Role of the pleural clinical nurse specialist in improving the patient pathway

Background: Malignant pleural effusion often presents as an emergency, has a high symptom burden and poor prognosis. Reducing time spent on the diagnosis and inpatient bed days is vital. Service provision using trainee physicians is challenging, given variable thoracic ultrasound (TUS) and procedural competencies. Delivery of pleural education is also challenging, prompting development of a Pleural Clinical Nurse Specialist (CNS) role within a tertiary pleural disease centre. Methods: The Pleural CNS was appointed in January 2019 (1WTE), using funding from a charity partner (Action on Asbestos). Essential training needs were identified including formal TUS training, education sessions alongside a consultant, attendance at local anaesthetic thoracoscopy (LAT) lists and a LAT assistant’s course. A TUS and procedure book was kept. Patients reviewed by the CNS were linked into the pleural service for MPE diagnosis and management. Results: Between Jan-Mar 2019, theory-based and observational learning was undertaken. Supervised pleural aspirations started in Mar 19. Activity since then has included 245 calls/email referrals, 34 clinics (including 113 patient reviews), 103 inpatient reviews, 28 MDTs, 40 LATs and education sessions in ED, HDU and wards. 45 aspirations have been performed (20/45 unsupervised) and 3 supervised chest drain inserted. No complications have occurred. 59 supervised TUS scans have been performed. Conclusion: The Pleural CNS provides an alternative service model that is not dependant on trainee physicians. Basic competencies can be acquired with clinical supervision. Future aims include developing a reactive ambulatory pleural pathway to reduce hospital admissions and diagnostic pathway time.