TABLE 2.
Results of each Delphi round.
| Item number | Delphi round 1 | Delphi round 2 | Delphi round 3 | Delphi round 4 | Final version of item | ||||
|---|---|---|---|---|---|---|---|---|---|
| Mean; median; SD | Modification | Mean; median; SD | Modification | Mean; median; SD | Modification | Mean; median; SD | Modification | ||
| 1. Obtains informed consent |
6.0 7.0 2.0 |
Added subtext: “Except in urgent cases” |
6.88 7.0 0.314 |
Modified to “May not be possible in emergent cases” |
6.77 7.0 0.682 |
N/A |
6.77 7.0 0.628 |
N/A | 1. Obtains informed consent
|
|
2. (Originally checklist item #3) Positions patient appropriately
|
6.55 7.0 0.831 |
Added to text: “in a supported manner” Cut from first subtext: “with arms resting on a table with a pillow” Cut from third subtext: “(with ipsilateral hand behind or above head if planning lateral approach)” Added fourth subtext: “Alternatively: supine oblique, as when performing procedure under CT guidance” |
6.88 7.0 0.314 |
Moved from Step #3 to Step #2 Modified first subtext to: “Sitting on edge of bed and leaning forward” |
6.88 7.0 0.314 |
N/A |
6.77 7.0 0.628 |
N/A | 2. Positions patient appropriately in a supported manner
|
|
3. (Originally checklist item #4) Inspects chest wall |
6.44 7.0 0.831 |
N/A |
6.33 7.0 1.56 |
Moved from Step #4 to Step #3 |
6.77 7.0 0.682 |
N/A |
6.55 7.0 0.831 |
N/A | 3. Inspects chest wall |
|
4B. (Originally checklist item #5) Identifies effusion or pneumothorax (as applicable) via ultrasound |
5.44 6.0 2.006 |
Added to text: “or CT” |
6.88 7.0 0.314 |
Moved from Step #5 to Step #4 |
7.0 7.0 0 |
Cut step from checklist |
(Cut from final checklist) Identifies effusion or pneumothorax (as applicable) via ultrasound or CT |
||
|
4. (Originally checklist item #6) Uses ultrasound as a guide to mark an appropriate site of entry
|
5.55 6.0 1.892 |
Modified to “Using ultrasound or CT as a guide, marks an appropriate site of entry” Cut “Ideally, an intercostal space one to two ribs below the upper level of fluid” |
6.44 7.0 0.955 |
Moved from Step #6 to Step #5 |
6.33 7.0 1.247 |
Moved from Step #5 to Step #4 Modified to “Using imaging (e.g., US or CT) as a guide …” |
6.44 7.0 1.571 |
N/A | 4. Using imaging (e.g., US or CT) as a guide, marks an appropriate site of entry |
|
5. (Originally checklist item #8) Opens kit |
6.22 7.0 1.872 |
N/A |
7.0 7.0 0 |
Moved from Step #8 to Step #6, before step “Washes hands” |
7.0 7.0 0 |
Moved from Step #6 to Step #5 |
7.0 7.0 0 |
N/A | 5. Opens kit |
|
6. (Originally checklist item #7) Washes hands |
6.22 7.0 1.872 |
N/A |
7.0 7.0 0 |
Swapped positioning to come after step “Opens kit” |
6.66 7.0 0.942 |
Moved from Step #7 to Step #6 |
6.66 7.0 0.942 |
N/A | 6. Washes hands |
|
7. (Originally checklist item #9) Applies cap, mask, sterile gown |
6.33 7.0 1.05 |
Modified to “Dons appropriate personal protective equipment” |
7.0 7.0 0 |
Moved from Step #9 to Step #8 |
6.77 7.0 0.682 |
Moved from Step #8 to Step #7 |
6.88 7.0 0.314 |
N/A | 7. Dons appropriate personal protective equipment |
|
8. (Originally checklist item #10) Applies sterile gloves |
6.66 7.0 0.942 |
N/A |
7.0 7.0 0 |
Moved from Step #10 to Step #9 |
7.0 7.0 0 |
Moved from Step #9 to Step #8 |
7.0 7.0 0 |
N/A | 8. Applies sterile gloves |
|
9. (Originally checklist item #11) Arranges material appropriately, including placing straightening catheter in pigtail |
6.11 7.0 1.286 |
N/A |
7.0 7.0 0 |
Moved from Step #11 to Step #10 Modified to “Arranges materials appropriately, including placing internal stiffener into pigtail catheter” |
6.88 7.0 0.314 |
Moved from Step #10 to Step #9 |
6.66 7.0 0.942 |
N/A | 9. Arranges materials appropriately, including placing internal stiffener into pigtail catheter |
|
10. (Originally checklist item #12) Preps over marked site and surrounding skin with chlorhexidine or appropriate alternative |
6.77 7.0 0.628 |
N/A |
