Interdisciplinary teamwork for chest tube insertion and management: an integrative review

Aim

This integrative literature review aimed to search for articles related to the thoracostomy procedure that convey the procedure and the standard care to the medical staff and the nursing team, and interdisciplinary teamwork.

The databases searched and other information sources

The search was performed in the following databases: Medical Literature Analysis and Retrieval System Online – PubMed® (National Library of Medicine) and Scientific Electronic Library Online – SciELO. PubMed® includes citations for biomedical literature from MEDLINE, life science journals, and online books. SciELO is an electronic library providing access to scientific journals in Portuguese and Spanish.

Search strategy and intervention

This is an integrative literature review, with a qualitative approach [13]. The steps were: (1) choice of research objective; (2) definition of the criteria for inclusion and exclusion of studies; (3) search of databases; (4) inclusion of selected studies in frame format; (5) analysis of results, identifying differences and conflicts; and (6) discussion and analysis of results.

Data collection process and search outcomes

Application of inclusion and exclusion criteria (1^st stage), which contained the descriptors listed in the medical subject headings (MeSH): “Chest Tube AND Nursing; Chest Tube AND Care; Chest Tube AND Drainage; Chest tube AND Insertion (this descriptor was not defined by the MESH, but by its appearance in many articles)”. And the descriptors should refer to the insertion of the chest drain into humans. Publications were selected when they were available in English, Portuguese, Spanish, or French. Exclusion criteria were as follows: theses; dissertations; abstracts of works published in annals of events; editorials; letters to the editor; and articles not available online and not free to access.

The second step was to read the titles and abstracts, and the third step was to read the full article and delete repetitive or irrelevant studies. Five relevant manuscripts were used in addition to the development of the literature review because they were of great relevance, so they did not go through the selection process [14–18]. Critical evaluation of the studies was based on the results of the aforementioned reference documents, and from reviewing of the articles found in the databases, and selection of information relevant to the theme in its context in the study.

Study design

Data collection on teamwork in thoracostomy from the literature, between January 2012 and September 2020, was done in December 2020.

Quality assessment

To validate the integrative review methodology, prior to conducting the research, a protocol was developed. This research protocol was endorsed by an expert researcher on methods of integrative review and another expert researcher in the area of thoracostomy and interdisciplinary teamwork. This was done in order to validate the descriptors and their relevance to the subject. This research was exempt from Ethics Committee approval because it did not involve human beings.

Data abstraction and process

The collection of the articles was carried out in each database individually. The beginning and/or ending was not predefined, i.e. it occurred randomly. The selection criteria and the process are shown in Figure 1.

FIGURE 1

Organization chart of integrative literature review

Synthesis

For the analysis procedure, we opted for content analysis [19]. This analysis was developed via 3 steps: (1) pre-exploration of the material or floating readings; (2) selection of units of analysis (or units of meanings); and (3) the non-priority categorization and sub-categorization process. The categories emerged entirely from the context of the research material. This procedure required the researchers to go back and forth from the reading of the material analysed and the objectives of the study. Each emerging category was discussed in the form of a frame within the information relevant to the study in a comparative way, along with the extraction of new information to enrich the theme.

Study risk of bias assessment and confidence in the assessment process

Two reviewers systematically evaluated the abstracts and articles to limit the risk of bias in the included or excluded studies. Only studies approved by the 2 reviewers were retained. During the analysis process, the reviewers worked independently. In the case of discrepancies in the outcome analyses, a third reviewer designated by the principal investigator reread the article.

Divergences in carrying out the procedure

When comparing the literature for insertion of chest drains [14–18] and articles found in the literature review, we identified differences between the procedure and care guidelines, with some divergences that could change fundamental aspects of practice, one of which is in the execution of a surgical procedure. This category, in which the closed thoracostomy is included, is strict regarding surgical asepsis. It involves patient safety as a key point, to avoid unnecessary patient complications such as discomfort and risk of death [27].

