Background: Small-bore pulmonary drains (PD) have been proven effective at replacing the previous large-bore chest tubes for resolution of pneumothorax (PTX), and management of complicated (CPEs) and recurrent pleural effusions (RPEs). The placement of these drains has traditionally been performed by Surgeons, Intensivists/Pulmonologists, and Interventional Radiologists. Our institution (large academic center) sought to determine whether a group of specially-trained and procedurally-focused Hospitalists could safely and effectively place PDs for resolution of PTXs, CPEs, RPEs, and empyema.
Purpose: Our bedside procedure team routinely places PDs, and performs bone marrow biopsies, thoracentesis, paracentesis, lumbar punctures, arthrocentesis, and vascular access under ultrasound guidance. This service allows our medicine teams to efficiently round without interruptions, surgeons to maximize operating room time, and the interventional radiology suite to perform more complex procedures. We performed a retrospective review of clinical outcome and safety profile for pulmonary drains placed between July 2015 and November 2017 and compared it to safety profile data from Vizient, which represents the data aggregate of UHC and VHA.
Description: Our procedure team consists of five specially-trained Hospitalists with two rotating internal medicine residents. We reviewed data from 92 consultations for PD from both Medical and Surgical services. Indications for drain placement included pneumothorax, recurrent pleural effusion, and complicated pleural effusions, by imaging (Chest X-ray, CT scans of the chest, or bedside ultrasonography). We defined complications as infection, hemothorax, organ injury, or death. Of 92 consults, we attempted placement in 85 patients (92.4%), and 84 of 85 PDs (98.8%) were placed, or attempted, without complication. Drains not attempted by our service (7) were deemed not medically necessary. Only 1 case (1.2%) had a complication. Additionally, of the 85 PDs attempted only 3 (3.6%) did not have the desired therapeutic effect thus requiring Interventional Radiology referral. The reported complication rate from Vizient, for approximately the same time period, was 2.97%.
Conclusions: Specially-trained Hospitalists can safely and effectively place PDs for the indications specified earlier. Further work needs to be done in reproducing the safety and efficacy profile of hospitalist-staffed procedure teams at other institutions to validate our findings. Future studies could include cost and time-saving analysis of a specially-trained Hospitalists team compared to use of an interventional radiology suite for placement of PDs and other common procedures.