Echo service.

[sevoflurane]

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Anyone doing this? Curious as to your thoughts.

Not trying to steal from Cards. They seem very happy with their elective cases.

Just trying to provide a needed service line that will help anesthesiologists and surgeons (trauma/ICU) have a easy way to address quickly evolving issues...ie hypotension post AVR/MVR or hypotension after a case that has gone to the ICU in the middle of the night. Acute TEE service in the middle of a difficult case.

Mainly:
Pre/intra/post-op, SICU/CTICU, trauma.

If anyone has this experience I would be very curious as to logistics- and weather you feel it's worth it or a hassle.

University of Utah does this service very well, but that is academics.

 

[sevoflurane]

http://medicine.utah.edu/anesthesiology/periopecho/

Perioperative Echocardiography
Welcome to the Division of Perioperative Echocardiography, a part of the University of Utah Department of Anesthesiology. For the past 12 years our group has been providing comprehensive perioperative echocardiography services (including transthoracic, transesophageal, and stress) at the University of Utah Hospital and the VA Medical Center. We staff the only anesthesiologist-run full-sevice echo lab in the country, and have achieved unparallelled success training our residents and fellows. We are now excited to begin offering our lectures, clips, and teaching material to our colleagues across the country and around the world!

 

[Doctor4Life1769]

Doesn't Nebraska have something similar?

 

[Noyac]

Do you want all the after hours echos?

 

[Ezekiel2517]

Don't see how this would be needed or worth it in PP. Outside of the heart room, doesn't make much sense to be doing TEE exams when we make more in our regular work. And it's not like we can just start dropping TEE probes down pt's throats outside the OR. For pts not in the OR, TTE is far more useful/practical, especially for anything acute since you can get your diagnosis within minutes simply by sticking the probe on the chest and without having to sedate. The anesthesiologist can do it pre/post op but in the ICU most intensivists can do basic surface echo. ED docs are learning it. It's not like we're looking for whether the pt has 1 vs. 2+ AI. Basically all you want to know is if it's a volume issue or if the heart is failing.

 

[fakin' the funk]

Mainly:
Pre/intra/post-op, SICU/CTICU, trauma.

If anyone has this experience I would be very curious as to logistics- and weather you feel it's worth it or a hassle.

Two thoughts:
1) bedside TTE ought to help in a lot of these cases
2) on-call anesthesiologist should be able to help safely place the probe and get some basic assessments?

 

[ryanjmy]

We do a few a month in the cvicu on post op cabgs on pts that aren't doing well. Tte is not as useful on post sternotomies as tee. Also use it for placement of bedside impella. I've only been called a few times at night for tee but I don't mind. The surgeons certainly value this type of service=job security.

 

[sevoflurane]

We do a few a month in the cvicu on post op cabgs on pts that aren't doing well. Tte is not as useful on post sternotomies as tee. Also use it for placement of bedside impella. I've only been called a few times at night for tee but I don't mind. The surgeons certainly value this type of service=job security.

Surgeons do indeed value this service and have expressed interest. Add to that list blunt and penetrating chest trauma/deceleration injuries if you are at a Level 1 trauma center. I actually wouldn't mind the work and I think this service line has clinical value. Also, seeing anesthesiologists in other areas of the hospitals increases our presence outside of the OR in a favorable way. (I'm amazed that the U if U runs the echo lab).

Regarding job security- I would think it would be a difficult task for an AMC to string together a good echo service when attempting to take over a contract.

Do you want all the after hours echos?

My understanding is that an echo service usually doesn't generate that many call-ins after hours. The call would be tied to whoever is covering hearts. This is certainly an aspect of the equation to consider.

 

[Noyac]

So here's my thought on this. The reimbursement will be less than attractive. I would think of a way to get the surgeons wanting this ( I bet you have already done this). Then negotiate with the hospital a fee for this service. Don't paint yourself into a corner.

Damnit, now I have to review my echo skills and get up to speed on that again and learn TAP blocks. I'm rapidly becoming obsolete.

 

[sevoflurane]

So here's my thought on this. The reimbursement will be less than attractive. I would think of a way to get the surgeons wanting this ( I bet you have already done this). Then negotiate with the hospital a fee for this service. Don't paint yourself into a corner.

