Improving Processes for Diagnostic Paracentesis at the Edward Hines Jr. VAMC

From the 2021 HVPAA National Conference

Poornima Oruganti (Edward Hines, Jr VA Hospital), Andrew Choi, Lauren Bloomberg, Corrin Hepburn, Tiange Zhang, Rizwan Mahmood, Meghan O’Halloran

Background

Diagnostic paracentesis is an important procedure to evaluate patients presenting for acute inpatient hospitalization with cirrhosis and ascites. According to multiple expert guidelines, a diagnostic paracentesis should be performed in all patients with cirrhosis and ascites at hospital admission to rule out spontaneous bacterial peritonitis (SBP), which carries a high mortality rate if untreated. Early diagnostic paracentesis performance for patients with cirrhosis and ascites presents multiple challenges for timely physician performance.

Objective

This project aims to increase the performance of diagnostic paracentesis within twelve hours of admission from baseline of 36% (34/95) to 50% for Veterans presenting with cirrhosis and ascites within 12 months by May 25, 2021.

Methods

Pre and post-intervention data was obtained from database using pre-identified ICD-10 codes related to cirrhosis followed by manual chart review. Patients admitted to acute care General Medicine from June 2018 to April 2021 were identified and systematically reviewed for completion of bedside diagnostic paracentesis. In addition, Internal Medicine residents were surveyed using a digital survey platform to determine barriers to timely diagnostic paracentesis performance and overall procedure task load. Barriers identified were used to inform intervention elements. Intervention included bundling ultrasound equipment with newly pre-assembled diagnostic paracentesis supply kits, development of a diagnostic paracentesis procedure checklist, and centralized re-location for improved 24-hour accessibility. The intervention was communicated to residents via multiple modalities, including monthly orientations, weekly emails, and in-person educational visits to team workrooms.

Results

Baseline survey of Internal Medicine residents with a response rate of 40% (51/128) revealed pre-procedure planning including challenges with access to ultrasound and supplies as the most significant barrier to performing a diagnostic paracentesis. From June 2018 to June 2020 (103 weeks), diagnostic paracentesis was deemed indicated for 95 unique admissions. Only 36% (34/95) of patients admitted to acute care General Medicine with cirrhosis and ascites received a diagnostic paracentesis within the first 12 hours of admission, while an additional 21% (20/95) received a diagnostic paracentesis at some time during the admission (Figure 1). Preliminary post-intervention results from February 2021 to April 2021 (9 weeks), demonstrate bedside paracentesis was deemed indicated for 14 unique admissions; 64% (9/14) received diagnostic paracentesis within 12 hours of admission and 14% (2/14) received the procedure at some point during admission (Figure 2).

Conclusions

Early 9-week post-intervention results post-implementation of bundled newly accessible equipment with pre-assembled supplies and checklist appears to improve the performance of diagnostic paracentesis within the first 12 hours of admission to General Medicine. Longer post-intervention study periods paired with iterations from additional Plan-Do-Study-Act cycles will be essential to understand sustainability. Future steps will include standardizing bedside procedure protocol, stream-lining consent protocol, and ensuring sustainability of diagnostic paracentesis supply kits.

Clinical Implications

Early diagnostic paracentesis, which has been associated with decreased mortality for patients with cirrhosis and ascites, must have operational support to ensure timely and reliable physician performance. Accessible equipment, supplies, and checklist for early diagnostic paracentesis is essential to improve physicians’ adherence to performance.

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