I M P L E M E N TAT I O N P R O J E C T

Evidence-based management of patients with chest

tube drainage system to reduce complications in
cardiothoracic vascular surgery wards
K. L. Jessica Gan and Mary Tan

Nursing Department, National University Hospital, Singapore

ABSTRACT

Aim: This evidence-based project was to implement the best practice to provide safe and effective care to patients
with chest tube drainage system in cardiothoracic wards.
Methods: Best practice recommendations on monitoring and maintenance of chest drains were retrieved from the
Joanna Briggs Institute COnNECTþ database. A checklist was developed based on these recommendations. Nurses in
the two cardiovascular wards were taught how to use the checklist. Two post-implementation audits on the nurses’
compliance to use the checklist were conducted. Data were analysed using the Joanna Briggs Institute Practical
Application of Evidence System.
Results: Initial post-implementation audit results showed that the compliance rates of monitoring underwater seal,
suction pressure and connector were 100%, checking of dressings 90%, and swinging and/or bubbling 70%. The
checklist also detected 36 near-miss events. The second post-implementation audit results showed that the
compliance rate of monitoring insertion site for air infiltration was 100%, checking of dressings 78%, and swinging
and/or bubbling 91%. Fifty-seven near-miss events were detected.
Conclusion: The use of the checklist prevented adverse events during the evidence implementation period. It can
thus be concluded that using a systematic guide to observe and monitor patients with chest tubes enhances the
effectiveness and safety of nursing care in the hospital.
Key words: cardiothoracic, chest drain, chest tube, evidence-based nursing
Int J Evid Based Healthc 2015; 13:58–65.

Background underwater seal, is a closed drainage system that

C hest tubes – also known as chest drains – are

usually seen in patients with conditions such as
pneumothorax, haemothorax, pleural effusion and
empyema.1 These tubes are inserted into the pleural
space to drain air, blood or pus so that negative
pressure can be restored within the pleural space,
enabling lung re-expansion and preventing lung col-
lapse.2 Patients who have undergone cardiothoracic
surgery also require chest tubes to remove air and
blood postoperatively.1 The chest tube, with its
Correspondence: Jessica Gan, BSc, Nursing Department, National
University Hospital, 5 Lower Kent Ridge Road, Singapore 119074.
E-mail: ganjessica@yahoo.com.sg
DOI: 10.1097/XEB.0000000000000041
allows only one-way movement of air and/or fluids
from the pleural space to the drainage bottle, and is
designed to prevent reverse flow from the drainage
bottle back into the pleural cavity.3
Nurses taking care of patients with chest tubes are
required to monitor closely the patients’ conditions and
their chest tube drainage systems. It is both important
and necessary for nurses to understand chest tube
management to prevent potential complications, which
could increase patients’ level of stress4 or prolong
patients’ recovery and length of stay in the hospital.5
Problems related to chest tube management include
dislodgement and occlusion of the tube,3 and these
problems could progress to more serious complications
if they are not detected by nurses. A coiled, looped or

