Reducing Iatrogenic Risk in Thoracentesis Establishing Best Practice Via Experiential Training in a Zero-Risk Environment
ABSTRACT 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.
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.
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).
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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ABSTRACT: Pleural infection remains a major healthcare problem in the 21st century. It is responsible for significant morbidity and mortality in both adults and children across developed as well as developing countries. Its incidence continues to rise globally despite the introduction of the pneumococcal conjugate vaccine in 2000 and modern advances in medical care. The pathobiology of empyema remains relatively poorly understood and its changing bacteriology over time is important to recognize as it is likely to have future implications in terms of patient management, outcome, and healthcare costs. Many questions still remain regarding the diagnosis and management of pleural infection. This paper reviews current data on biomarkers, bacterial tests, and imaging modalities, in addition to discussing potential future directions on research in the field.06/2012; 1(2). DOI:10.1007/s13665-012-0011-3
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ABSTRACT: All invasive pleural procedures have the potential to cause harm. Complications from pleural procedures include empyema, intercostal artery laceration, hemothorax, and pneumothorax as well as other organ puncture. Many of these complications will be life threatening and will increase morbidity and hospital length of stay. An understanding of iatrogenic pleural disease helps clinicians to appreciate how these risks can be minimized and complications managed promptly and effectively. This review systematically evaluates the current evidence and guidelines regarding iatrogenic pleural complications and their management. Whilst impossible to eliminate procedural risk entirely, complications will be reduced to a minimum by ensuring adequate medical training, use of pleural ultrasound, and adherence to guidelines and standard operating procedures (SOPs).06/2012; 1(2). DOI:10.1007/s13665-012-0009-x
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ABSTRACT: Bibliography: p. 63-64. "April 1979." U.S. Department of Transportation contract DOT-OS-60137 by Andrew Kurkjian ... [et al.].