sending patients home with catheters

  • Thread starter Thread starter deleted126335
  • Start date Start date
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
D

deleted126335

Members don't see this ad.
Trying to access the collective wisdom of the group on outpatient peripheral catheters:

1. popliteal for podiatric procedures.
2. Supraclavicular for outpatient shoulder scopes and early discharge (POD 1) for TSA's
 
dr doze said:
Trying to access the collective wisdom of the group on outpatient peripheral catheters:

1. popliteal for podiatric procedures.
2. Supraclavicular for outpatient shoulder scopes and early discharge (POD 1) for TSA's
Click to expand...

1. no idea
2. they come out by the time they get to the parking lot. We have had good success with posterior approach ISBs so we typically do those
 
We routinely send our patients home with catheters. Supraclaviculurs infraclavicular, all the upper extremity blocks except inter scalene catheters. We use ambit pumps for patients at home. Still do not know how to use those pumps. Do you routinely tunnel your catheters, here some attendings do some do not especially when placing the catheters in plane. As a soon to be professor if my patients are going home with a catheter it will be tunneled.
 
No tunneling. Simple catheter through needle technique for both popliteal and supraclavicular.
 
Send home interscalene caths home for most rotator cuff repairs. All acls go home with fem caths. Any foot jobs done by the orthos at our place go home with pop caths. Do infraclaviculars for any complicated hand cases. Never tunnel. Use dermobond, tegaderm and silk tape to keep it from leaking and keeping it in place respectively. We use the iflow product " on-q-c" pumps and have great success. We sent home 225, in the 4th quarter of 2011 and 175 in the 1st quarter of this year. If you want some help setting things up pm me and I will give you my number and we can chat. blaz
 
dr doze said:
Trying to access the collective wisdom of the group on outpatient peripheral catheters:

1. popliteal for podiatric procedures.
2. Supraclavicular for outpatient shoulder scopes and early discharge (POD 1) for TSA's
Click to expand...

Infraclavicular stay better and are more easily secured than supraclavicular.

don't tunnel - you can achieve the same affect by doing this - under direct visualization, withdraw the needle and once the needle is a cm or so a way from the nerve, start pushing all the catheter you can in the subq tissue so it snakes its way out as you withdraw the tuohy.

I would never send someone home with a femoral nerve catheter. This is a recipe for disaster. Apparently quad strength is really important.

Given that the outcome data for regional is not conclusive, your are on thin ice if your patient falls and breaks an ankle (like we have had atleast once, maybe twice).

And I am sure plenty of people will say - "Hey, I've sent over 100 people with femoral nerve catheters home and haven't had a problem." Well, good on ya, but the rule of three would say that based on those numbers, with 95% confidence your rate of significant event is 1/33. That isn't a great number for saftey if you ask me.

http://en.wikipedia.org/wiki/Rule_of_three_(medicine)
 
Last edited:
dr doze said:
Trying to access the collective wisdom of the group on outpatient peripheral catheters:

1. popliteal for podiatric procedures.
2. Supraclavicular for outpatient shoulder scopes and early discharge (POD 1) for TSA's
Click to expand...

Oh, and by the way, according to the data collected by the smart ones that write our journals, the outcome data on catheters have not been that great according to satisfaction scores (but pain scores are great).

Why are people not satisfied? Because they have this scary pump and a tube that sometimes leaks sticking out of their neck and they don't know who to call, or where to go, or what to do.

The only patients that said it made a difference were the ones that felt like they had a support system and didn't feel like they were left alone with this weird device.

So the take home message for us is this - we need to make sure they have readily available phone numbers to call 24 hrs a day for questions. We should give them instruction sheets with common questions and what to expect, etc, with clear directions. Also, tell them they can expect a call every day that the catheter is in place - to see how they are doing. I am sure that is very reassuring for them and makes a world of difference.
 
epidural man said:
I would never send someone home with a femoral nerve catheter. This is a recipe for disaster. Apparently quad strength is really important.
Click to expand...

Why draw the line at femorals? Seems like any LE catheter is a fall risk too, for a patient who tries to walk on the operative leg.

We offer disposable take-home pumps (Accufuser at the moment) for most of our ACLs. I offer popliteal catheters for achilles repairs and some painful foot whacks. They go home with instructions not to walk.

