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P209 CAN DOCTORS CORRECTLY IDENTIFY THE CORRECT SITE FOR CHEST DRAIN INSERTION?
J. L. Gallagher, N. Stevenson. Wirral University Teaching Hospital, UK
Background Chest drain insertion is a procedure commonly performed by doctors across a range of specialties. The British Thoracic Society (BTS) has guidance for the preferred site for insertion, the safe triangle.1 Adherence to the guidance reduces complications. A previous smaller audit has shown that a high number of doctors fail to identify the correct site for insertion.2
Method This audit surveyed 111 doctors across a range of specialties in a university teaching hospital from F1 to consultant level. They were asked to mark a site on one of three photographs (anterior, lateral and posterior) as to where they would insert a chest drain to treat an uncomplicated pneumothorax in a non-emergency setting. Information was collected regarding training grade, specialty and competence.
Results Of the 111 responses, 3 did not mark a photograph. Of the 108 who identified a site, 55 (51%) correctly identified the safe area. Of those correct, 31/55 (56%) felt competent to perform the procedure independently. 24/53 (45%) who were outside the triangle also felt competent to insert a chest drain. The most common error was siting the drain too low. Only 16/29 (55%) of SpRs/STRs in all specialties were correct. The majority of these (28/29) felt competent to perform the procedure. Table 1 illustrates the percentage of doctors who correctly identified the safe triangle in a variety of specialties. F1/F2 doctors were excluded as considered generic training. Of doctors with previous respiratory medicine or cardiothoracic surgery experience, 24/39 (62%) and 7/12 (58%) respectively correctly identified the safe triangle. The majority of doctors (99/111) felt further teaching and training would be beneficial.
Conclusion Despite BTS guidance, almost half of the doctors would have incorrectly placed a chest drain. This is true of doctors within the medical directorate (where most intercostal drains are inserted) and of SpRs/StRs who are most likely to perform chest drain insertion independently. Respiratory or cardiothoracic experience does not ensure correct placement. Worryingly, most doctors felt competent despite inaccurate placement. Further education and training is needed. Competency should be assessed before independent chest drain insertion.
P210 WAS THE NPSA ALERT ABOUT CHEST DRAINS JUSTIFIED?
T. P. R. N. Brown, W. A. Fayed, P. J. Andrews, D. E. Laws. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
Introduction and Objectives Following the NPSA alert in May 2008 highlighting the potential risks relating to chest drain insertions, we looked retrospectively at 140 drains at the Royal Bournemouth Hospital (RBH) focusing on safety and complications. RBH is a medium-sized DGH serving a population of 500 000 people in the East Dorset area.
Methods This was a retrospective audit of clinical notes, laboratory results and imaging, looking at all chest drain insertions at RBH over a 1-year period from 1 April 2007 to 31 March 2008.
37% of drains had a complication with more complications occurring in drains inserted out-of-hours (42%), particularly if these were non-urgent (49%), with a significantly increased risk of drains falling out or the patient experiencing ongoing pain (table 1).
The more experienced the person inserting the drain, the lower the risk of complications.
60% of drains were inserted by junior doctors and the majority of these were unsupervised. All of the patients who required a further potentially avoidable drain on the same admission had their drain inserted by an unsupervised junior doctor.
Image guidance halved the complication rate but was only used in 24% of chest drain insertions.
Of the 10 infective complications, two had no documentation of aseptic technique, with potentially significant medicolegal implications.
There was a significant increase in ongoing pain when a drain size greater than 12F was used.
Conclusions We found that potentially life-threatening complications were occurring with chest drain insertions at RBH as highlighted by the NPSA. Chest drains should not be inserted out-of-hours unless there is an urgent clinical need as more complications occur. As in many other hospitals, the majority of drains were inserted by unsupervised junior doctors with a clear link found between the experience of the doctor and complication rates. Radiological guidance dramatically reduced complication rates and should be used wherever possible. Based on these findings, we have already taken steps to improve local practice with a mandatory training course, a new patient information leaflet as well as new documentation to promote best practice and provide a robust tool for audit.