7.0 7.0 0 |
Moved from Step #12 to Step #11 |
7.0 7.0 0 |
Moved from Step #11 to Step #10 |
7.0 7.0 0 |
N/A | 10. Preps over marked site and surrounding skin with chlorhexidine or appropriate alternative |
|
11. (Item did not exist in initial checklist) |
N/A | Created new item #13: “Applies sterile drape, leaving only the procedure site exposed” |
7.0 7.0 0 |
Moved from Step #13 to Step #12 |
6.88 7.0 0.314 |
Moved from Step #12 to Step #11 |
7.0 7.0 0 |
N/A | 11. Applies sterile drape, leaving only the procedure site exposed |
|
12. (Originally checklist item #2) Performs a preprocedure timeout immediately before procedure
|
6.77 7.0 0.628 |
Posed question to experts: “Should the step above (“time out”) be positioned as is or immediately after step 7 “Washes hands”? |
7.0 7.0 0 |
Moved from Step #2 to Step #13 Cut “doing procedure” Posed question to experts: “Should the step above (“time out”) be positioned as‐is? If not, after which step should it be placed?” |
7.0 7.0 0 |
Moved from Step #13 to Step #12 Modified to “verification of patient ID” Added text “(including laterality)” |
7.0 7.0 0 |
N/A | 12. Performs a preprocedure time out immediately before procedure
|
|
13. Reconfirms that puncture site is on the superior aspect of lower rib of the selected intercostal space
|
6.33 7.0 1.247 |
Moved from Step #13 to Step #14 |
6.44 7.0 0.955 |
Modified to “Confirms that the marked entry site is immediately above the lower rib bordering the selected intercostal space” |
6.22 7.0 1.314 |
Moved from Step #14 to Step #13 |
6.44 7 1.065 |
N/A | 13. Confirms that the marked entry site is immediately above the lower rib bordering the selected intercostal space |
14. Injects lidocaine at site of procedure
|
6.77 7.0 0.415 |
Moved from Step #14 to Step #15 |
7.0 7.0 0 |
Modified text to “Injects local anesthetic (for example, lidocaine) at the entry site” Modified subtext to three separate subtext points: “Using 25‐ to 22‐G needle, creates a superficial wheal” “Then injects deeper into skin, aspirating before each injection for evidence of blood or entry into pleura” “When pleural fluid or air is obtained, notes depth, and injects additional 2–3 mL of anesthetic to anesthetize the parietal pleura” |
6.66 7.0 0.942 |
Moved from Step #15 to Step #14 Changed subtext “injects additional 2–3 mL of anesthetic” to “injects additional anesthetic” |
7.0 7.0 0 |
Added to subtext point 3: “pulls back needle slightly” | 14. Injects local anesthetic (for example, lidocaine) at the entry site
|
15. After reconfirming position immediately above the rib, uses appropriate blade to make a superficial skin incision that is parallel to the rib
|
6.77 7.0 0.628 |
Moved from Step #15 to Step #16 |
7.0 7.0 0 |
Modified second subtext to “Keeps incision superficial, enabling entry of catheter through the epidermis without causing injury to deeper structures” |
6.66 7.0 0.942 |
Moved from Step #16 to Step #15 |
7.0 7.0 0 |
N/A | 15. After reconfirming positioning immediately above the rib, uses appropriate blade to make a superficial skin incision that is parallel to the rib
|
| 16. Attaches appropriate sized syringe to large hollow bore needle hub (typically, an 18‐G needle is used) and after reconfirming position immediately above the rib, introduces needle through the incision site |
6.22 7.0 1.474 |
Moved from Step #16 to Step #17 Added subtext “If using real‐time imaging guidance, use of a syringe may be omitted” |
6.66 7.0 0.94 |
Modified text to “Attaches appropriately sized syringe to the hub of a large hollow‐bore needle” |
6.66 7.0 0.942 |
Moved from Step #17 to Step #16 |
6.33 7.0 1.885 |
N/A | 16. Attaches appropriately sized syringe to the hub of a large hollow‐bore needle (typically, an 18‐G needle is used) and after reconfirming position immediately above the rib, introduces needle through the incision site
|
