Download Guidelines for pleural procedures

Local Safety Standards for invasive procedures (LocSSIPs)- Pleural procedures
(a) Pleural aspiration and (b) chest drain insertion
Background
Pleural procedures involve the removal of air or fluid (including blood and pus) from the pleural cavity.
In 2008 the National Patient Safety Agency (NPSA) after reviewing 12 deaths and 15 cases of severe
harm associated with chest drains identified the following as important common themes:
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inadequate staff supervision and experience;
failure to follow manufacturer’s instructions;
the site of insertion and poor positioning;
anatomical anomalies and the patients clinical condition; and
lack of knowledge of existing clinical guidelines
Examples of patient harm include bleeding and solid organ injury due to poor siting of drains, excessive
use of dilators, loss of guidewires in seldinger drain insertions and pleural or drain site infection.
Scope of Document
This document’s purpose is to ensure safe and effective care is delivered to patients undergoing pleural
procedures within all clinical areas including Emergency Department, Medical wards, Surgical wards,
intensive care, radiology departments, outpatient departments, and surgical and endoscopy theatres.
The British Thoracic Society (BTS) guidelines for pleural disease (Havelock, 2010) and the Advanced
trauma Life Support manual (9th Edition) provide detailed guidance on clinical indication and how to
undertake pleural procedures. This local guidelines pulls together information from these documents to
standardise and harmonise practice across the trust to underpin patient safety in accordance with
National and Local Safety Standards for Invasive Procedures.
We anticipate this document will be used in conjunction with these documents on undertaking pleural
procedures.
Glossary
Procedure: Pleural aspiration and chest drain insertion
Procedure area/room: operating theatre, dedicated treatment room, endoscopy room, radiology CT or
ultrasound room, and patient bedside (Intensive care, patient in isolation or emergency room).
Procedure team: doctors, nurses, radiographers and healthcare assistants directly involved in the
performance of the procedure
Operators: Doctors or nurse practitioner performing pleural aspiration or drain placement
Senior Operator: Clinician with overall responsibility for procedure
US: Ultrasound
ED: Emergency Department
Governance
The accountability, responsibility, organisational culture, record keeping, team education and audit are
all important factors in delivering and improving patient safety.
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Every team member is responsible for delivery of safe care. It is important that team members
are given the opportunity to suggest improvements in LocSSIP.
Effective teamwork in a supportive environment makes patient care safer. It is important that
any member of the procedural team can express concerns about patient safety at any time
during the procedural pathway.
Continuous safety improvements depends on continuous audit of outcome and compliance with
safety standards
Adverse patient events and near misses with pleural procedures should be reported by the
Trust’s incident reporting system. These should be investigated and discussed at quarterly
Morbidity and Mortality meetings, Audit meetings and Clinical governance meetings as
appropriate. Learning points of incidents if applicable should be disseminated trust wide and
reported to National Reporting and Learning System.
Documentation of Invasive procedures
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Good documentation is key to effective implementation of standards. In the appendices 1 and 2
are combined checklists and record keeping for pleural aspiration and chest drain insertion
respectively.
This is available via the trust’s electronic medical records under the short code .pleuralproc
This promotes important steps in the pre-procedural, procedural and post procedural pathway.
It includes a vital stop if fluid or air cannot be aspirated with the instillation of local anaesthetic.
In order to accurately record and audit adverse incidents and near misses good documentation
is essential.
Workforce and Scheduling
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Due to the risks of undertaking pleural procedures especially chest drain insertion the NPSA
recommended the following questions be asked which relate to workforce and scheduling.
o Does it need to be done as an emergency – can it wait?
o Do I need to this?
o Have I enough training to feel confident to do this? Are senior staff to hand?
o Am I familiar with this equipment?
o Is ultrasound available, with trained staff, to position it safely?
It is essential for safe patient care that all members of the team have appropriate skills and
experience. The NPSA recommended chest drains are only inserted by staff with relevant
competencies and adequate supervision.
