A recent UK study evaluating the safety of pleural procedures analysed incidents related to pleural interventions, particularly chest drain insertions and aspirations. Lead author Dr Andrew Stanton provides expert insight into the study’s findings and emphasises the need for better compliance with guidelines, standardised training and improved hospital protocols, including mandatory appropriate use of ultrasound, to enhance safety.
The 2021 British Thoracic Society’s pleural services organisational audit highlighted ongoing risks of harm from pleural procedures. It analysed data from 111 institutions, including 85 Trusts, and raised significant concerns regarding patient safety and clinical governance.
A total of 62% of sites reported a patient safety incident related to thoracic ultrasound or pleural procedures, with 33% of these incidents resulting in severe harm and 20% in catastrophic harm or death.
We were understandably concerned about the report’s findings and sought to gain a deeper understanding of the underlying factors contributing to these issues by reviewing patient safety incidents from the National Reporting and Learning System (NRLS).
Our study requested incident-level patient safety data from NRLS for any Level 3 (moderate harm), 4 (severe harm) and 5 (catastrophic harm/death) incidents resulting from chest drain insertion or pleural aspiration submitted between 1 April 2018 and 30 March 2022.
A total of 256 incidents were identified, with 21 deemed relevant, including two fatalities. Of the incidents, 17 involved direct organ puncture, and 13 of those involved the liver.
Only four instances clearly detailed the use of an ultrasound-assisted approach. In the other cases, ultrasound usage was largely unmentioned, or the methods employed were unclear or inappropriate. Most of the events (n=19) took place outside of respiratory settings.
Training improvements and procedural changes for pleural procedures
We believe that anyone undertaking thoracic ultrasound or pleural procedures requires appropriate training. Trusts should ensure that anyone using thoracic ultrasound is properly trained, and the British Thoracic Society has published a training standard to facilitate this.
Our paper raised concerns that ultrasound may not have been used appropriately in certain instances, potentially contributing to incidents. We need to gain a better understanding of this. However, Trusts must ensure that individuals using ultrasound do so correctly and that pleural procedures are conducted either by those performing the procedure or by those guiding the procedure.
If an ultrasound is conducted by someone else, the proceduralist must witness the findings directly. Any remote or prior ‘X-marks the spot’ approach must be avoided.
According to the standards for ultrasound training, any operator conducting an ultrasound scan who is unsure of their findings must consult a more experienced operator before performing any invasive procedures.
Improving patient safety outside of respiratory environments and standard working hours
We are fully aware that providing emergency-level operators for both thoracic ultrasound and pleural procedures in out-of-hours settings is challenging, particularly in hospital environments lacking a specific respiratory on-call service. Nonetheless, we hope that the training standards for thoracic ultrasound will allow for a broader pool of emergency operators to be trained, promoting multidisciplinary collaboration in emergency, critical care and acute medicine to facilitate this process.
Facilitating conversations at the local level is essential for promoting close collaboration among all providers of pleural interventions.
It is crucial to recognise the need for a thoracic ultrasound before any pleural intervention for fluid. Leadership from speciality groups and societies is required to ensure that these safety protocols are integrated into practice across all areas where pleural interventions occur.
Impact on pleural procedure national guidelines and clinical practice
Our study primarily reinforces national guidelines regarding appropriate safety standards, particularly in the use of ultrasound. We still need to gain a better understanding of why these instances are occurring to provide actionable recommendations for organisations to improve safety standards. We hope the upcoming National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study will achieve that.
Key learning points
- Safety in pleural procedures has improved since 2008, but significant harm still occurs, and the risks associated with pleural procedures remain high; urgent national-level intervention is needed
- A total of 21 significant safety incidents, including two fatalities, were reported between 2018 and 2022. Some 17 incidents involved organ punctures, primarily impacting the liver
- The lack of ultrasound use or improper application may have contributed significantly to these incidents
- Most events occurred outside respiratory medicine settings, such as general surgery, emergency departments and intensive care units
- Guidelines mandate thoracic ultrasound for all pleural interventions for fluid, but many cases indicate non-compliance or improper usage
- Increasing awareness of risks and promoting mandatory appropriate use of ultrasound use before pleural interventions for effusions is essential
- Further research via the upcoming NCEPOD study to understand risks and improve patient safety is welcomed.
Author
Andrew Stanton MBChB MD FRCP
Consultant respiratory physician, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
This article is part of our Clinical Excellence series, which offers valuable first-hand insights into how experts from renowned Centres of Excellence are pursuing innovative approaches to optimise patient care across the UK and Europe.
