A Review of Paracentesis Performance in Ascites Following Simulation-Based Training

Abstract

Introduction: Guidelines recommend that a diagnostic paracentesis be performed in all patients with cirrhosis and ascites upon hospital admission. Paracentesis is often performed by internal medicine (IM) residents however few institutions have a formal training program. Delays in paracentesis >12 hours have also been linked to increased patient mortality. Methods: We implemented a simulation-based training (ST) course for IM residents to improve resident confidence and competence in paracentesis. 130 IM residents underwent ST which included precourse reading, small group discussions, and task training. We performed a retrospective review of all patients with ascites admitted in two 12-month periods, before and after ST at 2 academic teaching hospitals. The primary outcome was time from admission to paracentesis. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and development of acute kidney injury (AKI). Results: A pre-course survey revealed that most residents had never performed a paracentesis, had little prior training and were not confident in performing paracentesis. A total of 678 charts were reviewed, and a total of 89 paracenteses were performed pre-ST and 65 post-ST. IM residents performed more paracenteses following ST (23.6% vs. 33.9%). The remainder were performed by interventional radiology (IR). Mean time to paracentesis decreased for housestaff (49.1h to 39.9h) and increased for IR (57.5h to 82.2h) after ST. IM residents were more likely to perform paracentesis on patients with higher MELD scores and rate of ICU admission (see Table). There was a statistically significant decrease in development of AKI in the resident cohort (47.6% to 18.2%, p= 0.04) and remained unchanged in the IR-cohort (32.4% to 34.9%). Mean hospital LOS and in-hospital mortality decreased in the resident cohort, while they remained unchanged and increased in the IR-cohort (see Table).Table: Table. Results of Paracentesis Performance Following Simulation-Based TrainingConclusion: Our study shows that after implementation of a simulation-based paracentesis course, IM residents performed a greater proportion of procedures, a decreased time to paracentesis, and had improved patient outcomes. ST improved resident confidence in performing paracentesis and this likely explains the increase in procedures performed by them and in higher acuity patients. Increase in clinical knowledge post-ST regarding paracentesis may explain decreased time to procedure, lower rates of AKI, decreased hospital LOS, and in-hospital mortality seen in the post-intervention period.