BTS Audit shows pleural services need organisational improvements and additional pleural staff

The British Thoracic Society BTS today published its National Pleural Services Organisational Audit Report 2021.

This is the first project to bring together national guidance documents on the safe treatment of pleural disease (conditions that affect the tissue covering the outside of the lungs and inside of the chest cavity) into a set of auditable standards. The 2021 Audit examined how hospitals and clinicians adhered to these organisational standards.

The audit was completed by 111 hospital sites and provided organisational information on five key topics: medical leadership, service delivery, pleural nursing, out-of-hours care, patient safety and clinical governance. The audit collected data from 1 April to 30 June 2021.

The report highlights many areas in need of improvement relating to patient safety, clinical governance and staffing levels. The audit also found many sites were unable to meet the recommendations of the National Respiratory GIRFT Report.

Key findings

• 62% of sites reported a patient safety incident related to thoracic ultrasound and/or pleural procedures within the last three years (from 1 April 2021).
• 33% patient safety incidents were level 4 harm incidents (severe harm) and 20% were level 5 incidents (catastrophic harm / death).
• 9% sites have had both a level 4 and level 5 incident in the last 3 years (from April 2021).
• 63% of hospital sites do not have out-of-hours pleural disease management pathways
• 53% of hospital sites do not have out of hours access to an emergency-level thoracic ultrasound operator
• 70% of hospitals do not have any pleural specialist nurses as part of their pleural service. And only 6% were compliant with the number of recommended specialist pleural nurses
• Only 12% of hospital sites were compliant with the recommended number of medical sessions for the size of service
• The provision of key elements of infrastructure and resources to deliver a clinically effective service was poor including dedicated administrative support (36%), a specific telephone line for pleural referrals (32%), dedicated email for pleural referrals (47%) and an admission avoidance pleural pathway (48%).
  87% of hospital sites have a nominated pleural service lead but the designation of a thoracic ultrasound mentor and a pleural procedure training lead was lower at 52%
• The allocation of dedicated time within job plans to deliver these three roles was poor at 32% (pleural lead), 13% (TUS mentor) and 14% (pleural procedure training lead).

BTS used the results of this audit to set a number of national improvement objectives to be demonstrated locally within one year and permanently implemented by the time of the next BTS Pleural Services Organisational Audit.

National Improvement Objectives

1. Hospitals should have an agreed out-of-hours protocol to access appropriately trained thoracic ultrasound and pleural procedural operators (Target: 100%)
2. Trusts/Health Boards should identify nominated Thoracic ultrasound mentors & pleural procedure training leads. (Target: 100%)
3. Nominated thoracic ultrasound mentors and training leads should have recognised time within job plans to deliver these leadership roles (Target: 100%)
4. Hospitals should urgently appoint a pleural nurse where there are none, and all should work towards achieving the recommended nursing complement (1 band 6 nurse/300 pleural procedures (Target: 70%)
5. Hospitals should set in place admission avoidance pathways and appropriate infrastructure to reduce hospital length of stay and maximise the generation of the Best Practice Tariff for Pleural Effusion (in England) (Target: 95%)

Andrew Stanton, BTS clinical audit co-lead commented:

"The audit has brought together a series of national documents in pleural medicine into a single assessment of auditable standards and assessed the adherence to these standards across the NHS.

"It is heartening to see the number of sites in the UK that contributed to the audit, and this has led to a valuable dataset which highlights the need for additional resources to enable clinicians to deliver pleural medicine across all levels of complexity.

"BTS will continue its programme of work which champions and supports the GIRFT recommendations and calls for an urgent increase in the respiratory workforce. Targeted recruitment is the only way we will tackle the worrying lack of pleural specialist nurses and enable fully resourced, out-of-hours support using appropriately trained thoracic sound and pleural procedure operators."

Dr Matt Evison, BTS clinical audit co-lead said:

"BTS remains committed to ensuring that all patients have access to safe and timely treatment and to supporting the respiratory workforce. The patient safety issues reported in the Audit by 1 in 5 hospitals in the past three years, showed there is clearly a need to further understand and investigate the causes of harm and to enable the development of a dedicated action plan to protect patients.

"The pleural community would like to see the development of formal BTS Quality Standards of Care for patients with pleural disease. BTS will also repeat the pleural disease audit in future to measure the impact of the national improvement objectives for pleural services set out in this report."

References

1. Respiratory Medicine – GIRFT Programme National Speciality report. NHS England and NHS Improvement. March 2021. Accessed at www.gettingitrightfirsttime.co.uk/girft-reports/
2. NPSA. Chest drains: risks associated with the insertion of chest drains:NPSA/2008/RRR003.
   Havelock T, Teoh R, Laws D, et al. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:i61–76.
   Evison M, Blyth KG, Bhatnagar R, et al. Providing safe and effective pleural medicine services in the UK: an aspirational statement from UK pleural physicians. BMJ Open Respir Res 2018;5:e000307.
3. Stanton AE, Edey A, Evison M, et al. British Thoracic Society Training Standards for Thoracic Ultrasound (TUS). BMJ Open Resp Res 2020;7:e000552. doi:10.1136/ bmjresp-2019-000552
4. British Thoracic Society. Guidance to support the implementation of Local Safety Standards for Invasive Procedures (LocSSIPs) - Bronchoscopy and Pleural Procedures. 2020. Accessed at www.brit-thoracic.org.uk/quality-improvement/clinical-resources/interventional-procedures
5. Lung Cancer – GIRFT Programme National Specialty Report. Dr Paul Beckett, Dr Sarah Doffman, Dr Elizabeth Toy (GIRFT Clinical Leads for Lung Cancer), Victoria Anderson and Monica Hugh (Specialist Nursing Leads for Lung Cancer). April 2022 Accessed at www.gettingitrightfirsttime.co.uk/girft-reports/
6. British Thoracic Society. A Respiratory Workforce for the Future. 2022. Accessed at https://www.brit-thoracic.org.uk/workforce/