- Email: [email protected]
Vascular Centers: Why Me? and What Now?
When full-thickness skin loss occurs, there are several options. Specific treatment must be decided based on the patient, procedure, and the presence of underlying devices. In general, the older, sicker, or more fragile the patient and situation, the more likely direct surgical intervention is the best option. Surgical closure is also necessary for large wounds or for those with critical underlying structures or devices. In these cases, the necrotic skin can be excised, and the wound reclosed. This protocol decreases the risk of infection and resolves the situation more quickly. In younger patients, in select circumstances without underlying foreign bodies, the wound can be treated with daily dressings and allowed heal by contraction. This is most useful when the area of skin loss is less than 1 em in diameter. One-centimeter to three-centimeter wounds in noncritical area with loose surrounding skin also may heal by contraction in a reasonable time period.
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Surgical Treatment of Wound Infection The treatment of a wound infection depends on the specific nature of the infection. Local wound infections seldom need surgical drainage unless there is a fluid or pus accumulation. When present, these should always be drained completely. The presence of a device or foreign body increases the likelihood that antibiotic treatment alone will fail. This means that aggressive, i.e., surgical, treatment with drainage is more likely to be effective. Early initiation of effective antibiotics increases the salvage rates. Antibiotics should be chosen based on location of wound and what pathogens it is exposed to for optimal results. An initial attempt at percutaneous drainage of infected fluid is usually reasonable. If cellulitis does not resolve within 48 hours or if fluid re-accumulates, then a more extensive procedure should be considered. Surgical treatment should include complete drainage and debridement of any necrotic tissue or exudate. If available, pulse-lavage irrigation is an excellent adjunctive method of doing this. If there is a device in the infected space, when treatment is initiated early and the tissues surrounding an implant are healthy, an attempt can be made to leave the device in place. Fluid accumulation around the device must be kept to a minimum, and a prolonged course (at least 2 weeks) of antibiotics is given. Failure, progressive infection, or continued cellulitis after 48 hours means that the device is infected, and it should be removed. The treatment decision about whether or not the wound can be closed may be difficult. If treatment for the infection is begun early, the surrounding tissues and patient are healthy, and exposing an implanted device would be serious problem, then closing the wound after placement of a drain is reasonable. This is not the ideal manner of treating the infection, however, and device rescue should not outweigh patient well-being.
Drains
Open Drains Penrose, red rubber drains. Simple and cheap. Allow bacterial migration into drained space. They are most effective when used in dependent areas. Closed System Drains Jackson-Pratt, Blake drains. Limit bacterial ingrowth. Require airtight seal around drained space or continuous suction to continue to function.
Sunday, March 21, 1999 3:30 pm-5:30 pm Categorical Course: Interventional Radiology Practice Development Part (2) (C108) 3:30 pm Vascular Centers: Why Me? and What Now? Brian Stainken, MD, Michael Hallisey, MD, Barry Katzen, MD, Terry Matalon, MD, Mahmood Razavi, MD, Tom Vesley, MD, and Dan Picus, MD Albany Medical College Albany, New York Learning objectives: The objective of this portion of the categorical course in IR practice management is to expose the participant to a detailed, frank discussion ofthe rationales, pitfalls, and options available to academic and private practice interventional radiologists considering reorganization or affiliation of their clinical operations into a vascular center. A panel of practicing interventional radiologists representing contrasting center arrangements will discuss their experience before open discussion. Questions will be encouraged. To this end, ifyou have a question or a "situation"for the panel to
conSider,
please
forward
it
by
email
to
