Introduction In the UK, upon completion of Core Medical Training (CMT), procedural independence is expected for pneumothorax drains and is desirable for pleural effusions. In 2009, prompted by a National Patient Safety Agency report, a local guideline was introduced in our hospital aiming to reduce intercostal chest drain (ICD) complications for effusions by formalising training, increasing supervision and utilising bedside ultrasound scan (USS). Consequently, rates of adverse events have significantly been reduced. This raises the question, however, have such measures reduced the procedural exposure for CMT doctors.
We aimed to compare the numbers of ICDs inserted by CMT doctors for effusions in 2008 and 2012. The numbers of ICDs inserted by CMTs for pneumothorax compared to effusion in 2012 was also examined.
Methods All patients who received an ICD for effusion or pneumothorax in 2012 and for effusion in 2008 were retrospectively reviewed. We reviewed grade of doctor performing ICD insertion, supervision, and use of USS (for effusion).
Results CMTs inserted significantly less ICDs for effusions in 2012 (10/30, 33%) compared to 2008 (20/39, 51%) z = 1.75, p = 0.04. Supervision rates increased from 73% in 2008 to 100% in 2012. Bedside USS was used in 100% of effusion-related ICDs in 2012 compared to 0% in 2008.
In 2012 alone, CMTs inserted significantly fewer ICDs for pneumothorax (4/28, 14%) compared to effusions (10/30, 33%) z = -1.69, p = 0.046. A&E doctors inserted the majority of ICDs for pneumothorax (15/28, 53%), whilst a Respiratory Registrar/Consultant inserted the majority of ICDs for effusions (13/30, 43%).
Conclusions Since 2008, there has been a significant reduction in ICD insertions by CMTs. The majority of ICD insertions for pleural effusions being performed using USS by appropriately trained respiratory physicians may explain this. The significant fall in the number of ICD insertions by CMTs for pneumothorax (where USS guidance is not required) however, suggests that overall ICDs are becoming a specialist procedure rather than a generic competency. Trainees are at risk of not fulfilling their competency requirements and this poses the question should procedural training and curriculum objectives be readdressed in light of the growing need for USS experience.