Tell them non-weight-bearing, document that you told them non-weight-bearing ...

Ultimately you can't protect patients from themselves, but I don't see undue risk in the take-home disposable pump + catheter plan provided there's documented good postop instructions.
 
pgg said:
Why draw the line at femorals? Seems like any LE catheter is a fall risk too, for a patient who tries to walk on the operative leg.

We offer disposable take-home pumps (Accufuser at the moment) for most of our ACLs. I offer popliteal catheters for achilles repairs and some painful foot whacks. They go home with instructions not to walk.

Tell them non-weight-bearing, document that you told them non-weight-bearing ...

Ultimately you can't protect patients from themselves, but I don't see undue risk in the take-home disposable pump + catheter plan provided there's documented good postop instructions.
Click to expand...

Agree. Some of my single shots last 22-30 hours. So, they can fall or burn their arm just as easy with a single shot as with a catheter. My goal is to get the patient through the first night pain free. The second night is questionable whether most/all patients actually need that catheter.

That said, catheters are worth doing for some patients and good instruction with documentation is the key for patient safety and medico legal protection.
 
epidural man said:
Oh, and by the way, according to the data collected by the smart ones that write our journals, the outcome data on catheters have not been that great according to satisfaction scores (but pain scores are great).

Why are people not satisfied? Because they have this scary pump and a tube that sometimes leaks sticking out of their neck and they don't know who to call, or where to go, or what to do.

The only patients that said it made a difference were the ones that felt like they had a support system and didn't feel like they were left alone with this weird device.

So the take home message for us is this - we need to make sure they have readily available phone numbers to call 24 hrs a day for questions. We should give them instruction sheets with common questions and what to expect, etc, with clear directions. Also, tell them they can expect a call every day that the catheter is in place - to see how they are doing. I am sure that is very reassuring for them and makes a world of difference.
Click to expand...


You are correct. No evidence that the catheters really make a difference in terms of outcome/success of surgery. But, without Decadron added to your local we have no way to guarantee post op pain relief that first night with an early AM block.

Catheters make the first 48 hours much more pleasant for the patient and some simply can't tolerate PO pain meds (puke their guts out).

When allowed toradol and Tylenol are excellent alternatives to PO opioids. I've had more than a few patients get a block with a catheter plus pump followed by toradol/Tylenol with zero opioid use.
 
dr doze said:
Trying to access the collective wisdom of the group on outpatient peripheral catheters:

1. popliteal for podiatric procedures.
2. Supraclavicular for outpatient shoulder scopes and early discharge (POD 1) for TSA's
Click to expand...

Too many of my patients would try to inject something into it to get high... no caths outside of the hospital for us.
 
epidural man said:
So the take home message for us is this - we need to make sure they have readily available phone numbers to call 24 hrs a day for questions. We should give them instruction sheets with common questions and what to expect, etc, with clear directions. Also, tell them they can expect a call every day that the catheter is in place - to see how they are doing. I am sure that is very reassuring for them and makes a world of difference.
Click to expand...

This. Outpatient catheters take MORE time to manage than inpatient. On the floor, the burden is shared between physician(s) and nurse(s). The outpatient catheter is typically managed by one person over the phone. It can be a lot of work. If I did a lot of them, I would ask the hospital to provide a nurse to manage all the routine daily stuff and refer complicated stuff to me.

My happiest PNC catheter patient was one of our circulating RN's who had a RCR. I sent her home with a Bupi/Sufent ISB catheter. Checked on her twice a day and went out to her house once with a refill for the epidural pump that I borrowed from the hospital (we don't have the right disposable pumps to send home). She was extremely satisfied. It was too much work for the money, but I was willing to do it since she was a friend.

The biggest thing I learned from that catheter... don't do an initial light analgesic block for the surgery just because you have the catheter in and don't need a dense block to give you the duration you want. The patient woke up completely pain free, moving her arm around. After an RCR you either need a dense motor block or some pain to keep the patient from moving the arm around, putting the fresh repair at risk.

- pod
 
pgg said:
Why draw the line at femorals? Seems like any LE catheter is a fall risk too, for a patient who tries to walk on the operative leg.

