Securing a Chest Tube Properly: A Simple Framework for Teaching Emergency Medicine Residents and Assessing Their Technical Abilities.

BACKGROUND: Quality-improvement efforts at our institution have identified chest tube dislodgement as a preventable complication of tube thoracostomy. Because proper fixation techniques are not well described in the literature and are seldom formally taught, techniques vary among residents.

OBJECTIVE: Our aim was to develop and test a framework for teaching and assessing chest tube securement.

METHODS: A repeated-measures study design was used. At baseline, 19 emergency medicine residents (program years 1-3) placed and secured a chest tube in a cadaver. After a 45-min proficiency-based teaching session using a low-cost chest tube simulator (approximate cost, $5), each resident again placed and secured a chest tube in a cadaver, followed by 3-month retention testing. All securements were evaluated by two raters using a four-point checklist and a five-point global assessment scale (GAS). The checklist addressed suture selection, tying knots down to the tube, wound approximation, and tube displacement relative to skin.

RESULTS: After the initial educational intervention, median scores for the group improved significantly over baseline for the GAS (p < 0.001), checklist (p < 0.001), and amount of displacement (p = 0.01). At 3 months, GAS, checklist, and displacement scores did not differ significantly from the immediate post-test scores. Inter-rater reliability was substantial, with weighted κ values of .77 for the GAS and .70 for the checklist.

CONCLUSIONS: Quality of chest tube securement by emergency medicine residents can be significantly improved with an inexpensive chest tube simulator and a brief workshop. The four-point checklist served as a reliable and effective means for teaching and assessing chest tube securement.