Purpose or Case Report: Evaluate IR service performance and patient outcomes following implementation of a clinical pathway for parapneumonic effusion.
Methods & Materials: Background: Upon completing a 2.5 year IRB approved observational study (control, Group A), the IR team developed the following dosing protocol for pleural tPA based on chest ultrasound findings: Grade 1, <50% pleural echogenicity, 1 mg BID; Grade 2, > 50% pleural echogenicity, 2 mg BID.
Study period: IRB modification was obtained to review subsequent retrospective data and prospective data of patient characteristics and treatment responses during two discrete time periods: Group B - during pathway development: (July 2015-April 2017); and Group C - following pathway implementation: (May 2017-October 2017). Data elements of the review included diagnostic ultrasound, IR procedure note and daily IR rounding notes for chest tubes inserted exclusively for pneumonia. The following patient information was captured: age, gender, weight, tPA dose (1mg, 2mg), dose frequency, duration of tPA therapy, positive culture/PCR, subsequent IR procedure, need for surgery and hospital stay. Findings of the retrospective data review (Table 1) were leveraged to develop a hospital-wide clinical pathway for parapneumonic effusion. Statistical analysis included comparison of ultrasound grade and outcomes of the two discrete times periods listed above. In calculating hospital stay, subjects with co-morbid conditions that may have prolonged the hospital stay were excluded from the analysis.
Results: In Group B, duration of tPA therapy for Grade 1 (2.1 days) was lower than that of Grade 2 (3.8 days, p=0.03); positive cultures/PCR were more common in Grade 2 patients (p=0.03). In Group B, patients received the correct tPA protocol dose based on ultrasound grade (Grade 1 p<0.0001, Grade 2, p<0.0001). In the study period, days of BID dosing (84.6%) was greater compared to the control period (24.2%, p<0.0001) and more patients were Grade 2 (74.4%) compared to the control period (30.3%, p=0.0003). Duration of tPA therapy for Grade 1 (1.95 days) was lower than that of Grade 2 (3.64 days, p=0.004). Median hospital stay (8 days) did not differ compared to the control period (p=0.18).
Conclusions: An IR team standardized hospital-wide BID pleural tPA dosing by developing a clinical pathway. Despite treating more complex Grade 2 patients, hospital stay remained unchanged.