Between office-based labs (OBL), ambulatory surgical centers, and hospitals, patients are treated in various settings by endovascular specialists across the country. In this episode of the BackTable podcast, Dr. Mary Costantino talks about the benefits and drawbacks of working in an OBL compared to a hospital.
The BackTable Brief
Working in a single OBL versus multiple hospitals allows the physician to work with a similar group of nurses and techs; colleagues that understand your procedure-specific preferences lead to procedural efficiency.
Providing care to patients with various types of insurance policies can be challenging and costly in the hospital setting; working in an OBL allows the provider to treat all patients in a central location.
Dr. Costantino says her patients have been happy with both hospital and OBL experiences, yet the location and accessibility of her OBL is relatively stress-free for her patients.
Although infrequent, complicated cases may arise in an OBL practice; always put the patient first and be prepared to keep the OBL open past hours to ensure complete patient recovery.
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Working in an OBL Versus Hospital Setting: The Physician’s Perspective
Working in an OBL has many benefits over working in a hospital setting, says Dr. Costantino. The OBL allows the physician to consistently work with the same team of techs and nurses, ultimately making for a streamlined procedure. Furthermore, hospital-specific insurance requirements make it difficult to keep patients in a central location, leading to frequent travel between hospitals.
… What about the experience for the doctor? How does your approach for the procedure change when you're doing in the OBL rather than the hospital?
I ended up having to go to several hospitals because of insurance issues. If patients had a certain type of insurance, I'd have to go to hospital A or certain type of hospital B. I was going between two hospitals and in two hospitals, you have multiple techs, multiple nurses, it can really take a long time. It takes about a year before people get used to the things you do, if they ever do. You have to be pleasant. You have to be patient. You have to willingly wait for an hour or two. You have to accommodate. You have to turn around and say, "Can you open the Renegade?" It turns out they're out of them. You have to be very flexible on what equipment you use because you find out that some order didn't come in or maybe you have three UAEs that afternoon, but they only have a box of embolic.
I like it because when you're not a hospital IR and you're not there all the time, you're putting out little fires. Inevitably, there's always the tech that you love working with. The case is just so stress-free. Once in a while, you'll sense that. You'll have some case that goes quick and easy. You'll think, "Why are these so stressful all the time? This is so easy." It's because you're working with the guy who's one step ahead of you and usually, you're not and you're having to say. I literally have said to techs, "Okay, hand me the wire and they hand me the glide wire even though I have a microcatheter in," and I would say, "No, the little wire. Can you hand me the little wire?" You just end up having to do that over and over. You become the person who is working 10 times as hard, but that's just natural.
Now, I'm in the OBL with my one tech who's amazing. It's almost too easy. For the doctor, yeah, it's way easier. I also think that UFE generally isn’t a procedure where you need multiple IRs. You don’t need to collaborate with anybody.
Working in an OBL Versus Hospital Setting: The Patient’s Perspective
After speaking with many of her patients, Dr. Costantino says her patients have been happy with both hospital and OBL experiences. Unlike the hospital, however, her OBL is easily accessible and the periprocedural process occurs within the confines of an office setting. Same day discharge from the OBL means it’s important to assess the patient’s home environment; Dr. Costantino reviews what her patient’s home life is like and emphasizes the importance of rest and recovery with her patients’ families.
Mary, focusing on UFE again, you've done them in both the hospital and outpatient settings. How do you think the experience with a patient undergoing the procedure compares between the hospital and the OBL?
… I thought about that a lot and so I used to ask patients, "Were you glad you were in the hospital last night?" when we go see them in the morning. The other thing is that, I would go in the morning just as a social visit to say, "Hey, your night went great. See you later." I had the hustle on big time. They would all say they were happy they were in the hospital.
I tried to figure out why they were happy in the hospital. I always have my patients in maternity wards, which are great places to be. There are these big rooms. They're private. They are like birthing centers. They have these great TVs. People bring you dinner. You've got a nice view out the window. I thought the environment was really quiet and nice. It also removed the woman from her home environment, which can be chaotic with kids and needy husbands or whatever.
Totally. I've had patients tell me the same.
Yeah. I have always liked to know what their home life looks like. I've always done that. Like "Who's at home? Do you have dogs at home? Do you have cats at home? What are your kids like?" I love it when I meet the husbands because I can pinpoint them as, "Oh, he'll be a great support" or he's just going to be annoyed at her that she has to be down for a week. I'm really strict about telling them, "She is doing nothing for a week. No carpool pickups." All these things. I have two kids that are 11 and 13. I get it from the female's perspective of what we do at home. Not that the guys don't do things, but especially, mom should stay at home, you just have a lot more responsibility. I think they like that. I try to establish that environment for that at home.
