Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative Inquiry.

Care transition Emergency department Implementation outpatient clinic Paracentesis Qualitative research Safety net hospital

Journal

Digestive diseases and sciences

ISSN: 1573-2568

Titre abrégé: Dig Dis Sci

Pays: United States

ID NLM: 7902782

Informations de publication

Date de publication:
03 May 2024

Historique:

received: 30 09 2023

accepted: 13 02 2024

medline: 3 5 2024

pubmed: 3 5 2024

entrez: 3 5 2024

Statut: aheadofprint

Résumé

Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.

Sections du résumé

BACKGROUND BACKGROUND

AIM OBJECTIVE

This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital.

METHODS METHODS

The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics.

RESULTS RESULTS

Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling.

CONCLUSION CONCLUSIONS

This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.

Identifiants

DOI: 10.1007/s10620-024-08358-0 PMID: 38700627

pubmed: 38700627

doi: 10.1007/s10620-024-08358-0

pii: 10.1007/s10620-024-08358-0

doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

Subventions

Organisme : NCATS NIH HHS

ID : UL1TR001855

Pays : United States

Informations de copyright

Références

Pedersen JS, Bendtsen F, Moller S. Management of cirrhotic ascites. Ther Adv Chronic Dis. 2015;6:124–137.

doi: 10.1177/2040622315580069 pubmed: 25954497 pmcid: 4416972

Nephew LD, Serper M. Racial, gender, and socioeconomic disparities in liver transplantation. Liver Transpl. 2021;27:900–912.

doi: 10.1002/lt.25996 pubmed: 33492795

Sobotka LA, Modi RM, Vijayaraman A et al. Paracentesis in cirrhotics is associated with increased risk of 30-day readmission. World J Hepatol. 2018;10:425–432.

doi: 10.4254/wjh.v10.i6.425 pubmed: 29988878 pmcid: 6033715

Cheng YW, Sandrasegaran K, Cheng K et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. Abdom Radiol (NY). 2018;43:2190–2197.

doi: 10.1007/s00261-017-1406-y pubmed: 29188319 pmcid: 5975110

Gerber LD, Sgro G, Cyr JE, Conlin S. An academic hospitalist-run outpatient paracentesis clinic. Fed Pract. 2022;39:114–119.

pubmed: 35444390 pmcid: 9014930

Fagan KJ, Zhao EY, Horsfall LU et al. Burden of decompensated cirrhosis and ascites on hospital services in a tertiary care facility: time for change? Intern Med J. 2014;44:865–872.

doi: 10.1111/imj.12491 pubmed: 24893971

Thomson M, Tapper EB. Towards patient-centred and cost-effective care for patients with cirrhosis and ascites. Lancet Gastroenterol Hepatol. 2018;3:75–76.

doi: 10.1016/S2468-1253(17)30339-4 pubmed: 29150406

Duszak R Jr, Chatterjee AR, Schneider DA. National fluid shifts: fifteen-year trends in paracentesis and thoracentesis procedures. J Am Coll Radiol. 2010;7:859–864.

doi: 10.1016/j.jacr.2010.04.013 pubmed: 21040867

Ajzen I. The theory of planned behavior. Organizational behavior and human decision processes. 1991;50:179–211.

doi: 10.1016/0749-5978(91)90020-T

Biggins SW, Angeli P, Garcia-Tsao G et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the american association for the study of liver diseases. Hepatology. 2021;74:1014–1048.

doi: 10.1002/hep.31884 pubmed: 33942342

Grabau CM, Crago SF, Hoff LK et al. Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004;40:484–488.

doi: 10.1002/hep.20317 pubmed: 15368454

Dowlatshahi S, Koh J, Vyas A, Mack WJ, Turner BJ. Disparities in care for low-income patients with cirrhosis: implementing an innovative outpatient clinic for refractory ascites in a safety net hospital. J Gen Intern Med. 2024. https://doi.org/10.1007/s11606-024-08675-0 .

