Paramedics Inserting PICC Lines

[akflightmedic]

Currently nursing homes in our area and paying private companies to come out and they have an RN, bring an ultrasound and all the supplies and insert the PICC lines at the facilities, in the patients rooms. Then transfer maintenance of it over to the nursing staff. The problem is they are extremely over charging and are so busy they can't be reasonable on times. There is no reason you can't give a paramedic that same specialty training on inserting the PICC line and an ultrasound machine is only about $6,000. Thus it would make it more present in the community, save nursing facilities money and provide the patient with a more rapid intervention allowing them to receive the medications they need through a patent line.

I see your angle now and since everyone addressed their replies from the medical aspect, I will enlighten you with the business mind. Your reasoning is flawed. Very.

You seem to think you can just buy a 6K ultrasound, get some training and then do PICC lines for half price (maybe 2 for 1 Tuesdays)?

The rates charged are what Medicare and Medicaid allow. If this is the government standard, why on earth would you charge less? In all seriousness, the government does not care about cost savings, especially on this level. This is not even a blip on their radar. But aside from that you also seem to be putting yourself into the role and you falsely assume every person who assumes this role going forward would be as equally trained or diligent. While you yourself may be more than capable, do we want that precedent when we already agree the paramedic curriculum unto itself is inadequate?

So...to do PICC lines you need:

Training: How much will this cost, where will you get it and who will pay for it?
Ongoing training to prove competency: Same questions as above
Medical Direction: A MD who is willing to allow this of his/her paramedics might not be all that cheap.
Medical Malpractice Insurance: With the infection risk and the potential perception of allowing a lower educated person to perform a "nurse" skill, you better have some good insurance to cover anything and everything.
Workers Comp Insurance: Thats right, even another insurance to protect you in the event of an on the job injury.
Communications:This is all encompassing, you need cellphones, IT support, gadgets and gizmos....and you need to have HIPAA compliant policies and procedures in please before you can use any of it and also secure servers.
Ultrasound:Ok, so you buy ONE ultrasound. What do you do when it needs servicing or breaks? This means you need redundancy in your equipment. Wait! You also need a certified biomed technician otherwise you cant bill for your services as you are not qualified.
Transportation: Yep you need work vehicles and insurance and maintenance. And you insurance needs to be the higher work related insurance in case you get in a crash while en route to perform a procedure.
Supplies: You need vendors! Many of them as you want to get the cheapest price available so you often have to pit them against one another, but you also need volume in order to demand that.

So now we need an IT Team, Biomed person, a MD, and you the PICC placer. Do you need an assistant??

Anyways, this is a very SHORT list of the many flaws in your reasoning, I simply do not have the time to continue on.

And if you meant to say all of this would be incorporated into an existing EMS Service so its already covered...good luck getting the Risk Manager to sign off on this.

Its business....quite frankly, $800 sounds dirt cheap when you factor in all that overhead.

 

[Summit]

$800+ for a PICC? Give me a break. That's more than a ALS transport to the hospital in most areas. I could charge half that and still be profitable. They monopolized the market in the area and have no one challenging it so they can charge whatever they want

Consider the OPERATIONAL COST for an uncomplicated PICC insertion IN-HOSPITAL (cheaper) is about $400.

This is a 1-2 hour procedure on average. And you want to send the provider to the patient at an outside facility? $800 is cheap as heck!

So we've come down to the real basis which is "Paramedics should do it because they are cheaper!!!" Well, why don't we have community paramedics learn to suture and have them respond to ambulatory surgery centers to close? They'll be cheaper than PAs or RNFAs!

You think you can offer cut-rate service because you are paying the Paramedic $20/hr instead of $30/hr for the RN? Give me a break! And to save that $20 you are using a less experienced provider when the stakes are high.

RNs who do this do it all the time (1-4 insertions/shift) and were doing sterile procedures for years usually coming from ICU or OR. The experienced PICC RN will be faster, have lower infection rates, and lower failure rates. What is the price of failure? An ambulance ride to the hospital so the PICC can be placed in Interventional Radiology... and an ambulance ride back. The price for a line infection is much higher still.