We offer disposable take-home pumps (Accufuser at the moment) for most of our ACLs. I offer popliteal catheters for achilles repairs and some painful foot whacks. They go home with instructions not to walk.

Tell them non-weight-bearing, document that you told them non-weight-bearing ...

Ultimately you can't protect patients from themselves, but I don't see undue risk in the take-home disposable pump + catheter plan provided there's documented good postop instructions.
Click to expand...

Only weakend quad - you don't need much calf or foot strenght to walk really. Telling them to be non-weight bearing is a good idea.
 
Selection criteria
1. Must speak English and follow instructions
2. Must have phone number and home address
3. Must live nearby and have someone able to drive pt back to hospital for ER or troubleshooting
 
We have a busy ortho department in our private practice. No catheters for us... too much time and effort to place them... too much medicolegal risk (patients are *****s)... not much benefit beyond our single shot blocks (24-30 hours)... reimbursement not significantly higher than single shots.

The feeling of doing a 30-second supraclavicular block and sending the patient home pain free for 30 hours... neat.

No followup, phone calls, or worry about something going wrong with a catheter and getting sued... priceless.
 
When we sat down with the hospital after they asked us to do it we felt the same way. Not much more money and a lot more time. They went ahead and gave us a full time nurse that sets up everything and a space to do them preop as well as following them up with post op calls. We get paged maybe once or twice a month with disconnects or failures. We were still against it but forged ahead and we have seen a size able growth in income as well as an increase in volume as we are the only hospital in the area doing it and they have done their best to promote it. All of our ortho guys numbers have gone up and we get people from over an hour away coming in. So it may not be worth the investment in a per case basis but it is worth it if it adds over all volume. Blaz
 
I send 10-15 catheters home weekly. I give every patient my cell phone number and beg them to call me with any problems. I only get about 5-6 calls per year. Patients love it. Most surgeons love it. I spent the first 3 months of my practice trying to sell the benefits to the patients and surgeons and now 2 years later patients come down requesting "that pain ball thingy my surgeon told me I need to get".

Significant increase in revenue in my area. 5 extra units per. With smart patients you can give them a dial a flow and they can get 4-5 days out of 500cc's. Patients you don't trust as much, don't give them the option to change flows or don't put in a catheter.

They only take about 5 minutes more to place (use a sterile probe cover and then taping it in). Thats worth 5 units to me at my rate.

I understand the arguments against them, but in my neck of the woods, I couldn't be happier with them. Setting up the program is the key. Poor set up = poor product.
 
climbingak said:
I send 10-15 catheters home weekly. I give every patient my cell phone number and beg them to call me with any problems. I only get about 5-6 calls per year. Patients love it. Most surgeons love it. I spent the first 3 months of my practice trying to sell the benefits to the patients and surgeons and now 2 years later patients come down requesting "that pain ball thingy my surgeon told me I need to get".

Significant increase in revenue in my area. 5 extra units per. With smart patients you can give them a dial a flow and they can get 4-5 days out of 500cc's. Patients you don't trust as much, don't give them the option to change flows or don't put in a catheter.

They only take about 5 minutes more to place (use a sterile probe cover and then taping it in). Thats worth 5 units to me at my rate.

I understand the arguments against them, but in my neck of the woods, I couldn't be happier with them. Setting up the program is the key. Poor set up = poor product.
Click to expand...


5 minutes extra? You have a slick system then.

My single shot is chloraprep, tagaderm over probe, lube on skin, US look-see, lido wheal, 18 g ding, block needle in with preattached syringe, inject slowly, change syringe, finish injection, "I hope that wasn't too uncomfortable for you"

Catheter? Okay, first let's start with the draping, fiddle around with a probe cover condom job and lube inside, rubber band man, open the stuff and the little catheter bag, ... get the catheter snaked in, take the needle out, put the adaptor on, adhesive, super glue for you?, who's filling up the pump?, hook-it all up, etc. etc, etc X quite a few.

Chelly group study determined 30 minutes for their whole job. Oh, now I also have something additional to think and worry about.

Mrs. So-and-so, if you are uncomfortable with the relief you get from the pain meds when the single shot block wears off, you come back and see me at the surgery center and we'll redo it for you.
 
I believe JACHO won't let us hand fill the pumps: it has to be done under a pharmacy hood or prefilled by an outside company. The upside is that the pump is delivered to you or to PACU for an easy hookup.