[email protected]. Why Me? Interventional Radiologists are finding themselves in a defensive stance, driven by trends in managed care, market forces, and our own success, prompting increasing competition for vascular procedures and income. Vascular surgeons and Cardiologists are developing skills formerly held exclusively by the interventional radiologist. Our fields are rapidly converging. It is clear that, with the support of their peers and industry and by virtue of their primary referral position, these specialists pose a significant threat to our specialty as it now exists. It is important for interventional radiologists and health care leaders to carefully consider the impact of these trends as they relate to patient care as the current professional organization places the interventional radiologist, the undisputed technical expert, at a competitive disadvantage. From an organizational perspective, the fragmented multispecialty approach to vascular disease is redundant and tradition bound. It has failed to keep pace with
technology and arguably exists only to propagate itself, and it might continue to do so were it not for the progressive centralization of health care purchasers. These corporations, insurance companies, and managed care organizations prefer to buy their complete product (not the parts) all at once, at a low price, and with predictable and definable quality. They will not pay to sustain the current model. Enter the Vascular Center. By consolidating clinical practice, we have an opportunity to respond to the competitive threat. Centralization and integration may improve efficiency, reduce costs, and improve quality. Vascular Centers make sense, maybe. What Now? So what should we do? Should we all form centers? What about my radiology group? What will a center accomplish? What will happen to my practice, my independence, my income? What about protective covenants, what about antitrust? What about my diagnostic radiology work? Is this a good idea for me? Imagine what might happen if you were a division of a big company (Radiology Corp.). Identify what it is that you make and what this product is worth to you and to the competition. What approaches can you consider? Should you license your methods, sell off the division, merge corporations, acquire, acquiesce, ask for a transfer, quit, or shift your divisions, focus to another market? What is in the best interest of your parent company? Should they sell and reinvest the profit to better focus on their primaly consulting business or should they buy? Should they trade our practice for the competition's consulting practice? Can the parent company compete with the big guys? Are they wilJing to invest, do they have the board of trustee's support? Are you worried that your company may go under? Whose stock would you buy? Do you really want to go it alone? The answers lie in due diligence. The decision-making process must begin with a sober assessment of your assets, liabilities, and capabilities. A center built on combined strength is more likely to survive than one built on a dream. Do not exp~ct too much from a center; it is only a conceptual tool to institutionalize consensus and realign administration. Approach the process from the perspective of your patient. What is it that you have to offer, and who can help you deliver?
One Approach Begin with an honest and critical assessment of your own priorities. What is your expertise, your product line, and what keeps you from delivering optimal care? Are there other individuals or groups whose needs and strengths are complimentary? Is your current organization an asset or a liability? It is much easier to build on a strong base than to start anew. Where are the roadblocks to reorganization? The next step is to focus on the delivery of care to your targeted population. Map out the pathway that your
patients must follow, every step. Look for opportunities to integrate or eliminate redundancy and to standardize and eliminate random events. Ignore the political and financial reality, and work toward the ideal patient-centered model. Focus your operation on the areas that offer the greatest gains. Third, consider organization. Where is the current structure effective, and where is it a major impediment? Be specific. What level of integration serves your patient's needs? Some centers have evolved as a physical institutional entity with participation of several groups of providers each maintaining their own financial autonomy, others integrate finances, and still others integrate both finances and clinical operations. This is the time for blunt honesty with your potential partners. Who will supervise, and how will conflicts be resolved? Next, solicit organizational support. This is probably the single most problematic step and unlikely to succeed unless predicated by a solid, well-considered plan, a strong, well-chosen partnership, and a forward-thinking administration. Finally, build the organization. Concentrate on communication and ongoing quality improvement. The hard work in many ways begins after the joint venture is formed. Develop measurement tools for quality, efficiency, and volume. Stay focused on your goals.