Given the importance of this, one of the divergences in the literature concerns the most adequate antiseptic in the preparation of the patient for the chest drain insertion procedure. While some studies [5] mention povidone-iodine as the preferred solution, other studies refer to alcohol-based products (chlorhexidine) [18]. Chlorhexidine may be 6% to 10% more effective in preventing infections in surgical procedures compared to povidone-iodine in patients with the same characteristics [34, 35]. Another systematic review achieved the same level of evidence and considered the reduction of costs when using alcoholic chlorhexidine (up to $26 per procedure) [36]. Several authors state that the option with the lowest incidence of infection and the highest cost-benefit is chlorhexidine alcohol [14, 34–36]. Another point of divergence in the literature is the use of 1% lidocaine [14] versus using 2% lidocaine [29] versus using neither [8]. In the literature, there are no high-quality studies on the benefits or efficacy of one over the other, only indications of different dosages, and other articles also indicate that both concentrations are acceptable [37, 38].

Success in performing a thoracostomy is related not only to the insertion of the chest tube but also to its maintenance. Basic care to ensure its effectiveness and patency are necessary. Dressing was one of the points addressed in the articles and literature of reference [8, 15–18]. Some studies recommend, as a cover, a simple dressing with petroleum gauze or lint gauze covered with micropore or tape [14–16], while others recommend transparent dressing [8]. When comparing issues such as level of skin irritation, the literature reveals that both dressings showed the same performance, but that with regards to the level of wound recovery and costs, transparent dressing presented more positive results [39, 40]. In addition to other benefits, transparent dressing decreases the risk of infection and requires a smaller number of exchanges because it can be maintained for 3 to 7 days. To conclude, transparent dressing is the most suitable for the protection of the insertion site on the chest.

As a complementary aspect, 2 studies discuss pain control and analgesia as one of the fundamental procedures in pre- and post-surgical care [6, 8]. Pain can cause patient instability leading to failure, and/or it can become the main cause of complications during and after the procedure, and it increases the length of hospital stay. Therefore, professionals should value assessment of the aspects that involve the reduction of pain and reinforce patient’s confidence in safe relevant strategies [41, 42].

Interdisciplinary action and the quality of the procedure

It is essential to promote interprofessional healthcare education and training [43]. Among the 19 studies in the systematic review, 14 only approached chest drain insertion techniques for physicians or medical students [4, 21–33]. None studied interdisciplinary work in drain insertion or chest drain care, and only 1 presented any protocol for teaching and training students in drainage [28]. On the other hand, 5 studies presented nurses as the main actors, 1 of which was an evidence-based guideline on nursing practices in the management and care of the chest drain [15], while the other 4 evaluated nurses’ knowledge and practices about chest drain care [5, 6, 8, 20]. One study, elaborated by a surgical department of thoracic surgery [8], showed how important it is to know the other professions’ roles and their importance in patient health care. It also demonstrated how it is possible to enlarge vision to interdisciplinary teamwork to improve health care. When the general principles on the care of patients with thoracic drains are implemented correctly and effectively by nurses, it will accelerate the healing process [6]. Other studies confirm the importance of the procedure protocols; once they are standardized and systematized, patient care is substantially improved. In addition, the authors suggest that nurses’ knowledge of chest anatomy and physiology is critical for rapid intervention when patients with chest drains present complications, and that the nurse must also know the reason for insertion of the drain, thereby raising awareness of the care procedures needed to maintain patient safety [6].

Finally, only 1 study directly approached the doctor-nurse partnership in the procedure and care of the chest drain, including multidisciplinary collaboration as a key point in patient care. An interdisciplinary approach to patient care is fundamental because each professional has his/her own functions and roles during chest drain insertion and care; however, all must work together for the best patient outcome [20]. Collaboration among nurses and physicians allows better patient-centred care [2]. It is also important to emphasize that the chest drain training programs should include the presence of a nurse during the insertion procedure and that national and international guidelines should emphasize the roles and duties of the nurse in the care of the patient with a chest drain [6].