Montaño DE, Kasprzyk D. Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In: Health behavior: Theory, research, and practice, 5th ed. Hoboken: Jossey-Bass/Wiley; 2015:95–124.

Chiovitti RF, Piran N. Rigour and grounded theory research. J Adv Nurs. 2003;44:427–435.

doi: 10.1046/j.0309-2402.2003.02822.x pubmed: 14651715

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3:77–101.

doi: 10.1191/1478088706qp063oa

King N. Using templates in the thematic analysis of text. In: Cassell CSG, ed. Sage Publications; 2004; 257–270.

Brewster AL, Curry LA, Cherlin EJ, Talbert-Slagle K, Horwitz LI, Bradley EH. Integrating new practices: a qualitative study of how hospital innovations become routine. Implement Sci. 2015;10:168.

doi: 10.1186/s13012-015-0357-3 pubmed: 26638147 pmcid: 4670523

Kwan SW, Allison SK, Gold LS, Shin DS. Cost-effectiveness of transjugular intrahepatic portosystemic shunt versus large-volume paracentesis in refractory ascites: results of a markov model incorporating individual patient-level meta-analysis and nationally representative cost data. J Vasc Interv Radiol. 2018;29:1705–1712.

doi: 10.1016/j.jvir.2018.08.019 pubmed: 30392803 pmcid: 6334842

Shen NT, Schneider Y, Congly SE et al. Cost effectiveness of early insertion of transjugular intrahepatic portosystemic shunts for recurrent ascites. Clin Gastroenterol Hepatol. 2018;16:1503–1510.

doi: 10.1016/j.cgh.2018.03.027 pubmed: 29609068

Hill S, Smalley JR, Laasch H-U. Developing a nurse led day care abdominal paracentesis service. Canc Nurs Pract 2013;12:14–20.

doi: 10.7748/cnp2013.06.12.5.14.e942

Agency for Healthcare Research and Quality. Section 6: strategies for improving patient experience with ambulatory care. https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/index.html . Published March 2023. Accessed December 20, 2023.

Forman J, Heisler M, Damschroder LJ, Kaselitz E, Kerr EA. Development and application of the RE-AIM QuEST mixed methods framework for program evaluation. Prev Med Rep. 2017;6:322–328.

doi: 10.1016/j.pmedr.2017.04.002 pubmed: 28451518 pmcid: 5402634

Kwan BM, McGinnes HL, Ory MG, Estabrooks PA, Waxmonsky JA, Glasgow RE. RE-AIM in the real world: use of the RE-AIM framework for program planning and evaluation in clinical and community settings. Front Public Health. 2019;7:345.

doi: 10.3389/fpubh.2019.00345 pubmed: 31824911 pmcid: 6883916

Chou EY, Moore K, Zhao Y, Melly S, Payvandi L, Buehler JW. Neighborhood effects on missed appointments in a large urban academic multispecialty practice. J Gen Intern Med. 2022;37:785–792.

doi: 10.1007/s11606-021-06935-x pubmed: 34159548

Moghe A, Yakovchenko V, Morgan T et al. Strategies to improve delivery of cirrhosis care. Curr Treat Options Gastroenterol. 2021;19:369–379.

doi: 10.1007/s11938-021-00345-y pubmed: 34054289 pmcid: 8142883

Wagner EH, Aiello Bowles EJ, Greene SM et al. The quality of cancer patient experience: perspectives of patients, family members, providers and experts. Qual Saf Health Care. 2010;19:484–489.

pubmed: 21127109

Benson AB 3rd, Boehmer L, Mi X et al. Resource and reimbursement barriers to comprehensive cancer care delivery: an analysis of association of community cancer centers survey data. JCO Oncol Pract. 2023;19:e428–e438.

doi: 10.1200/OP.22.00417 pubmed: 36521094

American College of Emergency Physicians. Transition of care for emergency department patients. https://www.acep.org/patient-care/policy-statements/transition-of-care-for-emergency-department-patients . Published April 2021. Accessed December 20, 2023.

