Policy or Procedure Development: Safe and Efficient Removal of Chest Drains - Literature review Example

Procedure Development: Safe and Efficient Removal of Chest Drains Introduction This short essay attempts to discuss a process of developing and implementing an important nursing procedure, the safe and efficient removal of chest drains, which has a central relevance to my critical care workplace. The paper will assume the following structure. To begin with, the essay will provide an overview, which will be a basic description of the procedure under discussion. The overview will feature primary definition of the area and its rationale for a heart drain removal procedure, the overall objective of this procedure in contemporary practice, a description of the clinical condition addressed by the removal procedure as well as identification of the care provider targeted by the paper. The next section of the paper will provide background information on the removal procedure for chest drains, providing an evidenced investigation of the best practice possible, the benefits and or harms accruing from the interventions and a rigorous debate on the available literature in regards to chest drain procedures. This discussion will help develop a synthesised summary statement about the contemporary best available body of knowledge in chest drains procedures, such that the existing gaps of knowledge that this paper seeks to fill. The next section will discuss the dissemination and implementation of the procedure and the ideal strategies that can help to optimally disseminate and correctly implement the procedure developed herein. This will then lead to the next section, addressing the evaluation and revision of the developed strategies in readiness for its implementation in critical care settings. This done, the paper will then progress to clearly develop step-by-step guidelines on the safe and efficient removal of chest drains, before a tenable conclusion sums up the salient points of discussion raised throughout the paper. Safe and Efficient Removal of Chest Drains: Overview The human chest normally holds a small amount of natural fluid within the space lying between the chest and the lungs, to help the lungs move up and down during respiration without friction (Breuninger & Follin 2001, pp. 112–123). Air can however build-up in this space to result to a condition called pneumothorax, or sometimes even blood to cause haemothorax, or pus to cause pyothorax (Cassivi and Deschamps 2004, pp. 175–183). Such build-ups can result from injuries, diseases, surgeries, etc and bar the lungs from expanding fully during respiration (Mattox & Allen 1986, pp. 309-312; Bailey 2000, pp. 111-114). This can grow to a partial and or total collapse of a person’s lungs (Bailey 2000, pp. 111-114). To treat the condition, a surgical insertion of a specially designed chest tube called thoracostomy tube/thoracic catheter helps drain the fluids or air out of the space (Robinson 2001, pp. 109 – 116; Cassivi & Deschamps 2004, pp. 175–183). A chest drain in clinical practice refers to a specially designed conduit that aids in the removal of fluid and or water from the human pleural cavity in the chest. According to Gray (2000, pp. 65) and Tomlinson and Treasure (1997, pp. 248-252), the chest drain is surgically inserted there if the clinician needs to remove pleural effusion, air, pus, blood and other or fluids from a patient’s thoracic cavity while also preventing the same from re-entering the cavity after removal. The removal of the contents allows the underlying lung to expand and amplify respiratory efficiency (Robinson 2001, pp. 109 – 116; Gray 2000, pp. 67). Gray (2000, pp. 68) notes that a properly functioning chest drains installation must necessarily prevent the drained substances from re-entering the chest. This is a temporal measure that a patient may undergo (Baumann 2003, pp. 276). Once the fluids and or substances have been drained completely, the chest drains lose their usefulness and have to be surgically removed (Baumann 2003, pp. 276). It is this procedure that is of chief interest to this paper, that of surgically extracting/removing the chest drains that have already served their purpose. It is important that the drain is removed if it has effectively served the purpose for which it was inserted before it damages the internal organs surrounding its location (Bailey 2000, pp. 111-114; Robinson 2001, pp. 109 – 116). In most cases, a simple pneumothorax can be used to remove the drain within 24 hours (Baumann 2003, pp. 276). The problem is there is a high risk of complications developing in the removal procedure (Cassivi & Deschamps 2004, pp. 175–183; Etoch 1995, pp. 521-525). The most common complication is piercing of internal body organ located within the thoracic cavity or even the abdominal cavity (Cassivi & Deschamps 2004, pp. 175–183). Early complications of poorly removed chest drains include, haemothorax, tube displacement within the thorax, lung laceration, penetration of the diaphragm and or abdominal cavity, bowel injury especially if unrecognised diaphragmatic hernia is present etc (Breuninger & Follin 2001, pp. 112–123). The late complications of the removal procedure include, retained haemothorax, emphysema and pneumothorax after the drain is removed (Etoch 1995, pp. 521-525). In the US, over 13% of patients who underwent the chest drains removal procedure developed one or more of these complications in 2002 (Cassivi & Deschamps 2004, pp. 175–183). This is a horrifying number considering the increased use of the chest drains in contemporary health care across the world (Cassivi & Deschamps 2004, pp. 175–183). It is the mandate of this paper, its central purpose as such, to develop a step by step guideline for nursing practitioners who attend critical care patients undergoing removal of chest drains so that such removals are both safe and efficient. It is imperative that such a simple procedure should not yield such a high rate of complications as 13% of chest drain patients in one country in a whole year (Robinson 2001, pp. 109 – 116; Cassivi & Deschamps 2004, pp. 175–183). The paper attempts to resolve this regrettable outcome by conceiving an evidenced guideline that will avoid such complications in all instances of the procedure in critical care nursing contexts. The guideline thus developed and advocated for herein, is limited for the application of registered nurses, registrars and ICU RMO’s only and any other certified practitioner who is duly instructed, assessed and certified for the procedure by the nationally accredited Nurse Educator centers or responsible Senior Medical staff (Tomlinson & Treasure 1997, pp. 248-252). This guideline should not be used as a training manual for novice practitioners or as a self-help manual for those who have not been trained for the surgical operation. In its entirety, the guideline is aimed at helping those who know how to, are trained and certified to and are charged with the responsibility of conducting chest drain removal procedures beforehand, just as a means of helping then conduct the procedure more safely and efficiently (Robinson 2001, pp. 109 – 116). Again, the procedure developed herein, demands that it be conducted in a certified and accredited health care facility where such procedures can legally be done. The institution should have all emergency surgical equipments and protocols to handle any outcomes and eventualities as prescribed by the health authorities of the jurisdiction in question. As such, this procedure should only be implemented in critical care establishments accredited and licensed to conduct such procedures under qualified medical personnel. In this regards, it is aimed that following the guideline developed herein will help reduce and even eliminate the complications resulting from chest drains removal procedures by guaranteeing the patient’s safety and the efficiency of the procedure itself. Any legal liabilities that the health care establishments and medical personnel are liable to in carrying out the procedure and the need for practitioner’s insurance cover must be put in place before such procedures are undertaken, since this guideline does not dispel the liability to such. Background Information It is important to begin by pointing out that, all chest tube insertions must necessarily be removed within a week after insertion, regardless of the reason they were inserted (Baldt et al 1995, pp. 539-43). If the drains are left in the chest for longer than a maximum of seven days, the risk of an infection within the cavity is increased by a hundredfold (Bailey 2000, pp. 111-114). There are several clinical indicators to inform the critical care nurse that the patient is ready for chest drains removal procedure, beginning with improved respiratory status (Bailey 2000, pp. 111-114). However, a respiratory rate that tallies at less than 24 breaths in a minute is yet another indication of readiness for a chest drains removal procedure (Breuninger & Follin 2001, pp. 112–123). Again, if the tube was inserted to drain excess fluids, once the drainage reaches a rate of 200 ml/24 hours, the drains should be removed (Breuninger & Follin 2001, pp. 112–123). If the insertion was made to drain blood, removal readiness will be indicated by a minimal output as well as a change from bloody drain to serous. If air precipitated the insertion of chest drains, (pneumothorax), removal is safe when bubbling stops or fluctuation of the water-seal chamber ceases when the patient coughs or breathes (Etoch 1995, pp. 521-525; Bailey 2000, pp. 111-114). The literature concurs that a chest X-ray must always precede a chest drains removal procedure so as to confirm the right timing and the attainment of insertion objectives (Bailey 2000, pp. 111-114). The literature agrees that chest drain removal procedures should employ an aseptic technique in such a way that minimizes the patient’s discomfort while simultaneously ensuring absolutely no entry of air is permitted into the patient’s pleural cavity (Bailey 2000, pp. 111-114; Etoch 1995, pp. 521-525). A non-random sampling of the literature available since 1990 specifically providing the procedural directions of removing chest drains indicates that there are a set of conditions