58 International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute

©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

clotted chest tube that affects drainage from the pleural
space to the drainage bottle could lead to a tension
pneumothorax or surgical emphysema.1
According to the electronic Hospital Occurrence
Report (eHOR) database of the National University Hos-
pital (NUH), Singapore, from year 2005 to 2010, there
were 10 incidents of dislodgement or disconnected
chest tubes, 5 incidents related to clamped chest tubes
and 1 incident of the chest tube fixed to a wrong port on
the drainage bottle. These incidents could occur because
of wide variations in how the nursing staff performed
checks on patients with chest tubes, for example, incon-
sistent sequence of checking, omission of essential steps
during the checks and failure to document the checks.
The lack of a standard sequence for checking patients’
chest tube drainage systems and documentation
increases the risk of an adverse event or outcome due
to variability in checking procedures and handover of
information, thereby compromising patients’ safety. It
has been suggested that communication failures are the
leading cause of inadvertent harm to patients, but
effective communication within a team can help reduce
adverse events.6
Furthermore, a systematic guide on the care of chest
tube drainage systems was not available for both current
and new nurses to aid them in the provision of care to
patients with chest tubes and drainage systems. These
concerns warranted a review of the best evidence on
providing nursing care of patients with chest tubes.
Objective
The objective was to identify the best available evidence,
and then to develop an evidence-based clinical audit
project to use as a guide for evaluating current nursing
practice and implement a change strategy to increase
compliance with best practice standards for nursing
patients with chest tubes. Another objective was to
improve handover of care among nurses, with the ulti-
mate goal of enhancing safety and effectiveness of
nursing care provided to these patients.
The clinical question for the evidence-based project
was: What is the best available evidence in the manage-
ment of patients’ chest tube drainage systems in cardi-
othoracic vascular surgery (CTVS) wards, and how
compliant are nurses in adhering to chest tube care best
practice recommendations?
Methods
Sample
Convenience sampling was used in view of the nurses’
varying daily assignments and patients’ availability
within the given time frame for the project. Although
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
IMPLEMENTATION PROJECT
the targeted sample size was 30 registered nurses for the
first post-implementation audit, only 10 registered
nurses were audited due to a limited number of patients
with chest tubes during the project. The targeted sample
size for the second post-implementation audit was
also 30 registered nurses, of which 23 were eventually
audited.
Inclusion/exclusion criteria
All registered nurses in the two CTVS wards were edu-
cated on how to use the Chest Tube Checklist. Patients in
these two wards with at least one chest tube were
included, whereas those with other types of drains such
as pigtail and Redivac drains were excluded. As the aim
of this project was to implement an evidence-based
standard on caring for patients with chest tubes, only
patients in the two CTVS wards were considered for this
pilot project instead of implementing hospital-wide.
The project was carried out in two CTVS adult wards
in NUH and consisted of four phases.
Phase 1: pre-implementation of practice
(7 March 2011–28 March 2011)
After a team of six members had been assembled, the
team proceeded to search for evidence in the Joanna
Briggs Institute (JBI) COnNECTþ database, where the ‘Evi-
dence Summary and Best Practice’ sheets could be found.
Best practice recommendations on monitoring
(‘Chest-Drains: Monitoring’)7 and maintaining chest
drains (‘Chest-Drains: Maintenance’)8 were retrieved
from the JBI database. On the basis of these recommen-
dations, a simple 12-step checklist was developed. The
items in the Chest Tube Checklist were related to:
insertion site dressing, tubing connection, drainage vol-
ume, bubbling, change in the colour of water in the
underwater seal and suction pressure. Performing
checks on the patient and the chest tube drainage
system and checking off each action performed on a
Chest Tube Checklist was considered as one check.
The audit criteria for assessing nurses’ compliance to
the new practice were also devised in phase 1. The audit
criteria for chest tube care were identified from JBI
Practical Application of Evidence System (PACES), an
online tool for data collection and analysis by the JBI.
These criteria were screened for suitability for this proj-
ect, and two criteria applicable to the project were then
adopted, listed as follows:
(1) The insertion site is checked daily and kept clean,
dry and free of odour.
(2) The chest drain is monitored for swinging and/or
bubbling and drainage.
59
 KLJ Gan and M Tan
As it had been observed prior to implementation of
the project that a visual guide on chest tube care was not
available to nurses for reference, the project team devel-
oped a visual aid showing a systematic method for
checking a chest tube drainage system for the nurses.
The focus was for nurses to check thoroughly from
patients’ end (insertion site) to the drainage’s end (drain-
age bottle). Single words and short phrases were used in
the visual aid to help nurses remember on what to check
for chest tube drainage systems. The visual aid aimed to
act as a resource or reference for nurses in providing care
for patients with chest tubes, and was an important
strategy for standardizing care and assessment.
As this was a pilot project on finding the best avail-
able evidence on managing patients with chest tube
drainage systems and implementing it, there was no
baseline audit done and hence no baseline compliance
data collected prior to implementation of the project.
Phase 2: implementation of practice (4 April
2011–9 May 2011)
Nurses in the two selected wards were educated on the
importance and correct use of the Chest Tube Checklist
and visual aid. A communication list was used to keep a
record of nurses who had attended the teaching sessions
and help the project team members to follow up those
who were absent from the sessions. After the teaching
sessions, the visual aid was placed in the nurses’ meeting
room so that nurses would have easy access and could
easily refer to it when in doubt about the chest tube care
best practice recommendations.
The use of the checklist was incorporated into the
nurses’ daily routine during handover of the report. The
Chest Tube Checklist was placed on patients’ clipboard
together with other monitoring charts, such as vital signs
and intake/output records. The chest tube drainage
system was checked according to the items in the
checklist, during routine physical checking of patients
at handover of report. The nurses would then document
the findings on the checklist.
Phase 3: post-implementation of practice
(9 May 2011–10 June 2011)
A post-implementation audit was conducted by direct
observation of nurses performing the checking of the
chest tube drainage system. One team member would
join in during shift handover and observe any nurse who
was performing physical checks on patients with chest
tubes, to see if nurses were compliant to the steps in the
Chest Tube Checklist. Ten registered nurses were audited
according to the JBI audit criteria. Data gathered from
the chest tube checklists and audits were analysed in the
60 International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
JBI PACES. The outcomes were presented to nurses of the
two selected wards. The team members convened a
meeting to review barriers and feedback received during
the implementation phase. The team improved the
current checklist based on the feedback, and devised
a follow-up plan.
Phase 4: follow-up phase (5 August 2011–16
February 2012)
Checking for subcutaneous emphysema at the dressing
site and bacterial filter change per patient were added to
the checklist based on the feedback given by nurses. The
presence of any subcutaneous emphysema at the chest
tube insertion site must be reported, and monitoring for
its extent is important as the patient’s airway can be
compromised in severe cases.2 The hospital’s standard
operating procedure also states to ‘palpate for crepitus at
the insertion site to detect subcutaneous emphysema’
and to ‘check disposable hydrophobic bacteria filter
between the chest tube bottle and the pump’.
With these new additions in the revised Chest Tube
Checklist (Table 1), now with a total of 14 items, the audit
criteria (Table 2) and visual aid (Fig. 1) were amended to
include the changes. JBI PACES criteria on chest tube care
used in the audit tool were updated to include a third
criterion – ‘check for air infiltration at insertion site’. The
items on the checklist were also grouped under four
subheadings (insertion site, tubing connection, suction,
drainage bottle) to provide a clearer overview of the
sequence of steps. Visual aid pictures were grouped
according to the four main subheadings in the Chest
Tube Checklist, so as to help the nurses correlate the
images with the items in the checklist. The nurses were
briefed on the improvements made to the checklist and
the visual aid.
The Chest Tube Checklist was used by the nurses to
care for patients with chest tubes, whereas the audit tool
was used by the auditors to monitor the nurses’ com-
pliance in following the steps involved for checking
patients with chest tubes. After another 2 weeks of
implementation with the new checklist, a second audit
was conducted. In addition, survey questionnaires were
distributed to nurses in the two CTVS wards to solicit
their perspectives on the Chest Tube Checklist. Data from
the checklists, audits and surveys were analysed.
Ethical considerations
This is an evidence-utilization quality project; therefore,
ethical approval was not sought. However, confidential-
ity and anonymity of data were maintained throughout
the project. Individual patient’s as well as nurses’ data
were not collected and thus there was no identifiable
 IMPLEMENTATION PROJECT

