Clinical research study
Clinical Outcomes after Bedside and Interventional Radiology Paracentesis Procedures

https://doi.org/10.1016/j.amjmed.2012.09.016Get rights and content

Abstract

Background

Increasingly, paracentesis procedures are performed in interventional radiology (IR) rather than at the bedside. No guidelines exist to aid decision-making about the best location, and patient outcomes are unknown. Our aims were to develop a prediction model for which location (bedside vs IR) clinicians select for inpatient paracentesis procedures, and to compare clinical outcomes.

Methods

We performed an observational medical records review of all paracentesis procedures performed on the hepatology service of an 894-bed urban tertiary care hospital from July 2008 through December 2011. We developed a prediction model to determine factors for IR referral. Clinical outcomes including blood product transfusions, intensive care unit (ICU) transfer, hospital length of stay, inpatient mortality, 30-day readmission, and emergency department visit within 30 days of discharge were compared between patients who had bedside versus IR procedures.

Results

Five hundred two patients who underwent a paracentesis were included in the analysis. Being female, higher body mass index, lower volume of ascites removed, and attending physician of record predicted the probability of IR referral. IR referrals were associated with 1.86 additional hospital days (P = .003). Platelet and fresh frozen plasma transfusions were more common in patients who underwent IR procedures (odds ratio [OR] 4.56; 95% confidence interval [CI], 2.13-9.78 and OR 4.07; 95% CI, 2.03-8.18, respectively). Subsequent ICU transfers also were more common among patients who had IR procedures (OR 2.21; 95% CI, 1.13-4.31). All other clinical outcomes were similar between groups.

Conclusions

The decision to perform a paracentesis procedure at the bedside or in IR is largely discretionary. Paracentesis procedures performed at the bedside result in equal or better patient outcomes. Clinicians should receive the training needed to perform paracentesis procedures safely at the bedside. Large prospective studies are needed to confirm the findings of this study and inform national practice patterns.

Section snippets

Design

We performed an observational medical records review of all paracentesis procedures performed on the hepatology service at Northwestern Memorial Hospital, an 894-bed urban tertiary care hospital, from July 2008 through December 2011. The hepatology service is staffed by an internal medicine second- or third-year resident, 2 or 3 first-year residents, a gastroenterology fellow, and a supervising attending physician from the Section of Hepatology at Northwestern University Feinberg School of

Results

The EDW search and chart adjudication identified 806 paracentesis procedures performed on 614 patients. A final sample of 622 procedures from 502 patients remained after removing procedures due to exclusion criteria (Figure 1).

Discussion

To our knowledge, this is the first study to address clinical decision-making about performance of paracentesis procedures at the bedside or in IR. Our findings show that our overall ability to predict decision-making on the basis of patient characteristics is poor. Specifically, decisions about procedure location are not aligned closely with known predictors of morbidity and mortality in patients with liver disease (eg, age, sex, systolic blood pressure, serum sodium, platelet count, and MELD

Conclusions

In summary, this study shows that the decision to perform a paracentesis at the bedside or in IR is largely discretionary and rarely based on patient characteristics. Paracentesis procedures performed at the bedside result in equivalent or better patient outcomes, and increasing the number of bedside procedures could result in significant cost savings. Based on these findings, we recommend that residents and other clinicians continue to receive the education and training necessary to perform

Acknowledgements

We acknowledge Drs Douglas Vaughan and Mark Williams for their support and encouragement of this work. We thank Darlene Ferranti for her assistance with the Enterprise Data Warehouse.

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    Funding: Excellence in Academic Medicine Act of the Illinois Department of Public Aid administered by Northwestern Memorial Hospital. Dr. McGaghie's contribution was supported in part by the Jacob R. Suker, MD professorship in medical education and by grant UL 1 RR 025741 from the National Center for Research Resources, National Institutes of Health (NIH). The funding source had no role in the preparation, review, or approval of the manuscript.

    Conflict of Interest: None.

    Authorship: All authors were involved in the conception and design of the study or analysis of data, participated in the writing of the manuscript, and have seen and approved the submitted version.

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