South West cohort study In Pleural Empyema (SWIPE)

Introduction

The optimal management of pleural infection is uncertain. Randomised controlled trials have demonstrated the efficacy of intrapleural fibrinolytics, but uptake into local guidelines has been variable. Anecdotally, the access to surgery on-site affects referral rates and timing. We aimed to assess the epidemiology and variability of management of pleural infection in the South-West of England using a novel registrar research collaboration.

Methods

Through the PRISM trainee network, respiratory and thoracic surgery registrars identified cases of pleural infection across the South West (9 sites) over a 6-month period. Inclusion criteria was based on previous epidemiological studies of pleural infection.

Results

From January 1^st to June 31^st 2020, 104 admissions to the selected hospitals with pleural infection had demographic, biochemical and outcome data recorded. The median age was 62 (IQR 51-76) and was male predominant (n=65/104). 25% had a positive pleural fluid culture (n=26).

The median RAPID score of the group was 3 (33 low, 44 moderate, 27 high risk groups. None in the low risk group died and length of stay (median 17 days for entire cohort) was significantly longer with higher RAPID score (p-0.03). RAPID score was not associated with the need for surgery or fibrinolytics. Intrapleural fibrinolytics were used in 33% (n=34) at a median of 3 days after chest drain insertion. Forty patients were managed with thoracic surgery, 38/40 with Video-assisted thoracoscopic surgery (VATS) approach. Patients admitted to a surgical centre were more likely to have a surgical referral made and surgery performed sooner (3 days versus 8 days). There was no difference in hospital length of stay between patients managed with surgery or intrapleural fibrinolytics (p-0.56). Twelve patients died during their hospital admission (12%).

Conclusion

Management of pleural infection varied across the region. Patients admitted to surgical centres were more likely to be referred for surgery and we observed less use of intrapleural fibrinolytics in these hospitals. Hospital length of stay and mortality did not differ significantly between surgical and non-surgical centres.

Using a regional network to identify trends in practice of and training in pleural procedures

Introduction

There has been variation in practice of pleural procedures between hospitals, despite clear guidance from the BTS and other bodies¹. It causes significant anxiety out of hours for General Medical (GIM) registrars (SpRs), whose experience with these procedures has reduced since the advent of mandatory thoracic ultrasound.

Aims

We assessed practice in eight hospitals across a training deanery to identify trends that may enable a more standardised approach to training and practise of pleural procedures both in and out of hours.

Methods

We used the PRISM network to disseminate a questionnaire to all Respiratory and GIM registrars and consultants. Domains included number of procedures performed, self-rated confidence undertaking them out of hours and the availability of standard operating procedures (SOPs), safety checklists and procedure rooms.

Results

137 responses were received from eight hospitals. 90.4% of respondents said that out-of-hours procedures were the responsibility of the GIM SpR. 39 GIM SpR respondents had a mean confidence of 2.4 (95% CI 2.09, 2.78) (Likert 1 not confident-5 very confident in performing said procedure in an emergency, compared to 3.9 (95% CI 3.26, 4.55) amongst respiratory respondents. 70.7% of GIM SpRs desired further training. 53.3% of respondents knew of a pleural safety checklist and only 20.7% knew of it being used regularly. 53.0% did not know where to find the SOP for pleural procedures. Respiratory consultants felt that trainees require more experience to achieve competency than their GIM counterparts. 18.0% of respiratory trainees had regular access to a procedure room and only 15.8% had dedicated time in their schedule for procedures.

Discussion

As expected, there was a wide variation in practice and experience across multiple trusts and specialties. While it remains on the GIM curriculum, it is important to ensure that non-respiratory trainees have their confidence and experience increased. Further work will look to address this by piloting a formalised training programme with certification across multiple sites via the PRISM network, and looking to increase access to SOPs.

References

1. Havelock T, Teoh R, Laws D, et al. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:i61-i76