Table 1. Chest Tube Checklist

H ¼ Yes X ¼ No NA ¼ not
applicable
Date:
Time:

Insertion site Dressing is dry and intact, and free of odour

Absence of subcutaneous emphysema in the surrounding skin
Exposed tube marking from ___________
Tubing connection Correct connector size
Connection is secured
Not clamped
Not kinked
Suction Correct suction port
Bacterial filter change per patient
Correct pressure
Drainage bottle Drainage <200 ml/h
Oscillation
No air leak
Colour of underwater seal unchanged
Initial
Remarks

information in this quality improvement project. All data
collected were accessible only to the authors.
Results
Checking off each item on the Chest Tube Checklist was
considered as one check. A total of 309 checks were
recorded during the first implementation phase. Of these
309 checks, 36 near-miss events (11.6%) were detected:
6 (1.9%) were due to wrong suction pressure; 14
(4.5%) were due to bubbling; 3 (1.0%) were related to
a change in the colour of the water in the underwater
seal and 13 (4.2%) were due to loose connection. The first
post-implementation audit showed that the compliance
of registered nurses to the monitoring of the underwater

Table 2. Audit tool

Audit tool: chest tube and chest drainage system
Date:
Ward No./Bed No.:
JBI PACES Criteria Mode of audit: observation Met Not Met Remarks
C1: The chest drain is Exposed tube marking
monitored for swinging Correct connector size
and/or bubbling and drainage Connection is secured
Not clamped
Not kinked
Correct suction port
Bacterial filter change per patient
Correct pressure
Drainage <200 ml/h
Oscillation
No air leak
Colour of underwater seal unchanged
C2: The insertion site is checked Dressing is dry and intact, and free of odour
daily and should be kept clean,
dry and free of odour
C3: The site is assessed for air infiltration Absence of subcutaneous emphysema in the surrounding
skin
Chest tube and chest drainage system. JBI, Joanna Briggs Institute.

