JULY 2017

Chapter i – Introduction to Pleural disease subgroup

A – Background – pleural disease is a common condition;  according to the British Thoracic Society pleural disease guideline of 2010 it affects 3000 people per million of population every year.  There are a few characteristics of this respiratory condition.

  • It is often associated with malignancy of the lung or other organs.
  • It crosses speciality boundaries since often pleural effusions are found in other conditions such as heart, liver or kidney failure.
  • It often involves the need for emergency management (such as pneumothorax or significant volume pleural effusions).
  • It involves procedures for the diagnosis and management of the pleural disease, procedures which are performed by Respiratory Physicians and their trainees (occasionally by trained advanced nurse practitioners).
  • Some pleural conditions are managed with chest drains which involve care by nurse specialists, ward nurses and occasionally district nurses (for chest drains managed in the community). Therefore the management of pleural disease often crosses the boundary between secondary and primary care as well as has a direct interface with the acute front door services and in more complex cases, with thoracic surgery.
  • Recently the National patients safety standards for invasive procedures (NatSSIproc) document has identified pleural procedures as the one group of medical procedures which need to come under the guidance of this National standards (most specialities that come under the NatSSIproc guidance are surgical procedures).  Moreover, the National Patient Safety Investigation into serious complications of chest drain insertions (2008) has lead to increased awareness and governance issues (training, national auditing) of pleural interventions and chest drain insertion in particular.  Patients with pleural disease often need diagnostic tests which involve invasive procedures from simple aspiration of the pleural fluid or pneumothorax to diagnostic and therapeutic thoracoscopy.

B – Composition of the group

  • The Wales Pleural Interest Group came together several years ago as a group of professionals interested in and dealing with the diagnosis and management of pleural disease as well as research into pleural conditions. The Wales Pleural interest group (WPIG) consists of the pleural leads in each Health Board (more than 1 lead per Health Board if more than 1 hospital providing pleural service in each Health Board) and of advanced nurse specialists who independently perform some of the pleural interventions (pleural aspiration and Seldinger chest drain insertion).

C – Aims and objectives

  • The Pleural stream has come together to ensure high quality care is provided in each Health Board, to deliver fast and effective care and to provide a forum for discussion of challenging pleural cases.

D – Data collection

  • The Wales Pleural Interest Group has agreed that data collection is important for quality assessment and collaborative work. Data collection takes place in various forms in several Health Boards and it is one of the objectives of the Welsh Pleural Interest Group to work together and agree on a more structured and unified way of collecting relevant data for the purpose of audit, quality improvement and collaborative research.

Chapter ii – Detecting disease early

  • Pleural disease has various causes, often malignancy or infection but it crosses speciality boundaries since it is frequently encountered in heart, kidney and liver disease or some rheumatological conditions, therefore one of the characteristics of this speciality is that referrals come towards the pleural specialist from numerous specialities.
  • Infection of the pleural space is a serious condition therefore early treatment is of paramount importance.
  • Patients with suspected empyema are referred to the speciality from Primary Care of Acute Services as well as other specialities. The management of empyema involves close discussion with Thoracic Surgeons and in some cases early referral for surgery.
  • Pneumothorax – if primary spontaneous, usually affects young adults and if non-resolving also involves referral to surgical centres for definitive treatment.

Therefore in such conditions, as well as occasionally in cases of suspected pleural malignancy, collaboration with surgical centres is of paramount importance.  Prompt management of the pleural disease often prevents complications, reduces hospital stays and re-admission rates and the pleural services being able to manage aspects of the pleural disease via ambulatory care pathways.

Chapter III – Delivering fast effective care

  • As mentioned in the previous paragraph, pleural disease can occasionally be managed through ambulatory pathways and with support of specialist nurses trained in the management of pleural disease, forms of pneumothorax and occasionally recurrent malignant pleural effusions are examples of effective management in the community where the patients are supported by trained nurses.
  • Patients who are managed in hospital chest drains are best looked after on specialist wards where attention is given to the training of nursing staff who deals with chest drains and maintenance of skills of both nursing staff and doctors who work on such units is ensured. WPIG has as objective to encourage support for such pleural units in all Health Boards in order to deliver safe care to patients who need chest drains or other pleural intervention, prevent complications related to such procedures, ensure effective care of the chest drain and support for the patients as well as their families in cases of chest drains dealt with in an ambulatory fashion in the community.

Chapter IV – Proposed developments

  • WPIG has agreed that training and maintenance of skills for all professionals involved in the management of patients with pleural disease and professionals performing pleural intervention is of great importance to the safety of patients, therefore 2 documents have been discussed and shared by pleural units across Health Boards in Wales;
  1. A document containing standard operating procedures for pleural interventions performed by Advanced Nurse Practitioners.
  2. A document, containing standard operating procedures and other guidance, as well as assessment tools for nursing staff involved in pleural intervention (as well as for other professionals such as junior doctors and consultants, who deal with pleural patients, manage chest drains and other pleural devices).
  3. A number of matrixes have been agreed (see next section) in view of this sub speciality often having an interface with thoracic surgical colleagues. Some of the matrixes relate to this interface. Collection of data and a more unified and structured database for collection of pleural procedure information (basic procedures and advanced procedures) is work in progress at present.

 Chapter V Matrix data.

  1. Number of cases referred for opinion and advice to the WPIG.
  2. Number of cases referred to surgery, days wait to Surgery and outcome (conservative management or intervention) (empyema).
  3. Number of patients with pneumothorax referred to surgery, days wait to surgery.

Matrix data to be obtained from individual Health Boards and from the 2 thoracic surgical centres in Wales.

19th July 2017                                                       Dr. Andreea Alina Ionescu – RHIG Pleural group lead

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