A plan for paracentesis

Background

In the past, patients with cirrhosis and refractory abdominal ascites often sought care at the ED at LA General. The pandemic highlighted the need to reduce demands on the ED, including for paracentesis. "Emergency departments were struggling with all kinds of care, but part of it seemed unnecessary, especially to the hospitalist I work with," said Barbara J. Turner, MD, MSEd, MA, MACP. "She thought that instead of patients going in and getting repeated paracentesis [in the ED], there should be an alternative."

Although interventional radiology would be a typical outpatient setting for the procedure, publicly insured and uninsured patients at safety net hospitals like LA General have less access to this care, explained Dr. Turner, who is a professor of clinical medicine at Keck School of Medicine of the University of Southern California (USC). Technological innovations have also made it more possible for paracentesis to be provided in specialty settings, she noted. "Now that we have ambulatory ultrasound, it becomes more feasible to do it in clinics."

The hospitalist with the idea, Shadi Dowlatshahi, MD, MSc, convinced her facility's administration to financially support an experimental solution with "a little bit of a deal," explained Dr. Turner. "She had to reduce the demand on the emergency room for repeated paracentesis."

How it worked

The outpatient FLuid ASPiration (FLASP) clinic launched at LA General in March 2021, taking referrals from the ED. It was staffed at first by just Dr. Dowlatshahi and a nurse, providing a few paracentesis procedures a day. By July, it had enough business to take on an intern; then a nurse practitioner joined the team in September. Physicians across LA General Hospital began referring patients to the clinic.

Clinicians working in the FLASP clinic were trained by Dr. Dowlatshahi to perform ultrasound-guided paracentesis, removing no more than 5 L of fluid. Clinic staff monitored vital signs and laboratory tests and provided education about diet and medication adherence in English or Spanish. The FLASP clinic also worked to connect patients with hepatology specialists to potentially receive transjugular intrahepatic portosystemic shunts or even liver transplant.

"Reaching out to the emergency department and making it quite clear they can manage patients in the short term—like the next day—it expanded very quickly," said Dr. Turner, who noted that the clinic provided over 2,600 paracenteses in its first 14 months.

Results

But did the FLASP clinic pay up on the "deal" underlying its creation? Yes, according to results published by the Journal of General Internal Medicine on Feb. 20.

A comparison of 172 patients who received paracentesis in the ED before the clinic opened with 225 treated by the clinic found that the demand for paracentesis in the ED was reduced by two-thirds. Mean monthly visits to the ED for paracentesis declined significantly, from 4.11 per 1,000 ED visits before the clinic opened to 1.37 per 1,000 afterward.

"Interestingly, the emergency department utilization was reduced only for the patients who are discharged after having the procedure. If they had to be hospitalized, it didn't make much of a dent," said Dr. Turner. "One would think that's appropriate because these folks that did need to go into the hospital were sicker."

The study of the clinic also looked at safety, finding that 39 patients (1.5%) developed spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (<0.001%) hypotension. "Those were lower than published rates [for paracentesis] so the safety was very good, partly because they really conducted careful training with very rigorous standards," said Dr. Turner.

Patient satisfaction was also high, which makes sense, she said. "It was safe and much more efficient [than the ED]. The team was very attentive to their needs and taught them about how to change their diet to make it less likely that they would need paracentesis as often. Ultimately, because they had longitudinal relationships with patients, they were able to establish them in hepatology where they got the opportunity to have more long-term solutions."

Challenges

Getting patients and the ED to engage with the FLASP clinic took some effort, Dr. Turner noted. ED staff received an in-person or video orientation with a handout about eligibility, clinic procedures, and referral logistics.

"The patients really needed a fair amount of handholding initially to transfer over to the clinic. You know, 'Tomorrow you have your appointment, let me tell you where to go.' It's easy for patients to just say, 'Oh, I know where the emergency department is. I walk in there.' This is a different way of getting care," she said.

Next steps

The clinic now also performs additional procedures, including thoracentesis, joint injections or aspirations, and lumbar puncture, providing them more quickly than specialty services typically can. "That makes it easier for the clinicians and for the patients," said Dr. Turner.

Words of wisdom

This project highlights the importance of collaboration—across medical specialties (ED and hospital medicine) and between clinicians and researchers, according to Dr. Turner, who is a senior advisor at the Gehr Family Center for Health Systems Science at USC.

"Institutions that are striving to serve vulnerable, low-income populations can partner with researchers to evaluate implementation of novel models of care," she said. "The FLASP clinic would not have had the data to prove that the emergency department utilization went down without us really digging into the data."