As for redoing pumps, when my program gets going, I envision that we won't redo any nerve catheter unless the pt is already in the hospital (ie PACU or ER). Otherwise I plan to tell them to crank the rate up to 14cc/hr (max) and take two vicodin.
 
I just use an epidural kit for the catheter. The only things extra are the sterile probe cover and then taping it in. My probe cover is large enough that i just stick my hand in it inside out, grab the pre lubed probe and then pull it over.

There is no way it should take 30 minutes. I don't find them that cumbersome to manage and I follow them all myself. If it was that big of a hassle, noone would do them, especially in private practice. If they need to come back in during the day to troubleshoot the catheter I welcome it. I am already there, and the reason I put it in in the first place is to help the patient through the first 3 days. This is extremely rare anyway. If it was common, noone would do them.

Docs don't place these to increase their revenue only. They place them because they work and they are not that hard to manage. Its something extra we bring to the table to help the patient and the surgeon. The revenue increase is nice, but wouldn't be worth it to anyone if it was super time intensive.

If you set up your program from the start so that it works well, its all downhill from there. Very few problems.
 
climbingak said:
I send 10-15 catheters home weekly.
Click to expand...

For what type of case to you leave catheters? As much as i love the concept the thing is not many procedures really require a block to last more than 24-30h which i can get with most single shots.
How do you avoid the leak you get at the skin along the catheter? Glue? Any tips on how you prevent them from falling out?

Thanks
 
dhb said:
For what type of case to you leave catheters? As much as i love the concept the thing is not many procedures really require a block to last more than 24-30h which i can get with most single shots.
How do you avoid the leak you get at the skin along the catheter? Glue? Any tips on how you prevent them from falling out?

Thanks
Click to expand...

Disagree. We have a podiatrist who does alot of foot and ankle surgery. Single shot popliteals, particularly those earlier in the day don't get the patients through the first night. Trying to figure out the balance between providing good service and improving patient satisfacrion and being a little twitchy about catheters that are not monitored and complications and liability.
 
It's worth saying again: it's all about your assistant. The experienced RNs at the surgicenter have got the probe tegadermd or covered, chlorapreps, and anything else that might be necessary. Catheter shouldn't take too much longer than single-shot with them. With the preop RNs at our main hospital -- you're lucky if the ultrasound is in the preop area. Sometimes I get tired of doing my job and the nurse's job as well. :laugh:
 
DrRobert said:
It will be interesting to see how bundled payments affect regional anesthesia, catheters, etc.
Click to expand...

Compensation in my area for regional is not that great anyway. We do regional because it's good for patients and what the surgeons want. Well, some of them anyway. That being said, bundled payments might mean more catheters if the name of the game is to get the word anesthesiology all over the chart (preop, intraop, ICU, pain, etc).
 
The goal is pain free the first night. The pump usually allows a second pain free night. That said, as long as you can get the block to last until the next morning the pump isn't needed in my opinion.

However, only by adding Decadron does your nerve block last until the following day. Even then only certain blocks performed with Rop/Bup with Decadron last for more than 24 hours. A pump allows your diabetc patint to be comfy overnight (im not adding Decadron for them).

I don't worry if the catheter falls out or there is a problem the next day. I just tell the patients to discontinue the catheter or come in and we will do it quickly for them.
 
If you have the patient come back in, do you have them admitted/registered so it's official? That seems like a pain, possibly expensive for the patient, and might give red flags to administrators (oh look anesthesia caused a readmission) Or do you do it informally?
 
Oggg said:
If you have the patient come back in, do you have them admitted/registered so it's official? That seems like a pain, possibly expensive for the patient, and might give red flags to administrators (oh look anesthesia caused a readmission) Or do you do it informally?
Click to expand...

Informal. I make a note and make sure it is added to chart/medical record. I'll take care of the issue in PACU (or holding) as this gets the patient out within 15 min of arrival.

I treat is exactly the same as if the patient simply had some follow-up questions. The fact that the patient came to the hospital or ASC to "talk with me" doesn't change my approach.
 
