S2690 Integrating Outpatient Paracentesis into an Internal Medicine Residency Clinic: Feasibility and Outcomes

Introduction: About 60% of patients with cirrhosis develop ascites, of which 25%-40% experience refractory ascites requiring recurrent paracenteses. Limited access to paracentesis through specialty services leads to frequent emergency department (ED) visits or hospitalizations. This study evaluates the feasibility and preliminary outcomes of integrating outpatient paracenteses into an internal medicine residency clinic which can potentially reduce the burden on ED and inpatient resources. Methods: Established clinic patients with diuretic refractory or tense ascites were eligible for outpatient paracentesis if they had stable renal function and no signs of acute infection. Ultrasound guided paracenteses were scheduled into residents' existing continuity clinic templates and performed with attending supervision. A maximum of 5,000 mL was aspirated per procedure as albumin was not available in clinic. The number of paracenteses performed, fluid removed, procedure duration, complications, and clinical outcomes of 9 patients were analyzed. Results: Over 16 months, 35 paracenteses were performed by 17 different residents on 9 patients, 77% of which were man. Alcohol related cirrhosis was the most common etiology. The median number of paracenteses performed per patient was 3 (range 1-12).The median procedure duration was 50 minutes (range 33-79 minutes), this excluded rooming and post-procedure monitoring by clinical staff. Equipment setup and time to initial fluid aspiration varied between residents. Ascitic site leakage was the only post-procedure complication occurring in 3 procedures requiring minimal intervention. Diuretic therapy was adjusted during at least one paracentesis visit. Four of 5 patients referred to gastroenterology for transjugular intrahepatic portosystemic shunt completed the procedure. While one of them eventually transitioned to comfort care and died, others no longer require paracentesis. Two other patients died during this time course. No re-accumulation of ascites has been noted in the remaining 2 patients. Scheduling patients within the existing templates in a timely manner was one of the main challenges. Conclusion: Integrating outpatient paracentesis within a resident primary clinic is a feasible model for managing ascites, connecting patients with specialty care, and enhancing patient care and resident education. Addressing scheduling challenges will be important to optimize workflow. Future work will evaluate if this integration leads to any changes in ED or hospital utilization.