advocated for a safe and efficient procedure. These include cessation of the air lock, absence of pneumothorax on the pre-operation chest X-rays, cessation of drainage or at least a reduction to 100mls drainage/12 hours, haemodynamically stability in the patient or is the removal is prescribed by qualified ICU Registrars or consultants based on valid medical grounds (Bailey 2000, pp. 111-114). In such instances, the equipment advocated for by the literature include a dressing pack, adhesive tape, suture cutter, suture holder, sterile scissors, metal forceps, black silk suture, narrow combine (vasgauze opsite), chlorhexadine/alcohol, goggles, sterile gloves, blue sheet, gloves for assistants and two Howard Kelly clamps. The removal procedure should ideally be performed by two people, one to occlude the drain site as the other removes the tube (Breuninger & Follin 2001, pp. 112–123). The drain should only be removed and an occlusive dressing applied, at the peak of inspiration or at the end of expiration to avoid any amount of air being admitted into the patient’s pleural cavity (Baldt, et al 1995, pp. 539-43). The site must always be cleaned thoroughly and sterilized before and after the procedure (Laws, Neville & Duffy 2003, pp.  53-59). It is advisable that the occlusive dressing be prepared beforehand and that all stay sutures be removed (Laws, Neville & Duffy 2003, pp.  53-59). Some experts advocate for the use of a U-suture or purse-string during insertion for use in closing the wound (Baldt, et al 1995, pp. 539-43). Such a U-suture or purse-string may be inserted during the drain’s insertion. However, while no medical risk is posed by using such a closing suture, many experts feel that U-sutures and purse-strings serve minimal purpose while producing an ugly scar (Baldt, et al 1995, pp. 539-43). In most of the literature sampled above, there lacked a sufficient explanation of the preparatory steps for clinicians before removing a chest drain, the patient preparations steps and the post-removal critical care. This is perhaps one of the reasons why there is a high rate of complications as noted earlier in a procedure that takes but a minute to complete. Sometimes the clinicians are unprepared for the procedure such as when the drain is removed before the dressing is prepared thus allowing air to enter the cavity before it is sealed. Adequate preparation provides for a fast, efficient and safe tube removal and air-tight sealing that is primarily necessarily (Laws, Neville & Duffy 2003, pp.  53-59). In the same way, most patients usually face anxiety before removal of the drains because they experience a lot of pain during its insertion to the extent that they fear that the same will be undergone during removal. While drains insertion is a very painful ordeal, patients should be taken through therapeutic care and informed that the removal procedure is both painless and rapid (Laws, Neville & Duffy 2003, pp.  53-59). An example of the post-removal critical care that is omitted by most of the sampled literature is an assessment of the patient’s respiratory status after the removal to confirm that the tube was not removed prematurely and that there's no possibility of recurrence of the pneumothorax (air) or an accumulation of other fluids (Baldt, et al 1995, pp. 539-43). Post-removal care also confirms that no air was accidentally admitted into the pleural cavity during the removal and if so, corrective action is taken immediately before further damage can be done (Baldt, et al 1995, pp. 539-43). Consequent to the above argument therefore, it is the conviction of this paper that the chest drains removal procedure in contemporary critical care practice lacks sufficient guidelines on three areas, preparatory steps for clinicians before removing chest drains, the patient therapeutic and physiological preparations steps for a good procedure and finally on the post-removal critical care necessity or objectives. This might actually be the underlying cause of complications in the easy procedure and which this paper seeks to address by developing a guideline procedure that incorporates these basic and vital components omitted by the current body of knowledge (Baldt, et al 1995, pp. 539-43). Dissemination and Implementation Strategy This guideline should be printed in small pamphlets, preferably on embossed printed papers with each pamphlet having at most 20 pages. The size of the pamphlet should ideally be A6 sixe, just slightly larger than a post card to allow clinicians conducting such procedures in critical health care settings to carry the pamphlet in their shirt or trouser pockets as they prepare for the procedure as well as for regular referencing. The embossed papers will be ideal to ensure that the pamphlet is long lasting, since the papers are hard and resistance to the wear and tear that average printing papers are subject to. The ideal format of the text should be spacious and employing several diagrams and illustrations for the procedure to aide in understanding. This will also promote legibility of the pamphlet in that the clinicians can quickly skim and scan through the guideline