In my last post, I went over the rationale for developing a practice guideline for something as simple and lowly as chest tube management. Today, I’m posting the details of the guideline that’t been in use at my hospital for the past 15 years. I’ve updated it to reflect two lessons learned from actually using it.
Here’s an image of the practice guideline. Click to open a full-size copy in a new window:
Here are some key points:
- Note the decision tree format. This eliminates uncertainty so that the clinician can stick to the script. There are no hedge words like “consider” used. Just real verbs.
- We found that hospital length of stay improved when we changed the three parameters from daily monitoring to three consecutive shifts. We are prepared to pull the tube on any shift, not just during the day time. And it also allows this part of the guideline to be nursing driven. They remind the surgeons that criteria are met so we can immediately remove the tube.
- Water seal is only used if there was an air leak at some point. This allows us to detect a slow ongoing leak that may not be present during our brief inspection of the system on rounds.
- The American College of Surgeons Committee on Trauma expects trauma centers to monitor compliance with at least some of their guidelines. This one makes it easy for a PI nurse or other personnel to do so.
- The first of the “new” parts of this guideline is: putting a 7 day cap on failure due to tube output greater than 150cc per three shifts. At that point, the infectious risks of keeping a tube in begin to outweigh its efficacy. Typically, a small effusion may appear the day following removal, then resolves shortly.
- The second “new” part is moving to VATS early if it is clear that there is visible hemothorax that is not being drained by the system. Some centers may want to try irrigation or lytics, but the data for this is not great. I’ll republish my posts on this over the next two days.
Click here to download a copy of this practice guideline for adults.
Click here to download the pediatric chest tube practice guideline.
I’m devoting the next series of posts to revisiting the management of hemo- and/or pneumothorax. These clinical issues are some of the most common sources of variability in how trauma professionals approach them. Let’s start with the seemingly simple chore of managing a lowly chest tube.
Management of chest tubes is one of those clinical situations that are just perfect for practice guideline development: commonly encountered, with lots of variability between trauma professionals. There are lots of potential areas for variation:
- How long should the tube stay in?
- What criteria should be used to determine when to pull it?
- Water seal or no?
- When should followup x-rays be done?
Every one of these questions will have a very real impact on that patient’s length of stay and potential for complications.
We developed a chest tube clinical practice guideline (CPG) at Regions Hospital way back in 2004! Of course, there was little literature available to guide us in answering the questions listed above. So we had to use the clinical experience and judgment of the trauma faculty to settle on a protocol that all were comfortable with.
Ultimately, we answered the questions like this:
- The tube stays in until three specific criteria are met
- The criteria are: <150 cc drainage over 3 shifts, no air leak, and no residual pneumothorax (or at least a small, stable one)
- Use of water seal is predicated on whether there was ever an air leak
- An x-ray is obtained to determine whether any significant pneumo- or hemothorax is present prior to pulling the tube, and 6 hours after pulling it
This CPG has been in effect for over 15 years with excellent results and dramatically shortened lengths of stay. However, as with any good practice guideline, it needs occasional updates to stay abreast of new research literature or clinical experiences. We recognized that occasional patients had excessive drainage for an extended period of time. This led us to limit the length of time the tube was in to seven days. And we also noted that a few patients had visible hemothorax on their pre-pull imaging. These patients were very likely to return with clinical symptoms of lung entrapment, so we added a decision point to consider VATS at the end of the protocol.
I’ll share the full protocol tomorrow and provide a downloadable copy that you can modify for your own center. I’ll also give a little more commentary on the rationale for the key decision points in this CPG.