The role of a pleural service in optimising pleural disease management

Introduction The complication rate of Pleural procedures is reduced from 8% to 1% when managed by a pleural specialist. We reviewed pleural disease managed by the department of medicine at our hospital in London to assess the potential effect a dedicated pleural service on patient safety, doctor training and on reducing length of stay. Methods Patients admitted over 12 months were identified, length of stay analysed and management audited against criteria for Ambulatory care and British Thoracic Society guidelines. Doctors were surveyed to assess training and confidence in pleural procedures. An economic analysis was performed. Results 349 patients were admitted for pleural effusion management. Average length of stay under a Respiratory team was substantially shorter than under a general medicine team. 30% of admitted patients could have been managed in an ambulatory setting. Early involvement of a Respiratory team could have saved over 700 bed days over 1 year. Only 50% of patients managed by a non-respiratory team had pleural procedures performed compliant with national guidelines. Junior doctors covering 'out of hours' did not feel confident in performing pleural procedures, and few had sufficient experience and training in ultrasound use. An economic analysis demonstrated that a pleural service would be cost effective. Conclusion This audit clearly establishes the need for a dedicated pleural service at our hospital. The main drivers from an organisational perspective are improved patient safety and reduced length of stay. We have identified a serious deficiency in training for junior doctors who cover the hospital out of hours, which will be addressed by a new training programme run by the pleural team.