Lee H, Kim BK. Real-world clinical features, health-care utilization, and economic burden in decompensated cirrhosis patients: a national database. J Gastroenterol Hepatol. 2022;37:2154–2163.

doi: 10.1111/jgh.15962 pubmed: 35862281

Soster CB, Anschau F, Rodrigues NH, Silva L, Klafke A. Advanced triage protocols in the emergency department: a systematic review and meta-analysis. Rev Lat Am Enfermagem. 2022;30:e3511.

doi: 10.1590/1518-8345.5479.3511 pubmed: 35293563 pmcid: 8966058

Tocia C, Dumitru A, Alexandrescu L, Popescu R, Dumitru E. Timing of paracentesis and outcomes in hospitalized patients with decompensated cirrhosis. World J Hepatol. 2020;12:1267–1275.

doi: 10.4254/wjh.v12.i12.1267 pubmed: 33442453 pmcid: 7772729

Brown C, Aksan N, Chang P et al. Delayed diagnostic paracentesis Is associated with increased preventable healthcare utilization in disadvantaged patient populations with advanced liver disease and elevated INR. Dig Dis Sci. 2023;68:2954–2962.

doi: 10.1007/s10620-023-07937-x pubmed: 37052775

Chatterjee P, Schpero WL. Realigning reality with intent in funding safety-net hospitals. JAMA Health Forum. 2023;4:e232000.

doi: 10.1001/jamahealthforum.2023.2000 pubmed: 37477924

American Medical Association. RBRVS overview. https://www.ama-assn.org/about/rvs-update-committee-ruc/rbrvs-overview . Published October 24, 2023. Accessed December 20, 2024.

Shah R, Leno R, Sinert R. Impact of provider-in-triage in a safety-net hospital. J Emerg Med. 2020;59:459–465.

doi: 10.1016/j.jemermed.2020.04.059 pubmed: 32595053

Siddique SM, Porges S, Lane-Fall M et al. Reducing hospital admissions for paracentesis: a auality improvement intervention. Clin Gastroenterol Hepatol. 2019;17:2630–2633.

doi: 10.1016/j.cgh.2019.09.001 pubmed: 31518719 pmcid: 6874893

Siddique SM, Lane-Fall M, McConnell MJ et al. Exploring opportunities to prevent cirrhosis admissions in the emergency department: a multicenter multidisciplinary survey. Hepatol Commun. 2018;2:237–244.

doi: 10.1002/hep4.1141 pubmed: 29507899 pmcid: 5831018

Scaglione S, Kliethermes S, Cao G et al. The epidemiology of cirrhosis in the United States: a population-based study. J Clin Gastroenterol. 2015;49:690–696.

doi: 10.1097/MCG.0000000000000208 pubmed: 25291348

Kabbany MN, Conjeevaram Selvakumar PK, Watt K et al. Prevalence of nonalcoholic steatohepatitis-associated cirrhosis in the United States: an analysis of national health and nutrition examination survey data. Am J Gastroenterol. 2017;112:581–587.

doi: 10.1038/ajg.2017.5 pubmed: 28195177

Doran J, Hanna R, Nyagura-Mangori T et al. Stakeholder perspectives on current determinants of ultrasound-guided thoracentesis in resource limited settings: a qualitative study. BMJ Open. 2022;12:e064638.

doi: 10.1136/bmjopen-2022-064638 pubmed: 36523247 pmcid: 9748956

Davis MM, Howk S, Spurlock M, McGinnis PB, Cohen DJ, Fagnan LJ. A qualitative study of clinic and community member perspectives on intervention toolkits: “Unless the toolkit is used it won’t help solve the problem.” BMC Health Serv Res 2017;17:497.

doi: 10.1186/s12913-017-2413-y pubmed: 28720092 pmcid: 5516321