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 KLJ Gan and M Tan

Chest tube management

Insertion site Tubing

Secured
connection
Dressing dry and intact
nil odour

Not clamped

Marking
Correct connector size

Nil subcutaneous
emphysema
Not kinked

Drainage bottle Suction

Filter change
per patient

Drainage < 200 mls/hr

Correct pressure Correct suction

port

Air leak Wrong

suction port

Oscillation

Colour
unchanged

Figure 1. Visual aid.

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 IMPLEMENTATION PROJECT

0
0

Criterion
70
1 91 Cycles
1st Audit
90 2nd Audit
2 78

3 100

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Compliance %
Criteria
1. Monitor oscillation and/or bubbling and drainage
2. Check for dressings that are dry and clean
3. Check for air infiltration at insertion site

Figure 2. Rate of compliance of nurses.

seal, suction pressure and connector were 100%, check-
ing of dressings 90%, and monitoring of oscillation and/
or bubbling and drainage 70%.
The second post-implementation audit concluded
with 407 checks, out of which 57 near-miss events
(14%) were detected: 15 (3.7%) were related to the
insertion site; 2 (0.5%) were related to tubing; 3 (0.7%)
were related to suction and 37 (9.1%) were related to
drainage bottle events. In the second post-implementa-
tion audit, the compliance of registered nurses to the
monitoring of the chest tube insertion sites for air
infiltration was 100%, checking of dressings 78%, and
monitoring oscillation and/or bubbling and drainage
91%. Figure 2 shows a comparison between the results
of the first and second audits using the JBI PACES. The
second audit had an additional criterion (criterion 3) due
to the revised audit tool derived in phase 4 of the follow-
up phase.
Fisher’s exact test was conducted to determine the
statistical significance between the results of the first
and second post-implementation audits (Table 3). The
improvement in nurses’ compliance in monitoring oscil-
lation, bubbling and drainage, from 70 to 91%, was not
statistically significant, probably due to the small sample
sizes in both the audits.
Nurses from the two wards were also surveyed to
solicit their perspectives on the Chest Tube Checklist.
Forty-five registered nurses completed the question-
naire, out of which 51% had more than 1–2 years of
nursing experience, 27% had 3–4 years of nursing
experience, and 22% had at least 5 years of
nursing experience. Among the nurses surveyed,
94% agreed that the checklist had improved patient
care and 90% of the nurses agreed it had been helpful
for the performance of physical checks on patients. As
to whether using the checklist had been an additional
workload, 35% of the nurses felt it did not pose an
additional workload to them, whereas 47% of the
nurses were neutral. Responses for the open-ended
question included views that the checklist had pro-
vided a standard of care for checking chest tube
drainage systems in patients; the use of the checklist
decreased variability in care and assessment of chest
tube drainage systems, and might benefit patient
safety. Nurses also mentioned that the visual aid
was helpful in acting as a visual reminder or reference
for them on chest tube care.
Discussion
Near-miss events detected in the first and follow-up
implementation phases showed that, with the use of
the checklist, nurses were alerted to problems within the
chest tube drainage system during handover and were
able to intervene immediately to prevent further com-
plications. This was evident by the remarks documented
at the ‘Remarks section’ of the checklist to explain in
detail if an item was not checked. The remarks included
interventions taken by nurses to resolve problems. How-
ever, some nurses failed to provide an explanation in the
‘Remarks section’ for items that had not been met, and
failure to do so could compromise patients’ safety
because important information was not relayed to
nurses on the next shift or on subsequent shifts. A study
by Pothier et al.9 showed that verbal handover resulted
in the loss of all data after three handover cycles,
compared with traditional note-taking which saw 31%
of data transferred correctly, and a typed handover sheet
which had minimal data loss. Hence, the project team
emphasized the importance of documentation and
reinforced the use of the checklist as a handover tool
and for reference during handover, instead of relying on
the verbal report. Nurses on subsequent shifts would
then be informed of the resolved problems from the
previous shift, a new problem that warrants medical

