A Hospitalist-Run Procedure Service Safely Streamlines Inpatient Intrathecal Chemotherapy

Background In patients with hematologic malignancies, intrathecal chemotherapy by means of a lumbar puncture (LP) has found a critical role in delivering vital medications to patients with central nervous system (CNS) spread. However, many oncology patients who require this procedure have refractory thrombocytopenia that can lead to delays in intrathecal chemotherapy administration, as well as potentially the excess use of platelet transfusions, which are a limited resource. At our institution, intrathecal chemotherapy is delivered by radiology with a strict minimum number of platelets or a hospitalist-led medical procedure service (MPS), with a more individualized threshold. We sought to compare outcomes and complications of intrathecal chemotherapy administered using radiologist-guided fluoroscopy or bedside with the MPS. Methods We conducted a retrospective cohort study of adult inpatients referred for intrathecal chemotherapy from August 2019 to May 2022. An electronic medical record tool extracted demographics, laboratory results, and procedure timing. Relevant imaging within seven days of the LP was individually reviewed to determine major complications. Separately, patients were evaluated for traumatic taps based on their cerebrospinal fluid (CSF) red blood cell (RBC) count. Results There were 564 procedures that fit the inclusion criteria, 485 done by radiology and 79 by MPS. MPS teams conducted the procedure at lower platelet thresholds (49% with platelets below 50,000 in MPS as opposed to 6.4%, p < 0.001). Both teams had a low complication rate, 1.3% for MPS and 1.6% for radiology, though the MPS completed LPs sooner after consultation requests (six versus 24 hours; odds ratio {OR}: 0.41; p<0.001), with a 71% decrease in traumatic tap occurrence compared to those performed by radiology (OR = 0.29; p = 0.002). Conclusions Our study suggests that a hospitalist-run MPS can substantially expedite patient care in this vulnerable oncology population with a low complication rate, despite conducting the procedures with a higher proportion of patients with thrombocytopenia. Further research is warranted to determine MPS's impact on the length of stay (LOS), as well as potential cost savings associated with the procedure.