The BTS recommended all healthcare personal expected to be able to insert chest drains should
be trained using a combination of didactic lecture, simulated practise and supervised practise
until considered competent.
o At present medical trainees in medicine, surgery, emergency medicine and anaesthetics
are expected to describe the procedure and complications in an exam.
o There are no nationally agreed standards for assessing independent practice. Regional
guidance has been produced by the Northern Trauma Network (appendix 3) or West of
Scotland (2012).
o Only operators who have been signed off as competent who have completed a
minimum of 4 satisfactory direct observed procedural skills or passed and hold a current
ATLS certificate will be recognised as trained.
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In all other circumstances pleural procedures should be supervised by a senior doctor or pleural
nurse specialist who regularly places drains and has achieved trust competency.
The British Thoracic Society have incorporated the NPSA recommendations into an algorithm
(appendix 4) to guide the scheduling of cases on the basis of emergency and skills mix.
Handover
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There should be a formal handover of the ward team to the practitioner receiving the patient
for pleural procedures. This pre procedural handover should include:
o Patient name with patient identifying themselves against checked identity band
o Procedure and side
o Relevant clinical features (diabetes) including relevant medication (anti-coagulation and
blood products given to correct coagulopathy))
Post pleural procedure there should be a formal handover from the procedure team to the post
procedure team caring for the patient. This should include:
o Patient name with patient identifying themselves against checked identity band
o Actual procedure undertaken and side
o Post-operative management plan including:
 Frequency of observations
 Rate of drainage of fluid recommended
 Actions required for any specimens taken during the procedure
 Prescription of Analgesia post drain insertion
 Additional medications including antibiotics prescribed
 Complications encountered during procedure and interventions to correct them
 Does the drain require thoracic suction and if so how much?
 Who will be expected to review the post procedure Chest X-Ray?
Procedural verification
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Prior to undertaking any pleural procedure up to date radiology (Chest X-ray or CT) should be
reviewed.
When undertaking a pleural procedure for fluid, thoracic ultrasound (US) should be undertaken
by an operator who has achieved Royal College of Radiologist Level 1 certification.
The site for the procedure should be marked with an indelible marker.
Pleural procedures for fluid should be undertaken either immediately after the site is marked or
under real time with ultrasound control.
Safety Briefing
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A safety briefing must be undertaken prior to the start of any pleural procedure. This is usually
done prior to the patient being bought into the procedure room.
These include the risk of bleeding and the need for blood products, infection risk (MRSA, TB,
influenza etc), patient positioning (including truncal instability), allergies (including latex) and
special equipment required for the procedure (tunnelled indwelling pleural catheters)
Sign in and Time out
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With pleural procedures due to their brevity, the sign in and time out procedures may
seamlessly combine. It is important to however to view these as separate steps.
The sign in process must be completed on arrival at the procedure area they include:
o Verification of patient name and checked against identity band
o Review of the consent form
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o Review of radiology (including relevant Chest Xray and CTs)
o Allergy review (especially latex)
o Review of the risk of bleeding (especially in haematology and liver disease patients)
o Marking the site for the procedure including undertaking thoracic US
The time out is an essential safety check prior to initiating the procedure. It includes checks of
items in the sign in procedure but includes checks of the monitoring equipment and ultrasound
equipment. It also encompasses a review of safety consideration eg. truncal stability to position
the patient for the procedure.
Prosthesis verification and Prevention of retained foreign bodies
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When placing a tunnelled indwelling pleural catheter the manufacturer, size and unique
identifier for the catheter should be recorded in the notes.
Where Seldinger chest drains have been inserted using an over the wire technique. It should be
recorded that the guidewire has been removed and this has been verified by a witness.
Sign Out
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Post pleural procedures a sign out check must be undertaken to confirm:
o The procedure performed and site
o The guidewire has be removed if a seldinger chest drain has been inserted
o All specimens have been correctly labelled
o Equipment problems including stock levels for inclusion in the debriefing
Debriefing
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A team debriefing post pleural procedure should be undertaken to identify what went well with
the procedure, any problems with equipment including stock levels and identify areas for
improvement.
Records of the debriefing should be made to be included in an action log that can be used to
communicate examples of good practice and any problems encountered. These should be
discussed at the quarterly clinic morbidty & mortality meeting and fed back into the governance
meetings if indicated.
