Ward-based, nurse-led, outpatient chest tube management: analysis of impact, cost-effectiveness and patient safety

Tcherveniakov, Peter; Siqueira, Jullyana de Souza; Milton, Richard; Papagiannopoulos, Kostas

doi:10.1093/ejcts/ezr231

Cited by 12 publications

(8 citation statements)

References 8 publications

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“…Therefore, more surgeons are increasingly sending patients home with in situ chest tubes connected to 1way valve mechanisms. [4][5][6] The development of an outpatient setting for the man agement of PAL appears to be costeffective and well appreciated by patients. There are some concerns that out patient management is not riskfree, and some evidence in the literature suggests increased rates of empyema and readmission associated with prolonged chest tube dura tion.…”

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Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study

Minervini

Hanna

Brunelli

et al. 2022

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Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study Background: Prolonged air leaks are increasingly treated in the outpatient setting, with patients discharged with chest tubes in place. We evaluated the incidence and risk factors associated with readmission, empyema development and further interventions in this patient population. Methods:We undertook a retrospective cohort analysis of all patients from 4 tertiary academic centres (January 2014 to December 2017) who were discharged home with a chest tube after lung resection for a postoperative air leak lasting more than 5 days. We analyzed demographics, patient factors, surgical details, hospital readmission, reinterven tion, antibiotics at discharge, empyema and death.Results: Overall, 253 of 2794 patients were analyzed (9.0% of all resections), including 30 of 759 from centre 1 (4.0%), 67 of 857 from centre 2 (7.8%), 9 of 247 from centre 3 (3.6%) and 147 of 931 from centre 4 (15.8%) (p < 0.001). Our cohort consisted of 56.5% men, and had a median age of 69 (range 19-88) years. Despite similar initial lengths of stay (p = 0.588), 49 patients (19.4%) were readmitted (21%, 0%, 23% and 11% from centres 1 to 4, respectively, p = 0.029), with 18 (36.7%) developing empyema, 11 (22.4%) requiring surgery and 3 (6.1%) dying. Only chest tube duration was a significant predictor of read mission (p < 0.001) and empyema development (p = 0.003), with a nearly threefold increased odds of developing empyema when the chest tube remained in situ for more than 20 days. Conclusion:Discharge with chest tube after lung resection is associated with serious adverse events. Given the high risk of empyema development, removal of chest tubes should be considered, when appropriate, within 20 days of surgery. Our data suggest a potential need for proactive postdischarge outpatient management programs to diminish risk of morbidity and death.Contexte : De plus en plus, les fuites aériennes prolongées sont traitées en contexte ambu latoire, le patient retournant à la maison avec un drain thoracique en place. Nous avons évalué l'incidence et les facteurs de risque associés à la réadmission, au développement d'un empyème et aux interventions ultérieures dans une population de patients de ce type.Méthodes : Nous avons mené une analyse de cohorte rétrospective de tous les patients rat tachés à 4 centres universitaires tertiaires (de janvier 2014 à décembre 2017) qui, après une fuite aérienne de plus de 5 jours suivant une résection pulmonaire, sont retournés à la maison avec un drain thoracique. Nous avons examinés les paramètres suivants : données démographiques, facteurs liés au patient, détails chirurgicaux, réadmission à l'hôpital, réintervention, antibiotiques prescrits lors du congé, empyème et décès.Résultats : Au total, nous avons analysé 253 patients sur 2794 (9,0 % de toutes les résec tions), dont 30 des 759 patients du centre 1 (4,0 %), 67 des 857 patients du centre 2 (7,8 %), 9 des 247 patients du centre 3 (3,6 %) et 147 des 931 pa...

