Credentialing as a Hospitalist for Intubations and Lines

[thatpersonim]

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Hello everyone I just needed your assistance and advice. I am a second year IM resident and a few jobs I am looking at require intubations and lines as a hospitalist. We have lots of CCM exposure and fair line exposure but almost no intubations [anasthesia]. The administration has agreed on a rotation with anesthesia to learn this, however they asked how many are required to become credentialed???. If my goal is to graduate next year with the ability to intubate place central lines and arterial lines how many should I need for each? How many to be actually competent and how many for credentialing? Is this standard? Also is there a way to achieve this post graduation. Advice from anyone who has undergone credentialing as a hospitalist would be appreciated.

Thanks!

 

[IMGASMD]

When you’re out of training, it’s just how comfortable you are at doing any procedures. If you think you have the skill, and your department chair and your credential committee think you have the skill then you’re good. At end of the day, it’s your license on the line. When I was in training for IM most procedures that need to be signed off, are between 5-10 “attempts.” So if you think you’re competent after that number, who says you cannot be credentialed?

Here is another perspective that I will also provide..... as an anesthesiologist watching ED physician intubate, it scares the **** out of me, EVERY SINGLE TIME. And I assume they’ve done it more than 10 times. As far as I am concerned, unless you have the number in the 100s, you should not be doing it, especially in an emergency.

So take what you want from this post.

PS. Before someone says something, I finished my IM residency less than 10 years ago, then finished an anesthesia residency.

 

[Lexdiamondz]

EM resident - honestly “competence” and credentialing are two different things. I’ve logged approx 120 intubations as a PGY-2 and I still don’t feel 100% comfortable tubing without an attending present, whereas most IM residents are lucky to get >20 tubes over the course of their entire residency.


Truthfully, airway isn’t something you “sort of” manage - either you do it a lot or you shouldn’t really do it at all.

 

[chessknt]

You'll get a lot of opinions about airways and who should and shouldn't be doing them here but to answer your question--it completely varies by hospital with no universal answer.

 

[Druggernaut]

I'm EM rather than IM, but credentialing numbers will vary by hospital. I suspect the numbers for credentialing will be much lower than the numbers required for true competence. This link summarizes a bunch of studies on number of intubations to achieve competence, though I'd argue 80-90% success rate isn't adequate for someone taking an airway without someone standing behind them who can take over: How many intubations does it take to become competent?

At least 100 intubations seems like a good goal to me too, but this isn't realistic for an internal medicine residency. Video laryngoscopes might bring that down a bit but aren't always appropriate. Good BVM ventilation and use of supraglottic airways can buy time until a more experienced operator can get there but you'd still need to have backup coming. Lines are almost never truly emergent, so you can get away with lower numbers.

 

[rokshana]

Hello everyone I just needed your assistance and advice. I am a second year IM resident and a few jobs I am looking at require intubations and lines as a hospitalist. We have lots of CCM exposure and fair line exposure but almost no intubations [anasthesia]. The administration has agreed on a rotation with anesthesia to learn this, however they asked how many are required to become credentialed???. If my goal is to graduate next year with the ability to intubate place central lines and arterial lines how many should I need for each? How many to be actually competent and how many for credentialing? Is this standard? Also is there a way to achieve this post graduation. Advice from anyone who has undergone credentialing as a hospitalist would be appreciated.

Thanks!

personally I wouldn't take a hospitalist position that required lines and intubations and now a days I don't even ask for those privileges anymore. I certainly would not take that type of job fresh out of residency, since m/l you are the only one there and that can be overwhelming as a new grad...having others around the 1st 6-12 months of being a Hospitalist is very beneficial.

 

[emergentmd]

Assuming you are working in the US, in most hospitals, you will not even be allowed to intubate or put in central lines. Your Medical staff may not allow this as a competency, your IM group may not allow this, or your Insurance carrier would not allow this. Even if your insurance carrier allows this, your premium will likely go up and your IM group/hospital may balk at paying it.

