A Secure Chat-Based Pairing Model Doubled Paracentesis Certifications in Four Months

At 2 p.m. on a crowded admitting day, our cirrhotic patient still waited for a paracentesis—because no one on call felt confident with a needle.

Problem Statement

As procedural certification is no longer a mandated part of internal medicine residency training, many hospitalists lack experience in bedside procedures like paracentesis. The imperative to perform diagnostic paracentesis as proximal to admission as possible has been firmly established, but a simple, cost-effective, and consistently reliable solution to ensure timely performance has proven elusive to date.^1,2

Previously studied strategies to reduce delays include admission order sets, education, electronic health record (EHR) alerts, and dedicated procedure services— especially resident-run models, which outperform others.^3-7 Reviews show these services boost volume, confidence, and success rates, and may reduce length of stay (LOS), but require heavy oversight.^8,9 Before our intervention, the process of ensuring expedient paracenteses at our hospital was often haphazard and protracted.

Solution Overview

The intervention involved establishing a secure chat group on our EHR (Epic) through our department of information technology (IT). This group consisted of members either previously certified or seeking certification in performing paracenteses among the 252 internal medicine residents and 40 hospitalists across our two hospital sites. The secure group was moderated by one attending and one resident member to ensure strict protocols were followed. Initially, awareness of the group was promoted within the residency program and hospitalist group via only word of mouth and digital communication platforms.

When a patient needs paracentesis, the admitting team posts the patient information, location, and clinical indication in the chat, facilitating speedy identification of a trained physician to perform the procedure, as well as providing opportunities for trainees to gain experience and move toward certification. Trainees are routinely reminded to use the comprehensive training modules provided by our department of critical care medicine to help ensure proper technique.

A comprehensive protocol was drafted before implementation of the pilot, determining the scope, purview, eligibility, chain of command, procedural precedence, documentation, training and competency standards, and guidance for safety and in the event of complications. Finally, individual procedures and ultimately certifications were tracked via our program’s New Innovations platform.

Implementation Process

The implementation process included five steps:

• Identify program champions: We ensured oversight from both faculty and house staff members to help maintain balance and communication with all relevant stakeholders in the initiative.
• Contact IT: This step is required to establish a dedicated secure chat group for the paracentesis team.
• Create buy-in from the program: Information about the existence and purpose of the group was disseminated to all relevant stakeholders, including attending physicians and house staff. This may be accomplished, for example, via departmental email, a brief presentation during didactic sessions, or printed materials hung in workrooms. Both certified proceduralists and those seeking certification were added to the group. Alternatively, depending on institution policy, an opt-out method may be used wherein all members of the department are added and then given the option to leave the procedure group.
• Clarify billing protocols: A discussion was held between the hospital billing department and department administration regarding appropriate billing procedures (e.g., who should bill for the procedure when an attending other than the primary attending of record is performing or supervising the procedure).
• Clarify procedure and certification protocols: Educational materials were made freely available to trainees to ensure proper knowledge of the requisite technique. Depending on hospital policy, a decision must also be reached regarding requests placed by other specialties within the hospital seeking assistance from the procedure group. In our case, we determined that requests must be routed through the internal medicine consultation service, and if approved, may then be directed to our group. Additionally, program leadership should decide on a reasonable number of supervised procedures required before a trainee may become independently certified (our program requires five).

The timeline for implementation of our program required no more than a few days. Importantly, it does not require any financial resource allocation, requires minimal administrative oversight, and is inherently structured in a positive feedback cycle by proliferating new training opportunities and creating more certified supervisors to facilitate further training.

Outcomes and Impact

In the first 111 days after implementation of this pilot, an average of 4.5 chats were started each week, with a mean time of 1.4 minutes to identify a certified proceduralist and trainee dyad. Notably, the number of certified proceduralists more than doubled in the program during this time, from 16 to 34.

Residents were enthusiastic: “Getting a paracentesis was incredibly difficult during my intern year, and it made it a barrier for me to even attempt one. As a PGY-2, I was only able to log my first paracentesis due to the para team chat! It makes it a much more approachable and equitable approach to getting procedural experience and guidance, which can be difficult in our busy academic setting.”

“This group has expedited patient care since its initiation. I no longer have to wait for paracentesis to be done during a busy day on service. Residents on my team who are not certified in paracentesis or lack the knowledge on how to perform bedside POCUS to assess for a pocket now have the ability to learn in real time.”

