Insertion of chest drains: summary of a safety report from the National Patient Safety AgencyBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4923 (Published 02 December 2009) Cite this as: BMJ 2009;339:b4923
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National Patient Safety Agency alert on Insertion of chest drains: Feasibility of a hands-on Consultant-led service
We read with interest the article by Lamont et al (BMJ 2009; 339:
b4923) shortly after the anniversary of the deadline for the
implementation of the initial recommendations in the national patient
safety alert on the complications from intercostal chest drain (ICD)
insertion in the United Kingdom.
In response to the alert, we ran a five-month pilot of a Consultant
Respiratory Physician-led service to provide 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 264000 starting on 17 Nov 2008. We focussed our
attention on addressing the issue of inadequate supervision by trying to
reduce unnecessary out-of-hours insertion of chest drains through making
casualty and emergency medicine on call doctors aware of the question
"Does it need to be done as an emergency or can it wait?" and providing
direct supervision to the chest drains inserted during normal working
hours either by a consultant or by an registrar well-experienced in the
procedure and personally signed off as competent by the consultant. Direct
teaching and reminding through computer screen savers were used. Every
chest drain inserted out-of-hours for any indication was notified to one
of the three respiratory consultants and all the 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%) patients 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 9 (17.30%) in the accidents & emergency department.
Data on exact geographical location within the hospital where ICD was
inserted was not available in 8 (15.4%) but were all out-of-hours and were
either in the accidents & emergency department or the medical
admission ward. Out of the 34 patients with pleural effusions, 31 patients
(91.17%) had radiological imaging to confirm pleural effusion prior to ICD
insertion. The 3 out of the 34 patients (8.82%) who had ICD without prior
radiological imaging were done in suspected empeyma in emergency admission
department. Two ICD insertions performed in emergency department, 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 ("had fallen out") in
8 patients needing further ICD insertions (15.38%).
Our 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. Our experience therefore calls for appropriate job planning 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
Competing interests: No competing interests
The safety report from the national patient safety agency on
insertion of chest drains is worrying but not surprising (1). It is
shocking that in this age of technology we are still inserting chest
drains blindly, which would have been comprehensible 50 years ago.
Ultrasound is cheap, widely available, does not need major training to
operate and saves lives. In a study to assess the value of chest
ultrasonography vs clinical examination for planning of diagnostic
pleurocentesis, 15% of the puncture sites were found to be inaccurate on
ultrasound examination. Furthermore, physicians were unable to locate a
puncture site in 33% of cases. Ultrasound prevented possible accidental
organ puncture in 10% of all cases and increased the rate of accurate
sites by 26% (2). In another study which looked at the incidence of
complications from thoracentesis performed under ultrasound guidance by
interventional radiologists concluded a lower complication rate than that
reported for non-image-guided thoracentesis (3). CT and ultrasound allow
very accurate assessment of the underlying pathologic process and are
crucial in planning the drainage procedure and guiding the placement of
drains (4). Ultrasound guided chest drain insertion should be a norm
rather than exception and this should be stressed in the new British
Thoracic Society guideline for insertion of chest drains.
(1) Lamon T, Surkitt-Parr M, Scarpello[A] J, Durand M, Hooper C,
Maskell N. Insertion of chest drains: summary of a safety report from the
National Patient Safety Agency. BMJ 2009; 339:b4923.
(2) Diacon AH. Brutsche MH. Soler M. Accuracy of pleural puncture
sites: a prospective comparison of clinical examination with ultrasound.
Chest 2003; 123(2):436-41.
(3) Jones PW. Moyers JP. Rogers JT. Rodriguez RM. Lee YC. Light RW.
Ultrasound-guided thoracentesis: is it a safer method?. Chest 2003;
(4) Moulton JS. Image-guided management of complicated pleural fluid
collections. Radiologic clinics of NA 2000; 38(2): 345-74.
Competing interests: No competing interests