A service evaluation on the use of digital chest drains following thoracic surgery on postoperative mobilisation and time on physiotherapy caseload

Introduction

Patients require chest drains following thoracic surgery to remove air and fluid that collects in the chest (Lijkendijk et al. 2015; Shoji et al. 2016). Chest drains limit the patient’s ability to move away from their bed space, cause patient’s pain, reduce their independence and pose a potential infection risk (Bertholet et al. 2011). Chest drains are traditionally non-digital and require attachment to wall suction. This causes subjective measurement of air and fluid drainage (Lijkendijk et al. 2015) and often delays postoperative mobilisation (Rathinam et al. 2011; Lijkendijk et al. 2015), lengthening drain duration and hospital length of stay (LOS) (Agostini et al. 2014; Lijkendijk et al. 2015). The use of digital drains allows more accurate measurement of air leak/fluid drainage allowing drains to be removed when they meet protocol or when no air leak was reported shortening drain duration (George & Papagiannopoulos 2015; Lijkendijk et al. 2015; NICE 2018). Portable digital drains also enable patients to mobilise earlier postoperatively as they do not need to wait to be detached from wall suction (Rathinam et al. 2011; Lijkendijk et al. 2015; NICE 2018). This facilitates earlier re-expansion of the operated lung reducing the risk of postoperative pulmonary complications (PPCs) and aiding earlier drain removal (NICE 2018). Early chest drain removal helps reduce patients’ pain levels and reduces infection risk (Bertholet et al. 2011). It also allows patients earlier liberation from the bed space and encourages early patient independence (Bertholet et al. 2011; Agostini et al. 2014; Lijkendijk et al. 2015; Yeung 2016; NICE 2018). Better lung expansion, reduced risk of PPCs and early postoperative mobilisation can reduce time spend on the physiotherapy caseload. Earlier discharge from physiotherapy can also encourage earlier independence. Early chest drain removal, postoperative mobilisation, discharge from physiotherapy and patient independence can all contribute to a reduction in hospital LOS (Bertholet et al. 2011; Agostini et al. 2014; Lijkendijk et al. 2015; NICE 2018). Whether the use of digital chest drains reduces the time taken to mobilise postoperatively, and the time spent on physiotherapy caseload following thoracic surgery, has not been explored or measured within existing research.

The primary aims were to explore whether the use of digital drains allowed earlier postoperative mobilisation and reduced time on physiotherapy caseload compared to under water seal (UWS) drains. Secondary aims were to explore whether the use of digital drains reduced chest drain duration and hospital LOS compared to UWS drains and reduced hospital LOS.

Method

A service evaluation was conducted exploring retrospective data collected from the 1st February 2017 to 31st July 2017. This service evaluation was registered with, and approved by, the Blackpool Teaching Hospitals NHS Foundation Trust’s Research and Development team. Ethical approval was not required in-line with the trust policy on undertaking service evaluations.

The use of digital drains commenced in February 2017 at the Lancashire Cardiac Centre on the cardiac intensive care unit and the cardiothoracic surgical wards. Prior to February 2017 only UWS drains were used following thoracic surgery. From February 2017 all patients undergoing thoracic surgery performed by one of the thoracic surgeons had a digital drain and patients undergoing thoracic surgery performed by the other surgeons continued with UWS drains. The protocol for UWS drains removal was:

• Lobectomy/pneumonectomy: drain to be removed following at least 48 hours with no air leak for 24 hours.
• Wedge resection: removal after 24 hours if there is no air leak for 12 hours.
• Bullectomy/Pleurodesis: removal after 72 hours if no air leak for 24 hours.
• Biopsy: removal day 1 if no air leak for 12 hours.
• For all other surgeries drains were removed following surgeon approval.

The protocol for digital drain removal was less than 30ml air leak within 12 hours with no pneumothorax/air airspace and no surgical emphysema on chest radiograph (CXR) and less than 200mls of fluid drainage within 12 hours. Drain removal was subject to surgeon approval.

All patients who received inpatient physiotherapy following thoracic surgery with a chest drain in situ postoperatively on cardiac intensive care or one of the cardiothoracic wards at the Lancashire cardiac centre were included in this service evaluation. Patients were identified from the electronic patient referral system and physiotherapy patient contact sheets.

The following data were retrieved:

• Date of surgery.