Lessons Learned

Our decentralized certification model demonstrated that procedural training can be expanded efficiently using existing resources and with minimal administrative burden. Several key lessons emerged:

• Use existing infrastructure: Leveraging Epic’s secure chat functionality enabled rapid implementation without requiring new platforms or significant financial investment.
• Shared oversight drives success: Appointing both a faculty and resident moderator promoted accountability and sustained engagement. This structure ensured the initiative was both well-managed and responsive to trainee needs.
• Real-time access improves learning and care: The group chat allowed clinicians to connect rapidly with certified proceduralists, reducing delays in care and increasing real-time teaching opportunities.
• Culture matters: Trainees appreciated the transparency, accessibility, and equity the system offered. Making procedural experience feel more approachable helped foster a stronger learning culture.
• Minimal resources, maximum scalability: The program required no added personnel or funding, making it highly replicable in other institutions with similar infrastructure.

Recommendations

• Institutionalize the model by incorporating it into onboarding, education, and clinical workflows.
• Maintain oversight through rotating leadership to ensure continuity and shared ownership.
• Track and celebrate progress using tools like New Innovations to monitor certifications and identify training gaps.
• Clarify billing protocols and define cross-department procedures early with administrative leadership.
• Expand gradually to other procedures or departments with clear protocols in place. Using system-level changes, structured education, and EHR integration, we created a decentralized, low-resource, and high-impact model. Epic’s secure chat connects learners to certified supervisors in real-time, while a certification program ensures skill development and documentation. This streamlines workflow, enables timely paracentesis, and supports resident growth—without ongoing coordination, and without contributing any resource burden.

Future Directions

As we build on the success of our decentralized certification model, our next phase will focus on evaluating its clinical impact—particularly whether it reduces time to paracentesis, a key quality metric linked to improved outcomes. We also plan to track broader indicators such as length of stay, in-hospital mortality, complications, and duration of antibiotic use.

To further increase participation, we are considering transitioning the Epic chat group from opt-in to opt-out, automatically enrolling all relevant residents and hospitalists to streamline communication and broaden access. We will also formally introduce the program during resident didactics to boost awareness and engagement among trainees.

Expanding the number of attending physicians certified in paracentesis is another priority. A larger pool of certified attendings will enhance procedural continuity, improve supervision availability, and support more consistent training across teams and shifts.

These efforts aim to deepen the program’s educational value while rigorously assessing its effect on patient care, with the ultimate goal of creating a sustainable, scalable model for procedural training and timely intervention.

Key Points

• Instant activation: Epic chat to Mount Sinai Morningside/West Paracentesis Group starts right at admission.
• Rapid Pairing: Learners are instantly matched with supervisors for timely procedures.
• Skill-Building Loop: More trainee procedures means more certified supervisors, leading to faster, better care for patients.

Dr. Abraham

Dr. Singh

Dr. Maresky

Dr. Abraham is an internal medicine resident physician at Mount Sinai Morningside/West in New York. Dr. Singh is an associate professor of medicine and medical education and associate program director for the internal medicine residency program at Mount Sinai Morningside/West in New York. Dr. Maresky is an assistant professor of medicine at Mount Sinai West in New York.

References

1. Beran A, et al. Early diagnostic paracentesis improves outcomes of hospitalized patients with cirrhosis and ascites: a systematic review and meta-analysis. Am J Gastroenterol. 2024;119(11):2259-2266. doi: 10.14309/ajg.0000000000002906.

2. Ge PS, et al. Treatment of patients with cirrhosis. N Engl J Med. 2016;375(8):767-77. doi: 10.1056/NEJMra1504367.

3. Bhavsar-Burke I, et al. Use of a cirrhosis admission order set improves adherence to quality metrics and may decrease hospital length of stay. Am J Gastroenterol. 2023;118(1):114-120. doi: 10.14309/ajg.0000000000001930.

4. Lim N, et al. Impact on 30-d readmissions for cirrhotic patients with ascites after an educational intervention: A pilot study. World J Hepatol. 2019;11(10):701-709. doi: 10.4254/wjh.v11.i10.701.

5. Leibowitz RM, et al. Sa1109 using QR code technology to improve guideline-directed care for admitted patients with decompensated cirrhosis. Gastroenterology. 2024;166(5):S-342. doi.org/10.1016/ S0016-5085(24)01261-7.

6. Sherman Z, et al. Integration of cirrhosis best practices into electronic medical record documentation associated with reduction in 30-day mortality following hospitalization. J Clin Gastroenterol. 2023;57(9):951-955. doi: 10.1097/ MCG.0000000000001787.

7. Ritter E, et al. Impact of a hospitalist-run procedure service on time to paracentesis and length of stay. J Hosp Med. 2021;16(8):476-479. doi: 10.12788/jhm.3582.

8. Nandan A, et al. Characteristics and impact of bedside procedure services in the United States: a systematic review. J Hosp Med. 2022;17(8):644-652. doi: 10.1002/ jhm.12848.

9. Berger M, et al. Improving resident paracentesis certification rates by using an innovative resident driven procedure service: 980. American Journal of Gastroenterology. 2018;113:S552.