Improving the quality of paracentesis practices in people with advanced cirrhosis in an ambulatory care setting

Spontaneous bacterial peritonitis (SBP) is a lethal complication of decompensated cirrhosis with a 90% mortality rate if untreated. Despite AASLD guidelines, a practice gap exists in fluid cell count (FCC) collection during paracentesis. We initiated a quality improvement (QI) project to increase FCC collection from 78% to 100% in an ambulatory setting between September 11, 2022, and April 17, 2023.

We evaluated 233 ambulatory patient encounters for paracentesis procedures at a quaternary care centre in Toronto. A multidisciplinary QI initiative included focused groups, AASLD guideline education, a paracentesis bundle, and workflow streamlining. Descriptive statistics and statistical analyses using run charts and p-charts were conducted via QI Macros. Institutional QI Review Committee approval was obtained.

Baseline FCC adherence was 78%. Process mapping identified inconsistencies in documentation, label printing, and FCC collection. Bedside paracentesis bundles were introduced, increasing FCC collection marginally to 79.6% with no special cause variation. Subgroup analysis showed FCC collection rates of 100% among RNs/NPs, 97% among residents, and 92% among attending physicians. General hepatology had a 97% collection rate, while specialty hepatology had 40%. The SBP rate was 1.62% (N = 3).

This study highlights a persistent gap in FCC collection during ambulatory paracentesis. Understanding reasons for non-compliance and assessing the FCC collection's impact on morbidity and mortality in ambulatory settings are next crucial steps to optimize care for this high-risk population.