Even if you are set on doing these procedures and completely competent with thousands done during residency, you will still be under an intolerable amount of scrutiny unless all/most IM docs in the hospital have this as a competency. If you are the only doc that does intubation, and something bad happens you likely will not have a leg to stand on. You will open yourself up to a big lawsuit esp when the plaintiff figures out that you are the only IM doc to intubate.

When I finished EM residency at a really busy county hospital, I did a bunch of Thoracentesis for pleural effusions and a bunch of paracentesis for symptomatic ascites. All done via only landmark. All of my community jobs has pulmonary/Interventional IR do these procedures. Although I felt comfortable, I dropped doing this because it left me exposed to a lawsuit because I was the only EM doc who did this.

Be careful if you are practicing outside of hospital/community standard of care.

 

[jdh71]

Hello everyone I just needed your assistance and advice. I am a second year IM resident and a few jobs I am looking at require intubations and lines as a hospitalist. We have lots of CCM exposure and fair line exposure but almost no intubations [anasthesia]. The administration has agreed on a rotation with anesthesia to learn this, however they asked how many are required to become credentialed???. If my goal is to graduate next year with the ability to intubate place central lines and arterial lines how many should I need for each? How many to be actually competent and how many for credentialing? Is this standard? Also is there a way to achieve this post graduation. Advice from anyone who has undergone credentialing as a hospitalist would be appreciated.

Thanks!

I'll go maybe a step further than those in here so far, you simply should not be intubating as an only IM trained person. The community standard basically everywhere in this country is that Anesthesia and EM plus the critical care trained are doing intubations. Even IF you get good/competent/proficient at them you leave yourself open for a huge professional liability if one goes sideways (and there is little chance ONE won't at some point . . . give it time . . . and one is all that needed to give you a lot of trouble).

 

[IMGASMD]

Sort of a follow up after I’ve seen everyone’s responses so far. I was moonlighting as a hospitalist under the radar when I was doing my anesthesia residency. Even during that time when I needed intubation I called our EM physician. I would actually stand back and let them do the procedure and be their “backup.” Since I was not credentialed to do intubation as a hospitalist and I wasn’t sure what my liability would be.

Just more food for thought.

 

[Crayola227]

so what I've mainly gathered from this, is it seems consensus is that only gas are really qualified to intubate

this seems a little strange to me

 

[chocomorsel]

To the OP, I am not of the belief that only Anesthesia, EM or CCM docs should be the ones doing intubation.

Simply put, not every little hospital in America has those specialties and in many little hospitals, FM and IM are running the ER.

So if you are going go be working at a small little hospital without any of the above specialists to help you, please get as many intubations as possible to do your patients the best amount of justice you can.

I would try to get at least 50 intubations in your anesthesia month and during third year do yet another rotation in anesthesia and do more intubations. And learn about LMAs and Glidescopes as well and of course anesthetic induction drugs. Please don’t go running around tubing people by yourself though, if you have someone with higher expertise around.

This is coming from an anesthesiologist who does CCM currently.

People, let’s be real. We got NPs doing lines and intubations. Come on.

And you all gotta realize that not every hospital has airway docs.

 

[Lexdiamondz]

so what I've mainly gathered from this, is it seems consensus is that only gas are really qualified to intubate

this seems a little strange to me

I think the general consensus rather is that if you're going to do airway, you need to own it, and you can't simply approach it from the perspective of "how many tubes do I need to become credentialed". Airways are one of the few things that we do in medicine that you can very quickly find ourself drowning up ****'s creek if you fxck things up, and airway management is a skill that really isn't stressed outside of anaesthesia (and to a lesser extent EM, CCM and ENT). That's not to say that there aren't IM and FM trained physicians with competent airway management skills - just that those skills are much harder to acquire from those training pathways.

Truthfully, any job requiring an IM or FM trained attending to intubate is a job that you probably should think twice about taking, since it's likely you won't have much backup if things go south.

 

[InternistDO]

Our medics technically only needed 5-10 tubes in school and then were set loose into the world where they would likely be intubating without backup in poor conditions.

