VOL: 98, ISSUE: 26, PAGE NO: 48
Cathy Tooley, RN, is respiratory sister, Department of Respiratory Medicine, James Paget Hospital, Great Yarmouth
Expansion of the respiratory team at James Paget Hospital, Great Yarmouth, gave us the opportunity to explore which aspects of respiratory care could be developed or improved. Medical and nursing staff had frequently raised concerns about the management of chest drains, and the team decided to audit current practice in the hospital.
Chest drains may be used to remove air (pneumothorax) or fluid (haemothorax, pleural effusion) from the pleural space (Bourke and Brewis, 1998). No hospital guidelines were available on their use and management at this time, and a literature search showed that there was a lack of literature on the subject. The range of products available is often confusing, and many choices seem to be based on personal preference rather than clinical evidence (Tang, 1999). It has also been suggested that patients are more likely to develop complications when practitioners lack skills and knowledge in dealing with chest drains (Tang, 1999).
As a respiratory team in a district hospital, we expect to see an average of six or seven chest drains a month. At these levels, it is likely that some staff caring for patients with chest will not have the skills and knowledge to do so effectively and safely. We therefore decided to audit the current practice, with a view to making recommendations for future developments in the management of chest drains.
The aims of the audit were to:
- Establish current practice within the hospital;
- Provide a tool for the development of best practice guidelines based on British Thoracic Society Guidelines (Miller and Harvey, 1993);
- Improve patients’ experience of chest drain insertion and management;
- Identify needs for further staff training.
The audit was retrospective and consisted of a questionnaire on current chest drain management for doctors and nurses and a postal questionnaire for patients who had had a chest drain inserted at the hospital.
There are a number of issues to consider in the management of chest drains. Those initially highlighted included the use of analgesia, types of sutures, clamping, types of dressings, low-pressure suction and breathing techniques used for drain removal. It was decided to focus specifically on four areas:
- Use of analgesia;
- Type of suturing;
- Clamping of drains;
- Use of suction.
The patient audit
A postal questionnaire was sent out to 15 patients who had undergone chest drain insertion in the past three months. They were asked what type of information they received about the procedure and whether they experienced any discomfort during the procedure or while the drain was in place. They were also asked if they could suggest any improvements to the procedure.
Ten patients responded, and even though this was a small number the responses were overwhelmingly similar. Seven (70%) described chest drain insertion as a painful experience, and many described the whole experience in detail in their written responses.
Quotes from patients included:
- ‘This was the most painful and stressful experience I have ever had to endure’;
- ‘From start to finish it was a most unpleasant and nasty experience which I will remember for a long time’;
- ‘I consider myself to have quite a high pain threshold but was in agony during this procedure’.
Not all the responses were negative; some patients had had a positive experience. Patients also requested better information about the procedure, and some said they would like written information. They also felt it would have been reassuring for them if they could have had a nurse they knew with them during the procedure.
The staff audit
The staff audit consisted of a questionnaire which was distributed to 60 doctors and nurses, of whom 15 (25%) responded. Nine (60%) respondents were nurses and six (40%) were doctors. Topics covered by the questionnaire included use of analgesia, sutures, clamping of drains and recommended suction pressures.
A multidisciplinary focus group was convened to discuss the results of the audit and to generate hospital guidelines on the insertion and management of chest drains.
Seven (47%) staff recommended that patients be given analgesia before insertion of the drain and six (40%) recommended that analgesia be given as required while the drain was in place. A few felt that the lignocaine given before the procedure would be adequate analgesia. However, British Thoracic Society guidelines (Miller and Harvey, 1993) recommend that oral and intramuscular analgesia is prescribed. Tomlinson and Treasure (1997) also state that the insertion of a chest drain is a painful procedure. This view was supported by 70% of patients in this audit, who described chest drain insertion as painful, yet only 47% of staff in the audit recommended analgesia. The results from the patient audit clearly showed that pain management is of paramount importance if the experience of chest drain insertion is to be improved.
We decided to separate the use of analgesia into three areas in the hospital guidelines:
- Initial insertion of the drain;
- Maintenance analgesia while the drain is in situ;
- Analgesia for drain removal.
The guidelines recommend that individual patients’ needs in relation to pain control and anxiety are assessed before the procedure. A morphine-based analgesia 30 minutes before the procedure is recommended, and if the patient is very anxious 2-5mg of midazolam may be appropriate; 10-20ml of lignocaine is recommended as local anaesthetic. The medical staff are asked to prescribe regular oral analgesia at the time of chest drain insertion.