| 17. While inserting needle, continuously aspirates syringe to immediately recognize fluid or air return from pleural space |
6.0 7.0 2.0 |
Moved from Step #17 to Step #18 Added subtext “If using real‐time imaging guidance, this step may be omitted” |
6.66 7.0 0.94 |
N/A |
6.88 7.0 0.314 |
Moved from Step #18 to Step #17 |
7.0 7.0 0 |
N/A |
17. While inserting needle, continuously aspirates syringe in order to immediately recognize fluid or air return from pleural space
|
|
18. Removes syringe from needle hub while carefully maintaining position of needle
|
6.0 7.0 2.0 |
Moved from Step #18 to Step #19 Posed question to experts: “Should the subtext pertaining to ‘places gloved thumb over hub of needle’ be kept or removed?” Added subtext “If using real‐time imaging guidance, use of a syringe may be omitted” |
6.55 7.0 0.955 |
Cut subtext “Once syringe removed, places gloved thumb over hub of needle” |
7.0 7.0 0 |
Moved from Step #19 to Step #18 |
7.0 7.0 0 |
N/A | 18. Removes syringe from needle hub while carefully maintaining position of needle
|
|
19. Threads guidewire through hollow‐bore needle
|
6.44 7.0 1.065 |
Moved from Step #19 to Step #20 Modified first subtext to “The guidewire should be inserted at least several centimeters beyond the tip of the needle” Cut second subtext |
7.0 7.0 0 |
Modified text to “Threads guidewire through the hollow‐bore needle” Modified second subtext to “If resistance to guidewire insertion is encountered, stops and reconfirms placement of needle” |
7.0 7.0 0 |
Moved from Step #20 to Step #19 |
7.0 7.0 0 |
N/A | 19. Threads guidewire through the hollow‐bore needle
|
| 20. While continuously holding guidewire, removes hollow‐bore needle from site |
7.0 7.0 0 |
Moved from Step #20 to Step #21 |
7.0 7.0 0 |
Modified text to “While continuously holding guidewire, removes hollow‐bore needle” |
7.0 7.0 0 |
Moved from Step #21 to Step #20 |
7.0 7.0 0 |
N/A | 20. While continuously holding guidewire, removes hollow‐bore needle |
| 21. While continuously holding guidewire, inserts dilator with a clockwise/counterclockwise twisting motion over guidewire until an abrupt loss of resistance (i.e. “give”) is felt |
6.33 7.0 1.563 |
Moved from Step #21 to Step #22 Modified text to “While continuously holding guidewire, inserts dilator over guidewire until an abrupt loss of resistance (i.e. ‘give’) is felt.” Added subtext “Subsequently, using small back and forth movement (racking) of the guidewire, confirms that it is freely moving and not kinked.” |
6.55 7.0 0.955 |
Modified text to “While continuously holding guidewire, inserts dilator over guidewire” Added subtext “The appropriate depth of dilator placement may be determined using the previously noted depth in Step 15 and/or when an abrupt loss of resistance (i.e., ‘give’) is felt” |
6.88 7.0 0.314 |
Moved from Step #22 to Step #21 |
6.88 7.0 0.314 |
N/A | 21. While continuously holding guidewire, inserts dilator over guidewire
|
| 22. While continuously holding guidewire, removes dilator |
6.88 7.0 0.314 |
Moved from Step #22 to Step #23 |
6.88 7.0 0.314 |
N/A |
6.88 7.0 0.314 |
Moved from Step #23 to Step #22 |
6.88 7.0 0.314 |
N/A | 22. While continuously holding guidewire, removes dilator |
| 23. While continuously holding guidewire, inserts pigtail catheter (with straightening catheter in place) over the guidewire, stopping if any resistance is noticed |
6.88 7.0 0.314 |
Moved from Step #23 to Step #24 Added subtext “Keeps inserting until the tip is inside the pleura, then advances only the pigtail and not the straightening catheter” |
7.0 7.0 0 |
Modified text “straightening catheter” to “internal stiffener” Modified subtext “inserting” to “advancing” |
6.33 7.0 1.885 |
Moved from Step #24 to Step #23 |
7.0 7.0 0 |
N/A | 23. While continuously holding guidewire, inserts pigtail catheter (with internal stiffener in place) over the guidewire, stopping if any resistance is noticed.
