Letter of the Editor: Survey of attitudes and knowledge of early paracentesis guidelines and performance in providers in the Veterans Health Administration

To the editor, Among hospitalized adults with cirrhosis and ascites, early paracentesis (performed within 24 h) is associated with reduced inpatient mortality, particularly among high-risk patients, such as those with acute kidney injury and/or HE.1,2 Failure to perform early paracentesis is associated with higher odds of acute kidney injury, transfer to the intensive care unit, and inpatient mortality. Despite the recommendation from the American Association for the Study of Liver Disease (AASLD) that patients with ascites from cirrhosis admitted to the hospital undergo a diagnostic paracentesis, even in the absence of signs and symptoms of infection, a recent study by Patel et al3 revealed a low rate (14.3%) of early paracentesis performed in this population in the Veterans Health Administration (VHA). To understand barriers to early paracentesis, we developed and emailed a 20-question survey to clinicians responsible for performing inpatient paracentesis in VHA. A total of 114 participants from 24 VHA hospitals completed the survey, including 84% physicians and 10% advanced practice providers, most of whom specialized in Internal Medicine (48%) and Interventional Radiology (22%). Most respondents (62%) were familiar with the AASLD recommendation for paracentesis but described barriers including time (51%), provider comfort (51%), and supervisor availability (29%). Only 16% had a designated procedure team, and only 15% reported a standard operating procedure for inpatient paracentesis at their facility. These findings suggest several potential strategies to increase early paracentesis completion (Figure 1). Education and training could address the confidence gap described by Internal Medicine providers who perform the bulk of these procedures and are likely the major referral source to Interventional Radiology. Availability of prepackaged paracentesis kits containing the necessary supplies in the emergency department and the wards may help address the time burden. Likewise, standardized order sets for patients admitted with ascites could increase efficiency and prompt providers to address numerous quality issues, including timely paracentesis. Further research into noninvasive means to exclude spontaneous bacterial peritonitis may be beneficial.FIGURE 1: Early paracentesis has been shown to improve multiple important metrics in patients with decompensated cirrhosis admitted to the hospital, including mortality. In the Veterans Health Administration, rates of paracentesis completion in the first 24 hours of admission remain low. Based on our survey of Veterans Health Administration providers, there are a number of potential interventions that may increase early paracentesis completion and thereby improve patient outcomes. Abbreviations: AKI, acute kidney injury; ICU, intensive care unit.In summary, the study by Patel and colleagues highlighted an important quality gap in cirrhosis care in the VHA. Our survey documents a lack of time and comfort as the major barriers to early paracentesis. We suggest strategies such as prepackaged paracentesis kits, availability of procedure teams and ascites care-specific order sets to drive improvement in this important patient care metric.