 

[Akulahawk]

From the business aspect of things, AK is pretty much on the money, so to speak. If you're looking at the actual item cost of placing a PICC (tray, x-ray shot, etc) then you probably do think that you could train someone to place a PICC and charge "just" $400/placement. Unfortunately there's a LOT of overhead that is built into doing these procedures. You have to pay for a medical director. You have to have (or contract for) biomed service. You have to acquire sufficient US machines to do the job and sufficient back-up machines that will allow you to continue working uninterrupted until you can get your primary unit back from either biomed service or manufacturer service. Those machines also need to be serviced/calibrated periodically. You need to pay for initial training in the procedure and ongoing training as well. You may also need to pay for chart audits to ensure that the PICC lines are placed consistently and properly. You have to pay for various forms of insurance (including malpractice), and so on. What AK didn't touch on at all is that assuming you actually are able to get the service up and running, there's still a ramp-up time where you'll have to pay for someone to be ready to place a PICC but you won't yet have the business yet and then once you do have facilities utilizing your services, there's still the issue of billing for said service. When you send out the bill, you may not see a dime from that for a few weeks.

So what I'm also saying is that start up costs would be significant and you'd have to reimburse someone for the start-up loans you'll need and that can only come from your future earnings that you wouldn't have in hand yet.

Since there are private RN-PICC companies out there now, experience has shown how much funding it takes to keep those businesses up and running successfully. Just one of those things is that those companies won't likely hire someone that doesn't already have PICC placement training because then someone else bears the cost of initial training so all the company has to do is verify a competency as opposed to training someone to an appropriate level of competency.

So, in addition to the medical aspect of things, it's just not a good business move unless you've got a large fortune that you're willing to turn into a much smaller fortune to get something like this up and running.

 

[Akulahawk]

You think you can offer cut-rate service because you are paying the Paramedic $20/hr instead of $30/hr for the RN? Give me a break! And to save that $20 you are using a less experienced provider when the stakes are high.

RNs who do this do it all the time (1-4 insertions/shift) and were doing sterile procedures for years usually coming from ICU or OR. The experienced PICC RN will be faster, have lower infection rates, and lower failure rates. What is the price of failure? An ambulance ride to the hospital so the PICC can be placed in Interventional Radiology... and an ambulance ride back. The price for a line infection is much higher still.

Totally agree with this. Considering that an experienced RN doing these may actually be worth north of $60/hr considering the local market and experience... while using a Paramedic might be "cheaper" by maybe $40, the Paramedic just doesn't normally have the requisite experience base. I'm not saying that a Paramedic can't learn to place a PICC, there's something to be said for experience working in a sterile field. One of those experiential things is knowing how to move sites... Once upon a time there was a PICC nurse that was attempting to place a PICC. Unfortunately the first placement failed. So the RN had to change to an alternate site and do it without breaking sterility. It was done and the second attempt went beautifully, but it wasn't easy and I had the unenviable task (at the time) of watching everything to ensure that the sterile field wasn't broken. It won't be easy teaching a Paramedic that hasn't had much (if any) experience working in a sterile field how to do exactly this.

In the the long run, it might be cheaper to start up an Interventional Radiology company as a fixed-place of business, attach an ambulance company to it and shuttle patients to the IR company for various procedures, including PICC placement... but remember that means taking a large fortune, turning it into a small one, in the hopes of building back up a large fortune...

 

[Summit]

I'm not saying allow everyone on the service to do it. But have a designated group of people that you have trained by certified staff at the hospital and keep them in the loop on Inservices to allow them to remain up to date on the practices.

He isn't interested in forming a company with medics who do this full time (that would be boring after-all). He wants this to be "yet one more skill" for a special-few-elite Community Paramedics to do every couple weeks/months.

 

[akflightmedic]

Correction Summit.....2 weekends a month, 2 weeks a summer!

Hoo-Ah!

 

[Tigger]

The flashy skills are simply not going to make community paramedics effective. As an industry, I believe we need to partner with the people that do the flashy things for a living and help them. And then there's the whole part about just keeping people of hospitals which is cheap and does not require an enormous training outlay.