Safety and predictors of the success of lumbar punctures performed by a medicine procedure service.

BACKGROUND: Medicine procedure services (MPS) increasingly perform bedside procedures, including lumbar punctures (LPs). Success rates and factors associated with LP success performed by MPS have not been well described. OBJECTIVE: We identified patients undergoing LP by an MPS September 2015 to December 2020. We identified demographic and clinical factors, including patient position, body mass index (BMI), use of ultrasound, and trainee participation. We performed multivariable analysis to identify factors associated with LP success and complications. MAIN OUTCOME AND MEASURES: We identified 1065 LPs among 844 patients. Trainees participated in 82.2%; ultrasound guidance was used in 76.7% of LPs. The overall success rate was 81.3% with 7.8% minor and 0.1% major complications. A minority of LPs were referred to radiology (15.2%) or were traumatic (11.1%). In multivariable analysis, BMI > 30 kg/m2 (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.21-0.48), prior spinal surgery (OR 0.50, 95% CI 0.26-0.87), and Black race (OR 0.62, 95% CI 0.41-0.95) were associated with decreased odds of successful LP; trainee participation (OR 2.49, 95% CI 1.51-4.12) was associated with increased odds. Ultrasound guidance (OR 0.53, 95% CI 0.31-0.89) was associated with lower odds of traumatic LP. RESULTS: In a large cohort of patients undergoing LP by an MPS, we identified high success and low complication rates. Trainee participation was associated with increased odds of success, while obesity, prior spinal surgery, and Black race were associated with decreased odds of success. Ultrasound guidance was associated with lower odds of a traumatic LP. Our data may help proceduralists in planning and assist in shared decision-making.

Implementation of a fracture liaison service for patients with hip fracture cared for on a hospital medicine service.

OBJECTIVE: Hip fracture is a common and morbid condition. Prior studies have shown that the majority of patients with fragility fracture are not treated for underlying osteoporosis. Our hospitalist-led co-management service for patients with acute hip fracture had no system for evaluating and treating osteoporosis in this cohort. Our objective was to implement a fracture liaison service (FLS) to assist patients with acute hip fracture and assess subsequent impact on diagnosis and treatment of osteoporosis. METHODS: We conducted a pre-post study design at our tertiary academic center, including patients >50 years old hospitalized with acute hip fracture. We implemented a FLS, whereby all patients received endocrinology consultation. Outcome measures included the proportion of patients evaluated for osteoporosis by time of hospital discharge, comparing pre-implementation (12 months) and post-implementation (9 months) cohorts. We also measured the proportions of patients evaluated for and offered treatment for osteoporosis within 3 months of discharge for patients with post-discharge encounters visible in the medical record. RESULTS: We identified 167 patients before and 124 after FLS implementation. In univariate analysis, the proportion of patients evaluated for osteoporosis before discharge increased from 0.6% to 72.6% (p < 0.001) pre- vs. post-implementation. The proportion of patients offered osteoporosis treatment within 3 months after discharge increased from 25.3% to 46.3% (p = 0.01). In multivariate analysis, post-implementation patients had higher odds of osteoporosis evaluation while hospitalized (OR = 470.4, p < 0.001) and higher odds of being offered osteoporosis treatment within 3 months (OR = 2.8, p = 0.008). CONCLUSIONS: Establishment of an FLS partnered with a hospitalist-led co-management service for patients with hip fracture was associated with significant improvements in the proportions of patients evaluated and offered treatment for osteoporosis. Wider adoption of this model has the potential to improve care for patients with hip fracture by narrowing the osteoporosis treatment gap.