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Reducing Iatrogenic Risk in Thoracentesis: Establishing Best Practice Via Experiential Training in a Zero-Risk Environment

Darlene R. Duncan, MD; Timothy I. Morgenthaler, MD, FCCP; Jay H. Ryu, MD, FCCP; Craig E. Daniels, MD, FCCP
Author and Funding Information

*From the Department of Internal Medicine (Dr. Duncan) and the Division of Pulmonary and Critical Care Medicine (Drs. Morgenthaler, Ryu, and Daniels), Mayo Clinic, Rochester, MN.

Correspondence to: Craig E. Daniels, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Gonda South 18, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: daniels.craig@mayo.edu


This research was supported by Mayo Clinic Institutional Funds.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

For editorial comment see page 1120


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1315-1320. doi:10.1378/chest.08-1227
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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.

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