Background: Cirrhosis is the result of advanced liver damage and causes significant morbidity, mortality, and burden on the U.S. healthcare system. In 2016, more than 40,000 Americans died because of complications related to cirrhosis, and this number continues to grow. A common complication of decompensated cirrhosis is refractory ascites, which is often managed through large-volume serial paracentesis if the patient is not a candidate for liver transplant or a transjugular intrahepatic portosystemic shunt (TIPS) procedure. Patients requiring serial paracentesis pose a challenging problem to the healthcare system due to over-utilization of emergency department (ED) resources for relatively simple procedures that could otherwise be managed safely in an outpatient clinic.
Purpose: The purpose of this study is to investigate the impact of opening a half-day fluid aspiration (FLASP) clinic on decreasing ED burden at LAC+USC, a large and metropolitan safety-net hospital. In this case-control study, we identified patients presenting to the ED for routine paracentesis and transitioned their care to a dedicated outpatient procedure clinic with the goal of 1) reducing ED presentations for routine paracentesis, 2) reducing denied hospital days, 3) reducing procedure-related complications, 4) improving patient flow through the ED, and 5) improving patient satisfaction.
Description: The FLASP clinic was established on February 11, 2021. We conducted a retrospective analysis of all patients who received a paracentesis in the LAC+USC ED from December 1, 2020 through July 31, 2021. Cases from December 1, 2020 to February 10, 2021 were placed in the control group (A), while cases after opening the FLASP clinic were placed in the experimental group (B). The following information was collected from each patient encounter: age, gender, indication for paracentesis, complications from the procedure, and whether the patient was admitted or discharged from the ED. Data was analyzed using Welch 2-sample t-tests looking at the mean and standard deviation (SD) for both groups.
Conclusions: There were 121 cases in the control group and 178 cases in the experimental group. No significant difference was found between the two groups with regards to age, gender, or complication rate. There was a significant decline in daily ED case volume after establishment of the FLASP clinic in the experimental group compared to the control group (1.05 vs. 1.70, p < 0.001). Additionally, there was a significant decline in the daily number of cases that resulted in discharge from the ED after establishment of the FLASP clinic (1.05 vs. 0.42, P< 0.0005), implying that fewer patients went to the ED for routine paracentesis and a higher percentage of patients had other medical problems that required admission into the hospital. 71.9% of cases in the control group were discharged from the ED, and 53.4% of cases in the experimental group were discharged from the ED. The daily number of cases that required admission was not significantly different between the two groups. Of the patients that were referred to the FLASP clinic, 58% came from Internal Medicine, 40% came from Emergency Medicine, and 2% came from Obstetrics/Gynecology. The attendance rate of scheduled paracentesis clinic appointments was 90%. Of the patients who did not show up for their appointment, 50% were already admitted to the hospital at the time of appointment. Overall, the establishment of a FLASP clinic in a large safety net hospital led to decreased ED burden and utilization of resources.
