service lines in addition to their primary cash cow of cardiology. I have seen so many patients who basically have their cardiologist acting like their PCP where I am.

The real reason they wont do sedation--reimbursement is horrible if you are also doing the procedure. Reimbursement for conscious sedation from CMS is less than a happy meal at mcdonalds. If they were allowed to bill the same as anesthesiology does I guarantee they would not be asking for you to do these cases.

Many times they can’t even pass the echo probe without our help . Cardiologists are not facile with OR stuff, sedative medications, airway, etc . They don’t have any realization that doing 3 TEEs sporadically over 8 hours is not efficient

 

[cchoukal]

Just looked at our board. 6 TEEs today, starting at noon (after endo closes), all lined up and ready to go... I'd take that assignment...

 

[Twiggidy]

If you're not doing the Echo read and only providing the anesthesia cant you use 01922 (anesthesia for non-invasive imaging exam) and if you place the probe bill for probe placement (93313). I'm sure 01922 will start another debate but that's the code we've used for years with no problems and I believe it also starts at 6 or 7 units.

Also these fall under the same general annoyance as EGD by GI and probably should be treated the same. I have no problem using propofol in a good majority of these patients as we do with EGDs and trust me the patients are thankful as well. With the addition of HFNC it's made these cases much easier. Try to get them to schedule them in a block if possible.

 

[PpfSuxTube]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

Lol, you just got your pants pulled down son.
Don't worry it will get better soon
Just a couple more chips to go from those shoulders.


Quick turn around for tee... ha ha ha that's a good laugh

 

[PpfSuxTube]

If you're getting asked to do tee's there's usually a bad reason for it...

 

[nimbus]

If you're getting asked to do tee's there's usually a bad reason for it...

Where I work it is more operator dependent. The cardiologists who do anesthesia cases all the time (EP and structural) always ask for anesthesia and we usually squeeze them in between their longer cases. The general cardiologists rarely ask for our assistance and get by numbing their throat, minimal to moderate sedation, and sweet talk.

At our hospital 80-90% of EGDs are also done without anesthesia.

 

[2Fast2Des]

We do this. I did 10 TEEs today and wrapped up around 2pm. Plus a stipend. Nice day.

Love the TEEs. Fastest and easiest units to make. They are all usually ASA 3 and old and done in about 10 minutes. Easiest 10 to 14 units. Painful part is watching the cardiologist trying to perforate the esophagus with their attempts at getting the probe in.

 

[Luv2N2B8]

We do them all the time. Cardiologists can't give propofol, so it fell to us. We carved out a position that includes sedation for cath lab procedures in general. Most of the time it's TEE, cardioversion, but has grown to include some heart cath stuff as well if needed. Hospital pays daily stipend. So, even if we have "long turnovers," we're getting paid to sit around. Cardiologists (influential hospital department) love the service and love us. Win-win.

 

[jwk]

Where I work it is more operator dependent. The cardiologists who do anesthesia cases all the time (EP and structural) always ask for anesthesia and we usually squeeze them in between their longer cases. The general cardiologists rarely ask for our assistance and get by numbing their throat, minimal to moderate sedation, and sweet talk.

At our hospital 80-90% of EGDs are also done without anesthesia.

We don't routinely squeeze anyone in. All our TEEs and CVs are scheduled cases. If they're there for A-fib, the first thing the nurses do is an EKG. If they're in sinus rhythm, they're canceled on the spot and we never see them. On a busy day, we'll do 10, and the nurses try not to schedule them after 1:00pm, since that's about as late as they can do them and have the patient gone by 3pm when all their nurses leave.

We now have a separate EP/Cath lab anesthetist just about every day. We've got EP cards with block time, so it's turned into an every day thing. We now just keep an anesthesia machine in that cath lab and schedule all those cases in there. We only do one at a time - no flipping rooms - now that we have a machine there full time, it doesn't get moved.

 

[Twiggidy]

Love the TEEs. Fastest and easiest units to make. They are all usually ASA 3 and old and done in about 10 minutes. Easiest 10 to 14 units. Painful part is watching the cardiologist trying to perforate the esophagus with their attempts at getting the probe in.

Given that a GI doc can EGD just about everyone and the size difference between the probes isn’t very different it should go in easy. I will literally stop the cardiologist if they’re struggling because patients will complain more than anything if their mouth looks like they’ve gone 12 rds. Generous lubricant and well anesthetized and it slides right in. Maybe a little forward head tilt if approaching from front.

 

[dannyboy1]

Surprised how many people here still know/care about units. Thought we were all employed/hourly.

 

[Simba1711]

I don’t mind tee either since its 7 start up units but the annoying part is not the billing. It’s waiting around for the cardiologist. We never started on scheduled time and even with patient in room they would take forever to come in. Also turnover time was long for some reason. Also, they’re not as facile as sticking the probe in compared to Gi doctors.

 

[CopaceticOne]

I don’t mind tee either since its 7 start up units but the annoying part is not the billing. It’s waiting around for the cardiologist. We never started on scheduled time and even with patient in room they would take forever to come in. Also turnover time was long for some reason. Also, they’re not as facile as sticking the probe in compared to Gi doctors.

There's one cardiologist I cover TEEs for that is impressive. In over 8 years I have never seen a patient gag with them putting in the probe. They are just smooth and seem to have a feel for when its the right time to insert.

The rest of them and the fellows just make me cringe sometimes.