Documentation of Ascitic Paracentesis

Introduction

Abdominal paracentesis is a common procedure that is undertaken in patients with decompensated liver cirrhosis. Although the complication rates arelow, approximately 1.6% with complications ranging from local mild complications, up to significant bleeding and rarely death

The British Society of Gastroenterology (BSG) haspublisheda large volume paracentesis safety toolkit This quality improvement project aims to improve documentation of ascites drains to improve patients’ safety

From our baseline study, we have identified that 46.4% of the documentation satisfies the key elements recommended by the BSG’s safety toolkit Following this, we have worked with the IT department inimplementinganascitic drain insertion and removal proforma onour electronicdocumentation system (Quadramed). Parameters used were recommended by the BSG safety toolkit

Proforma Template

Name of persondoing the procedure

Designation

Confirmcorrectpatient

Presence of drainable ascites (clinically or USS)

Written consent

IV access

Albumin requested and on the ward

Therapeutic anticoagulation

Pre-drain weight

Surgical ANTT

Time of insertion

Site of insertion

Number of attempts

Colour of initialascites

For Has

Time of removal (max 6hours)

Stop diuretics for 24-48 hourspost drain

Optimize nursing care (show in documentation): Apply dressing. Leave in free drainage. Avoid clamping Keep drainbelowpatient.

Monitor (Show in documentation): Colour of fluid Drain output.Halfhourly patientobservationsduringdrain.

Notes/Comments

Fishbone Diagram

Lessons Learnt

• Since the proforma was introduced, 38.1% of the patients notes used the proforma for ascitic draindocumentation. Overall, compliance with the proforma was inadequateas the fill rate of the entireproforma was 53.9% on average.

• Management errors can occur in the absence of clear documentation of drainageplans. This is because not all healthcareworkers are experienced in paracentesis and there is no unified streamlined protocol to follow.

• Furthermore, implementing the proforma on its own into the IT system is not enough, as fill rate remains inadequate, this needs to be supplemented with increased awareness

Aims

1. To improve efficiency of documentation in ascitic paracentesis and ascitic drain removal

2. Decrease time needed for documentation

3. Improve safety and communication between medics and nursing team.

PDSA Cycle

• Identify problems

• Retrospective data collection for baseline data between 1st January 2020 and 30th April 2020.

• Implementation of the proforma on QuadraMed. Retrospective data collection of post-proforma implementation between 1st July 2021 and 30th October 2021.

• Data analysis of baseline data and post-implementation data. Conducted survey forward staff which showed improvement in satisfaction with plans and time of documentation and data accessibility on ward rounds.

• Planning of 2nd cycle to increase awareness of proforma implemented.

• To increase awareness of abdominal paracentesis’ management and importance of clear documentation of plans with further cycles to be carried out.

Driver Diagram

Results

The mean documentation compliance pre proforma was 46% and after the introduction of proforma was 53%.

Next Steps

Moving forward, our next steps consist of:

• Increasing awareness of the proforma.

• Measuring the length of hospital stay and complication rates.