A subsidy for the service would indeed be a nice touch.

 

[sevoflurane]

Damnit, now I have to review my echo skills and get up to speed on that again and learn TAP blocks. I'm rapidly becoming obsolete.

Ha! you ARE getting old! Better start you on some ambien and some betablockers.

We'll take it easy on you:

USD for femoral n block will be your first lesson.

😱

 

[OB1🤙]

We have established a rudimentary version of this, and are looking to formalize and expand it going forward. We offer TEE or TTE as the clinical situation may warrant, to the OR (for cardiac obv. but also noncardiac cases) and cardiac ICU 24/7. After hours calls are nearly non-existent, and mostly involve evals for tamponading patients who have to be brought back anyway.

I absolutely agree that this is the kind of service that adds a lot of value to what you provide, and an AMC would be very, very hard-pressed to come up with a similar arrangement.

Some people have bought in on the whole PSH thing in the orthopedic realm, and that's fine, with the chip-shot preop/postop medical management and pain/block stuff. But honestly that kind of thing isn't my bag, other than the blocks which we're doing already.

But when we talk to the hospital, presenting a 24/7 acute care echo service run by people that can also perfonally perform any necessary critical care (start/manage resuscitations/lines/drips/whatever) as well for those non-infrequent times that the intensivists are busy with other sick patients, they truly value that. We find ways to make ourselves indispensable to the hospital, and they see and acknowledge that, and they pay us for it.

To my way of thinking, this is a sustainable way forward for us to prove our value to the hospital, stake out our piece of the bundled pie, all while doing the kind of medicine that we actually went into anesthesia to do. Our ICU guys all suck at echo so they don't see us as competing for their jobs; rather we supplement what they do in the ICUs and they are glad to have us around. Everyone wins, honestly.

 

[urge]

We have established a rudimentary version of this, and are looking to formalize and expand it going forward. We offer TEE or TTE as the clinical situation may warrant, to the OR (for cardiac obv. but also noncardiac cases) and cardiac ICU 24/7. After hours calls are nearly non-existent, and mostly involve evals for tamponading patients who have to be brought back anyway.

I absolutely agree that this is the kind of service that adds a lot of value to what you provide, and an AMC would be very, very hard-pressed to come up with a similar arrangement.

Some people have bought in on the whole PSH thing in the orthopedic realm, and that's fine, with the chip-shot preop/postop medical management and pain/block stuff. But honestly that kind of thing isn't my bag, other than the blocks which we're doing already.

But when we talk to the hospital, presenting a 24/7 acute care echo service run by people that can also perfonally perform any necessary critical care (start/manage resuscitations/lines/drips/whatever) as well for those non-infrequent times that the intensivists are busy with other sick patients, they truly value that. We find ways to make ourselves indispensable to the hospital, and they see and acknowledge that, and they pay us for it.

To my way of thinking, this is a sustainable way forward for us to prove our value to the hospital, stake out our piece of the bundled pie, all while doing the kind of medicine that we actually went into anesthesia to do. Our ICU guys all suck at echo so they don't see us as competing for their jobs; rather we supplement what they do in the ICUs and they are glad to have us around. Everyone wins, honestly.

What's so special about your services? Sounds like the cardiac call person does an echo here and there when requested 24/7. Any group with a cardiac call person (PP, AMC, or academic) can do the same (and probably has been doing for a long time).

 

[urge]

Do you want all the after hours echos?

The echo cardiologists have answered with a resounding no.

The question is do we want the business that they turned down?

If you are in-house and not busy, it does not seem to be a problem.

Most likely you are on home call, or doing a case in the OR, in which case getting the echo done might be problematic. Who wants to do a 3AM echo when you have to work the next day?

 

[urge]

If anyone has this experience I would be very curious as to logistics- and weather you feel it's worth it or a hassle.

I can only see this working in very large groups where call is not very often, and where there is an anesthetist in addition to the echo anesthesiologists.

If you do cases solo at night when on call, you cannot do any echos. You would need a 2nd attending on echo call. Who wants to sign up for that?

