Office Fluoro Build Out

[cbest]

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Hey Team,

I've searched through a bunch of threads on the forums but haven't quite found what I'm looking for.

I'm currently the only PM&R/Pain doc in an ortho group and have been doing my spine injections at a few different ASCs so far. They seem pleased with my work so far and are considering building out an office fluoro suite for me. As such, they've asked me to put together a list of what we'd need and a rough estimate on a budget. A couple of buddies of mine have been through the process and estimated around $150K. Here's my list so far:

Fluoroscopy machine
Medications (Depo-Medrol 40/80, Dexamethasone 4/10, Lidocaine 1%/2%, Omnipaque/Isovue)
Needles (spinal needles, Tuohy needles, RF needles, 27G, 18G)
Chloroprep
Towels
Syringes (LOR , 10cc, 5cc, 3cc)
Lead
Physicist Evaluation
Lead floors and/or walls?
Process to upload/save fluoro images
RF machine
RF probes and system to sterilize them
Crash cart
Monitoring equipment
Oxygen

Any input/feedback/experience about this process would be greatly appreciated!

 

[painfree23]

Hey Team,

I've searched through a bunch of threads on the forums but haven't quite found what I'm looking for.

I'm currently the only PM&R/Pain doc in an ortho group and have been doing my spine injections at a few different ASCs so far. They seem pleased with my work so far and are considering building out an office fluoro suite for me. As such, they've asked me to put together a list of what we'd need and a rough estimate on a budget. A couple of buddies of mine have been through the process and estimated around $150K. Here's my list so far:

Fluoroscopy machine
Medications (Depo-Medrol 40/80, Dexamethasone 4/10, Lidocaine 1%/2%, Omnipaque/Isovue)
Needles (spinal needles, Tuohy needles, RF needles, 27G, 18G)
Chloroprep
Towels
Syringes (LOR , 10cc, 5cc, 3cc)
Lead
Physicist Evaluation
Lead floors and/or walls?
Process to upload/save fluoro images
RF machine
RF probes and system to sterilize them
Crash cart
Monitoring equipment
Oxygen

Any input/feedback/experience about this process would be greatly appreciated!

Did you want an ultrasound?
Will also need gadavist or something like that
Marcaine
I use paper gowns that the patients change into prior to procedure
IV start kits (just in case, or if doing cervicals)
IV bags

 

[Aether2000]

First thing is to find the x-ray room shielding requirements for your particular state. Different divisions and agencies handle this in each state. Secondly, used vs. new. Just starting out I would recommend used or refurbished for the C-arm. C-arms used cost $15,000-100k and new cost $80k-180k depending on the year. Newer machines have an image capture with USB storage or transfer options. RF machines can be obtained used for $5k-20k or new from $20k-45k. No need for expansive use of towels....we use one strip paper rectangular drape at the inferior part of the patient for RF and caudals. Paper gowns are useful for cervical or thoracic blocks. AED is preferred to manual defibrillation. US is nice but not absolutely necessary, although I use mine every day.

 

[painfree23]

would

First thing is to find the x-ray room shielding requirements for your particular state. Different divisions and agencies handle this in each state. Secondly, used vs. new. Just starting out I would recommend used or refurbished for the C-arm. C-arms used cost $15,000-100k and new cost $80k-180k depending on the year. Newer machines have an image capture with USB storage or transfer options. RF machines can be obtained used for $5k-20k or new from $20k-45k. No need for expansive use of towels....we use one strip paper rectangular drape at the inferior part of the patient for RF and caudals. Paper gowns are useful for cervical or thoracic blocks. AED is preferred to manual defibrillation. US is nice but not absolutely necessary, although I use mine every day.

what is one strip paper rectangular drape at the inferior part of the patient for RF and caudals? link?

also, for lumbar medial branches, do you use towels? im using the 4 sticky rectangle papers to create a window, but feels like it takes too long to drape (not that long...but will do anything to improve efficiency)

 

[geauxg8rs]

what is one strip paper rectangular drape at the inferior part of the patient for RF and caudals? link?

also, for lumbar medial branches, do you use towels? im using the 4 sticky rectangle papers to create a window, but feels like it takes too long to drape (not that long...but will do anything to improve efficiency)

For
Mbb i just use a single paper drape with a single center hole. Then i rip the hole to fit my desired size. Cheap and quick

 

[lobelsteve]

The rectangular drape is called a half sheet. The standard drape is 18x26 and is fenestrated with a 3" opening. Large enough for L3-5 MBB. I use these for SCS as well.