• Gender of patient.

• Age of patient.

• Type of surgical incision and surgical procedure.

• Type of chest drain.

• Day first mobilised postoperatively.

• Time spent on physiotherapy caseload (measured in days from day 1 postoperatively until day discharged from physiotherapy).

• Chest drain duration (number of days chest drain(s) remained in situ postoperatively measured from day 1 postoperatively until day chest drain removed.

• Hospital LOS (measured in days from day 1 postoperatively until day discharged from hospital).

Date of surgery, gender and age of the patient, type of surgical incision and surgical procedure, type of chest drain, day first mobilised and time spent on physiotherapy caseload were collected from physiotherapy patient contact sheets and the hospital electronic patient database. Date of chest drain removal was collected from the patient’s routine post-drain removal CXRs. Hospital discharge date was obtained from the hospital’s electronic patient database. The time spent on physiotherapists’ caseload was defined as the number of days patients received treatment from the cardiothoracic physiotherapy team from the day first assessed by the physiotherapist postoperatively (usually day 1 postoperatively) until the day the patient was discharged from physiotherapy.

Data were analysed using descriptive statistics and statistical tests. Data were plotted using histograms to check the normality of the data. Median values were used for all outcomes due to their skewed distribution. Upper and lower quartiles were used to explore the spread of the data. The non-parametric Mann Whitney U Test was used to test for statistically significant differences between data from the digital drain group and the UWS drain group.

Results

Over the six-month period, from 1st February 2017 to 31st July 2017, 195 patients received in-patient physiotherapy following thoracic surgery. Two patients died and were excluded due to incomplete data. A third patient was excluded as they did not have a chest drain inserted. Of the remaining 192 patients, 110 had a digital drain and 82 had an UWS drain(s) postoperatively. Table 1 shows the characteristics of patients in the two different drain groups. Both groups were comparable in ratio of male to female patients and the mean age of both groups of patients was the same.

Table 1: The characteristics of patients in the digital chest drain group and the UWS chest drain group.

n = number, UWS = underwater seal, VATS = video-assisted thoracoscopic surgery.

Table 2: Thoracic surgical procedures patients in the digital chest drain group and the UWS chest drain group underwent.

UWS = under water seal, VATS = video-assisted thoracoscopic surgery.

Table 2 shows the types of thoracic surgery that patients underwent in the two different drain groups. Lobectomy and wedge resection were the most common surgical procedures that patients underwent in both groups.

Table 3 shows the clinical outcomes for the digital drain group and UWS drain group.

Table 3: Clinical outcomes for the digital chest drain group and UWS chest drain group.

LQ = lower quartile, UQ = upper quartile, UWS = under water seal, CI = confidence interval.

The median day that patients first mobilised postoperatively was statistically significantly shorter for the digital drain group compared to the UWS drain group (observed median difference 2 days, 95% CI 1 to 2 p = 0.0001).

Time on physiotherapy caseload was statistically significantly shorter for the digital drain group compared to the UWS drain group (observed difference 1 day, 95% CI 1 to 2, p = 0.02). There was no statistically significant difference in chest drain duration between the digital group and the UWS group (observed median difference 1 day, 95% CI 0 to 0 p = 0.91). Median hospital LOS was shorter for the digital drain group than the UWS drain group however this difference did not reach statistical significance (observed median difference 1 day, 95% CI 0 to 1 p = 0.06).

Discussion and conclusion

In this service evaluation patients receiving a digital chest drain were mobilised significantly sooner than those with a non-digital UWS drain. The use of portable digital drains with inbuilt suction allows patients to mobilise with drains in and on suction. In contrast, patients with UWS drains need to wait until suction is no longer required, or for suction to be removed prior to mobilisation (Rathinam et al. 2011; Lijkendijk et al. 2015; NICE 2018). Benefits of early postoperative mobilisation for patients following thoracic surgery include reduced risk of deep vein thrombus and pulmonary embolism, reduced risk of PPCs, earlier liberation from the bed space (allowing mobilisation to the bathroom and away from the ward) and earlier independence with mobility (Yeung 2016).

