LP CLINICs
The LP clinic is an important outpatient rotation to aid in the diagnosis of our colleagues’ patients and learn procedural skills. The rotation is a mix of LP clinic (Frenkil and VA), VA clinic, and Continuity Clinic. You may also be asked to perform LPs for the inpatient services.
GOALS & OBJECTIVES
Be able to perform LP independently
Be able to utilize US to find landmarks
Be able to counsel patients/families on LP procedure and what to expect
Understand indications for LP and how to interpret results
Be able to evaluate undifferentiated neurological patients, formulate their cases, and propose appropriate diagnostic and therapeutic plans.
Appropriately order and interpret neuroimaging studies.
Counsel patients and families regarding diagnosis and treatment, discuss goals of care, and negotiate conflicts among family/patient and the treatment team.
Clearly and completely document patient care in a timely fashion.
Incorporate feedback and develop a learning plan.
Review literature to incorporate evidence-based medicine in patient care.
Develop appropriate differential and initiate further diagnostic testing and management for movement, neuromuscular, cognitive/behavioral, demyelinating, seizure, neuro-oncologic, and neuropsychiatric/somatofoam disorders, along with headache and neurologic manifestation of systemic disease.
Be able to appropriately request consultations from neurologic subspecialists.
Be able to use non-technical terms to explain procedures, such as EEG/EMG.
Performing Lumbar Punctures Independently
You will log all your LPs in MedHub. As a PGY2, you need to complete five LPs, two of which must be successful, before you are able to perform LPs independently. For your 5th logged LP, have the person who supervised you complete the on-the-fly evaluation in MedHub called ‘LP’. This can be done by any attending OR by any PGY3 or PGY4 resident. You need to score at least a Level 4 (Can Perform Independently) on this evaluation in order to be cleared to perform LPs independently.
DAY 1
Pre-chart / Schedule check in the “Neurology Clin Fre” to see what patients are scheduled for you for LP and continuity clinic for your first week. Your first day (Monday) will be LPs at Frenkil.
You must be familiar with Frenkil LP logistics. It is very different from inpatient LPs! Review Frenkil LP Clinic logistics, with particular attention to Resident Checklist.
If you are not familiar with Sprotte needle or Ultrasound guidance for LP landmark identification, please reach out to VA Clinic resident prior to LP for supervision or learn it before your rotation.
Your EPIC inbox will look different because you will be covering. Residents who are on Vacation will also have their Epic Inbox’s forwarded to yours. You are responsible for returning patient phone calls, completing refills, and answering other clinic questions in a timely manner (within 48 hours).
FRENKIL LP clinic
SCHEDULE AND ROOMS
Rooms
Room 1: Room 14 (EMG room with stretcher)- Primary Procedure Room (first room)
Room 2: Room 13 (EMG room with stretcher) – Primary Procedure Room
Room 3: Procedure Room B – Overflow room
Room 4: Procedure Room A (dentist chair) – main room for “lay flat 15 minutes” post procedure
Schedule
Resident A in Room 1
8am LP
9:30am LP
Resident B in Room 2
8:30am LP
10am LP
Attending and Resident Flow
Residents will complete both of their assigned LPs in the same room.
The attending will move between room A and room B through the morning and bring ultrasound machine between the two rooms.
PERSONNEL
Faculty – one of Fredrich, Ahmad, Jin
Resident – VA LP resident and VA Clinic resident
RN – typically Sharon and Valerie, but all able to help if needed
Frenkil LP Resident Checklist
The checklist will be printed and set in the LP room on day of clinic
The checklist is stored on our OneDrive and can be found here. You must be logged into your SOM account in order to access this link.
It is MANDATORY to review the checklist prior to clinic. This contains a comprehensive, step by step list of your duties in the clinic.
PRIOR TO LP CLINIC DAY
Check personal Epic clinic schedule. You will be assigned a schedule with two patients, either at 8am and 9am or 8:30am and 9:30am. You are expected to arrive at the clinic no later than 7:45am, regardless of schedule assignment. It is recommended you arrive by 7:30am on your first day to begin following the resident checklist.
If your schedule is empty, you may have no LPs scheduled that day. Please double check with Ashley Kaufman on the Friday prior to clinic to ensure there are no add-ons.
The ordering provider is responsible for ordering and following up on coagulation studies, if necessary, prior to the LP. All results should be reviewed and uploaded into Epic if performed at outside lab.
CLINIC DAY OVERVIEW
There is a resident checklist which will be provided to you in the day of clinic. Below provides an overview of your duties:
A nurse will be assigned to help prepare the room. In the room you will have a resident checklist, consent form, LP kit, Sprott needles, gown, mask, face shield, chlorhexidine scrubs and gloves (please let the MA or Nurse know your glove size or any additional supplies needed). The nurse will also obtain the ultrasound if you are assigned to the first LP of the morning. If you have the second LP of the morning, the attending will bring the ultrasound to you.
Paper lab requisitions for CSF studies should be printed prior to starting the procedure. If lab orders were not placed but were specified by the ordering provider, please order these labs prior to starting the procedure and print the requisitions. Check carefully for expired labs that need to be re-ordered. Send out labs require a separate Send Out Lab sheet which is available in the procedure room. You will need to label the tubes with the patient’s provided name stickers. Be sure to initial and date each sticker. You will physically walk the CSF with the printed lab requisitions to the 2nd floor pathology lab in North Hospital following both LPs.