 

[Aether2000]

The point is, in an office setting you need not go overboard with OR style sterile drapes, gowns for patients (we leave them in their clothing and simply pull down their pants). Prep of skin can be a bottle of chlorhexidine pouring a little onto a 4x4. Masks are preferred for any spinal injections for medical-legal purposes only but sterile gowns and shoe covers are overkill. Head covering??? We never wear them for any procedure in the office. Sedation, if any, is preop xanax or sublingual ketamine/midazolam with no IV sedation used in the office. We do not use local on the skin since 25ga quincke tip needles are used for most procedures, and the skin local hurts more than the long needle insertion. Skin local is used for RF (18ga needles) or for Epimed coude tip needles (through a 16ga angiocath). We do not drape the C-arm but do wipe the surface of the I/I. Some locations use washable inexpensive sheets on the fluoro table, some use disposable paper from rolls. One practice I am affiliated with does not use trays (except for interlaminar ESI)- they use a sterile cover for a mayo stand and then open needles onto the stand along with autoclaved hemostats to place a bend on the needle tip. One practice has the techs draw up the standard injection solutions in a syringe then hand the syringes to the physician after the needles are placed- another places empty syringes and needles on the field and the physician draws up the medications. So there are ways to do things safely and effectively without breaking the bank. In a start-up practice, I would suggest not buying brand new equipment since you don't know how well the practice will do. Volumes of patients having procedures and reimbursement for these procedures are gradually declining. A two-office new interventional pain practice in the Tampa/St Pete area just folded after less than a year in operation, so being financially cautious is prudent.

 

[Dr Manhattan]

The point is, in an office setting you need not go overboard with OR style sterile drapes, gowns for patients (we leave them in their clothing and simply pull down their pants). Prep of skin can be a bottle of chlorhexidine pouring a little onto a 4x4. Masks are preferred for any spinal injections for medical-legal purposes only but sterile gowns and shoe covers are overkill. Head covering??? We never wear them for any procedure in the office. Sedation, if any, is preop xanax or sublingual ketamine/midazolam with no IV sedation used in the office. We do not use local on the skin since 25ga quincke tip needles are used for most procedures, and the skin local hurts more than the long needle insertion. Skin local is used for RF (18ga needles) or for Epimed coude tip needles (through a 16ga angiocath). We do not drape the C-arm but do wipe the surface of the I/I. Some locations use washable inexpensive sheets on the fluoro table, some use disposable paper from rolls. One practice I am affiliated with does not use trays (except for interlaminar ESI)- they use a sterile cover for a mayo stand and then open needles onto the stand along with autoclaved hemostats to place a bend on the needle tip. One practice has the techs draw up the standard injection solutions in a syringe then hand the syringes to the physician after the needles are placed- another places empty syringes and needles on the field and the physician draws up the medications. So there are ways to do things safely and effectively without breaking the bank. In a start-up practice, I would suggest not buying brand new equipment since you don't know how well the practice will do. Volumes of patients having procedures and reimbursement for these procedures are gradually declining. A two-office new interventional pain practice in the Tampa/St Pete area just folded after less than a year in operation, so being financially cautious is prudent.

algos: I havent used sublingual sedation. can you tell me more about your dosage and protocol for this? i googled, and everything was in regards to sedation prior to cataracts. sounds appealing

orally, i use valium 5-10mg, or triazolam 0.25-0.375 for the more anxious. i use versed when i have IV access

 

[Aether2000]

I will get our sublingual protocol for you. It takes the edge off the procedure but does not interfere with patient responses during the procedure. The elderly may have delayed sedation onset- one of the few caveats.

 

[deleted185747]

Pillow and pillowcase
Linen for table

Laundry service

 

[hyperalgesia]

Don't forget the actual fluoro table, which will be your second most expensive item.

I would check with your state health department but they will probably tell you to set everything up first. Then they will send a medical physicist to look at radiation levels and certify you or give further guidance. My state radiation folks told me that in their entire experience they have never once required lead lining for a room with a c-arm.

150k seems about right if you are careful and thrifty. It's important that you have a budget for maintenance too, if the c-arm breaks, for example.

 

[Doctodd]

As for bending the needle tip, i use the plastic condom that comes prepacked with each spinal needle to bend the tip. Never use a hemostat....for anything.

 

[lobelsteve]

I bend tbe top between my fingers. 25g easy, 22g easy. Strong like bull. Twice as smart.

