Maine Medical Center

Just-in-time Paracentesis: Improving Early Diagnosis and Treatment of Spontaneous Bacterial Peritonitis

Project Lead: Lesley Gordon, MD, MS 

Project aim(s): We aim to increase the frequency and improve the timeliness of paracenteses for patients with decompensated cirrhosis to facilitate diagnosis and treatment of spontaneous bacterial peritonitis. 

Narrative Description

To better target our interventions, we performed focus groups and written surveys with hospital medicine attendings and internal medicine residents (specifically, 11 focus group participants, 28 residents completing a written survey, and 24 attendings responding to a written survey). Respondents identified that the major barriers to performing paracenteses included a lack of adequate time as well as recognition of the clinical imperative; residents also pointed to the difficulty of finding attending supervision and lack of clarity regarding the requirements to perform unsupervised.    

Our QI intervention had three major arms: 1) Addressing the knowledge gap regarding SBP by providing clinical updates to our providers and embedding Clinical Decision Support tools within the Electronic Health Record; 2) Building provider experience and confidence in performing abdominal ultrasound and paracenteses through enhanced ultrasound training opportunities and a personalized instructional video for diagnostic paracentesis; 3) Reducing logistical barriers by producing a pre-prepared diagnostic paracentesis kit in an accessible location, creating a patient-centered hand-out for patients who have undergone the procedure, and improving procedural support for our teams. 

Implementing these interventions resulted in a substantial improvement in the percentage of patient candidates undergoing diagnostic paracenteses, moving from a 3-month rolling average of 55.9% in November 2020 to 83.8% in September 2021.   In regards to paracenteses completed within 24 hours, we moved from a 3-month rolling average of 44.5% in November 2020 to 70% in September 2021. 

Our multimodal approach to lowering the barriers to completing diagnostic paracenteses on patients with decompensated cirrhosis at Maine Medical Center resulted in a higher rate of paracenteses and increased timeliness. A significant positive change from this project has been increased collaboration between Hospital Medicine and Gastroenterology in caring for our decompensated cirrhotic patients. We believe the improved education on the importance of diagnostic paracentesis for earlier detection of spontaneous bacterial peritonitis in Hospital Medicine has also increased patient advocacy within our group, including when completing admission phone calls from the ER for the medical admission of these patients.

Publications and Resources 

Herrle EL, Thim M, Buttarazzi MS, et al. Quality improvement project demonstrating a sustained increase in the assessment and sampling of ascites for hospitalised patients with cirrhosis. Frontline Gastroenterology. Published Online First: 20 October 2023. doi: 10.1136/flgastro-2023-102531

Gordon LB, Herrle E, Buttarazzi M, Thim M, Ptaschinski JS, Molina V, Channell N.  Improving the Care of Patients with Cirrhosis at MMC [Poster and Oral Presentation]. Costas T. Lambrew Research Retreat. 2021. 

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

Root causes/causative factors addressed by the intervention

  • Workflow (includes testing, follow-up, and referrals)
  • Work system factors (including physical environment) 
  • Information sharing and accessibility

Setting of the diagnostic quality improvement intervention

  • Emergency department
  • Acute care hospital inpatient area