Perceived and Actual Barriers to Performing Diagnostic Paracentesis

Abstract

Introduction: Decompensated cirrhosis with ascites carries a significant risk of mortality largely due to spontaneous bacterial peritonitis (SBP). Practice guidelines recommend diagnostic paracentesis in all hospitalized cirrhotic patients with ascites. Recent data suggests early paracentesis within 12 hours of presentation may reduce mortality and length of stay in patients with SBP. However, many hospitalized patients with cirrhosis and ascites do not undergo diagnostic paracentesis early or at all during admission. The causes underlying this failure in practice have yet to be fully elucidated. We sought to determine the perceived and actual barriers to performing diagnostic paracentesis. Methods: An electronic 6-item survey was circulated among internal medicine and emergency medicine trainees. Respondents were asked to declare their department affi liation, training level, and experience and comfort performing diagnostic paracentesis. Participants were asked to free-text any barriers to performing bedside paracentesis. Each unique barrier was counted independently. Descriptive statistical analyses were performed. Results: 69 participants initiated the survey and 64 completed the survey. 71% were internal medicine trainees and 29% were emergency medicine trainees. There were 26.1% first year post-graduate trainees (PGY1), 24.6% PGY2's, 26.1% PGY3's, 5.8% PGY4's, 2.9% attending physicians, 11.6% medical students, and 2.9% allied health professionals. Most respondents were ‘Comfortable' or ‘Very Comfortable' performing paracentesis, 32.8% and 46.9% respectively. More than half of respondents had performed 6 or greater paracentesis (54.7%). The most common barrier to paracentesis was time (29.1%), followed by no barrier (16.3%), space (14%), equipment (12.8%), safety concerns (8.1%), clinical volume (4.7%), training level(4.7%), procedural training (3.5%), consent/legal concerns (3.5%), and nursing support (2.3%). Conclusion: Most surveyed medical providers feel comfortable and have adequate experience performing diagnostic paracentesis. The most commonly cited barrier to performing paracentesis was lack time followed by adequate space and access to the necessary equipment. Safety issues and procedural training were also cited as barriers, although less often. These perceived and/or actual barriers to bedside paracentesis represent viable targets for intervention in order to improve adherence to current best practice guidelines.