 

[lonelobo]

I bend tbe top between my fingers. 25g easy, 22g easy. Strong like bull. Twice as smart.

I used to do the same, but after my PRP injections I just bend it using my mind

 

[Ducttape]

substitute "spoon" for "needle"

 

[Aether2000]

The ketamine/midazolam protocol used was using 50mg/ml ketamine plus midazolam 5mg/ml mixed 1:1 with total for ketamine ranging from 25-100mg. The patients swish and hold the medication as long as they can in their mouth before swallowing, swishing under the tongue and to the cheeks. The effect begins in about 10 min and is very mild for most patients.

 

[lobelsteve]

The ketamine/midazolam protocol used was using 50mg/ml ketamine plus midazolam 5mg/ml mixed 1:1 with total for ketamine ranging from 25-100mg. The patients swish and hold the medication as long as they can in their mouth before swallowing, swishing under the tongue and to the cheeks. The effect begins in about 10 min and is very mild for most patients.

Do you add coconut milk as a flavoring agent? Why not?

 

[Doctodd]

A two-office new interventional pain practice in the Tampa/St Pete area just folded after less than a year in operation, so being financially cautious is prudent.

Which?

 

[cbest]

Thanks so much for all the information! Two more questions:

1) What is the minimum size one would need for an office fluoro suite? GE rep I met with recommended minimum 15 X 15 but said 20 X 20 would be ideal. Current space being considered is only 14 X 9. Too tight?

2) Other than me generating about double in terms of professional fees, how else might a PM&R/pain doc sell his ortho partners on this fluoro build out?

Thanks again!

 

[hyperalgesia]

Thanks so much for all the information! Two more questions:

1) What is the minimum size one would need for an office fluoro suite? GE rep I met with recommended minimum 15 X 15 but said 20 X 20 would be ideal. Current space being considered is only 14 X 9. Too tight?

2) Other than me generating about double in terms of professional fees, how else might a PM&R/pain doc sell his ortho partners on this fluoro build out?

Thanks again!

14 x 9 is very tight but if that's what you got, you could set it up diagonally, with the table and c-arm in the shape of an X. Otherwise the table has to occupy the 9' dimension. You should make a scale model and see your options to arrange things.

To sell the fluoro, in addition to the fees,
-Your efficiency/turnover will be significantly improved.
-You have more control of scheduling and can therefore accommodate more pts.
-You can keep better records, ie saving images.
-You can accept cash more easily. An ASC will charge 700+ minimum for a LESI which is rather prohibitive. You can offer a new pt with an acute disc a same day LESI for $300 cash and everybody wins.

 

[drusso]

Thanks so much for all the information! Two more questions:

1) What is the minimum size one would need for an office fluoro suite? GE rep I met with recommended minimum 15 X 15 but said 20 X 20 would be ideal. Current space being considered is only 14 X 9. Too tight?

2) Other than me generating about double in terms of professional fees, how else might a PM&R/pain doc sell his ortho partners on this fluoro build out?

Thanks again!

14X9 by is tight but do-able.

Sell it by reminding your partners that everything in medicine is getting commoditized and moving to the lowest cost setting. As others have pointed out. Why should an insurance pay for an ASC-facility fee if it can be done in an office.

 

[painfree23]

14 x 9 is very tight but if that's what you got, you could set it up diagonally, with the table and c-arm in the shape of an X. Otherwise the table has to occupy the 9' dimension. You should make a scale model and see your options to arrange things.

To sell the fluoro, in addition to the fees,
-Your efficiency/turnover will be significantly improved.
-You have more control of scheduling and can therefore accommodate more pts.
-You can keep better records, ie saving images.
-You can accept cash more easily. An ASC will charge 700+ minimum for a LESI which is rather prohibitive. You can offer a new pt with an acute disc a same day LESI for $300 cash and everybody wins.

are you allowed to charge cash like that if they have insurance?

 

[hyperalgesia]

are you allowed to charge cash like that if they have insurance?

If you are contracted with their insurance plan, and the patient reports/complains about being charged, you could theoretically get kicked off the plan. However, I'm not sure who really cares about this. Most pts understand that insurance coverage is limited, requires pre-auth, etc, etc. Most insurance people will hang up the phone and move on when they realize they don't have to pay anything.

I know a guy who started a concierge practice and continued to bill BCBS and he got kicked off the panel so anything is possible. That guy ended up being a very happy and rich by the way.