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:

  • 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.

  • 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

  • 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 recordand audit adverse incidents and near misses good documentation is essential.

Workforceand Scheduling

  • 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.
  • Does it need to be done as an emergency – can it wait?
  • Do I need to this?
  • Have I enough training to feel confident to do this? Are senior staff to hand?
  • Am I familiar with this equipment?
  • 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.
  • At present medical trainees in medicine, surgery, emergency medicine and anaesthetics are expected to describe the procedure and complications in an exam.
  • 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).
  • 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.
  • 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

  • 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:
  • Patient name with patient identifying themselves against checked identity band
  • Procedure and side
  • 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:
  • Patient name with patient identifying themselves against checked identity band
  • Actual procedure undertaken and side
  • 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

  • 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

  • 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

  • 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:
  • Verification of patient name and checked against identity band
  • Review of the consent form
  • Review of radiology (including relevant Chest Xray and CTs)
  • Allergy review (especially latex)
  • Review of the risk of bleeding (especially in haematology and liver disease patients)
  • 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

  • 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

  • Post pleural procedures a sign out check must be undertaken to confirm:
  • The procedure performed and site
  • The guidewire has be removed if a seldinger chest drain has been inserted
  • All specimens have been correctly labelled
  • Equipment problems including stock levels for inclusion in the debriefing

Debriefing

  • 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


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.

Appendix 4