Time on physiotherapy caseload was also significantly shorter for patients within the digital drain group. This could be attributed to patients mobilising earlier postoperatively with digital drains enabling them to achieve their mobility goals earlier and allowing patients to be discharged from physiotherapy even with drains in-situ. Time on physiotherapy caseload following the use of digital drains after thoracic surgery has not been previously explored. Benefits of reduced time on physiotherapy caseload for patients include earlier patient independence. By reducing the length of time patients spend on the physiotherapy caseload post-thoracic surgery provides the physiotherapy service with the opportunity to allocate more staff and resources to patients who require more intensive physiotherapy interventions, which may have a secondary benefit in facilitating a reduction in hospital LOS for these patients.

Chest drain duration was shorter for the digital drain group than the UWS drain group following thoracic surgery, however this difference did not reach statistical significance. There was also no statistically significant difference reported in median hospital LOS between groups. It was anticipated that the use of digital drains would shorten drain duration by allowing more accurate measurement of air leak/drainage than UWS drains leading to digital drains being more likely to be removed once drains met protocol and no air leak was reported (George & Papagiannopoulos 2015; Lijkendijk et al. 2015; NICE 2018). As this service evaluation took place during the first six months following the implementation of digital drains, it is possible that staff were initially cautious regarding digital drain removal, lacking the confidence and experience regarding the use of the drains. Previous studies have also all reported no significant difference in drain duration or hospital LOS between digital drains and UWS drains (Bertolaccini et al. 2011; Gilbert et al. 2015, Lijkendijk et al. 2015; De Waele et al. 2017). In contrast others have reported significantly shorter drain duration and in hospital LOS with digital drains compared to UWS drains (Cerfolio & Bryant 2008; Brunelli et al. 2010; Filosso et al. 2010; Mier et al. 2010; Pompili et al. 2014; Shoji et al. 2016; Wang et al. 2019).

The introduction of digital chest drains has changed practice enabling the physiotherapy team to mobilise patients further one day after thoracic surgery and allowing patients to mobilise away from the bed space. Traditionally individuals following thoracic surgery would have UWS drain(s) in situ and would be limited to bedside mobility, for example marching on the spot one day after thoracic surgery with physiotherapy staff, often not mobilising away from the bed space until three days or later after thoracic surgery.

There were several strengths to this service evaluation. Firstly the influence of drain type on physiotherapy practice has not previously been extensively explored. It is an important area given that chest drains can limit physiotherapists’ ability to mobilise patients away from the bed space. Since both types of drains were used over the same time period, it can be assumed that all other medical and surgical care remained similar. This adds weight to the suggestion that it is drain type that influences time to first mobilisation and time on physiotherapy caseload, rather than other unknown factors.

A few limitations can be noted. One of these is that digital drains were newly introduced and staff may not yet have been confident in their usage. Moreover only patients who received in-patient physiotherapy were included in this service evaluation therefore not all data for patients with a digital drain following thoracic surgery were captured. Also the retrospective collection of data from the physiotherapy ward sheets potentially affects the accuracy of the data collected as this relies on staff accurately completing data. The majority of operations in the digital drain group were performed by the lead thoracic surgeon whilst all operations in the UWS group were performed by other thoracic surgeons. Differences in surgeon drain removal preferences between the groups could have influenced differences in outcomes.

Future studies could obtain feedback from patients on the type of drain they had and their levels of satisfaction. It may also be advantageous to explore whether there are any factors/reasons that prevent patients with digital chest drains mobilising one day postoperatively to identify further ways of encouraging earlier postoperative mobilisation. The use of digital chest drains with inbuilt suction has enabled individuals to mobilise earlier following thoracic surgery facilitating earlier liberation from the bed space. The use of digital chest drains has also facilitated earlier discharge from physiotherapy. In this service evaluation there was no significant difference in chest drain duration or hospital LOS between those with a digital chest drains and those with a UWS drain.

Key points

• The use of digital drains allowed significantly earlier postoperative mobilisation facilitating earlier liberation away from the bed space.

• The use of digital chest drains enabled significantly earlier discharge from physiotherapy caseload.

• The use of digital chest drains did not significantly reduce chest drain duration or hospital LOS.

Acknowledgements

Thank you to the Cardiothoracic Physiotherapy Team for their hard work and dedication to the introduction of the digital chest drains. Thank you to all the thoracic surgeons and cardiothoracic nursing and medical staff for using the digital chest drains. Thank you to the Library services, Research and Development Department and the Trust statistician at Blackpool Teaching Hospitals NHS Foundation Trust.

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