Before the LP procedure, you will perform a brief history/exam, review the procedure with the patient, and obtain consent for the LP procedure.
LP resident must write a pre-procedure note (dot phrase “.nacpreprocedure”) and sign prior to starting procedure (select “sign on closing note”). Following the procedure you will need to write a second note using the Neuro Lumbar Puncture Procedure Smartset.
Use of Sprotte needle and ultrasound for landmark identification is mandatory. They are standard of care for LPs in our department.
To perform the procedure place the patient in the appropriate position, either lateral decubitus or seated. It is often much easier to complete the test with your patient in the seated position. If an opening pressure is required, the patient should be in the lateral decubitus position.
LP resident should not perform more than 3 ATTEMPTS at obtaining CSF before the attending physician should assist for the remainder of the procedure. An attempt includes repositioning the needle without coming out of the skin. 3 attempts can occur only with attempting access at 1 level.
Should you fail to obtain CSF from a patient they will have to be scheduled for the procedure with diagnostic radiology. You will be responsible for placing this referral and following the failed bedside LP workflow.
Following the LP, the patient remains in the room to lay flat for 15 minutes before the MA or Nurse releases them. The clinic nurse will give them after care instructions, but it’s always good to explain to them what to expect yourself.
Once you have completed the LP you will need to complete the Neuro Lumbar Puncture Procedure Smartset, which includes your procedure note, orders for LP procedure, billing, and LOS. You will have to add a diagnosis to be able to sign the note. If you are unsure of the diagnosis there is an “encounter for lumbar puncture” diagnosis. Document your patient time as 0 (if MA recorded any time you should change those to 0 as well). Witnessing attending should be the cosigner.
FOLLOWING LP CLINIC
If you are LP clinic resident, it is your responsibility to deal with any complications that arise from the procedure (post-LP headache, etc.). Patients should receive a timely response to their concerns; please return calls ASAP.
Blood Patch: If your patient has a post-LP headache, the UMROI or Camden pain management groups can help with expedited appointments. For emergencies, anesthesia can assist in-hospital overnight
Camden group: Email UMOA-CallCenter@som.umaryland.edu and jkarri@som.umaryland.edu with subject line: "urgent referral - Dr. Karri for blood patch." Can usually be same day or next day.
UMROI group: Email patient access rep Cheryl Conaway cconaway@umm.edu or call the center at 410-448-6450. Can usually be done same day or next day.
Please check the chart the following day to ensure the correct studies are completed or in process at the lab.
special csf order circumstances
Prion Diseases: When collecting and testing CSF for prion disease, remember there are special handling and cleaning requirements around potentially infective CSF
You should already be using sterile technique with gloves, gown and facemask with face shield for all LPs. There is nothing different you need do during your collection.
Please let the MA/RN you are working with who might be handling samples or in room with you know that this is being sent for PRION testing.
After collection, the samples need to be bagged in special RED bags for transport to the lab. Please remind the MA/RN who is taking your samples, THESE NEED TO GO IN RED bags.
If there is a leakage or spillage of CSF, please let MA/RN know – there are specific cleaning requirements around potential PRION CSF.
OCBs or IgG index: DO NOT order IgG index or oligoclonal bands. These are performed by the UM lab and are inaccurate.
The preferred order is “Multiple Sclerosis Panel” which includes both IgG index and oligoclonal bands. If the ordering provider placed orders for IgG index or OCBs, please re-order as Multiple Sclerosis Panel.
CSF orders requiring matching serum samples: If the following orders are requested, they require blood samples in addition to CSF. Please ask the nurse to draw blood immediately after the procedure if any of the following are requested by the ordering provider.
Multiple sclerosis panel (2 yellow top tubes)
Mayo ENS2 panel (1 red top tube)
Mayo PAVAL panel (1 red top tube)
Mayo ADEVL (Alzheimer’s Disease CSF panel): this requires a special collection tube for CSF. These are available in the clinic
Forms are necessary for most send-outs. Please fill based on provider requests.
Form for Mayo Tests (ENC2, ENS2, PAVAL, ADEVL)
Client Account Number 7041771
LP Antithrombotic Policy
The UMMS antithrombotic policy for lumbar punctures is stored on our OneDrive and can be found here. You must be logged into your SOM account in order to access this link.
VA LP CLINIC
You will be notified of pending LPs by Liz Lounds but can also review the schedule (“BT neu LP” under clinics on CPRS) earlier in the week to see if any patients have been scheduled. You should plan to review any and all scheduled patients to ensure that coags, platelets an/or head imaging is completed prior to the day of if necessary. You will also need to make sure that all requested labs have been ordered appropriately. There is typically only one patient scheduled for an LP on Fridays at the VA. If more have been scheduled this will have been discussed previously between the resident and Liz.
VA LP Procedures:
Plan to arrive ~30 minutes before scheduled appointment. Make sure labs are ordered under “orders.”
Go to 4A procedure room, you can ask the nurse or VA senior where that is if you get lost.
Fill out consent form on CPRS: Under “tools” -> iMedConsentWeb -> click on neurology consents and fill out the LP consent with patient
Complete time out
Remember to fill out procedure note. On CPRS, enter “procedure <universal protocol procedure note>”
Should you fail to be able to obtain CSF from a patient they will have to be scheduled for the procedure with interventional radiology. This can be ordered in CPRS as a referral. Be sure that the patient has an INR and platelet count ordered in the past 30 days.
Last Updated: October 2023