 

[OB1🤙]

What's so special about your services? Sounds like the cardiac call person does an echo here and there when requested 24/7. Any group with a cardiac call person (PP, AMC, or academic) can do the same (and probably has been doing for a long time).

No question, as it stands now, there isn't a huge difference, other than that we are empowered to act on what we find. That is, I'm not *just* [edited] reporting my findings to another physician to act on (unless I want to), I can institute the appropriate therapy myself (if I want to).

The other thing we're slowly doing is getting anesthesia/ccm guys in the ICU. Once we get a critical mass, we will be involved in every aspect of the patient's hospital stay for cardiac surgery, from preop (where we already work with NPs to coordinate appropriate workup and avoid unnecessary testing) through surgery to the ICU, putting out any fires that may arise along the way.

 

[urge]

No question, as it stands now, there isn't a huge difference, other than that we are empowered to act on what we find. That is, I'm not reporting my findings to another physician to act on (unless I want to), I can institute the appropriate therapy myself (if I want to).

Someone called you for that echo. I doubt you are going to leave them out of the loop. You will quickly make a lot of enemies if you do.

Why would you suddenly become the primary MD after only doing an echo? Doesn't make sense.

 

[OB1🤙]

Of course nobody is being left out of the loop. We -anesthesiologists, surgeons, intensivists- all work well together.

I'm saying that if the necessary treatment or intervention is different from what is currently taking place, or if the intensivist is off doing something else, I can and do take charge of the change in plan. I'm not becoming the primary MD, but I can act on what I find if the situation calls for it, and I will let the intensivist know what I've done. No toes are being stepped on.

I don't just file my report and let the ICU do with it what they will, which is what cardiology-run echo services do.

I edited my above post to make it clearer.

 

[Stank811]

HB, the direction your group is heading is what I foresee as the future of anesthesiology....involved in every aspect of an acute patient's care. I will be very interested in your progress, keep us all posted.

 

[sevoflurane]

I can only see this working in very large groups where call is not very often, and where there is an anesthetist in addition to the echo anesthesiologists.

If you do cases solo at night when on call, you cannot do any echos. You would need a 2nd attending on echo call. Who wants to sign up for that?

Urge, I agree that you need the right setup. A group of 3 cardiac echo guys might not cut it. I can imagine many scenarios in which there is no CRNA/AA involvement and the system would work. Our current setup would support this service. There may be the occasional time where we would not be available at night to cover an echo, but that would be when we are tied up doing an emergency heart in the middle of the night- which does happen... but by no means is the norm. There would have to be an understanding that if we are busy with a heart we wouldn't be able to do it. Our current volume supports 10 cardiac anesthesiologists (and often times two of us are on call together). That seems like a very reasonable number to get things kicking into gear.

To my way of thinking, this is a sustainable way forward for us to prove our value to the hospital, stake out our piece of the bundled pie, all while doing the kind of medicine that we actually went into anesthesia to do.

Of course nobody is being left out of the loop. We -anesthesiologists, surgeons, intensivists- all work well together.

Agree HB. While an echo service may not necessarily be a money maker (maybe it will be...IDK?), it certainly would help to expand our value inside and outside of the OR. These are trying times and every inch we can gain is a big plus for our future. I think that your point in managing drips in the ICU after an echo consult is an excellent one.

 

[Ezekiel2517]

Of course nobody is being left out of the loop. We -anesthesiologists, surgeons, intensivists- all work well together.

I'm saying that if the necessary treatment or intervention is different from what is currently taking place, or if the intensivist is off doing something else, I can and do take charge of the change in plan. I'm not becoming the primary MD, but I can act on what I find if the situation calls for it, and I will let the intensivist know what I've done. No toes are being stepped on.

I don't just file my report and let the ICU do with it what they will, which is what cardiology-run echo services do.

I edited my above post to make it clearer.

I gotta agree with urge, what you're talking about doesn't make sense. Good luck with that

 

[BLADEMDA]

Medicare reimburses very poorly for Echo services. A TEE in the ICU will likely pay less than a central line. Good luck earning any money with your service.

Instead, hire an ICU doc with basic echo certification and let him/her do the Echo at bedside like I do in my holding area from time to time.