Use of protocols for patient safety

Among the 20 studies evaluated in the integrative review of the literature, only 5 reported the use of protocols for insertion and management of the chest drain [6, 20, 24, 29, 33]. Two of them approached the use of protocols for teaching and training for medical students and physicians in the technique of insertion of the drain [29, 31]. Another study commented on the partnership between doctors and nurses in the care of patients with a chest tube [20]. This study assessed patient satisfaction with the ability of nurses to manage postoperative needs in a ward-based nurse-led clinic managing patients after thoracic surgery. The use of a protocol for outpatient care was created with the aim of allowing the nurses to provide their own independent care, with the option to request a physician if necessary. Most of the patients (99%) were satisfied with the care. Among the two-thirds of patients who were treated according to the protocol and without referring to a physician, very few considered that a medical consultation was necessary. Another article described a step-by-step approach for ultrasound-guided chest tube drainage [24]. Finally, a study evaluating nurses’ knowledge on chest drains suggested the creation of protocols for drainage care [6].

Patient safety needs to be the priority to the health care team [44]. Studies show that the use of evidence-based protocols contributes to patient safety, because nurses are thereby trained in patient care and are given knowledge of drainage systems [45] and the types of drainage to expect from whichever device is inserted into a patient. They can also contribute to patient safety and prevent potential harm because they can collaborate in the rehabilitation process since adequate drainage management improves effectiveness [45]. In addition, some authors argue that protocols may improve communication between doctors and nurses during care and that a standardized document improves interdisciplinary communication and drainage care [45]. Thus, it is fundamental that protocols involving procedures and patient care can be developed to delineate each discipline’s roles and responsibilities. Another fundamental factor in patient care is education. Providing patients with accurate and easy to understand information decreases recovery time and increases positive outcomes [16].

New technologies for the insertion of chest tubes

Studies also discussed the use of technology for the instruction of procedural techniques [4, 29, 33]. The use of animal models that mimic human physiology enables the development of practical skills, given the high cost and lack of accessibility of simulators or cadaver labs. Other studies go further and seek alternatives with materials that can achieve high fidelity without high-cost technology, developing their own instruments with recycled materials and proving their effectiveness for improved learning [30]. Low-cost training models for chest tube insertion were developed and tested [28, 46]. The use of a low-cost 3D-printed model for medical teaching of the procedure was analysed [21]. This model is cost-effective and valid for teaching thoracostomy. Another approach emphasized the importance of expanding knowledge of the procedure beyond the medical domain, encouraging interdisciplinary activity, and deepening knowledge and nursing responsibilities in chest drain insertion [5, 8, 20]. In this context, it behoves us to mention digital chest drainage, using digital devices that have been proven to have important benefits such as objective assessment of real air-leak, early active intervention or conversion to a one-way valve system that would allow for outpatient management, early patient mobilization, and therefore early hospital discharge [47]. Another important component is thoracic ultrasound, an imaging diagnostic technique that helps to identify the best puncture site and guides the procedure for insertion of the drainage. Chest ultrasound is essential during these invasive manoeuvres to increase safety and decrease potentially fatal complications [48].

Future research

Interdisciplinarity represents the combined courses of 2 or more disciplines like nursing and medicine [49]. In healthcare settings, clinical situations like life-threatening events require interprofessional management of the patient based on the unique disciplinary knowledge of the health professionals [49]. Reeves and Zwarenstein [50–53] have demonstrated in several studies that that interprofessional teamwork improves healthcare outcomes. When analysing the existing literature on thoracostomy and care, we can identify a large number of studies. Notwithstanding this vast amount of information, the literature is fragmented into disciplines and isolated analyses. Each discipline addresses the aspects that pertain to its own responsibilities in the execution of the procedure, but in practical reality, all actions have the same orientation (the patient’s well-being), and the different disciplines need to act together. This study enabled a comparison of surgical and nursing practices in the placement of chest drains through a dialogue with several authors on integration review and content analysis, compiling the information and defining an international standard for the procedure and materials used. From this study, it was possible to define an interdisciplinary and updated practice with safe means promoting safe chest drain insertion. Future research should aim to develop a learning and assessment tool for interdisciplinary chest tube insertion. Finally, future studies should concentrate on extensive patient education. It is essential in this type of interdisciplinary care to consider patient education and, more specifically, to train him/her in the management of thoracic drainage [54, 55].