SECTION 2: PROCEDURES 2.1 ARTHROCENTESIS Arthrocentesis, the aspiration of synovial fluid from a joint, • Perform a time-out before the procedure. is frequently performed in the diagnosis and management • Use appropriate sterile technique throughout the proce- of joint effusions to determine whether these are associat- dure to minimize risk of infectious complications for pa- ed with infectious, traumatic, or rheumatologic conditions. tients and providers. More than 38,000 arthrocentesis procedures are performed • Anticipate and manage complications of arthrocentesis annually in US hospitals.1 Hospitalists may identify a joint after the procedure, which may include bleeding, hema- effusion during the history and physical examination and toma, or infection. should use clinical expertise and evidence-based deci- • Interpret cell counts and biochemical analysis of synovial sion-making to determine whether arthrocentesis is required fluid to determine an appropriate management plan. in the diagnosis and management of the patient’s illness. • Appropriately use splinting and analgesia to reduce joint inflammation and pain when indicated. KNOWLEDGE • Employ multidisciplinary teams, including physical and Hospitalists should be able to: occupational therapy, to assist with inpatient and outpa- • Define and differentiate the disease processes that may tient rehabilitation when appropriate. lead to the development of joint effusion. • Obtain informed consent and effectively communicate • Distinguish between the clinical features of a joint effu- with patients and families to explain the procedure, its sion and soft tissue swelling surrounding a joint. expected diagnostic or therapeutic benefits, and potential • Explain indications and contraindications for arthrocen- complications. tesis including potential risks, benefits, and complications. • Identify and locate anatomic landmarks to guide proper ATTITUDES entry points for arthrocentesis. Hospitalists should be able to: • Describe indications for the use of ultrasonography to as- • Demonstrate awareness of and ability to address peripro- sess and/or to guide arthrocentesis. cedural emotional and physical discomfort. • Explain the appropriate diagnostic tests to accurately characterize synovial fluid. SYSTEM ORGANIZATION AND IMPROVEMENT • Recognize the indications to pursue additional radio- To improve efficiency and quality within their organizations, hos- graphic imaging to further characterize a joint effusion. pitalists should: • Recognize the indications for specialty consultations, • Lead, coordinate, and/or participate in multidisciplinary which may include orthopedic surgery, rheumatology, in- initiatives to optimize resource use. fectious diseases, or interventional radiology. • Lead, coordinate, and/or participate in efforts to develop strategies to minimize institutional complication rates of SKILLS arthrocentesis. Hospitalists should be able to: • Lead, coordinate, and/or participate in patient safety and • Elicit a thorough and relevant medical history to identify quality improvement programs to monitor hospitalists’ comorbid conditions and risk factors for the development performance and/or supervision of procedural competence. or complications of a joint effusion. • Lead, coordinate, and/or participate in patient safety • Perform a physical examination to evaluate for signs to programs designed to coordinate care transition and the determine the primary condition responsible for the de- handoff of pending test results at the time of hospital velopment of a joint effusion, including traumatic injury, discharge. infection, inflammation, or rheumatologic disease. • Demonstrate the optimal position for the patient and the References patient’s joint to perform an arthrocentesis. 1. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization • Select the necessary equipment to safely perform arthro- Project. U.S. Department of Health & Human Services. Available at: http:// centesis. hcupnet.ahrq.gov/. Accessed May 2015. S44 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 12 | No S1 | April 2017.