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 KLJ Gan and M Tan
Table 3. Sample size and degree of compliance
JBI PACES criteria 1st audit
Sample size Met criteria (%)
C1: Monitor oscillation and/or 10 7 (70%)
bubbling and drainage
C2: Check for dressings that 10 9 (90%)
are dry and clean
JBI, Joanna Briggs Institute.
team’s attention or a recurring one that had been noted
by them.
The two audits showed encouraging results, as well as
highlighted areas for improvement. There was an
increase from 70 to 91% in nurses’ compliance to
monitoring for oscillation and/or bubbling and drainage,
whereas nurses’ compliance to checking for air infiltra-
tion at the insertion site achieved a good rate of 100% in
the second audit. However, team members whom the
nurses knew were performing the audits by direct
observation and might have some influence on the
nurses’ actions – that is, observer-expectancy effect or
the Hawthorne effect – thus affecting compliance rate.
The Hawthorne effect refers to the tendency of people
changing their behaviour because of the fact that they
are being observed as patients in a research context.10 In
the second audit, not all results were as satisfactory as
the first: nurses were found to be less compliant to
checking the state of dressing at the insertion site, with
a decrease in compliance by 12%. Reinforcement of new
practice is constantly required and important to the
success of evidence implementation. It can be accom-
plished by reiterating the purpose(s) for the change and
demonstrating the correct way to use new checklists and
carry out new procedures.11 Perhaps, highlighting the
‘end-to-end’ process may help nurses remember to
check chest tube drainage systems starting from the
patients’ end (i.e. the insertion site) to the drainage’s end
(i.e. the drainage bottle). Being part of a team, nurses
should also make a conscientious effort to remind
one another to check chest tube drainage systems
thoroughly to prevent potential complications in
patients.
The checklist was incorporated into nurses’ daily
routine of physical check and at handover, and used
as a standard care for the management of chest tube
drainage systems to prevent omission of care and
adverse events. Checklists are increasingly being recom-
mended as tools to improve care processes and patients’
safety.12 According to JBI’s best practice evidence
summary regarding nursing handover,13 the use of
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©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
2nd audit P value (Fisher’s
exact test)
Sample size Met criteria (%)
23 21 (91%) 0.149
23 18 (78%) 0.395
documentation (i.e. care plans, standardized handover
forms) during the handover process is recommended.
Although the introduction of a new checklist might
be perceived by some nurses as increasing documen-
tation, the survey results reflected that nurses generally
supported the implementation of the chest tube check-
list, and only 18% of the nurses felt that the checklist
resulted in additional workload. The team reinforced the
benefits of using the checklist and were open to feed-
back so that modifications could be done to make the
checklist more user-friendly.
Other barriers encountered during the project
included the following: some nurses took more time
to accept change, to gather all the nurses during the
planned teaching sessions was difficult and there were
communication gaps on the progress of the project.
Nurses who supported the change in practice were
encouraged to influence other nurses who took a longer
time to accept the change with positive peer pressure.
The former group shared with the latter group the
benefits of using the checklist for patients and nurses.
An increasing amount of evidence has shown that peer
pressure can promote cooperative behaviours.14 Individ-
uals are more agreeable to change when they identify
the need for change.15 The team members who worked
alongside the nurses during the implementation phases
reminded them to use the checklist when they forgot to
do so.
Some nurses who missed the teaching sessions were
given one-to-one teaching when they returned to work.
Apart from ensuring that all nurses were aware of
the change in practice, there was also a need to ensure
that the nurses felt they were actively involved in the
project. When nurses were able to contribute to
decision-making in practice, they were likely to have a
stronger connection to their work setting.16 Therefore,
the team gave regular updates to nurses on the progress
of the project and provided them with opportunities
for clarification.
Given the positive findings and feedback demon-
strated in this pilot project, the team hopes to

disseminate the use of the Chest Tube Checklist to other
wards in the hospital in phases. However, due to the
project’s small sample size of patients and nurses, further
studies conducted with bigger sample sizes, in different
specialty wards and over a longer period are needed to
determine the impact of using the checklist. Auditing
nurses’ use and acceptance of the new practice in a
discreet manner rather than direct observation should
be considered in future studies to reflect real practice
behaviour.
Conclusion
The visual aid and handover checklist in this project
helped nurses to familiarize with the management of
chest tube drainage systems. Using a systematic guide to
observe and monitor patients with chest tubes
enhanced the effectiveness of nursing care. It allowed
nurses to detect problems within the chest tube drain-
age systems early and prevent adverse events from
occurring. However, nurses’ compliance to checking
chest tube drainage systems in a systematic manner
still needs monitoring and periodical reinforcement. In
general, most of the nurses involved in this project
supported the implementation of the Chest Tube Check-
list. With the use of the checklist extended to other wards
and incorporated as the standard of care hospital-wide,
safe care could be provided to patients with chest tubes
in the near future.
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IMPLEMENTATION PROJECT
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