A Resident-Led Quality Improvement Project to Increased Internal Medicine Resident Comfort With Performing Timely Diagnostic Paracentesis

Introduction: Diagnostic paracentesis for hospitalized patients with cirrhosis should ideally be completed within 24 hours of admission to decrease preventable healthcare utilization and mortality. This quality improvement project aims to increase performance of early and appropriate diagnostic paracentesis by internal medicine residents at a single residency program in Texas by decreasing resident-reported barriers and improving performer comfort with the procedure. Methods: We created a kit containing diagnostic paracentesis supplies and an educational comic reviewing patient preparation, procedure performance, and appropriate lab ordering (Figure 1A and B). Kits were distributed to resident workrooms. Residents were notified of kit availability by 3 methods: 1. House Staff meeting 2. email, and 3. in-person. Resident comfort with performing the procedure, perceived barriers, and post-graduate year were collected with a survey prior to kit introduction. Residents who had seen or used the kit repeated the survey three-months after the kits were introduced. Results: Barriers to procedure performance were highest for time spent gathering material (71%), time spent doing the procedure (68%), and discomfort or lack of familiarity with the procedure (55%), which remained unchanged after intervention. One-hundred percent of residents indicated that the kit would cut down on time needed for the procedure and would increase their comfort doing the procedure. Prior to intervention, 48% of residents indicated that they were either very uncomfortable or uncomfortable with performing paracenteses, which decreased to 24% after intervention (Table 1). Conclusion: The preliminary data of this quality improvement project demonstrates increased comfort performing diagnostic paracentesis for internal medicine residents utilizing a simplified diagnostic paracentesis kit with educational materials. It directly addressed the barriers most often reported by residents in the survey by decreasing time spent collecting supplies, increasing resident comfort, and may result in faster procedure time. Further investigations include tracking increases in paracentesis performed by internal medicine residents and impact on preventable healthcare utilization and patient mortality.Figure 1.: A) Page 1 of educational cartoon. B) Page 2 of educational cartoon. Table 1. - Results from pre and post-intervention surveys Pre-Intervention 3 Months Post-Intervention PGY Year - - PGY-1 48% 30% PGY-2 29% 35% PGY-3 23% 35% Self-Rated Comfort with Performing Paracentesis - - Very or mostly uncomfortable 48% 24% Neither comfortable nor uncomfortable 26% 41% Mostly of very comfortable 26% 35% No Yes Has the paracentesis kit increased your comfort in doing the procedure? 0% 100% Has the paracentesis kit cut down on the time needed to do the procedure? 0% 100%