Reducing iatrogenic risk in thoracentesis: Establishing best practice via experiential training in a zero-risk environment

Darlene R. Duncan, Timothy Ian Morgenthaler, Jay H Ryu, Craig E. Daniels

Research output: Contribution to journalArticle

112 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)1315-1320
Number of pages6
JournalChest
Volume135
Issue number5
DOIs
StatePublished - May 1 2009

Fingerprint

Pneumothorax
Practice Guidelines
Pleural Diseases
Lung
Ambulatory Care Facilities
Cough
Radiology
Hypotension
Safety
Pain
Thoracentesis

Keywords

  • Pleural effusion
  • Pneumothorax
  • Quality improvement
  • Simulation
  • Sonography
  • Thoracentesis

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Reducing iatrogenic risk in thoracentesis : Establishing best practice via experiential training in a zero-risk environment. / Duncan, Darlene R.; Morgenthaler, Timothy Ian; Ryu, Jay H; Daniels, Craig E.

In: Chest, Vol. 135, No. 5, 01.05.2009, p. 1315-1320.

Research output: Contribution to journalArticle

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abstract = "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.",
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