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Improving care through Pleural Ambulatory Units and Simulation Training in South Wales

Wednesday, June 5, 2024

Respiratory Futures recently spoke to Dr. Andreea Alina Ionescu (Consultant Respiratory Physician/Pleural Lead), Artemio P. Gonzales (Advanced Pleural Nurse Practitioner) and Dr. Gethin King (Senior Pleural Fellow/Specialist Registrar) at Aneurin Bevan University Health Board (ABUHB) in South Wales. The team shared with us insight into their Advanced Nurse Practitioner (ANP) led pleural ambulatory unit (PAU), and how it is used to provide rapid access to pleural diagnosis and intervention for patients in their area.

Tell us a little about the Advanced Nurse Practitioner led pleural ambulatory unit (PAU) – how does it work and what needs does it address?

The Advanced Nurse Practitioner (ANP) led pleural ambulatory unit (PAU) provides rapid access to pleural diagnosis and intervention. Referral is electronic or by open access, the ANP ensures triage according to symptoms.  PAU is supported by a consultant (on the phone or on site in another clinic), an interventional pleural fellow and a health care support worker, four days per week, with a one-stop approach. The ANP provides:

  • Thoracic ultrasound (TUS)
  • Diagnostic  or therapeutic pleural aspirate
  • Seldinger Intercostal chest drain insertion
  • Tunnelled Indwelling Pleural Catheter insertion, management and removal
  • Thoracic vent insertion and management
  • Thoracoscopy preparation

In addition, the PAU is part of the TUS and pleural training programme for junior doctors. The PAU clinical sessions accommodate juniors who have been through the initial part of the programme (simulation). They perform TUS and pleural intervention under direct observation with trainers (ANP and/or Consultant) and gain experience in a managed environment. 

What successes have you seen with the Advanced Nurse Practitioner led pleural ambulatory unit (PAU) so far, and what impact has it had on patient outcomes?

Since the commencement of ANP led PAU, pleural patients are provided with a more efficient service, the access is being electronic or by self - referral.

The number of patients seen on the unit has increased, the waiting time decreased, often unplanned hospital admission of patients with malignant pleural effusion is avoided and the speed of discharge home from hospital has increased. Patients presenting to the emergency department or acute medical units can safely be discharged home if presenting out of hours, with a plan for ‘next day ‘ pleural review and intervention if required.

The service provides a “care at home pathway” where district nurses and family members can be involved in the care of ambulatory chest drains, with support from the ANP led PAU.

Feedback from patients showed that they felt supported by a service that was put in place for their needs and that works arounds them.

You have been involved in developing a programme of thoracic ultrasound simulation training and pleural intervention to Internal Medicine and Specialist Trainees. What does this programme look like?

We begin with trainees signing up via the postgraduate department to attend a thoracic ultrasound (TUS)/procedures simulation session that we run frequently. Prior to the session they are sent learning modules including a mix of pleural cases via online tutorial, a guide to basic TUS and videos of the basic pleural interventions - aspiration and Seldinger drain insertion. Having completed this learning, they would attend the practical session. These sessions are split into two sections. First, an introduction to TUS on an interactive simulator followed by demonstration and practice of pleural procedures on a mannequin. Having completed this part, we open access to trainees to attend our pleural ambulatory unit and have clinical practice in TUS and pleural intervention under supervision. For those keen to progress in TUS along the BTS pathway we put them in touch with trainers to achieve sign off at emergency and sometimes primary operator level. 

What impact have these education and training interventions had on workforce pressures within Aneurin Bevan University Health Board (ABUHB)?

The dedicated pleural service in ABUHB is relatively well established, therefore, for much of the time, these interventions have a relatively limited impact on workforce pressures as pleural staffing is generally sufficient to deal with any issues as they arise during normal working hours. Out of hours, it will hopefully have had the effect of making the on-call teams, from a medical perspective, as well as ITU/ED colleagues that have also attended sessions, better equipped, and educated to deal with any pleural issues that arise, as intermittent as they may be. The PAU provides service and teaching to junior staff at the same time, in an efficient way.

If somebody was interested in learning more about these initiatives, where could they go to grow their knowledge?

We are happy to hear directly from any interested colleagues; we have previously welcomed colleagues from other health boards or trusts who were interested to visit the pleural unit. We have a number of interactive pleural cases and other learning resources (videos of simulated procedures and others) on the ABUHB intranet – if of interest, we will apply for permission from the ABUHB management to share such resources.