Monday, March 22, 1999
3:30 pm-5:30 pm Categorical Course: Clinical Management Part (2) (C201) Moderator: Melvin Rosenblatt, MD 3:30 pm Contrast Media: Issues for the Interventionalist Michael C. Soulen, MD
University of Pennsylvania Philadelphia, Pennsylvania Compatibility Papaverine can precipitate or induce thrombosis when mixed with contrast. There are case reports of limb thrombosis when using papaverine as a vasodilator. Flush well between injections of contrast and drug. GJucophage (metformin) is a hypoglycemic drug for diabetes that is entirely metabolized and excreted by the kidney. Ninety-nine percent is cleared in 24 hours. There is no direct interaction between contrast and Glucophage. If a patient goes into acute renal failure due to contrast, the drug is not cleared from the body, potentially resulting in lactic acidosis with a 50% mortality. The recently revised package insert recommends not taking Glucophage for 48 hours after contrast administration and assuring that renal function has remained normal before resuming the drug. The previous recommendation that metformin be stopped 48 hours before contrast administration has been discontinued. Given the rarity of
367
366
Surgical Treatment of Wound Infection The treatment of a wound infection depends on the specific nature of the infection. Local wound infections seldom need surgical drainage unless there is a fluid or pus accumulation. When present, these should always be drained completely. The presence of a device or foreign body increases the likelihood that antibiotic treatment alone will fail. This means that aggressive, i.e., surgical, treatment with drainage is more likely to be effective. Early initiation of effective antibiotics increases the salvage rates. Antibiotics should be chosen based on location of wound and what pathogens it is exposed to for optimal results. An initial attempt at percutaneous drainage of infected fluid is usually reasonable. If cellulitis does not resolve within 48 hours or if fluid re-accumulates, then a more extensive procedure should be considered. Surgical treatment should include complete drainage and debridement of any necrotic tissue or exudate. If available, pulse-lavage irrigation is an excellent adjunctive method of doing this. If there is a device in the infected space, when treatment is initiated early and the tissues surrounding an implant are healthy, an attempt can be made to leave the device in place. Fluid accumulation around the device must be kept to a minimum, and a prolonged course (at least 2 weeks) of antibiotics is given. Failure, progressive infection, or continued cellulitis after 48 hours means that the device is infected, and it should be removed. The treatment decision about whether or not the wound can be closed may be difficult. If treatment for the infection is begun early, the surrounding tissues and patient are healthy, and exposing an implanted device would be serious problem, then closing the wound after placement of a drain is reasonable. This is not the ideal manner of treating the infection, however, and device rescue should not outweigh patient well-being.
Drains
Open Drains Penrose, red rubber drains. Simple and cheap. Allow bacterial migration into drained space. They are most effective when used in dependent areas. Closed System Drains Jackson-Pratt, Blake drains. Limit bacterial ingrowth. Require airtight seal around drained space or continuous suction to continue to function.
Sunday, March 21, 1999 3:30 pm-5:30 pm Categorical Course: Interventional Radiology Practice Development Part (2) (C108) 3:30 pm Vascular Centers: Why Me? and What Now? Brian Stainken, MD, Michael Hallisey, MD, Barry Katzen, MD, Terry Matalon, MD, Mahmood Razavi, MD, Tom Vesley, MD, and Dan Picus, MD Albany Medical College Albany, New York Learning objectives: The objective of this portion of the categorical course in IR practice management is to expose the participant to a detailed, frank discussion ofthe rationales, pitfalls, and options available to academic and private practice interventional radiologists considering reorganization or affiliation of their clinical operations into a vascular center. A panel of practicing interventional radiologists representing contrasting center arrangements will discuss their experience before open discussion. Questions will be encouraged. To this end, ifyou have a question or a "situation"for the panel to
conSider,
please
forward
it
by
to
[email protected]. Why Me? Interventional Radiologists are finding themselves in a defensive stance, driven by trends in managed care, market forces, and our own success, prompting increasing competition for vascular procedures and income. Vascular surgeons and Cardiologists are developing skills formerly held exclusively by the interventional radiologist. Our fields are rapidly converging. It is clear that, with the support of their peers and industry and by virtue of their primary referral position, these specialists pose a significant threat to our specialty as it now exists. It is important for interventional radiologists and health care leaders to carefully consider the impact of these trends as they relate to patient care as the current professional organization places the interventional radiologist, the undisputed technical expert, at a competitive disadvantage. From an organizational perspective, the fragmented multispecialty approach to vascular disease is redundant and tradition bound. It has failed to keep pace with