|
| 24. Removes guidewire and straightening catheter together while placing finger/thumb tip over exposed hub |
6.875 7.0 0.330 |
Moved from Step #24 to Step #25 Modified text to “Removes the guidewire, and then, removes the straightening catheter” Posed question to experts: Should the text pertaining to “while placing finger/thumb tip over exposed hub” be kept or removed?” |
7.0 7.0 0 |
Modified text “straightening catheter” to “internal stiffener” |
7.0 7.0 0 |
Moved from Step #25 to Step #24 |
6.33 7.0 1.247 |
N/A | 24. Removes the guidewire and then removes the internal stiffener |
|
25. (Originally checklist item #26) Attaches catheter tubing to chest drain tubing and secures tightly via twisting motion.
|
7.0 7.0 0 |
Moved from Step #26 to Step #27 |
7.0 7.0 0 |
Moved from Step #27 to Step #26 |
7.0 7.0 0 |
Moved from Step #26 to Step #25 Modified first subtext “as desired” to “as appropriate” Added second subtext “Alternatively, attaches catheter tubing to a Heimlich valve” |
7.0 7.0 0 |
N/A | 25. Attaches catheter tubing to chest drain tubing and secures tightly via twisting motion.
|
|
26. (Originally checklist item #27) Secures chest tube in place using either a sterile suture or alternate device |
6.77 7.0 0.628 |
Moved from Step #27 to Step #28 |
6.66 7.0 0.666 |
Moved from Step #28 to Step #27 |
7.0 7.0 0 |
Moved from Step #27 to Step #26 |
7.0 7.0 0 |
N/A | 26. Secures chest tube in place using either a sterile suture or alternate device |
|
27. (Originally checklist item #25) Obtains a small amount of fluid for diagnostic workup if indicated, using the side/flushing port and a syringe (e.g., 60‐mL syringe) |
6.44 7.0 0.684 |
Moved from Step #25 to Step #26 Modified text to “Obtains fluid for diagnostic workup if indicated, using the side/flushing port (if available) and a syringe” Posed question to experts: “Should the above step take place as is, after the next step “Attaches catheter tubing to chest drain tubing and secures tightly via twisting motion,” OR after the following step: “Secures chest tube in place using either a sterile suture or alternate device?” |
6.66 7.0 0.942 |
Moved from Step #26 to Step #28 Modified text to “Obtains fluid for diagnostic workup if indicated, using the side/flushing port and a syringe (e.g., 60‐mL syringe)” |
7.0 7.0 0 |
Moved from Step #28 to Step #27 |
7.0 7.0 0 |
N/A | 27. Obtains fluid for diagnostic workup if indicated, using the side/flushing port and a syringe (e.g., 60‐mL syringe) |
| 28. Places a clear dressing over the catheter entry site |
6.22 6.0 0.785 |
Moved from Step #28 to Step #29 Modified to “Places a dressing over the catheter entry site” |
6.77 7.0 0.628 |
N/A |
6.88 7.0 0.314 |
Moved from Step #29 to Step #28 Modified to “Places a dressing at the catheter entry site” |
7.0 7.0 0 |
N/A | 28. Places a dressing at the catheter entry site |
|
28B. (Originally checklist item #29) Disposes of sharps appropriately |
6.88 7.0 0.314 |
Moved from Step #29 to Step #30 |
7.0 7.0 0 |
N/A |
7.0 7.0 0 |
Merged into item #29 “Cleans up” |
Merged into item #29 “Cleans up” (Disposes of sharps appropriately) |
||
|
29. (Originally checklist item #30) Cleans up |
6.22 7.0 1.872 |
Moved from Step #30 to Step #31 |
6.88 7.0 0.314 |
N/A |
6.33 7.0 1.885 |
Moved from Step #31 to Step #29 Added subtext “Disposes of sharps appropriately” |
7.0 7.0 0 |
N/A | 29. Cleans up
|
|
30. (Originally checklist item #31) Writes procedure note in appropriate space |
6.22 7.0 1.872 |
Moved from Step #31 to Step #32 |
7.0 7.0 0 |
Modified to “Writes procedure note” |
7.0 7.0 0 |
Moved from Step #32 to Step #30 |
6.77 7.0 0.628 |
N/A | 30. Writes procedure note |
|
31. (Originally checklist item #32) Orders a chest radiograph and interprets it |
5.88 7.0 1.852 |
Moved from Step #32 to Step #33 Modified to “Confirms appropriate catheter positioning via chest imaging” |
6.77 7.0 0.628 |
N/A |
7.0 7.0 0 |
Moved from Step #33 to Step #31 |
6.77 7.0 0.628 |
N/A | 31. Confirms appropriate catheter positioning via chest imaging |