There are three major barriers to implementing FLASP-like clinics: patient, provider, and administrator buy-in. These may pose more severe limitations to the success of a FLASP clinic than were characterized by the authors.

Many patients feel that symptomatic ascites is urgent, requiring immediate relief; many patients have also grown accustomed to full and thorough evaluation typically performed in the ED versus the briefer assessment typical of problem-focused visits. That FLASP requires redirecting patients from the ED led to several issues. One is that redirection to a FLASP clinic can entail a delay of relief of a day or more, with consequent frustration, compounded by patients also forgetting their FLASP appointments once scheduled. The authors therefore recommend educational initiatives aimed at overcoming logistical barriers and reframing patient expectations.

Many outpatient clinicians refer exclusively to the ED for paracentesis without consideration of alternatives. Further, many ED providers reflexively admit patients with symptomatic ascites given concerns related to the severity of the underlying disease. Beyond clear guidance for ED clinicians, it would be more efficient to the patient and the system to entirely avoid referrals to the ED in the first place, which in practice is difficult since referral to the ED is usually the path of least resistance. The ED is attractive since it is reliable, open 24/7/365, accepts all patients, and cannot be questioned as a locus of medical care. By shifting responsibility to other providers, a referral to the ED simplifies management, avoiding the challenges inherent in marshaling resources to address semi-acute, unscheduled procedures.

Administrators may also present an uncharted barrier. The effort and clinical space for FLASP is supported financially by the hospital, an investment that has inherent risks: patient attendance is unpredictable, the opportunity cost of the space is the possibly more lucrative scheduled clinic visits, and staff time is expensive. Admissions for ascites generate revenue, albeit less than that obtained for the management of true emergencies. Accordingly, the business case requires substantial research, nuanced calculations, and attention to detail.