Orders for Chest Drainage

Q. Hi, I am a practicing clinical RN at a adult transplant ICU in a large teaching hospital. The residents in our hospital always argue with me on how to write chest tube orders. So there is water seal, which does not require any suction, except gravity. Sometime they would write -20 cm water seal suction. Is this a valid order to write? My understanding is that you either put it to water seal, or -20 cm water suction, which is control by the chamber to the most left in Atrium Ocean model. Please help me. Thank you very much.

A. Unfortunately, I was unable to find any standards for how orders are written for chest drainage. However, there are some interesting studies about communicating accurately and potential errors that can result from communication errors, which is what you describe.

All patients with chest tubes have a water seal (or a mechanical equivalent in dry seal drains) which is the one-way valve that allows air to leave the chest and prevents it from re-entering. Applying suction to the chest tube is an option; as you describe, some patients have suction applied and others do not. It seems that the physician literature uses the term “water seal” to describe a situation in which suction is not being used. I have used and prefer to describe a drain with no suction as being “gravity drainage,” since it describes how drainage is leaving the chest. If you have suction, the negative pressure pulls air and fluid out of the chest; without suction, it is the pressure differential caused by the position of the drain below the chest – gravity — that allows air and fluid to drain.

Using this terminology, orders would read:

  • Chest drain to -XX cmH2O suction drainage
  • Chest drain to gravity drainage

But, as the literature shows, being “correct” may not be as safe as being consistent in terminology. I’m sure you have been through inservices on handoffs, but clear orders are equally important.1-3 Root causes of sentinel events have consistently been communication problems more than 60% of the time since 1995.2 One study of malpractice claims showed communication errors were postoperative 32% of the time, between one transmitter and one receiver 64%, information communicated was inaccurately received 44%, and between persons from two different disciplines 34% of the time1 – each of these factors apply to your concern.

How can this problem be addressed? First, a common terminology needs to be agreed to by a multidisciplinary team of nurses and surgeons. (I’m sure with a little investigation, you’ll see chest drainage is not the only terminology issue.) Standardized postoperative orders and clinical pathways incorporating the agreed upon terminology will not only reinforce the terms but set standards so deviations can be clarified (suction not ordered when expected and vice versa).3 Finally, house staff need to be oriented to hospital policy and protocol; one survival skills curriculum presented through the month of July focuses on communication skills, writing orders and progress notes, and problem solving by simulating “midnight” calls from nurses about a variety of patient scenarios.4 This would be an ideal opportunity to clarify just the issue you raise.

1. Greenberg CC, SE Regenbogen, DM Studdert, et al.: Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg Apr 2007;204(4):533-540. 17382211

2. O’Byrne WT, 3rd, L Weavind, J Selby: The science and economics of improving clinical communication. Anesthesiol Clin Dec 2008;26(4):729-744, vii. 19041626.

3. Stahlfeld KR, JM Robinson, EC Burton: What do physician extenders in a general surgery residency really do? J Surg Educ Sep-Oct 2008;65(5):354-358. 18809165.

4. Todd SR, BN Fahy, J Paukert, ML Johnson, BL Bass: Surgical intern survival skills curriculum as an intern: does it help? Am J Surg Dec 2011;202(6):713-718; discussion 718-719. 22019283.