Improving Awareness of Indications and Yield of Diagnostic Paracentesis

Background

Diagnostic paracentesis (ascitic tap) is indicated in all patients presenting with decompensated liver disease with ascites. This is to identify underlying aetiology of ascites as well as complications, including spontaneous bacterial peritonitis (SBP), which in particular carries a high mortality (1).

In decompensated liver disease, the first 24 hours is important for early intervention to reduce mortality and length of hospital stay, which is reflected in the British Society of Gastroenterology (BSG) admission bundle (2).

BSG guidance recommends that the following parameters should be measured in ascitic tap samples: fluid cultures, white cell count, albumin, protein, cytology. However all of these parameters are not always measured when samples are taken. This could therefore result in delayed identification and management of serious aetiology or complications of ascites, which in turn can increase hospital stay and mortality.

Aims

1. Retrospective analysis of all ascitic taps performed between May and November 2021 at Chelsea and Westminster Hospital

Audit data: patient demographics, indication of ascitic tap, requested parameters, time from patient presentation to ascitic tap being done, and outcomes

2. Baseline survey of junior doctors

1) To evaluate whether diagnostic paracentesis is being performed in a timely fashion

3)

Methods Results

Experience and confidence with ascitic taps, including technique, indications and contraindications, and knowing which parameters need to be measured

2) To evaluate whether all recommended parameters as per BSG guidelines are being measured in ascitic tap samples

1. Data collection:

All diagnostic paracentesis samples taken in May to November 2021 at Chelsea and Westminster Hospital were included (n=90).

Data was collected on patient demographics, indication of ascitic tap, requested parameters, time from patient presentation to ascitic tap, and outcomes

Most common indication was decompensated liver disease (83%)

Outcomes in patients diagnosed with SBP (n=11): Full treatment was given in 25%, mortality in 27%

In patients with suspected malignancy (n=11), cytology was not sent in 18%.

2. Survey of junior doctors: 35 responses from a range of grades (FY1 SpR) and specialties 37.1% were not confident in requesting all of the recommended parameters for ascitic tap samples

Only 51.4% correctly identified that diagnostic paracentesis should be done within 1h of a patient presenting with suspected SBP 94% would find it useful having a standardised order set on the hospital computer system for ordering all recommended parameters for ascitic tap samples

Lessons Learned & Next Steps

A large majority of diagnostic paracentesis samples were not sent with all recommended parameters as per BSG guidelines. This could result in a delay in recognition and management of both underlying diseases and life-threatening complications of ascites.

Planned interventions based on results:

1. Teaching sessions for junior doctors, in liaison with the postgraduate education team

2. Creating a standardised order set for the hospital computer system to order all recommended parameters for ascitic tap

Following the interventions, we will reaudit to assess for improvement in the following aspects:

Greater proportion of ascitic taps have all recommended parameters requested and measured

Shorter mean time from patient presentation to ascitic tap

Higher levels of confidence of junior doctors with performing ascitic taps

These interventions aim to raise awareness of the indications for ascitic taps and the parameters that need to be measured, as well as make this easier with the use of a standardised order set. The aim of this is to enable early recognition and management of underlying diseases and complications of ascites, which is important in reducing length of hospital stay and mortality in patients with decompensated liver disease (2).