Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment.
BACKGROUND
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.


METHODS
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.


RESULTS
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).


CONCLUSIONS
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.
Duncan
Darlene R
DR
Department of Internal Medicine, Mayo Clinic, Rochester, MN.
Morgenthaler
Timothy I
TI
Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
Ryu
Jay H
JH
Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
Daniels
Craig E
CE
Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. Electronic address: daniels.craig@mayo.edu.
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019985:Benchmarking; D002983:Clinical Competence; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D019152:Paracentesis / Q000009:adverse effects* / Q000379:methods* / Q000592:standards; D010996:Pleural Effusion / Q000628:therapy*; D011030:Pneumothorax / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies; D012306:Risk; D018084:Ultrasonography, Interventional