I have gotten other things like acupuncture and music. I do all these other things to make the OBL environment really pleasant. It's also very stress-free. They don't have any stress parking. They walk in. It's all familiar faces. They know where they're going. They walk in the door. They walk 12 feet beyond the door. They get their IV. It's all just very gentle. I think they like that.
Do patients stay overnight in the OBL?
Complicated cases requiring prolonged patient observation may arise following outpatient procedures. Working in a hospital setting has the option of sending patients to the 24-hour observation unit, however, OBLs likely do not have this option. Although this situation happens infrequently, one of the benefits of having an OBL is that you can keep it open as long as needed. Putting the patient first is most important; Dr. Costantino says it’s critical your OBL team understands this, as the physician and nurse may need to stay with the patient until they are ready for discharge .
What are your strategies in the OBL? Because you're in a situation that, barring a disaster, you absolutely need to get these patients home the same day. You don't really have that same option of keeping them there overnight. What do you do to ensure that you're going to get them home that day?
Yeah. Well, UFE patients, it's always interesting how they respond to UFE. I've carefully monitored what kind of medications patients have needed overnight in the hospital. We have them on 24-hour obs. I would generally start the cases around 3:00 or 4:00. Part of the reason I kept people in the hospital overnight was because I didn't want them driving home at 11:00 p.m. I tried to recreate the outpatient scenario in the hospital even though they spent the night in the bed. One thing is, do your cases early. I would never start a UAE in an OBL at three o'clock.
We start about 7:00, 8:00, 9:00. Then, you always have to have a nurse monitoring. That nurse's job is to pay close attention to the patient, how they respond to medications. I usually use some Dilaudid. I start them on OxyContin extended release prior to the procedure. They get some narcotic onboard. Then I use intraarterial lidocaine. I think that's really important. They do really well, actually, for the first about four hours. The challenging part comes between hours 5 and 10.
Because they're feeling fine and then they go home. What happens is, there can be a gap in their medication. I just recently went to just saying, "Take a Percocet every two hours." Now, we're not even going to try to have you judge whether or not you need it because they misjudge. We can keep the OBL open as long as we need to. If I have a patient who is not doing well, then we both stay there. The nurse might stay there until they're doing well. We take full responsibility for it. If they need to be admitted for pain control, then I have to admit them. At this point, I can't imagine that their pain would be that bad, that we can't get it under control in an OBL.
I did have to come back one night. I had a patient who was throwing up, she couldn't take her Percocet, she was panicking, the family was panicking. The nurse and I just drove in at nine o'clock at night. We got her settled. We gave her some fluids. She couldn't pee. We put her in a Foley. She felt much better. We got her some Dilaudid. We watched her for a couple hours and she did fine. She was great, went home, and had no other issues. We are available to open up our lab should that need to be done. You have to be open to doing all of the stuff because ultimately, it's your responsibility.
I guess I didn’t really think about that. That flexibility to keep it open because it is your office. You stay long as you want.
Yeah. I can use whatever I want in there. I just walk in.
Right. Exactly. I'm used to the more general inflexibility of hospitals.
Yeah. You just have to have a nurse. This is getting your team on the same page, right? Look, we're here for patients, first and foremost. Even if that means that we have to go in for an hour or two at nine o'clock. However, that's not the goal of an OBL. Then it's like being on-call. We like to avoid that situation. The other thing is, a lot of the surgery centers have 24-hour recovery. You just have to have two people there.
Let’s say I was doing 10 UFEs a day, which I can't imagine I'll ever be doing, but let's say I am. As long as you have two people, you can keep these places open overnight. This is what a lot of the surgery centers are moving to. Generally, people will hire a paramedic and a nurse.
Dr. Mary Costantino is a practicing interventional radiologist at the Comprehensive Integrated Care practice in Portland, Oregon.
Dr. Michael Barraza is a practicing interventional radiologist at Radiology Alliance in Nashville, Tennessee.
Cite this podcast:
BackTable, LLC (Producer). (2018, December 19). Ep 36 – Building the UFE and OBL practice with Dr. Mary Costantino [Audio podcast]. Retrieved from http://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.