Yesterday, 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.
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.
Most trauma centers have at least a few practice guidelines to help the standardize the way they manage common injuries. Solid organ injury. Elder trauma. Chest tube management. But they are all designed for use in patients who present shortly after their injury.
What about someone who presents a day or two, or more, after their injury? That changes the picture entirely. Most guidelines have a time component built in. A TBI protocol requires a repeat head CT after a certain period of time. Solid organ injury patients may have restricted activity or frequent vital signs for a while.
But all too often, trauma professionals treat the patient with delayed presentation exactly the same as fresh trauma. For example, a patient falls and bumps their head. They have a persistent headache, and after two days decide to visit their local ED. The CT scan shows a small amount of subarachnoid blood in the area of the impact. Your practice guidelines says to admit for observation, frequent neruo checks, and repeat head CT in 12 hours.
Or a young male playing sports took a hit to his left flank. After 3 days, he’s just tired of the pain and comes to the ED for some pain medication. CT scan shows a grade III spleen injury with a small amount of hemoperitoneum. Your protocol says to admit, make NPO, liimit activity, and observe for 2 days.
What would I do in these cases? Think about it! If the patients had presented right after the event, they would have gone through your guideline and would have been discharged already. So I would review the images, talk to the patients about their injuries, then send them home from the ED with followup. They’ve already passed!
Bottom line: Remember, practice guidelines are not etched in stone. Variances are possible, but need to be well thought out in advance. And hopefully documented in the chart to expedite the inevitable trauma performance improvement inquiry. If the requisite amount of time has gone by, and the history and exam are reasonable, the patient has already passed your protocol. Send them home.
All US trauma centers verified by the American College of Surgeons are required to have clinical practice guidelines (CPG). Trauma centers around the world generally have them, but may not be required to by their designating authority. But don’t confuse a policy about clinical management, say for head injury, with a real CPG. Policies are generally broad statements about how you (are supposed to) do things, whereas a CPG is a specific set of rules you use when managing a specific patient problem.
- Look around; don’t reinvent the wheel! This is the first mistake nearly every center makes. It seems like most want to spend hours and hours combing through the literature, trying to synthesize it and come up with a CPG from scratch. Guess what? Hundreds of other centers have already done this! And many have posted theirs online for all to see and learn from. Take advantage of their generosity. Look at several. Find the one that comes closest to meeting your needs. Then “borrow” it.
- Review the newest literature. Any existing CPG should have been created using the most up to date literature at the time. But that could have been several years ago. Look for anything new (and significant) that may require a few tweaks to the existing CPG.
- Create your draft, customizing it to your hospital. Doing things exactly the same as another center doesn’t always make sense, and it may not be possible. Tweak the protocols to match your resources and local standards of care. But don’t stray too far off of what the literature tells you is right.
- Make sure it is actionable. It should not be a literature summary, or a bunch of wishy-washy statements saying you could do this or consider doing that. Your CPG should spell out exactly what to do and when. (see examples below)
- Create a concise flow diagram. The fewer boxes the better. This needs to be easy to follow and simple to understand. It must fit on one page!
- Get buy-in from all services involved. Don’t try to implement your CPG by fiat. Use your draft as a launching pad. Let everyone who will be involved with it have their say, and be prepared to make some minor modifications to get buy-in from as many people as possible.
- Educate everybody! Start a campaign to explain the rationale and details of your CPG to everyone: physicians, nurses, techs, etc. Give educational presentations. You don’t want the eventual implementation to surprise anyone. Your colleagues don’t like surprises and will be less likely to follow along.
- Roll it out. Create processes and a timeline to roll it out. Give everyone several months to get used to it.
- Now monitor it! It makes no sense to implement something that no one follows. Create a monitoring system using your PI program. Include it in your reports or dashboards so providers can see how they are doing. And if you really want participation, let providers see how they are doing compared to their colleagues. Everyone wants to be the top dog.
Some sample CPGs:
Over the last three days, I reviewed some data on lytics at the request of some of my readers. Then I looked at a paper describing one institution’s experience dealing with retained hemothorax, including the use of VATS. But there really isn’t much out there on how to roll all this together.
Until now. The trauma group at Vanderbilt has a paper in press describing their experience with a home-grown practice guideline for managing retained hemothorax. Here’s what it looks like:
I know it’s small, so just click it to download a pdf copy. I’ve simplified the flow a little as well.
All stable patients with hemothorax admitted to the trauma service were included over a 2.5 year period. The practice guideline was implemented midway through this study period. Before implementation, patients were treated at the discretion of the surgeon. Afterwards, the practice guideline was followed.
Here are the factoids:
- There were an equal number of patients pre- and post-guideline implementation (326 vs 316)
- An equal proportion of each group required an initial intervention, generally a chest tube (69% vs 65%)
- The number of patients requiring an additional intervention (chest tube, VATS, lytics, etc) decreased significantly from 15% to 9%
- Empyema rate was unchanged at 2.5%
- Use of VATS decreased significantly from 8% to 3%
- Use of catheter guided drainage increased significantly from 0.6% to 3%
- Hospital length of stay was the same, ranging from 4 to 11 days (much shorter than the lytics studies!)
Bottom line: This is how design of practice guidelines is supposed to work. Identify a problem, typically a clinical issue with a large amount of provider care variability. Look at the literature. In general, find it of little help. Design a practical guideline that covers the major issues. Implement, monitor, and analyze. Tweak as necessary based on lessons learned. If you wait for the definitive study to guide you, you’ll be waiting for a long time.
This study did not significantly change outcomes like hospital stay or complications. But it did decrease the number of more invasive procedures and decreased variability of care, with the attendant benefits from both of these. It also dictates more selective (and intelligent) use of additional tubes, catheters, and lytics.
I like this so much that I plan to adopt it at my center!
Download the practice guideline here.
Posts in this series:
Reference: Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma, in press, December 14, 2016.