Oggg said:
If you have the patient come back in, do you have them admitted/registered so it's official? That seems like a pain, possibly expensive for the patient, and might give red flags to administrators (oh look anesthesia caused a readmission) Or do you do it informally?
Click to expand...

Since you can not bill for the procedure (any re-injection etc is bundled into the initial code), there is no need to generate a visit. I suspect that if you could and did bill for it, then there would need to be an official visit.


- pod
 
So your nurses will let you sedate a patient, replace a nerve catheter, bolus some local anesthetic? I assume they make you do a new consent form? Do you monitor the patients after sedation or do you have the nurses monitor this unregistered patient? Sorry if these questions are a bit blunt, but if I try to bring pts back informally, my nurses and admin will probably try to stop me
 
No need to sedate for a reblock. The patient has motivation at that point (pain relief). I do "admit" them to the surgery center because otherwise you can't touch them. Its simply an administrative function completed by administrative people. It is a no charge readmission.

90% of my catheters are for shoulders. I do some femorals for TKA that we send to an assisted living facility. Also do some pop and infraclav on occasion, but not many of those need multi day blocks. Shoulders will be the bulk of outpatient catheters, at least in my practice.

I do use dermabond to help prevent leaks. I do my caths in plane so there is plenty of catheter in the patient to anchor it. I place them lateral for positioning so I do more of a posterior approach. Once the cath is by the nerve, I thread plenty of extra cath as I withdraw the needle. My biggest problem at first was having a taught catheter and then the surgeon would pull the skin when pulling off the 10-10 drape theoretically pulling the catheter away from the nerve. Now I have plenty of play in the catheter, plus I have my guys hold the catheter site down as the surgeons pull the 10-10 off. Not been a problem since then.

There are very few problems in these patients. The biggest problem I have is patients wanting to come back in to refill the pain ball.
 
Last edited:
climbingak said:
I do use dermabond to help prevent leaks. I do my caths in plane so there is plenty of catheter in the patient to anchor it. I place them lateral for positioning so I do more of a posterior approach. Once the cath is by the nerve, I thread plenty of extra cath as I withdraw the needle. My biggest problem at first was having a taught catheter and then the surgeon would pull the skin when pulling off the 10-10 drape theoretically pulling the catheter away from the nerve. Now I have plenty of play in the catheter, plus I have my guys hold the catheter site down as the surgeons pull the 10-10 off. Not been a problem since then.
Click to expand...

👍 thx
 
If you readmit,
1. You could bill an E&M code? 99231 is for inpatients I think but maybe something else
2. Will the bean counters count up your readmissions and count it against you and your block program? They probably will at my place.
 
We send older kids home with catheters all the time with their "pain balls". If it doesn't work/stops working the parents just pull it out. Switch to po pain meds. We use a drop of dermabond to seal the skin and a big tegaderm to secure it.

Cheers!
 
I wouldn't want to bill for a readmit. If the catheter isn't working, I feel thats on me, even though it may have been due to forces beyond my control. I offer them partial pain relief for a few days, and thats what they expect. Its so rare, though, that patients need to be seen again.

My admin does not hold it against me, but we are a very close knit team. It doesn't count against anyone to do it. I just readmit them as a pain procedure and she is happy to do that and not charge the patient. I'm lucky in that aspect I guess, but it makes total sense for the patient. If it happened everyday it might be an issue, but it is so so rare. I've maybe done it 4 times in the past year and a half or so? Most of my returns are for refills, but I just do that informally and not readmit.
 
Oh, and I get my pumps filled at an outside pharmacy. Only cost $10 more (they must get the meds cheaper en bulk) than buying the pump and meds separately and filling myself. Also takes the labor (about 5-10 mins) and liability away from me (I don't have a sterile hood lying around)
 
You must log in or register to reply here.

Similar threads

D
Pulling epidural catheters
Replies
3
Views
788
IlDestriero
IlDestriero
GaseousClay
Nurse murders multiple patients
Replies
14
Views
3K
Robotic Wis-Hipple
Robotic Wis-Hipple
D
Wrong end? Double lumen tube exchange catheter
Replies
10
Views
1K
urge
urge
FiO2@21
Intrathecal Catheters
Replies
17
Views
2K
FiO2@21
FiO2@21
nimbus
Oldest patient
Replies
40
Views
3K
ChiDO
ChiDO
Top