Supplementary Table1. Characteristics of the 4 Patients Clamped in Stage 2

Supplementary Table1. Characteristics of the 4 patients clamped in Stage 2

Patient 1 / Patient 2 / Patient 3 / Patient 4
Age / 68 / 60 / 81 / 71
Months since diagnosis / 5 / 70 / 6 / 0
PS / 2 / 1 / 3 / 2
Albumin / 28 / 30 / 20 / 21
Stage / 4 / 3 / 3 / 4
Grade / Unknown / 1 / 3 / 3
Histology / Serous papillary / Serous papillary / Serous papillary / Adenocarcinoma
Debulked / No / Yes / No / No
Lines of chemotherapy / 2nd / 6 / 2nd / chemo naive
Receiving chemo / yes / no / yes / no
Taking antihypertensive medications / Yes / no / yes / no
Baseline BP / 106/67 / 121/72 / 128/80 / 105/60
Baseline Heart rate / 90 / 78 / 84 / 101
Time of lowest BP / 7am / 1.30am / 2.15pm / 9pm

Supplementary Table 2. Patients requiring paracentesis more than once in 17 months

No of drains / PS / Stage / Grade / Histology / Receiving chemo / Platinum sensitivity / Lines of chemo
Patient 1 / 4 / 1 / 3c / 1 / Serous papillary / No / Sensitive / 5
Patient 2 / 4 / 1 / 3c / 1 / Serous papillary / No / Resistant / 6
Patient 3 / 3 / 3 / 3c / 3 / Serous papillary / Yes / Resistant / 1
Patient 4 / 2 / 3 / 3c / 3 / Serous papillary / Yes / Resistant / 2
Patient 5 / 2 / 1 / 3c / Unknown / Serous papillary / Yes / Sensitive / 2
Patient 6 / 2 / 2 / 4 / Unknown / Serous papillary / Yes / Resistant / 2

SupplementaryFigure 1:AscitesOPD BasedPathway

Patientidentified throughClinic (nominal80%)

Q: Whatisthe turnaroundhere? Can it bedonetosupporta nextdayappointment

yes

Patientunder treatmentwith Ascites

Patientidentified throughGP (nominal10%)

CNS

Day 2: Assessby

Bookinto ascites clinic

ChemoDay Unit

UltrasoundSlot

Drain Event:0900-1600PatientReview

Patientarrives0900SHOreviewspatient

Patient self referral

(nominal10%)

ConsultantinOPD

LongtermplanSpR &orCNS

Nursebriefson theday

"Whathappens"

againstprotocol

First30patientsjointwithSpR

Hasthepatientbeento

AscitesOPD before?

Day 1: Coagulation screen

(DoinOPD)

Validity1 week

Yes

Ultrasoundguided draininsertion

HH: Tues0930

CXH: Tues ThursTBC

Drainremoved and dressing applied

Treat asin-patientatCXH

Suitablefor AscitesOPD

treatment?

Observations:

BP,Pulse, Temp,PainandDrain

Volume

0,1, 2and4 hours

Drain clamp criteria:

Maximumdrainvolume8l

Averagevolume5.5l

Discharge with information

OnCallnumber

Descriptionof procedure

Volumedrained

Timeline

ExclusionCriteria: Warfarintreatment Coagulationabnormalities Betablockers

LoculatedascitesPriorperitonealinfection Chemotherapywithrisk of neutropenia

Otheradmissionrequirement

Discharge summary toGP (see next)

Fax

ElectronicDischargeSummary

"FrequentUser" "NewUser"

BookintoclinicEarliestclinicslot

CoagulationScreenAssessinOPDEarliestclinicslot

Day1Day2Day3

Admit toCXHif:

BPsystolic90

Tempelevated Severepain Nausea/vomitting Bloodinfluid

Supplementary Figure 1: GP Letter

Oncology At ImperialCollege Health Care NHS Trust

C/O CXH, Fulham Palace Road

W6 8RF

Direct Line: 020 331 11234 ask for oncology SpR on call

Date:

Dear Dr ……

Re: Patient Name / DOB

Drainage of Ascites

Your patient has undergone a paracentesis today as a day case at CXH/HH Chemotherapy Day Unit.

A total of ………L were drained.

Any problems with persistently raised temperature or pain, please contact us directly on the above number. If the ascites reaccumulates, please contact us on the above number or via the patient’s CNS to arrange further drainage.