Occasionally concern is raised regarding the use of morphine-based analgesia for patients with chronic obstructive pulmonary disease, as this can depress respiratory function. It is recommended that these patients receive a smaller dose of analgesia and are closely monitored. However, they should not be denied analgesia for this painful procedure. Adequate analgesia is recommended for drain removal - some patients may find entonox helpful.
Type of suturing
Twelve (80%) staff recommended the use of purse-string sutures, while one (7%) recommended mattress sutures and two (13%) favoured anchor sutures. There is limited evidence on the advantages and disadvantages of different types of suturing, although Miller and Harvey (1993) recommend two horizontal sutures across the wound. It has been suggested that purse- string sutures may cause tissue necrosis if they are pulled too tight, and therefore the hospital guidelines recommend mattress sutures.
Use of clamping
Four (26%) staff reported clamping chest drains inserted for pneumothorax, particularly when patients were being transported within the hospital. However, this may result in a tension pneumothorax, particularly if an air leak is present, and the guidelines therefore recommend that chest drains are not clamped (Harris and Graham, 1991).
This recommendation raised a problem for hospital porters when the guidelines were first used. They had been told previously that all patients being transported with a chest drain in situ should have their drain clamped while they were being moved. The porters were quite determined to have drains clamped, as they believed this was the safest way to transport patients. This illustrates the importance of ensuring that all members of the multidisciplinary team are involved and fully informed when changes are being made, so everybody feels involved and part of the resulting decision.
Avery (2000) suggests that there should be no need to clamp the tube if care is taken when mobilising and transporting patients, provided the principles of good chest drain management are adhered to. The hospital has tried to adopt this approach in an attempt to stop staff clamping chest drains inserted for pneumothorax.
Use of suction
Eight (53%) respondents reported using suction on patients’ chest drains, but they were unsure of recommended pressures. This was particularly worrying - if staff use inappropriate suction equipment it could result in patient discomfort and parts of the lung being trapped in the drain. Tang (1999) has suggested that complications may be more likely if staff are not familiar with chest drain management.
A low-pressure suction unit should be used when applying suction. At the time of the audit, the hospital had only a limited number of low-pressure units available, and staff were unsure how to access them. All ward managers have now purchased a low-pressure suction unit for their ward area. Although there is no generally agreed recommended suction pressure, the most commonly used is 20cm H20/2.5-5 kpa (Tang, 1999), and this is now recommended in the hospital guidelines.
The audit also highlighted the fact that the hospital had no formal procedure for suture removal after patients’ chest drains were removed. This meant there was a risk that patients could be discharged home with sutures still in place, after which they may not be removed until the first out-patient appointment two to four weeks later. Suture removal was therefore included in the guidelines.
This small audit highlighted a lack of information on the management of chest drains for both professionals and patients. Hospital guidelines on the management of pneumothorax have since been developed, using a multidisciplinary approach that involved doctors, physiotherapists, nurses, porters and the hospital’s audit department.
The focus group’s discussions highlighted a general lack of unified guidance on techniques for inserting chest drains, which resulted in wide variations in practice (Tang, 1999). This lack of guidance was a significant source of worry for junior doctors and nurses and put patients at risk of unnecessary pain and even complications.
The newly developed guidelines aim to provide staff with evidence-based information in order to standardise the management of patients with chest drains. However, while this written information is useful, the group decided to produce a video illustrating best practice for chest drain insertion for use as a teaching aid.
The video has been well received, prompting discussion and questioning and therefore raising the profile of chest drain management among the medical and nursing staff. The next step is to make the video accessible on the hospital’s intranet so that all staff can access it at a time convenient to them.
The group has also created a wallchart for display in the ward areas (Fig 1). This serves as a quick reference guide, answering basic questions on chest drain management, and encourages staff to refer to hospital guidelines on the management of pneumothorax.
It was clear from the small survey that patients wanted more information about their chest drains, and an information leaflet on chest drains has now been designed. By offering patients verbal and written information we aim to enhance their autonomy and understanding of the procedure they are undergoing.
In a preliminary re-audit of 22 doctors and nurses, the issues identified in the initial audit were improved significantly, and there was a greater awareness of the need for follow-up for suture removal if sutures were not removed during the patient’s hospital stay.
Before this study, there was no written patient information available in the hospital, and this has now been addressed. However, education on the insertion and management of chest drains must be an ongoing process for both medical and nursing staff to ensure patients’ experience of the procedure is as positive as possible.