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MTG9: Implementation of PleurX at the Christie NHS Foundation Trust in Manchester

In this podcast Dr Hans-Ulrich Laasch, Consultant Radiologist and one of the clinical expert advisers for the guidance, discusses what impact using PleurX has for clinicians and commissioners.

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This podcast was added on 22 Mar 2012

Podcast transcript

Implementation of PleurX at the Christie NHS Foundation Trust in Manchester

In this podcast Dr Hans-Ulrich Laasch, Consultant Radiologist and one of the clinical expert  advisers for the guidance, discusses what impact using PleurX has for clinicians and commissioners.

“So could you tell me a little bit more about Christie’s experience of using the system?”

“We started introducing PleurX about three years ago, and I must say it’s been a story of success. In my personal view it’s been the easiest procedure I’ve ever introduced that’s made the biggest difference. It allowed patients to stay at home, it has prevented repeat procedures, and it has given patients autonomy as well as control on if and when to prevent drainage. To date we have done about 75 abdominal PleurX insertions, which is not a large number of procedures considering the number of patients we treat, but that again comes back to careful patient selection.

“The technical aspects are extremely simple and there were no problems integrating this procedure into the portfolio of the radiology department. It’s been a slightly bigger challenge to roll out the PleurX care in the community to the very many districts that refer to the Christie. And it has required really probably about a year and a half of extensive training to ensure that the involved district nurses and the GP practices are comfortable with looking after patients with the PleurX drain. It is technically not difficult and it is of a lower level than for example caring for internal central line. However, it is still a relatively new device and adequate training of the involved staff has to be ensured.

“Our current pathway for PleurX insertion is as follows: at the point where the radiology department receives a referral for a PleurX insertion, we will contact the relevant district nurses or the patient’s GP and ensure that the nurses are trained, and if they are not trained then we will make an appointment with the distributor to ensure that the necessary arrangements are in place to allow the patients to be discharged as soon as possible. 

“One particular advantage of the PleurX drain that is poorly understood is that the patient can technically be discharged as soon as the drain has been sited. With paracentesis, the patient needs to stay in until as much fluid as possible is drained, but with the PleurX the drainage can be continued at home and the patient does not need to stay in hospital for a long period of time.

“For patients who we have got little experience in how they respond to drainage, we might want to keep them overnight. But we are increasingly working towards a day case service where the patient is discharged on the day as the procedure was performed. 

“In the context of palliative care, PleurX has been extremely successful of relieving patients’ symptoms, and keeping them comfortable towards the end of life.”

“In what ways is the PleurX system better than conventional treatment?”

“In the past, we have admitted patients for between four and five days for a standard paracentesis. We now do over 400 drainage procedures per year. If you extrapolate that equates to somewhere between 1,600-1,800 inpatient bed days per year, which would be the equivalent of having four or five inpatient beds solely reserved for paracentesis.

“Obviously being able to save that is of huge benefit to the institution, because we can now use these beds for patients who require chemotherapy, who require operations, and it’s a much better use of resources.

“One of the advantages that I don’t think are really recognised sufficiently is that it avoids further punctures. Once the drain is in, the patient does not need to require a further procedure, only a bottle connecting on the outside of the drain.”

“Are there any reasons why the patient might choose day-case paracentesis over PleurX in the first instance?”

“There is always a question of body image – it is obviously a foreign body that is implanted. Some patients find that concept unattractive. Other patients find the benefits of not having to be readmitted or not having further procedures preferable. It is a decision that every patient has to make on their own but obviously with the input of the treating oncology team.”

“What are the cost implications of the PleurX system in comparison with paracentesis?”

“It has been a bit difficult to add a firm price tag to it. There is no question that PleurX will save money. To what extent that applies depends on what services are currently provided, and whether patients require an inpatient admission for a normal paracentesis, or whether this can be done as a day case. It also depends on how frequently the patient needs to perform drainage. The more frequent it is, the more cost effective it is. The vacuum bottles that are required to connect to the PleurX system are relatively expensive as a single item but compared to an inpatient admission of four or five days, the cost savings are enormous, and they may range, on a conservative estimate, from somewhere between 300-400 to over 2000 per patient per month.”

“So what kind of numbers are we talking about in terms of the number of patients that are currently using PleurX?”

“To date we’re approaching now 80 PleurX insertions in the abdomen and the numbers are going up year-by-year, if not month-by-month. Some of it is making the referring oncology teams aware that this option is now available. However, in our institution we are probably performing less PleurX insertions than a comparable centre might do, because we have the additional option of offering our patients a day case, conventional drainage service.

“So considering the large number of drainage procedures we perform, it is still a relatively small proportion of patients that receive PleurX. That is to with the fact that we would only reserve PleurX for patients where we know that the ascites is going to come back and no further treatment is planned. But equally because we have the additional option of day case paracentesis, to some extent we let our patients make the decision which type of drainage they prefer in the first instance. We often find that patients prefer to have a day case paracentesis for a few times before they decide they want to have a PleurX inserted. And again that is something that the referring oncologist will decide on a case-by-case basis with the patient. We have no strict referral criteria and every patient is managed individually.”

“So Dr Laasch, what would say are the important take home messages from this guidance?”

“The NICE guidance confirms that the PleurX system is an effective way of managing malignant ascites. It has good patient outcomes, and there are good benefits to the institution.

“It should really be available as a routine treatment strategy in any centre that sees a significant number of cancer patients.”

“Dr Laasch, thank you very much.”

“It’s been a pleasure, thank you.”

“A range of tools are available from our website to support the implementation of this guidance. These include audit and costing tools, as well as an educational resource, slide set and clinical case scenarios.”

22 March 2012

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This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.

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This page was last updated: 19 September 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.