when checking for a particular section of the guideline or when having an overview revision of the procedure just before conducting one. The guideline developed here should ideally be disseminated in every health care facility conducting chest drains procedures, particularly for the personnel involved in the actual operations. Every health establishment should facilitate that their clinicians, those charged with the responsibility of conducting, recommending and assessing the chest drains removal procedures, have a printed copy of the guidelines. Further, the same guidelines should be made available in the main database of such health care facilities where the respective personnel can access it any time they need to and from any remote location. It is advisable that the surgical and nursing teams involved in conducting such procedures should meet regularly to brainstorm through the guidelines and further enhance their understanding of the safe and efficient chest drains procedure. Continuous education, revision and frequent exchange of information are necessarily steps if the critical care personnel responsible in conducting such operations are to avoid the complications resultant from improper practices. It is the responsibility of section heads in such health care establishments to ensure that the guideline developed here is followed and inducted into the code of practice in their establishments either in full or with revisions. It is envisioned that the clinicians who have been conducting these procedures for many years will be opposed to the reeducation using this guidelines and that they will judge any attempt to impose a guideline on such a simple procedure. Nonetheless, these guidelines aim at saving lives and the administrative quarters of critical care establishments must enforce the guidelines if only to save the lives of patients and provide optimal care to the best of their ability, by eliminating the risk of complications from the chest drain removal procedure. All responsible clinicians should be mandated to oblige to the guidelines’ requirements. Evaluation and Revision strategy The guidelines developed herein are subject to any improvement that particular critical care establishments might deem fit in regards to their context, needs and experience. As noted earlier, the dissemination and implementation of the guidelines require that involved personnel in health care establishments meet in regular discussions and brainstorming of the procedure. In such settings, the experience of these qualified clinicians and their convictions can be included into the guidelines during revisions for as long as the revision is based on research, sound reasoning and practical experiences that the brainstorming groups agree on. During such meets, the health care establishments should select among themselves several individuals to be involved in assessing the success of the dissemination and implementation of the procedure guidelines within their facility, through regular checks on the documentation, patient outcomes, evaluations of reduced/increased complications and drop-in’s during the operations to evaluate how the personnel involved follows the guidelines. To determine whether the guidelines are positively relevant in patient outcomes, the number of complications resulting from the chest drains removal procedures in a particular establishment should be collected and compared between the periods before and after the guidelines are adopted and implemented. The guidelines should ideally reduce or even eliminate the occurrence of such complications. Safe and Efficient Removal of Chest Drains: Recommended Guidelines The following list of guideline are recommended by this paper as ideal in preventing complications that usually result from chest drains removal procedures. a) The procedure should involve two qualified personnel to prepare and operate together while removing the chest drain. b) The two should ideally meet and discuss the procedure before the actual removal as well as the patient’s specific information/orientation c) The entire group of clinicians including assistants and nurses to be involved in the process should meet prior to the operation and address the basic preparatory routine d) The patient should be taken through a counseling session to explain the procedure and provide facts. The ideal here is to reduce anxiety that the patient may feel prior to the operation. Adequate analgesia should also be sued before the drains removal ensues (Puntillo 2004, pp. 292). e) The removal procedure should be continuously monitored by SaO2. f) Once all preparations have been made, the necessarily equipment should be collected near the operating table. These should include, a dressing pack, adhesive tape, suture cutter, suture holder, sterile scissors, metal forceps, black silk suture, narrow combine (vasgauze opsite), chlorhexadine/alcohol, goggles, sterile gloves, blue sheet, gloves for assistants and two Howard Kelly clamps g) The next step is to correctly position the patient in a semi-recumbent position. h) The operating team should then wash their hands with the aseptic technique