References:
1. Chest drains: risks associated with the insertion of chest drains. National Patient Safety Agency.
May 2008
2. Havelock, T et al. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural
disease guideline 2010. Thorax (2010) 65s: i61-76
3. Advanced trauma life support (ATLS) student manual 9th Edition 2012. Publisher: American
College of Surgeons
4. National Safety Standards for invasive procedures. NHS England Sept 2015
5. Chest Drain Guidelines. Cambridge University Hospital NHS Foundation Trust 2013.
6. Sen, B. Policy for the Insertion and Management of Chest Drains (Adults). Northern Trauma
Network. Feb 2015
7. NHS Greater Glasgow and Cylde Chest Drain Guidelines – Decision Flow Chart 2012
8. Khan, B. Never events & the checklist manifesto for intercostal chest drains. Thorax (2013) 68:
A172-173
Pleural Aspiration Check list and Report
Name
Place undertaken ☐treatment room ☐ bedside ☐radiology ☐theatres ☐ICU ☐endoscopy ☐ED
Procedural Checklist and Report
DoB
Aseptic technique: Sterile ☐ Gown ☐Gloves
Hospital number
(please fill or affix patient label and confirm
identity)
Pre procedure Checklist (Sign in)
Name:__________ Name :_________
Have all team members introduced themselves
and role : ☐ Y ☐N (ICU, unconscious)
Indication: ☐ Air
☐ Fluid
Radiology reviewed: ☐CT
☐ Both
☐CXR
Confirm side of procedure: ☐ Left ☐Right
☐At least two applications of chloroprep
☐Sterile field protected by drapes
Observations: BP: ___ SpO2: ___FiO2:___HR:___
☐2% __ (mls)
Adrenaline present with lignocaine ☐ Y ☐N
Have all items of stock running low (<3 remaining) been ordered
urgently: ☐Y ☐ N or N/A
Are there procedural problems that need follow-up: ☐Y ☐N
Aspiration Kit used:
Size: _______Manufacturer: _______________
Amount aspirated initially: ___________ (mls)
Complications: Pain (0-10) __
☐Realtime US ☐immediate US marking
Confirm frequency of observations: ☐every 15 mins for 1 hour
then hourly for 2 hours then 4 hourly.
Concentration: _________________________
Samples: ☐Biochemistry ☐Cytology ☐ MC&S
Effusion depth (cm) __ Other findings:
_________________________________
☐N
Ensure specimens correctly labelled: ☐Y ☐N ☐N/a
Lignociane ☐1%
Patient’s coagulation and medication checked:
☐ Yes ☐ No
Platelets___ PT ___
Thoracic US findings:☐Echoic ☐anechoic
Order Post procedure CXR and handover for review: ☐ Y
Prescribe analgesisa ☐Y ☐N
Fluid appearance: _______________________
Thoracic US for Fluid done:☐ Y ☐N ☐N/A
Please undertake the below and handover to nursing team
STOP if unable to aspirate Air or
Fluid
with
local
anaesthetic
infiltration
Side:
☐left ☐right Site: _________________
Observations: BP: ___ SpO2: ___FiO2:___HR:___
Consent: ☐Written ☐ Verbal ☐ Part IV
Post Procedural Checklist (Sign Out)
Other:______________________________________
___________________________________________
___________________________________________
Doctor inserting drain:__________________ Grade: ______
Signature: ___________________ Date: ____/_____/_____
Supervised: ☐Y ☐N
Assistant ☐Y ☐N
Name:______________Grade:_______Signature:_____________
Appendix 1
Intercostal Chest Drain Check list and Report
Name
Place undertaken ☐treatment room ☐ bedside ☐radiology ☐theatres ☐ICU ☐endoscopy ☐ED
Procedural Checklist and Report
Post Procedural Checklist (Sign Out)
DoB
Hospital number
Aseptic technique: Sterile ☐ Gown ☐Gloves
Order Post procedure CXR and handover for review: ☐ Y
☐At least two applications of chloroprep
Start Chest Drain Chart ☐Y
(please affix patient label and confirm identity)
☐Sterile field protected by drapes
Pre procedure Checklist (Sign in)
Have all team members introduced themselves
and role : ☐ Y ☐N (ICU, unconscious)
STOP if unable to aspirate Air or
Fluid
with
local
anaesthetic
infiltration
Side:
☐left ☐right Site: _________________
Indication: ☐ Air
Lignociane ☐1%
Name:__________ Name :_________
☐ Fluid
Radiology reviewed: ☐CT
☐ Both
☐CXR
☐2% __ (mls)
Adrenaline present with lignocaine ☐ Y ☐N
Confirm side of procedure: ☐ Left ☐Right
Concentration: _________________________
Observations: BP: ___ SpO2: ___FiO2:___HR:___
Fluid appearance: _______________________
Patient’s coagulation and medication checked:
☐ Yes ☐No
Platelets___ PT ___
Samples: ☐Biochemistry ☐Cytology ☐ MC&S
Consent: ☐Writen ☐ Verbal ☐ Part IV
Thoracic US for Fluid done:☐ Y ☐N ☐N/A
Thoracic US findings:☐Echoic ☐anechoic
Effusion depth (cm) __ Other findings:
_________________________________
☐Realtime US ☐immediate US marking
Amount drained initially: ___________ (mls)
Drain Size: ___ Secured: ☐Suture ☐ Dressing
Closing mattress (>size 18) placed ☐ Y ☐N
☐N
Prescribe analgesisa ☐Y
Information leaflet on chest drain care given to patient and
explained: ☐Y ☐N (ICU)
Ensure specimens correctly labelled: ☐Y ☐N ☐N/a
Observations: BP: _____ SpO2: _____ FiO2:______ HR: ____
Confirm instructions on fluid drainage to nursing staff: ☐Y
 Drain no more than 1500mls of fluid at any one time.
 Stop drainage by closing tap if patient develops pain,
coughing, breathlessness or 1500mls drained for 2 hours
then reopen.
Confirm frequency of observations: ☐every 15 mins for 1 hour
then hourly for 2 hours then 4 hourly.
Have all items of stock running low (<3 remaining) been ordered
urgently: ☐Y ☐ N or N/A
Are there procedural problems that need follow-up: ☐Y ☐N
Doctor inserting drain:__________________ Grade: ______
Signature: ___________________ Date: ____/_____/_____
Complications: Pain (0-10) __ Other:__________
_______________________________________
Supervised: ☐Y ☐N
Guidewire removed: ☐Y ☐N ☐N/A
Name:______________Grade:_______Signature:______________
Appendix 2
_______
Assistant ☐Y ☐N
Appendix 3 Levels of training competencies for chest drain insertion (Northern Trauma Network)
Chest drain
Level 1
competency
insertion
competencies
Core medical trainee, or
equivalent in core accident
and emergency, anaesthetic,
intensive care, medical,
radiology, respiratory, and
surgical training
Can perform chest drain
insertion with supervision by
an operator (level 2 or greater)
who has recent experience of
chest drain insertion.
Level 2
competency
Accident and emergency,
anaesthetic, intensive care,
medical, radiology,
respiratory, and surgical
trainees ST3/equivalent and
above
It is expected that doctors
within this grade will have
undertaken a number of chest
drain insertions and have been
directly supervised
undertaking the procedure on
at least 2 occasions in each
year. Following such
assessment they may carry out
the procedure independently.
Level 3
Competency
Any senior medical personnel
experienced at performing
these procedures, preferably
with experience in ultrasound
assisted drain insertion.
These doctors are experienced
and independent operators
and may undertake the
observation and assessment
of other operators carrying
out the procedure.
Algorithm for pleural procedure scheduling
Pleural fluid or
Pneumothorax
requiring
investigation/
treatment
Does this need to be done as
an emergency?
Eg Tension
YES
Yes
Insert chest drain or
therapeutic
aspiration
NO
NO
Does the patient have
significant respiratory
compromise?
Is this outside
working hours?
YES
NO
Prepare patient for
Chest Drain
Delay procedure
until working ours
NO
Is the drain required for
fluid?
Insert Drain
YES
NO
Is the operator
experienced?
Seek Senior help
YES
Insert chest drain
Ultrasound strongly
recommended
Adapted from Havelock et al, Thorax 2010 65s: i65-i76
Appendix 4
Consider pleural aspiration to
relieve symptoms and delay
drainage until appropriate
supervision is available