Recommendations for the prevention of Iatrogenic Pneumothorax:
Identify Patients at Risk
- Develop a process to address common IP risk factors identified in the literature (De Lassence, 2006). For example, an Iatrogenic Pneumothorax (IP) Risk Score (De Lassence, 2006) which identifies ICU patients at high risk of IP, could be applied to improve the outcomes of such patients by adapting peri-procedural structure and process elements to decrease the risk of this complication. If, for instance, the management of a patient requiring central vein insertion is individualized such that: a more careful risk–benefit estimation of the procedure is made, a pre-procedure low CVP is corrected with volume repletion in order to better visualize the central vein by ultrasound, patient positioning is optimized (e.g. Trendelenburg position etc.), a physician more experienced in central line insertion is asked to supervise or perform the procedure, and/or the procedure is discontinued after a predetermined number of failed attempts. In addition, this risk score could be useful for comparing the IP rate across ICUs according to a specific level of risk.
Follow Safe Insertion Techniques during Pleural Procedures
- Standardize procedures and position techniques during pleural procedures, such as thoracentesis and chest tube insertion (Wrightson, 2010; Duncan, 2009; Mayo, 2009; Barnes, 2005). For example, improving knowledge to decrease/avoid pneumothorax in specific clinical conditions, e.g. mechanical ventilation/ARDS (Amato, 1998; Boussarsar, 2002; Miller, 2008; O'Boyle, 2014) and proning (Kopterides, 2009), asthma (Brenner, 2009), maxillofacial surgery (Chebel, 2010), high-flow oxygen delivery (Hegde, 2013; Milési, 2014), long-term ventilation (Vianello, 2004), percutaneous transthoracic needle aspiration and lung biopsy (Malone, 2013; Min, 2013; Tran. 2014; Wang, 2009; Zaetta, 2010). Further, appreciation of the established value of ultrasound in the prevention (Diacon, 2003; Gordon, 2010; Haynes, 2010; Havelock, 2010; Troianos, 2012) and diagnosis (Haynes, 2010; Volpicelli, 2012; Kumar, 2015) of IP will assist in its proactive and timely use in this context.
- Develop specified training components and criteria and establish a plan for continued competency (Wrightson, 2010; Duncan, 2009). For more information on training refer to Troianos, 2012, Duncan, 2009, and Lenchus, 2010.
- Develop and standardize practices for site identification, marking, and procedural practice (Wrightson, 2010; Duncan, 2009). For example, instill a culture that proactively seeks early diagnosis of iatrogenic pneumothorax in high-risk patients to avoid poor outcomes (see above), preferably by ultrasound, or other chest imaging as appropriate.
(1-4: AHRQ Quality Indicators Toolkit, 2014).
Conduct Clinical and System Reviews (see details below)
- Given the broad range of potential causes of iatrogenic pneumothorax, in addition to recommendations 1-4, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.
- If your review reveals that your cases of pneumothorax are linked to specific processes or procedures, the Agency for Healthcare Research and Quality (AHRQ) (AHRQ Quality Indicators Toolkit 2014) and National Institute for Health and Care Excellence (NICE) guidelines for Interventional Procedures (NICE 2015), respectively, may offer some assistance.
Clinical and System Reviews
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce the risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
As a means to develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and/or prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in the section Resources for Conducting Incident and/or Prospective Analyses.
Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified in the HHI. Chart audits help identify quality improvement opportunities.
Useful resources for conducting clinical and system reviews: