Pneumothorax is a known potential complication of thoracentesis, with an estimated incidence rate of 6.0% according to a recent meta‐analysis. Several interventions can reduce this accidental iatrogenic complication. At Jackson Memorial Hospital (JMH), in Miami, Florida, we created and implemented a simulation‐based curriculum in procedural instruction in July 2007. It encompasses standardized training, a validated checklist, bedside use of ultrasonography, a dedicated team‐based resident rotation for experiential learning, and direct attending supervision. We hypothesized that these novel changes would result in a lower postthoracentesis pneumothorax rate and compared those done by the procedure team with those that were not.
We prospectively collected standardized patient data on all thoracenteses performed by the procedure team between July 2, 2007, and June 30, 2010. Similar data of those done throughout the hospital during the first year (July 2, 2007, through June 30, 2008) were also collected through a retrospective chart review. The data was then analyzed to determine the rate of pneumothorax and subsequent chest tube requirement in both groups. This project was approved by our institutional review board.
From July 2, 2007, to June 30, 2008, a total of 378 thoracenteses were performed at JMH, with 18 resulting pneumothoraces, an overall postprocedure rate of 4.76%. Of those, 89 were done by the procedure team, with a single ensuing pneumothorax (1.12%), whereas the remaining 289 were done by other operators, with 17 subsequent pneumothoraces (5.88%). Although all these latter procedures were supervised by attending physicians, none were performed subsequent to their operators undergoing standardized simulation‐based training or using a checklist; ultrasound use was variable. The difference in complication rates was significantly better (P < 0.05), favoring those performed by the procedure team. This low complication rate has held over time. Over the 3‐year period, July 2007 through June 2010, 314 thoracenteses were performed by the procedure team, with an overall pneumothorax rate of 1.91%. A chest tube was required in 2 pneumothorax cases (33%), which is consistent with published data.
The procedure team at JMH incorporates a number of elements aimed at increasing patient safety: a standardized, simulation‐based curriculum in procedural instruction, the use of a validated checklist and ultrasonographic imaging, and a team‐based experience in the context of direct faculty supervision. This comprehensive approach to the performance of a thoracentesis demonstrated a lower postprocedure pneumothorax rate when compared with other operators at our institution as well as that of the average reported in a recently published meta‐analysis. The widespread adoption of these elements can have a significant impact on patient safety, ultimately leading to decreased morbidity, mortality, and health care expenditures related to procedural complications.
J. Lenchus ‐ Sanofi‐Aventis, Pfizer, speakers bureau, advisory board; A. Gallo de Moraes ‐ none; M. Garg ‐ none; V. Kalidindi ‐ none; A. Soto ‐ none; A. Pavon ‐ none