Yours faithfully,

SpR Oncology

Cc: GP

Patients notes

Patient (on leaving day unit)

Supplementary Material 1ASCITIC DRAINAGE PROFORMA

Patient sticker:

Dateofadmission: Dateoflast drainage:

Bloods sent :Date...... ⁯Time......

Platelets……… INR-Normal? Y/NAPTT-Normal? Y/N

Urea……...... Creat……...... eGFR………Alb...... Total Protein......

USSandmarking? / Date...... ⁯ / Time...... ⁯
Draininsertion:
Successful on 1stattempt? / Date...... ⁯
Y⁯N / ⁯ / Time......
Ifno,which attempt?
Doneby Radiology? / Y⁯N / ⁯

BPpredrainageHR predrainage

Date / Time / Timepost
insertion / Litres
drained this hour / BP / HR / Signature
1hour
2hours
4hours
6hours
8hours
12hours
16hours
20hours
24hours
28hours
32hours
36hours
DRAINOUT
1hourpost / xxxxx
2hours post / xxxxx

Patient passed urine?Y ⁯N ⁯

Renal function 1weekpost drainageUreaCreat

ClerkingDoctor

NameSignatureBleep

Supplementary Material 2 – Clinic proforma

DAYCASEPARACENTESIS

Patient details/label

Referralroute

Consultant CalltoCNS Calltodoctor Clinic

A+E

A. ELIGIBILITYCRITERIA (tobe completedbypersontakingreferral)

Name

DATE_//

IfNOforanyitem thenineligible forDaycase(Admitpatient for I/Pparacentesis)

Eligibilitycriteria / Yes / No
Clinicallysignificantascitesrequiringdrainage
Able towait2-7days for drainage
Performancestatus0-2
Mobile(abletoattend9amandleave6pmforw/ohospital transport)
NOT onWarfarin(LMWHpermissible)
DoesNOTrequireadmissionfor Sxcontrol,Ixor chemo

B.IFELIGIBLEFORDAYCASEPARACENTESISARRANGEFOLLOWING

Date
DATEOFPLANNED PARACENTESIS
Pls fill in datesfollowing werearranged forabove / Datearranged
1. AngiosuiteapptforUS guided insertion(Tues/Thurs, 9-10am)
2. DayUnitchairfor drainage+Notesbooked
3. Patientinformedof apptdatesandtimes
4. Patientgiven informationsheetondaycaseparacentesis
5. Checkandinformpatientson LMWHto omiteveningbeforedrainage
(restartpostdraininsertion)

C. AT LEAST24HRSto7daysBEFOREDRAINAGE CHECKFOLLOWING

IfNOforanyitem thenpatientineligible forDaycase(Admit patient for I/Pparacentesis)

Date / Yes / No
1. Clinical reviewfor fitnessin dayunit/clinic / Fit
2. Bloodtests:FBC andClotting / Plt100
Neut>1
Clotting-Normal
3. Bloodpressureassessment / SBP>110

Supplementary Material 2 – Clinic proforma

D.DAYUNITADMISSIONFOR PARACENTESISDATE_//

1. Patientarrivaltime(tocollectnotesthen gotoAngio):Time :

2. Timeof draininsertioninAngio:Time :

2. Timeof patientreturnfromAngio:Time :

3. Monitor BP/PRanddrainage(freeflow)as perradiology: YesNo

4. ContactDrfor reviewat4pm:Time :

CLINICALASSESSMENT:

PersonReviewing:………………………………… Grade:………………..Time :

Totaldrainagetimefrominsertion...... hours

Totalvolumedrained...... mls

FullydrainedRemovedrain,discharge,arrangeFU appt

Someresidual butnotclinicallysignificantRemovedrain,discharge,arrangeFU appt

Significantresidual needs further drainageIf well,sendhomewithdrainin situ

anddraining, andre-assessondayunit next morning

Ifpatient notfit/transportissuesArrangeadmission

Medical re-assessmentDay+1IF patientssenthome for overnightdrainage:

PersonReviewing:………………………………… Grade:………………..Time :

Totaldrainagetimefrominsertion...... hours

Totalvolumedrained...... mls

FullydrainedRemovedrain,discharge,arrangeFU appt

Someresidual butnotclinicallysignificantRemovedrain,discharge,arrangeFU appt

Significantresidual needs further drainageADMIT for in-patient drainage

Comments:

Supplementary Material 3 – Patient Information Sheet

Patient Information-Day CaseAscites Drainage

Whatis ascites?