and wear the sterile gloves. i) The first step in the operation will prepare the dressing to be used after removal of the drains alongside the sterile equipment j) Once the dressing is ready, the site should be cleaned and sterilized k) This done, the next step is to remove the old dressing from the drains site and discarding it. l) The blue sheet should then be placed under drains. m) In a very slow, deliberate and precise movement to avoid piercing other organs, the drain should then be removed from the suction n) If a patient is breathing spontaneously via an O2 mask, the clinician should instruct him or her to take three deep breaths, in and out, and to hold the third breath o) Next and very gently, the suture should be unwounded from the right drain using metal forceps. The drain should be removed when the respiratory cycle is at beginning of exhilaration or at the peak of inspiration. The airway pressure should never be allowed to go to below zero during the removal p) Immediately following the removal, a purse-string suture should then be tied firmly and the patient instructed to breathe normally. q) Each drain site should be swabbed with alcohol or chlorhexadine. r) This done, the suture should be trimmed with scissors. The dressings pack should then be opened the prepared dressing used to seal the suction s) Once this is done, the site should be cleaned delicately and further sterilized while the hands should be washed and sterile gloves worn. t) Immediately after the operation, a chest X-ray of the patient should be conducted to evaluate residual pneumothorax and the findings duly reviewed and recorded as part of the patient’s notes (Baldt, et al 1995, pp. 539-43). u) The procedure should be documented on the records that later evaluations will add on to establish the success or failure of the procedure and the registrar should review these assessments and recommend appropriate action in a timely manner (Laws, Neville & Duffy 2003, pp.  53-59). Conclusion This short essay has attempted to discuss the process of developing and implementing an important nursing procedure, the safe and efficient removal of chest drains. As the essay argues, it is important that the drain be removed if it has effectively served the purpose for which it was inserted before it damages the internal organs surrounding its location. The problem is there is a high risk of complications developing in the removal procedure. A non-random sampling of the literature available since 1990 specifically providing the procedural directions of removing chest drains was done. The finding was that, the chest drains removal procedure in contemporary critical care practice lacks sufficient guidelines on three areas, preparatory steps for clinicians before removing chest drains, the patient therapeutic and physiological preparations steps for a good procedure and finally on the post-removal critical care necessity or objectives. This might be the underlying cause of complications in the easy procedure. The paper has recommended that these guidelines be printed in small pamphlets, preferably on embossed printed papers with each pamphlet having at most 20 pages. The guidelines should be disseminated in every health care facility conducting chest drains procedures, particularly for the personnel involved in the actual operations with the aim of reduce or even eliminate the occurrence of complications. References Bailey, R 2000, Complications of tube thoracostomy in trauma, Journal of Accident Emergency Medicine, Vol. 17 (2), pp. 111-114. Baldt, M, Bankier, A, Germann, P, Poschl, G, Skrbensky, G. & Herold, C 1995, Complications after emergency tube thoracostomy: assessment with CT, Radiology, Vol. 195 (2), pp. 539-43 Breuninger, C and Follin, S eds 2001, Handbook of nursing procedures, Springhouse, PA: Springhouse Corporation, pp. 112 - 123. Baumann, M 2003, What size chest tube? What drainage system is ideal? And other chest tube management questions, Current Opinion on Pulmonary Medicine, Vol. 9 (4), pp. 276. Cassivi, S and Deschamps, C 2004, Chest tube insertion and management, in Albert, R, Spiro, S and Jett, J eds, Clinical respiratory medicine, Second Edition, St. Louis: C. V. Mosby, Inc., pp. 175 – 183. Etoch, S, Bar-Natan, M, Miller, F & Richardson, J 1995, Tube thoracostomy. Factors relating to complications, Archives of Surgery, Vol. 130 (1), pp. 521-525. Laws, D,  Neville, E and Duffy, J 2003, BTS guidelines for the insertion of a chest drain, Thorax, Vol. 58 (2), pp.  53-59. Mattox, K and Allen, M 1986, Systematic approach to pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema, Injury, Vol. 17 (1), pp. 309-312. Puntillo, K 2004, Appropriately timed analgesics control pain due to chest tube removal, American Journal of Critical Care, Vol. 13 (4), pp. 292. Robinson, C 2001, Assisting with chest tube placement, in Lynn-McHale, D and Carlson, K eds., AACN procedure manual for critical care, Fourth edition, Philadelphia: W. B. Saunders Company, pp. 109 – 116. Tomlinson, M and Treasure, T 1997, Insertion of a chest drain: How to do it, British Journal of Hospice Medicine, Vol. 58 (1), pp. 248-252. Read More