Obviously this isn't even remotely ideal (and they have almost no liability--which is a huge difference), but something to think about when we throw around just how expert you have to be to intubate in a hospital.

 

[jdh71]

so what I've mainly gathered from this, is it seems consensus is that only gas are really qualified to intubate

this seems a little strange to me

Incorrect. They are simply the best. They do more. Followed by the EM folks. And then the critical care docs. Community standards are important to remember. IM intubating and an irregularity not a common place phenomenon. You will find yourself as an IM doc in MUCH more trouble for that reason if an airway goes bad. It's a liability you don't need to pick up.

In a perfect world gas would do them all in the hospital I suppose but that spreads them very thin practically speaking in most places. Even as a critcal care trained guy if the rest of my partners didn't intubate even if I thought I could, I wouldn't.

 

[Lexdiamondz]

Our medics technically only needed 5-10 tubes in school and then were set loose into the world where they would likely be intubating without backup in poor conditions.

Obviously this isn't even remotely ideal (and they have almost no liability--which is a huge difference), but something to think about when we throw around just how expert you have to be to intubate in a hospital.

I mean, there are alot of failed intubations in the field though - I don't think that really is the standard we want to hold ourselves to. Furthermore, even if medics miss tubes, they're all being transported to hospitals where a physician can theoretically secure a definitive airway (and they don't have liability).

Most data out there suggests that it takes anywhere from 50-75 intubations before residents achieve a 90% success rate...which some may argue is still an unacceptably high failure rate given the potential ramifications of a failed airway.

 

[Psai]

I mean, there are alot of failed intubations in the field though - I don't think that really is the standard we want to hold ourselves to. Furthermore, even if medics miss tubes, they're all being transported to hospitals where a physician can theoretically secure a definitive airway (and they don't have liability).

Most data out there suggests that it takes anywhere from 50-75 intubations before residents achieve a 90% success rate...which some may argue is still an unacceptably high failure rate given the potential ramifications of a failed airway.

TBH I feel like a lot of medicine residents are either scared of doing procedures or too busy doing notes and other patient care

 

[InternistDO]

I mean, there are alot of failed intubations in the field though - I don't think that really is the standard we want to hold ourselves to. Furthermore, even if medics miss tubes, they're all being transported to hospitals where a physician can theoretically secure a definitive airway (and they don't have liability).

Most data out there suggests that it takes anywhere from 50-75 intubations before residents achieve a 90% success rate...which some may argue is still an unacceptably high failure rate given the potential ramifications of a failed airway.

Yeah its a terrible standard and I don't support it, I was just pointing out there are lots of people getting tubed by providers with limited training and exposure while we debate how many hundreds of tubes the various airway trained specialties get. There are some places that will never have in house anesthesia and/or no EM boarded docs in the ED and end up getting these ambulance patients with difficult or failed airways (I know of one that is twenty minutes outside a large East Coast city). In a perfect world they'd have CC/EM/Gas doctors available everywhere but what do we do until that day comes?


As a final note, my hospital requires the hospitalists to run codes and intubate, but has anesthesia in house 24/7 who actually perform all the intubations (except in the ED and ICU). So for some hospitalist jobs it may be a more flexible requirement?

 

[chocomorsel]

Incorrect. They are simply the best. They do more. Followed by the EM folks. And then the critical care docs. Community standards are important to remember. IM intubating and an irregularity not a common place phenomenon. You will find yourself as an IM doc in MUCH more trouble for that reason if an airway goes bad. It's a liability you don't need to pick up.

In a perfect world gas would do them all in the hospital I suppose but that spreads them very thin practically speaking in most places. Even as a critcal care trained guy if the rest of my partners didn't intubate even if I thought I could, I wouldn't.

And yet I see IM /Pulm/CCM guys intubating difficult airways all on their own on the MICU without asking the anesthesiologists for any assistance.
Hmm...

