Background Exudative pleural effusion (EPE) is a common presenting problem, associated with serious underlying pathology warranting expeditious and thorough investigation. The BTS guideline outlines a diagnostic algorithm and recommends referral of patients to chest physicians following inconclusive initial pleural fluid analysis.
We have carried out a series of audits on the management of EPE in a district general hospital (DGH). The first revealed deficiencies in the diagnostic pathway, with low diagnostic rates compared with published data. We instituted regular teaching sessions including simulated training of junior doctors, established a specialist pleural effusion clinic (SPEC) and during the same period there was increase in the number of respiratory registrars. In a previous study comparing results of the first retrospective audit cohort (RC) to the SPEC cohort showed improved outcomes in the latter. Unfortunately a significant proportion of patients with EPE are still diagnosed on acute admission. In this audit we compare the management of these patients to the RC.
Methods We carried out a retrospective re-audit (RA), against BTS guidelines, of non-elective admissions to the general medical take from January to December 2011 with EPE. Clinical records of patients with pleural effusion were reviewed and analysed for investigations, involvement of respiratory physician, length of stay and outcome. Those with transudate effusions were excluded. This was similar to the RC which covered the period from February 2005 to June 2006. We present comparative results.
Results Of 106 patients, 66 patients had diagnostic aspiration, 18 had small effusions unable to aspirate, 19 had known diagnoses and 3 had terminal cancer. The respective results in the RA compared to the RC showed that mean age was 65 vs 68 years, 86% had all the recommended tests vs 46%, 87% had chest physician input vs 50% and diagnosis confirmed in 95% vs 58%. The median length of stay in hospital was 4 days (range 0–51) vs 12 days (range 1–55). Table 1 demonstrates pleural fluid tests performed.
Conclusions The RA shows improved investigation, access to chest physician, diagnostic rates and average length of hospital stay in patients with EPE in this DGH. The change is likely multifactorial owing to increasing awareness, training, and better specialist services.