Ascites isthe medical term forthe fluid that accumulates in the abdomen.It can occur in manydifferent types of cancer. Thebuild up ofthe fluid can causeyou symptoms

suchas discomfort from abdominal swelling, fatigue, breathlessness and nausea. You mayalso haveapoor appetite.

Whatis ascitic drainage (paracentesis)?

Tohelp relievethesymptoms causedbyascites, itis possible to remove the fluid

through atube (drain). Itis usuallypossible to drain this fluid in4-8 hours. You may be able to come in to thehospital, havethe fluid drained andgo homeagain on the same day.

Tohelp us makesurethatwedrainthe fluidsafely, it is important thatyoutell the doctorifany ofthefollowing apply to you:

YouaretakingWARFARIN

Youhavedailyinjections ofCLEXANE / LMWH:

Yourequirehospital transporteverytimeyou come to hospital

Youarespendingthemajority ofthe dayinyourbed

Youarein significantpainordistress

Ifyou haveanyconcernsor questions regardingthis, please contact a member ofour team between 9am– 5pm on 0203 311 1234 and ask forthe OncologySpR on call.

Supplementary Material 3 – Patient Information Sheet

Youshould come to the chemo dayunit(at CXHorHH) at 9amonyour allocated day and collectyour notesfrom the receptionist

Walk to the radiologydepartment. Theywillbeexpecting you in theultrasound department foryour ascitic drainbefore10am

Whilstyou arelying flat,thedoctor will use an ultrasound machine to locatethe collection of fluid.Theywillthenuse asmall needle to insert local anaestheticinto the skin. This areawillthen benumbed to pain.

Thedoctor will insert thedrain into the collectionof fluid through theareaofnumb skin. This should notbepainful.

Thedrain will be taped toyour skin andattachedto a special bag. The fluid willdrain out ofyourabdomen intothe bag.

Thenursingstaff will monitoryour blood pressureuntil it istime foryou toreturn to the dayunit.

Porters willtakeyou back to the chemo dayunitin a chair withyour notes.

Youwill sit in a chair on the chemo dayunituntil 4pm.

Adoctor will reviewyouat approximately4pm to seeif mostof the fluid inyour abdomen has drained.

Ifthe doctor is happy,yourdrain will be removedat about 5pm andyou willbe free to go home. Adressing willbeplaced over theskin wherethe drain has been removed.

Ifthe doctorfeels that thereis stillalotof fluid left insideyourabdomen, theymay recommend thatyougo home with the drain still in and come back in themorningto havethe drain removed.

Supplementary Material 4– Patient satisfaction questionnaire

PATIENT SATISFACTION WITHDAYCASEDRAINAGEOFASCITES

1. Howsatisfiedwere youwith thescheduling processfor your ascitesdrainage?(Please circlea number below)

Notsatisfied / Satisfied / Verysatisfied
1 / 2 / 3 / 4 / 5

2. Howcomfortablewas the actualinsertion ofthe drain?

NotcomfortableComfortableVeryComfortable

12345

3. Howsatisfiedwereyou overall havingthis procedure asadaycase?

Notsatisfied / Satisfied / Verysatisfied
1 / 2 / 3 / 4 / 5

4. Haveyoupreviouslyhad ascites drainedasan inpatient?

YESNO

Ifyes,pleaseanswerquestion Q5to7regardingyour previousexperiencewith in-patientdrainage.

Ifyou answered No thenpleaseskip to Q8

5. Howsatisfiedwere youwith thescheduling processfor your ascitesdrainage?(Please circlea number below)

Notsatisfied / Satisfied / Verysatisfied
1 / 2 / 3 / 4 / 5

6. Howcomfortablewas the actualinsertion ofthe drain?

NotcomfortableComfortableVeryComfortable

12345

7. Howsatisfiedwere you overallhavingthis procedure asanin-patient?

Notsatisfied / Satisfied / Verysatisfied
1 / 2 / 3 / 4 / 5

8. Overall,wouldyou prefer havingyour ascites drainedasaninpatient(as before) oras a daycase(thecurrentway)? (Pleasecircleyour preference)

In-patientdrainageDaycasedrainage

9. Anyother comments?

Thankyou