Developing a ‘pleural team’ to run a reactive pleural service

The increasing burden of pleural disease

Evidence suggests that the incidences of some pleural diseases are on the rise internationally. The UK peak of mesothelioma in men is expected around 2015² and pleural infection, often linked to underlying pneumonia, has also been increasing in both adults and children.^3,4 Admissions to hospital resulting from pneumonia rose by a third between 1997 and 2005,⁵ with an increasingly elderly population most susceptible.⁶ Up to 57% of these patients develop a pleural effusion during the course of their illness,⁷ with many requiring some form of pleural intervention. Furthermore, increased cross-sectional imaging has undoubtedly contributed to the number of small effusions being detected in both acute medical and oncology patients. Pleural involvement in malignancy is common⁸ and frequently causes significant symptoms in those who usually have poor-prognosis metastatic disease.⁹ There are likely to be over 40,000 cases of malignant pleural effusion (MPE) each year in the UK¹⁰ and, as people diagnosed with malignancy continue to live longer while the number of new cases is escalating, efficient malignant effusion management is going to become even more important.

Over 50 different systemic conditions are known to affect the pleura,¹¹ and a number of these may co-exist in any one patient. Careful history and examination can lead to a diagnosis but, as pleural disease tends to manifest in a limited number of ways, further investigation is usually warranted for treatment to be targeted correctly.

Pleural investigations – the modern approach

The move towards specialty triage and care means that many junior doctors have limited exposure to pleural procedures, with chest drain management also increasingly unfamiliar to non-respiratory nursing staff. The potential issues resulting from this were highlighted by a National Patient Safety Agency (NPSA) report, which noted 27 deaths or incidences of serious harm caused by chest drain insertion over a 3 year period, alongside multiple accounts of poor management.¹² This was backed up shortly afterwards by a large-scale survey of acute trusts¹³ and has led to a push towards using thoracic ultrasound (US) for all drain insertions. There are also compelling data for the use of ultrasound guidance for more ‘simple’ thoracentesis, with an elegant study by Diacon et al.¹⁴ showing that US was both superior in identifying aspiration sites and able to improve patient safety. This weight of evidence has now been formalised in the British Thoracic Society guidelines on pleural disease,¹⁵ with ‘real-time’ ultrasound guidance strongly ­recommended for all pleural procedures.

The basis for a pleural team

All of the above has meant that the medical management of pleural disease has become progressively more reliant on specialist input. On top of this, over the past decade there have been significant advances in the investigation and treatment options for pleural disease, making the management of pleural disease far more complex and nuanced.

The traditional default management for any kind of significant pleural collection was admission to hospital for insertion of an intercostal drain. For those with malignancy, this usually resulted in an average inpatient stay of around 7 days,¹⁶ with potential delays if tissue diagnosis was required. Patients with pleural infection or a persistent air leak can require significantly longer admissions, often culminating in referral for surgical procedures.^17,18 Driven therefore in part by the spiralling costs of inpatient care and the need for rapid cancer diagnosis, as well as a desire to improve patient experiences, advancements such as pleural-specific cross-sectional imaging, local-anaesthetic (‘medical’) thoracoscopy, intrapleural thrombolytic therapy, and the use of indwelling pleural catheters (IPC) have become more mainstream.¹⁹ Such developments mean that many pleural patients can be safely and effectively managed as outpatients for almost the entirety of their disease course. The common aims of all pleural teams are to promote admission avoidance and procedural safety, and to provide a universally accessible and reliable service.

Pleural team personnel

The core members of individual pleural teams will vary greatly from centre to centre, based largely upon which facilities are available locally and how well-established they are. At the heart of any team, there must be an enthusiastic physician with an interest in pleural disease. Fig 1 and Table 1 suggest the specialties, departments and staff roles that should be seen as central to a comprehensive pleural service. It should be noted that, although often more convenient, not all resources need be on a single site. Indeed, using a well-established referral service might be more efficient than trying to introduce a new local one. In addition, multiple roles might be performed by single individuals without any compromise in quality or efficiency, and some responsibilities are heavily interchangeable between services.

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Fig 1.

The core services provided by a pleural team and the hospital staff who might form part of it.

Pleural team practicalities

A pleural service can be run from a number of different settings, including a medical admissions unit (MAU), a day-case ward or a respiratory out-patient clinic. For some smaller centres, a weekly pleural clinic or procedure list on the MAU might be all that can be staffed initially. With time, data showing reduced lengths of stay, admission avoidance or high levels of patient ­satisfaction might justify the expansion of the service. Extra resources are rarely required to start a service, but there must always be a ­willingness to challenge traditional ways of working.

In addition to having appropriate staff, a pleural team and service should aim to have in place an infrastructure that allows them to operate efficiently. Maintaining a prospective database of patients will allow a local audit to be performed and will maximise opportunities for engaging in observational research.

Dedicated pleural clinics, or clinic slots, are extremely useful in ensuring that patients can be seen in good time following referral from the community.²⁷ Lengthier appointments for new patients should be considered as many will require fluid aspiration during a consultation, although separate pleural intervention lists are becoming increasingly common. Such lists provide the opportunity to perform all manner of procedures, including standard chest drains, in a more controlled environment such as an endoscopy suite and, if timed well with clinics, can reduce referral to diagnosis delays to a few days or less.

Pleural teams can also maximise learning opportunities for trainees and allow skills that have already been gained to be consolidated. Ready access to bedside thoracic US has become essentially mandatory for dedicated pleural clinics and lists. Although a machine is often a major financial investment, the ability to make instant decisions without referral to radiology can be of great benefit and can be the catalyst for establishing a pleural service.

Conclusion

As pleural medicine continues to expand, so too does the number of dedicated teams and services across the country. Recent data suggest that the perceived benefits of this way of working are now being backed up with demonstrable improvements in waiting times, patient safety, admission durations and overall costs,²⁸ even at the level of small district general hospitals. By utilising and adapting locally available services, or by promoting the development of new ones, we believe that a ­successful pleural service is achievable in all UK hospitals.

A pleural team has the potential not only to streamline patient pathways but also to improve patient care and to ­provide opportunities for practical skills training to trainees.