technology and arguably exists only to propagate itself, and it might continue to do so were it not for the progressive centralization of health care purchasers. These corporations, insurance companies, and managed care organizations prefer to buy their complete product (not the parts) all at once, at a low price, and with predictable and definable quality. They will not pay to sustain the current model. Enter the Vascular Center. By consolidating clinical practice, we have an opportunity to respond to the competitive threat. Centralization and integration may improve efficiency, reduce costs, and improve quality. Vascular Centers make sense, maybe. What Now? So what should we do? Should we all form centers? What about my radiology group? What will a center accomplish? What will happen to my practice, my independence, my income? What about protective covenants, what about antitrust? What about my diagnostic radiology work? Is this a good idea for me? Imagine what might happen if you were a division of a big company (Radiology Corp.). Identify what it is that you make and what this product is worth to you and to the competition. What approaches can you consider? Should you license your methods, sell off the division, merge corporations, acquire, acquiesce, ask for a transfer, quit, or shift your divisions, focus to another market? What is in the best interest of your parent company? Should they sell and reinvest the profit to better focus on their primaly consulting business or should they buy? Should they trade our practice for the competition's consulting practice? Can the parent company compete with the big guys? Are they wilJing to invest, do they have the board of trustee's support? Are you worried that your company may go under? Whose stock would you buy? Do you really want to go it alone? The answers lie in due diligence. The decision-making process must begin with a sober assessment of your assets, liabilities, and capabilities. A center built on combined strength is more likely to survive than one built on a dream. Do not exp~ct too much from a center; it is only a conceptual tool to institutionalize consensus and realign administration. Approach the process from the perspective of your patient. What is it that you have to offer, and who can help you deliver?
One Approach Begin with an honest and critical assessment of your own priorities. What is your expertise, your product line, and what keeps you from delivering optimal care? Are there other individuals or groups whose needs and strengths are complimentary? Is your current organization an asset or a liability? It is much easier to build on a strong base than to start anew. Where are the roadblocks to reorganization? The next step is to focus on the delivery of care to your targeted population. Map out the pathway that your
patients must follow, every step. Look for opportunities to integrate or eliminate redundancy and to standardize and eliminate random events. Ignore the political and financial reality, and work toward the ideal patient-centered model. Focus your operation on the areas that offer the greatest gains. Third, consider organization. Where is the current structure effective, and where is it a major impediment? Be specific. What level of integration serves your patient's needs? Some centers have evolved as a physical institutional entity with participation of several groups of providers each maintaining their own financial autonomy, others integrate finances, and still others integrate both finances and clinical operations. This is the time for blunt honesty with your potential partners. Who will supervise, and how will conflicts be resolved? Next, solicit organizational support. This is probably the single most problematic step and unlikely to succeed unless predicated by a solid, well-considered plan, a strong, well-chosen partnership, and a forward-thinking administration. Finally, build the organization. Concentrate on communication and ongoing quality improvement. The hard work in many ways begins after the joint venture is formed. Develop measurement tools for quality, efficiency, and volume. Stay focused on your goals.
Monday, March 22, 1999
3:30 pm-5:30 pm Categorical Course: Clinical Management Part (2) (C201) Moderator: Melvin Rosenblatt, MD 3:30 pm Contrast Media: Issues for the Interventionalist Michael C. Soulen, MD
University of Pennsylvania Philadelphia, Pennsylvania Compatibility Papaverine can precipitate or induce thrombosis when mixed with contrast. There are case reports of limb thrombosis when using papaverine as a vasodilator. Flush well between injections of contrast and drug. GJucophage (metformin) is a hypoglycemic drug for diabetes that is entirely metabolized and excreted by the kidney. Ninety-nine percent is cleared in 24 hours. There is no direct interaction between contrast and Glucophage. If a patient goes into acute renal failure due to contrast, the drug is not cleared from the body, potentially resulting in lactic acidosis with a 50% mortality. The recently revised package insert recommends not taking Glucophage for 48 hours after contrast administration and assuring that renal function has remained normal before resuming the drug. The previous recommendation that metformin be stopped 48 hours before contrast administration has been discontinued. Given the rarity of
367