Reducing Hospital Admissions for Paracentesis: A Quality Improvement Intervention

Siddique, Shazia Mehmood; Porges, Stefanie; Lane‐Fall, Meghan; Mehta, Shivan J.; Schweickert, William D.; Kinniry, Joan; Taylor, April; Iqbal, Shaz; Goldberg, David S.; Shea, Judy A.; Stetson, Robert; Coniglio, Mary; Hoteit, Maarouf; Fishman, Neil O.; Khungar, Vandana

doi:10.1016/j.cgh.2019.09.001

Cited by 14 publications

(15 citation statements)

References 11 publications

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“…To address the problem of hospitalization for symptomatic ascites, Siddique et al evaluated hospitalization rates and time spent in the emergency department before and after the implementation of a paracentesis team staffed by advanced practice providers. (30) This program eliminated admissions after emergency department visits for symptomatic ascites (0/30) during the 2-year evaluation period, and as such it is the only study to explicitly reduce index hospitalizations for a cirrhosis complication. In 2016, Tapper et al evaluated the roles of checklists and the electronic medical record for reducing readmissions for HE in a pre-post study.…”

Section: Hcc Screeningmentioning

confidence: 99%

The Future of Quality Improvement for Cirrhosis

Tapper

Parikh

2021

Liver Transpl

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Cirrhosis has a significant and growing impact on public health and patient-reported outcomes (PROs). The increasing burden of cirrhosis has led to an emphasis on the quality of care with the goal of improving overall outcomes in this high-risk population. Existing evidence has shown the significant gaps in quality across process measures (eg, hepatocellular carcinoma screening), highlighting the need for consistent measurement and interventions to address the gaps in quality care. This multistep process forms the quality continuum, and it depends on clearly defined process measures, real-time quality measurement, and generalizable evaluative methods. Herein we review the current state of quality care in cirrhosis across the continuum with a focus on process measurement methodologies, developments in PRO evaluation on quality assessment, practical examples of quality improvement initiatives, and the recent emphasis placed on the value of primary prevention.

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Section: Hcc Screeningmentioning

confidence: 99%

The Future of Quality Improvement for Cirrhosis

Tapper

Parikh

2021

Liver Transpl

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“…However, symptomatic relief of ascites, typically with large-volume paracentesis (LVP), is also a common reason for seeking care in the ED 46,47 . A recent quality improvement initiative demonstrated that an ED observation unit designed to perform paracentesis for patients with low-risk ascites was feasible and resulted in significantly decreased admissions for ascites and length of hospital stay 46 . A recent multicenter survey among ED and hepatology providers also demonstrated that only 7% of providers believed that patients with ascites requiring LVP required inpatient admission, 48.9% believed that they would be admitted (primarily due to a lack of resources), and 83.2% felt that admission could be avoided with an ED observation unit protocol 48 …”

Section: Ascitesmentioning

confidence: 99%

“…[46,47] A recent quality improvement initiative demonstrated that an ED observation unit designed to perform paracentesis for patients with lowrisk ascites was feasible and resulted in significantly decreased admissions for ascites and length of hospital stay. [46] A recent multicenter survey among ED and hepatology providers also demonstrated that only 7% of providers believed that patients with ascites requiring LVP required inpatient admission, 48.9% believed that they would be admitted (primarily due to a lack of resources), and 83.2% felt that admission could be avoided with an ED observation unit protocol. [48] Intervention: Large-volume paracentesis Current guidelines recommend that all patients with tense ascites undergo LVP, defined as the removal of > 5 L of peritoneal fluid.…”

Section: Intervention: Hypertonic Salinementioning

confidence: 99%

Management of patients with cirrhosis in the emergency department: Implications for hospitalization outcomes

Sikerwar,

Zand,

Steel

et al. 2023

Liver Transplantation

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Sepsis in patients with cirrhosis is associated with particularly poor outcomes, [4] and several tools are available for the rapid identification of high-risk patients with sepsis in the ED. The recent Sepsis-3 criteria and the quick Sequential Organ Failure Assessment tool have been validated in patients with cirrhosis and are more accurate than the SIRS criteria in this population. [6][7][8] Additionally, the Chronic Liver Failure-Sequential Organ Failure Assessment model has demonstrated superior predictive performance for patients with cirrhosis presenting with infection compared to the Sepsis-3 criteria and Sequential Organ Failure Assessment [8][9][10] and could serve as a valuable tool for EM providers. Prompt critical care evaluation is crucial for patients identified as high-risk, particularly for

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“…Two of the main reasons for readmission are failure to either arrange outpatient paracentesis for symptomatic ascites or recognize warning signs of over-diuresis [4]. Data are limited, however, supporting interventions that can reduce the burden of hospitalization for patients with ascites [5][6][7][8][9].…”

Section: Introductionmentioning

confidence: 99%

A Telemonitoring Intervention for Cirrhotic Ascites Management Is Cost-Saving

et al. 2021

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Background Patients with cirrhosis and ascites experience frequent hospital admissions, leading to poor quality of life and high healthcare costs. Monitoring weight is a component of ascites care and telemonitoring may improve outcomes and costs. Goals We aimed to evaluate the cost and outcomes of current care compared to a telemonitoring system for ascites. Study We developed a decision-analytic model that examined 100 simulated patients over a 6-month horizon. We compared usual care to a new telemonitoring program, which we estimate costs $50,000/6 months. Results The cost of standard of care for 100 patients with cirrhotic ascites over a 6-month period is $167,500 more expensive than telemonitoring. By varying parameter probabilities by ± 10% and outcome costs by ± 20%, we found that standard of care remains more expensive than care with a telemonitoring intervention by $9400 to $340,200 per 6-month period. Standard of care leads to 9 more admissions (range 4 to 12) than a telemonitoring intervention, while telemonitoring leads to 9 more outpatient visits (range 6 to 9) and 28 additional outpatient large volume paracenteses (LVPs) (range 17 to 28). With more and less expensive telemonitoring interventions, standard of care remained more expensive. With 50% adherence to the intervention, standard of care was $89,848 more expensive. ConclusionsIn almost all probability and cost scenarios, a telemonitoring intervention is cost-saving for the management of cirrhotic ascites. Using hospital admissions as a surrogate for quality of care, patient outcomes are improved primarily though more proactive medical intervention and more LVPs.

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Reducing Hospital Admissions for Paracentesis: A Quality Improvement Intervention

Cited by 14 publications

References 11 publications

The Future of Quality Improvement for Cirrhosis

The Future of Quality Improvement for Cirrhosis

Management of patients with cirrhosis in the emergency department: Implications for hospitalization outcomes

A Telemonitoring Intervention for Cirrhotic Ascites Management Is Cost-Saving

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