Tapping into Trouble: Delays in Diagnostic Paracentesis
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Authors
Miller H.
Temperley L.
Khanna K.
Phillips A.
Patel K.
Wells G.
Hearn T.
Diver W.
Mandal P.
Davies A.
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2025
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Abstract
Background Spontaneous bacterial peritonitis (SBP) is a lifethreatening complication of decompensated cirrhosis, where timely diagnosis is crucial to improve outcomes. BSG and BASL guidelines recommend diagnostic paracentesis within 6 hours of hospital presentation. A previous multicentre survey found low procedural confidence and poor knowledge among resident doctors, raising concerns about whether timely diagnostic paracentesis is performed. We aimed to retrospectively assess whether diagnostic paracentesis was done within 6 hours of admission in decompensated cirrhotic patients with ascites. Methods We conducted a retrospective, multicentre audit across 7 hospitals in England. Adult emergency admissions with decompensated cirrhosis and ascites between 23 April - 23 October 2024 were identified via clinical coding. Demographic and clinical data were extracted from electronic records; statistical analysis was performed using RStudio version 4.5.0. Continuous variables are presented as median (interquartile range) unless otherwise specified. Results 207 patients met inclusion criteria (mean age 60.05 +/- 0.88 years; 71.0% male; 62.8% with alcohol-related liver disease). The admission Model for End-Stage Liver Disease (MELD) score was 16.3 (9.1) and in-hospital mortality rate was 18.0%. The overall median time to diagnostic paracentesis was 10 hours 51 minutes (22 hrs 27 mins), with admissions to a transplant centre receiving timelier paracentesis (7 hours [5 hrs 40 mins]). However, all centres failed to meet the 6- hour target. Time from triage to admission clerking was 3 hours 41 minutes (4 hrs 25 mins), and among those receiving antibiotics, time to administration was 9 hours 48 minutes (17 hrs 48 mins). Delayed paracentesis was significantly associated with delayed medical clerking (p<0.01), delayed antibiotic administration (p<0.05), and delayed gastroenterology/hepatology specialist review (p<0.01). Among survivors, significantly more were managed by gastroenterologists/ hepatologists compared to non-survivors (76.9% vs 64.9%, p<0.01). Survivors had lower admission MELD scores (15.37 [8.94] vs 20.20 [11.78], p<0.01) and were less likely to require ICU admission (9.5% vs 43.2%, p<0.01). Conclusion This study shows a failure to meet the recommended guideline for diagnostic paracentesis within 6 hours of presentation with decompensated cirrhosis and ascites. Patients waited a median of 7 additional hours from admission clerking to paracentesis. Correlation with delayed specialist review suggests this may stem from lack of knowledge or confidence in the procedure among the admitting team, consistent with our previous survey. Delays also correlated with late antibiotic initiation, indicating SBP risk is not promptly recognised. Further investigation into the causes of delay is warranted. Focused training could improve timely care and outcomes.
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