Quality improvement initiative increases total paracentesis and early paracentesis rates in hospitalised cirrhotics with ascites

Abstract

ObjectiveEarly paracentesis (EP) for rapid diagnosis of spontaneous bacterial peritonitis is considered best practice in the care of admitted patients with cirrhosis and ascites, but inpatient paracentesis is frequently not performed or delayed. We developed a quality improvement (QI) initiative aimed at increasing the proportion of admitted patients with cirrhosis who undergo paracentesis and EP.Design Pre–post study of a QI initiative.Setting A tertiary care hospital in a major metropolitan area.Patients Hospitalised patients with cirrhosis and ascites.InterventionsWe targeted care providers in the emergency department (ED) by raising awareness of the importance of EP, developing criteria to identify patients at highest risk of SBP who were prioritised for EP by ED providers and restructuring the ED environment to enable timely paracentesis.Results76 patients meeting inclusion criteria were admitted during the postintervention 9-month study period. Of these, 91% (69/76) underwent paracentesis during admission versus 71 % (77/109) preintervention (p=0.001). 81% (56/69) underwent EP within 12 hours of presentation or after a predefined acceptable reason for delay versus 48% (37/77) preintervention (p=0.001). There were no significant differences in in-hospital mortality or length of stay before and after intervention.ConclusionA multidisciplinary QI intervention targeting care in the ED successfully increased the proportion of patients with cirrhosis and ascites undergoing diagnostic paracentesis during admission and EP within 12 hours of presentation.

Factors Associated with Delayed Paracentesis in Patients with Spontaneous Bacterial Peritonitis

“…Such outcomes may significantly reduce early bedside paracentesis performed by ED physicians. This is further supported by a recent quality improvement project where a gap analysis performed to identify barriers to paracentesis reported that time and personnel required in the ED were the most common reasons cited [ 20 ].…”

Management of patients with cirrhosis in the emergency department: Implications for hospitalization outcomes

“…Routine correction of international normalized ratio (INR) and/or platelets is not required before diagnostic paracentesis, and the risk of bleeding is low even in patients with INR > 1.5 and platelets < 50 × 10 9 /L 5,6,11 . Given that diagnostic paracentesis is an essential early intervention in patients with cirrhosis with ascites, which informs additional downstream, time-sensitive critical interventions, it is important to emphasize the importance of this procedure in EM practice 15 …”

“…[5,6,11] Given that diagnostic paracentesis is an essential early intervention in patients with cirrhosis with ascites, which informs additional downstream, time-sensitive critical interventions, it is important to emphasize the importance of this procedure in EM practice. [15] Intervention: Antibiotics When suspicion of infection/sepsis is high, empiric antibiotics should be initiated immediately after cultures have been collected. [5] For SBP, once diagnosed by ascites neutrophil count, antibiotics should not be delayed while awaiting culture data.…”

Don’t delay: Early paracentesis can save lives in hospitalized patients with cirrhosis and ascites

“…Indeed, Jesudian et al proved that a quality-improvement initiative based on increasing the awareness of emergency medicine and internal medicine specialists, as well as providing procedural training, increased the rate of patients receiving a paracentesis within 12 hours from admission, from 48% to 81% in pre-intervention and post-intervention phases, respectively. [9] Another potential barrier to the implementation of paracentesis concerns the low reimbursement rate for the procedure. In fact, the high value of paracentesis is poorly recognized by the current reimbursement rate.…”

“…Diagnostic paracentesis is a procedure that requires simple equipment and takes only a few minutes to be performed properly; therefore, the implementation of early paracentesis mainly concerns the training of physicians and awareness of its value for patient care. Indeed, Jesudian et al proved that a quality-improvement initiative based on increasing the awareness of emergency medicine and internal medicine specialists, as well as providing procedural training, increased the rate of patients receiving a paracentesis within 12 hours from admission, from 48% to 81% in pre-intervention and post-intervention phases, respectively 9 . Another potential barrier to the implementation of paracentesis concerns the low reimbursement rate for the procedure.…”