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Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study

Minervini

Hanna

Brunelli

et al. 2022

cjs

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“…A common threshold reported in the literature for air leak which can be safely managed on an ambulatory chest drain is no worsening surgical emphysema or new/enlarging pneumothorax on chest X-ray while on an underwater seal [12,[16][17][18][19]. The introduction of digital drains has allowed quantification of air leak and delivery of mobile suction although their true benefit is disputed [20,21].…”

Section: Discussionmentioning

confidence: 99%

Ambulatory chest drainage with advanced nurse practitioner-led follow-up facilitates early discharge after thoracic surgery

Harrison

Alvarez²,

Snow³

et al. 2022

Gen Thorac Cardiovasc Surg

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Objectives To demonstrate the safety and feasibility of advanced nurse practitioner-led (ANP-led) outpatient follow-up after discharge with ambulatory chest drains for prolonged air leak and excessive fluid drainage. Methods Patients discharged with ambulatory chest drains between January 2017 and December 2019 were retrospectively reviewed. Discharge criteria included air leak < 200 ml/min or fluid drainage > 100 ml/24 h on a digital drain. Patients were reviewed weekly in the clinic by ANPs, a highly skilled cohort of nurses with physician support available. Outcomes included length of stay, duration of air or fluid leak and complications. Results Two-hundred patients were included, amounting to 368 clinic episodes. The median age was 68 ± 13 years and 119 (60%) were male. 112 (56%) patients underwent anatomical lung resection (total anatomical lung resections during the study period = 917) equating to a discharge with ambulatory chest drain rate of 12.2% in this group. The median length of stay was 6 ± 3 days and 176 (88%) patients were discharged with air leak versus 24 (12%) with excessive fluid drainage. The median time to drain removal was 12 ± 11 days. Complications occurred in 16 patients (8%) and 12 (6%) required readmission. An estimated 2075 inpatient days were saved over the study period equating to an annual cost saving of £123,167 (US$149,032) per annum. Conclusions Patients with air leak or excessive fluid drainage can safely be discharged with ambulatory chest drains, allowing them to return to their familiar home environment safely and quickly. ANP-led clinics are a robust and cost-effective follow-up strategy and are associated with a low complication rate.

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“…8,14–20 However, most studies are comprised of heterogeneous patient populations, combining data from multiple operative procedures and for a variety of indications. 20,21 In addition, few have examined the associated cost savings for early discharge with a chest tube (CT) and PDS, with estimates based loosely on billing and institution-specific charges rather than actual cost to the hospital. 10,19 …”

Section: Introductionmentioning

confidence: 99%

Outpatient air leak management after lobectomy: a CMS cost analysis

Schmocker

Vanness

Macke

et al. 2016

Journal of Surgical Research

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Background Air leaks after lobectomy are associated with increased length of stay (LOS) and protracted resource utilization. Portable drainage systems (PDS) allow for outpatient management of air leaks in patients otherwise meeting discharge criteria. We evaluated the safety and cost efficiency of a protocol for outpatient management of air leaks with a PDS. Methods We retrospectively assessed patients who underwent lobectomy for non–small-cell lung cancer at our institution between 2004 and 2014. All patients discharged with a PDS for air leak were included in the analysis. The study group was compared to an internally matched cohort of patients undergoing lobectomy for non–small-cell lung cancer managed without the need for outpatient PDS. Study end points included resource utilization, postoperative complications, and readmission. Results A total of 739 lobectomies were performed during the study period, 73 (10%) patients with air leaks were discharged with a PDS after fulfilling postoperative milestones. Shorter LOS was observed in the study group (3.88 ± 2.4 versus 5.68 ± 5.7 d, P = 0.014) without significant differences in 30-d readmission (11.7% versus 9.0%, P = 0.615). PDS-related complications occurred in 6.8% of study patients (5/73), and 2.7% (2/73) required overnight readmission. PDSs were used for 8.30 ± 4.5 outpatient days. A CMS-based cost analysis predicted an overall savings of $686.72/patient (4.9% of Medicare reimbursement for a major thoracic procedure), associated with significantly fewer hospital days and resources used. Conclusions In patients otherwise meeting discharge criteria, outpatient management of air leaks is safe and effective. This strategy is associated with improved efficiency of postoperative care and a modest reduction in hospital costs. This model may be applicable to other thoracic procedures associated with protracted LOS.

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Ward-based, nurse-led, outpatient chest tube management: analysis of impact, cost-effectiveness and patient safety

Abstract: Our results show that a dedicated chest tube monitoring clinic is a safe and efficient alternative to formal outpatient clinic review. It can lead to shorter hospital stays and is cost effective.

Cited by 12 publications

References 8 publications

Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study

Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study

Ambulatory chest drainage with advanced nurse practitioner-led follow-up facilitates early discharge after thoracic surgery

Outpatient air leak management after lobectomy: a CMS cost analysis

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