Chest
Volume 135, Issue 5, May 2009, Pages 1315-1320
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Reducing Iatrogenic Risk in Thoracentesis: Establishing Best Practice Via Experiential Training in a Zero-Risk Environment

https://doi.org/10.1378/chest.08-1227Get rights and content

Background

We studied the reasons why patients undergoing thoracenteses performed in our outpatient pulmonary clinic had a higher frequency of iatrogenic pneumothorax compared to that in the concurrent radiology practice in our institution, which utilizes ultrasound guidance. We reviewed our practice model and implemented a unique experiential training paradigm in a zero-risk simulation environment to improve efficacy, timeliness, service orientation, and safety.

Methods

We retrospectively determined the rate of clinically significant pneumothoraces in our practice (phase I, July 1, 2001, to June 30, 2002). The training system redesign included the following: (1) a designated group of pulmonologist instructors dedicated to treating pleural disease and reducing the number of iatrogenic complications; (2) the use of ultrasound image guidance for all thoracenteses; and (3) structured proficiency and competency standards for proceduralists. Postintervention (phase II) data were prospectively collected (January 2005 to December 2006) and compared with our baseline data.

Results

The baseline rate of pneumothorax was 8.6% (5 of 58 patients) in our pulmonary practice. Following intervention (phase II), the rate of pneumothorax declined to 1.1% (p = 0.0034). During phase II, the number of thoracenteses performed increased (186 vs 58 per year, respectively; p < 0.05). The iatrogenic pneumothorax rate was stable in the 2 years following intervention (2005, 0.7% [1 of 137 pneumothoraces]; 2006, 1.3% [3 of 226 pneumothoraces]; p > 0.9). Postintervention complications included procedure-related pain (n = 19), cough (n = 4), and hypotension (n = 10).

Conclusions

An improvement program that included simulation, ultrasound guidance, competency testing, and performance feedback reduced iatrogenic risk to patients. We recommend application of this process to procedural practices.

Section snippets

Materials and Methods

All data (except the initial baseline complication data [see introductory comments]) was collected as a quality improvement initiative, but in order to report the results here, we subsequently obtained approval from the Mayo Clinic Institutional Review Board. Our methodology followed the “design, measure, analyze, improve, control” (or DMAIC) framework.9

Phase I of the study included a review of the records of all patients with pleural fluid obtained from a thoracentesis procedure that had been

Demographic Data

We report the results of 363 of 367 patients (4 patients were excluded from the study due to lack of research consent) who underwent thoracentesis in our outpatient clinic in the 2 years following our quality intervention compared to the 58 preintervention patients (Table 1). More thoracenteses were performed on the right side and on men. Therapeutic thoracentesis performed solely for symptom relief was less common (18%).

Rate of Pneumothorax and Tube Thoracostomy

Prior to the institution of our quality improvement intervention, our rate

Discussion

The culture of procedural training in medicine has, for decades, been focused on experiential training using human subjects with the often-heard educational motto “see one, do one, teach one.”11 As a result, the adoption of a zero-risk environment for initial thoracentesis instruction was not previously used at our institution. The basis of our (phase II) methodology to train physicians with the use of ultrasound and to assure procedural competency included the creation of a zero-risk

References (19)

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This research was supported by Mayo Clinic Institutional Funds.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

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