 

[jdh71]

And yet I see IM /Pulm/CCM guys intubating difficult airways all on their own on the MICU without asking the anesthesiologists for any assistance.
Hmm...

It IS in the wheelhouse. And there is difficult and then there is DIFFICULT. Right?

I'd personally be happy to let the liability of any airway be the gas troll's but that's not the expectation where I work. I'm pretty conservative with intubations and I'm pretty good at them considering. But if I think they absolutely need first pass, "sux, prop, boom" period. No room to wiggle then I ask my colleagues to help. This thankfully isn't most airways even in the really sicks. I thank Weingart for his insights in the the sick sick airway. I thank my courses at Chest. I do my best. I'm no hero.

 

[nimbus]

All CA-1 anesthesia residents do over 200 intubations. But we don’t tell them, “You’re on your own!” beginning their CA-2 year. They are still novices, not experts, and still need supervision and backup. So different standards and expectations. Even after completing residency, most anesthesiologists’ airway skills are still improving.

As for the OP’s question, I think 100 is a closer number than 10-20.

Less for lines because the consequences of screwing up a line is usually not as bad as screwing up an airway.

 

[emergentmd]

I don't think most on here are debating how many is considered competent. Just having an EM or gas certificate doesn't mean they are better than an IM/FM doc who worked in the boonies for 10 years doing 500 intubations.

The point is you should practice within the community/hospital standard of care. If none of the hospitalist intubate, you should not regardless of how much experience you have.

I did paracentesis all throughout residency and completely comfortable which is what all residents did.

When I went to the community, I did about 3 until I figured out that I was the only ED doc doing these. They always called IR to do them. I quickly found out that it wasn't worth the risk to do them. One bad outcome and everyone on the QA committee would question why I was the only ER doc doing them.

 

[IMreshopeful]

I don't think most on here are debating how many is considered competent. Just having an EM or gas certificate doesn't mean they are better than an IM/FM doc who worked in the boonies for 10 years doing 500 intubations.

The point is you should practice within the community/hospital standard of care. If none of the hospitalist intubate, you should not regardless of how much experience you have.

I did paracentesis all throughout residency and completely comfortable which is what all residents did.

When I went to the community, I did about 3 until I figured out that I was the only ED doc doing these. They always called IR to do them. I quickly found out that it wasn't worth the risk to do them. One bad outcome and everyone on the QA committee would question why I was the only ER doc doing them.

Yeah, one of the private hospitals I rotated at during residency did not allow their hospitalists or residents to do ANY procedures outside an ICU. They were all done by IR and it was largely to help keep the system efficient - the floor docs kept the flow of patients constant with notes and discharged and H&Ps, while the IR guys procedurized. Plus I think it was more lucrative probably doing their paras in an IR suite as opposed to bedside

 

[KnuxNole]

I'll go maybe a step further than those in here so far, you simply should not be intubating as an only IM trained person. The community standard basically everywhere in this country is that Anesthesia and EM plus the critical care trained are doing intubations. Even IF you get good/competent/proficient at them you leave yourself open for a huge professional liability if one goes sideways (and there is little chance ONE won't at some point . . . give it time . . . and one is all that needed to give you a lot of trouble).

The problem where I work is that some of the specialists state the the Family Medicine or Internal Medicine doc should be the ones doing an intubation or central line without consulting them.

 

[jdh71]

The problem where I work is that some of the specialists state the the Family Medicine or Internal Medicine doc should be the ones doing an intubation or central line without consulting them.

Wow. That seems nonstandard. I think I’d document all refusals to consult on an airway.

 

[KnuxNole]

Wow. That seems nonstandard. I think I’d document all refusals to consult on an airway.

Thankfully it’s a minority, like 2-3 people who feel this way, usually everyone else is very happy to help.

 

[Lexdiamondz]

The problem where I work is that some of the specialists state the the Family Medicine or Internal Medicine doc should be the ones doing an intubation or central line without consulting them.

This sounds idiotic. They want you to attempt to induce and tube a patient without proper training...and then only consult them once you've failed? Dangerous.