Experience of a consultant-led service to improve the safety of insertion of chest drains
In response to the National Patient Safety Agency alert on the safety of insertion of intercostal chest drains (ICDs) in 2008, a pilot of a consultant respiratory physician-led service was run to offer advice, training and supervision for ICD insertion during normal working hours in a district general hospital (Milton Keynes) providing acute medical services to a population of over 264,000 over a five-month period starting on 17 November 2008. The issue of inadequate supervision was addressed by:
trying to reduce unnecessary out-of-hours insertion of chest drains through making casualty and emergency medicine on-call doctors ask themselves the question ‘Does it need to be done as an emergency or can it wait?’
providing direct supervision to chest drains inserted during normal working hours either by a consultant or by a registrar well-experienced in the procedure and personally signed off as competent by the consultant.
Direct teaching and reminders through computer screen savers were used. Every chest drain inserted out of hours for any indication was reported to one of the three respiratory consultants and all out-of-hours procedures were reviewed by them. Virtually all patients with ICDs were transferred to one of the two respiratory wards (except one patient with a traumatic haemothorax who was transferred directly from the acute medical unit to the care of thoracic surgery at a different hospital).
Over the five-month period, 52 unique patients had undergone ICD insertions. Out of these 18 (34.62%) had pneumothorax and 34 (65.38%) had pleural effusions. Twenty-five (48.07%) of the ICD insertions were performed in respiratory wards, 10 on the medical admission ward (19.23%), and nine (17.30%) in the accident and emergency (A&E) department. Data on exact geographical location within the hospital where ICDs were inserted were not available in eight cases (15.4%) but they did all take place out of hours and were either in the A&E department or the medical admissions ward. Out of the 34 patients with pleural effusions, 31 (91.17%) had radiological imaging to confirm the diagnosis prior to ICD insertion. Three of the 34 patients (8.82%) who had ICD without prior radiological imaging were done in suspected empyema in the emergency admission department. Two ICD insertions performed for symptomatic pneumothorax were complicated by infection of the pleural space with Staphylococcus aureus. No other major complications occurred in the remaining 50 patients. Initial ICD was displaced in eight patients needing further ICD insertions (15.38%).
This experience demonstrates that a consultant-led ICD insertion service is feasible in an acute hospital and that it improves patient safety. It can reduce unnecessary out-of-hours insertion of chest drains by less experienced trainees and can improve their training by more senior support. Appropriate job planning is needed to systematically include pleural procedure sessions for respiratory consultants to provide the necessary support to hospital-wide ICD insertions in order to improve the quality and the safety of the procedure.
Footnotes
Letters not directly related to articles published in Clinical Medicine and presenting unpublished original data should be submitted for publication in this section. Clinical and scientific letters should not exceed 500 words and may include one table and up to five references.
- © 2010 Royal College of Physicians
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