Background: Chest tube thoracostomy is frequently performed in the emergency department (ED) for patients with traumatic thoracic injuries. However, this procedure is associated with a high complication rate. Aim Statement: The aim of this study was to describe and assess predictors of complications following chest tube thoracostomy. Measures & Design: A retrospective chart review was conducted in a level 1 trauma center. Patients aged ≥16 who required a chest tube for a traumatic injury between 2016 and 2019 were identified. Variables including demographic data, Charlson Comorbidity Index, mechanism of injury, Injury Severity Score (ISS), chest tube insertion and technique (i.e. position, dislodgement, obstruction, organ perforation), complications and interventions were collected using a standardized data collection form. A second reviewer assessed all ambiguous files. Descriptive statistics and adjusted odds ratios were calculated. Evaluation/Results: 179 patients were included in the study, of which 141 were male (79%). Mean age was 54 18 and median ISS was 17 (Q1-Q3: 9-27). 207 chest tube thoracostomies were performed for pneumothorax (81%) or a hemothorax (38%) mainly after a blunt injury (92%). 183 standard chest tube (88%) and 24 pigtail catheters (12%) were installed. Overall, emergency medicine physicians/residents performed 70% of these procedures and 54% were performed by residents. Sixty-one patients (34%) suffered a total of 73 complications: 45 were infectious (62%) and 28 were technique-related (38%). Pneumonia was the most frequent complication (19%) followed by reintroduced or replaced chest tube (12%). After adjusting for the ISS, there was no statistically significant association between the type of tube (OR 0.36 95% CI: 0.08-1.68), the medical specialty (OR 1.19 95% CI: 0.55-2.58) or the level of training (OR 1.29 95% CI: 0.63-2.64) of the clinician and the incidence of at least one complication. Discussion/Impact: Our results show that one out of three patients experienced at least one complication following a chest tube thoracostomy in the ED, which confirmed existing literature (5%- 38%). After adjustment, the type of tube used, the specialty and level of training of the health professional who performed the procedure was not associated with the incidence of at least one complication.

Background: Chest tube insertion is a time and safety critical procedure with a significant complication rate (up to 30%). Industry routinely uses Lean and ergonomic methodology to improve systems. This process improvement study used best evidence review, small group consensus, process mapping and prototyping in order to design a lean and ergonomically mindful equipment solution. Aim Statement: By simplifying and reorganising chest tube equipment, we aim to provide users with adequate equipment, reduce equipment waste, and wasted effort locating equipment. Measures & Design: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Necessary equipment was identified. Next, two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student) to refine the equipment list and packaging. A final equipment storage system was produced and evaluated by an interprofessional team during cadaver training using a survey and Likert scales. Evaluation/Results: There were 47 equipment items in the pre-intervention ED chest tube tray. After prototyping 21 items were removed while nine critical items were added. The nine items missing from the original design were found in four different locations in the department. Six physicians and seven RNs participated in cadaver testing and completed an evaluation survey of the new layout. Participants preferred the new storage design (Likert median 5, IQR of 1) over the current storage design (median of 1, IQR of 1). Discussion/Impact: The results suggest that the lean equipment storage is preferred by ED staff compared to the current set-up, may reduce time finding missing equipment, and will reduce waste. Future simulation work will quantitatively understand compliance with safety critical steps, user stress, wasted user time and cost.

Acquired diaphragmatic hernia is a rare complication of pediatric intervention or surgery. In this study, we report an infant with iatrogenic diaphragmatic hernia following neonatal complex congenital cardiac surgery, and then we review the associated literature.

Limited evidence exists to guide chest tube management following cardiac surgery in children. We assessed chest tube practice variation by surveying paediatric heart centres to prepare for a multi-site quality improvement project. We summarised management strategies highlighting variability in criteria for chest tube removal between and within centres. This lack of standardisation provides an opportunity for quality improvement.

Introduction: Online medical education resources are becoming an increasingly used modality and many studies have demonstrated their efficacy in procedural instruction. This study sought to determine whether a standardized online procedural video is as effective as a standard recorded didactic teaching session for chest tube insertion. Methods: A randomized control trial was conducted. Participants were taught how to insert a chest tube with either a recorded didactic teaching session, or a New England Journal of Medicine (NEJM) video. Participants filled out a questionnaire before and after performing the procedure on a cadaver, which was filmed and assessed by two blinded evaluators using a standardized tool. Thirty 4th year medical students from two graduating classes at the Schulich School of Medicine & Dentistry in London, ON were screened for eligibility. Two students did not complete the study, and were excluded. There were 13 students in the NEJM group, and 15 students in the ATLS group. Results: The NEJM group’s average score was 45.2% (±9.6) on the pre-questionnaire, 67.7% (±12.9) for the procedure, and 60.1% (±7.7) on the post-questionnaire. The didactic group’s average score was 42.8% (±10.9) on the pre-questionnaire, 73.7% (±9.9) for the procedure, and 46.5% (±7.5) on the post-questionnaire. There was no difference between the groups on the pre-questionnaire (Δ +2.4%; 95% CI: −5.2, 10.0), or the procedure (Δ −6.0%; 95% CI: −14.6, 2.7). The NEJM group had better scores on the post-questionnaire (Δ +11.15%; 95% CI: 3.7, 18.6). Conclusion: The NEJM video was as effective as video-recorded training for teaching the knowledge and technical skills essential for chest tube insertion. Participants expressed high satisfaction with this modality. It may prove to be a helpful adjunct to standard instruction on the topic.

We report a case of reversible diaphragmatic paralysis caused by a malpositioned chest tube, a diagnosis to consider when unexplained respiratory failure occurs following drainage of pleural effusion. Prompt recognition and removal of the tube led to full recovery of diaphragm function.

A quick and simple technique for securing a chest tube in the prehospital setting is described. The technique makes use of a plastic tie with a self-locking mechanism that is wrapped around the tube and sutured to the skin. The use of a plastic tie is recommended as a valuable component to chest tube kits for use in the prehospital setting.

The reported case of a stab wound to the chest occurred in an isolated area with no specialized surgical care available. The need for transport and specifically by air, introduced particular questions in management. On a humanitarian basis and in line with its mandate, the Peace Monitoring Group, a United Nations endorsed entity in Bougainville, Papua New Guinea, provided transport to a facility with an appropriate standard of care. The questions of need for patient evacuation and chest drainage, with the timing of this maneuver are considered.