Tube Thoracostomy Across Emergency Medicine, Thoracic Surgery, and Intensive Care Residents: A Three-Year...

Background: Tube thoracostomy is performed by several specialties in several hospital settings, but institution-wide data comparing who performs the procedure, where, how, and with what complications are limited. Methods: In this retrospective observational cohort study, all tube thoracostomies performed over a three-year period at a tertiary university hospital were identified through the hospital information system. Procedures were grouped by performing team (emergency medicine, thoracic surgery, and intensive care) and by setting (emergency department [ED], operating room/ward, and intensive care unit [ICU]) and compared with respect to demographics, indications, operator seniority, anesthesia practice, chest tube size, and complications. Effect sizes are reported with 95% confidence intervals (CIs), and predictors of complications were examined in a multivariable binomial logistic regression model. Results: In total, 487 procedures were analyzed (76.0% male; median age 56 years). The emergency medicine team performed 47.2% of procedures (all in the ED), the thoracic surgery team 46.8% (the only team active in all three settings), and the intensive care team 6.0%. Indication profiles diverged (p < 0.001): traumatic (34.8%) and spontaneous pneumothorax (31.7%) dominated the emergency medicine caseload, pleural effusion (40.4%) the thoracic surgery caseload, and iatrogenic pneumothorax (72.4%) the intensive care caseload. Overall, 95.9% of tubes were 28 F or 32 F; the thoracic surgery team favored 32 F (75.9%; p < 0.001). First-year residents performed 39.8% of procedures, two-thirds of them on the thoracic surgery team. Complications occurred in 70 procedures (14.4%), 90.0% of which were tube malpositions. Crude complication rates were 10.0% for emergency medicine, 16.2% for thoracic surgery, and 34.5% for intensive care (p = 0.001), but rates rose with the acuity of the setting (ED 10.9%, ICU 26.8%) and within-setting differences between teams were not significant (ED p = 0.363; ICU p = 0.301). In a multivariable model adjusting for team, setting, age, indication group and operator seniority, neither team (p = 0.164) nor setting (p = 0.223) was independently associated with complications. Complication rates did not differ by postgraduate year (16.5%, 9.8%, 14.3% and 20.8% for years 0-1 to 3-4; p = 0.157, test for trend p = 0.738), by tube size (≤28 F 12.0% versus ≥32 F 15.8%; p = 0.287) or by age (p = 0.276). Conclusions: This hospital-wide map of procedural labor shows that the three teams served largely distinct patient populations. Team, setting and indication are so tightly linked in this hospital that no independent effect of specialty could be demonstrated in either direction. Operator seniority and tube size were not associated with complications. Malposition accounted for nine of every ten complications, which supports routine verification of tube position after insertion. Which team drains which pathology, where, and at what level of training is determined locally rather than by specialty training standards, and that map is the principal contribution of this series.