Overuse of small chest drains for pleural effusions: a retrospective practice review

Abstract

PurposeSmall-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place.Design/methodology/approachWe retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015–July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable.FindingsA total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03).Originality/valueRoutine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.

Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set

“…A practice audit showed that such a strategy led to almost half of the drains being inserted without a specific indication and with significant associated harms. 10 To address chest drain overuse, we developed a pleural drainage policy operationalized through an order set integrated into our electronic medical records (EMRs).…”

“…Historically, in our center, most nontrauma in-hospital pleural drainage procedures were performed in the radiology department, and the default procedure was a small drain insertion. A practice audit showed that such a strategy led to almost half of the drains being inserted without a specific indication and with significant associated harms 10. To address chest drain overuse, we developed a pleural drainage policy operationalized through an order set integrated into our electronic medical records (EMRs).…”