Impact of simulation-based training in surgical chest tube insertion on a model of traumatic pneumothorax
© The Author(s) 2016
Received: 8 February 2016
Accepted: 31 May 2016
Published: 10 June 2016
Chest tube insertion is required for most cases of traumatic pneumothorax. However, this procedure entails risks of potentially life-threatening complications. A “surgical” approach is widely recommended to minimize these risks. Simulation-based education has previously been used in surgical chest tube insertion, but not been subjected to rigorous evaluation.
The primary objective was to evaluate the success rate of surgical chest tube insertion in a task trainer (previously published). Secondary objectives were to assess performance with a performance assessment scale (previously designed), to measure the time of insertion, and to seek out a correlation between the learner’s status, experience, and performance and success rate. Participants were surveyed for realism of the model and satisfaction; 65 participants (18 residents, 47 senior physicians) were randomized into SIM+ or SIM− groups. Both groups received didactic lessons. The SIM+ group was assigned deliberate practice on the model under supervision. Both groups were assessed on the model 1 month later.
There was no difference between the SIM+ (n = 34) and SIM− (n = 31) groups regarding status (p = 0.44) or previous surgical insertion (p = 0.12). Success rate was 97 % (SIM+) and 58 % (SIM−), p = 0.0002. Performance score was 16.29 ± 1.82 (SIM+) and 11.39 ± 3.67 (SIM−), p = 3.13 × 10−8. SIM+ presented shorter dissection time than SIM− (p = 0.047), but procedure time was similar (p = 0.71). Status or experience was not correlated with success rate, performance score, procedure time, or dissection time. SIM+ gained more self-confidence, judged the model more realistic, and were more satisfied than SIM−.
Simulation-based education significantly improved the success rate and performance of surgical chest tube insertion on a traumatic pneumothorax model.
Insertion of a chest tube is a mandatory procedure for treatment of a significant traumatic pneumothorax [1, 2]. However, this procedure remains somewhat difficult, stressful, and at risk of potentially life-threatening complications [3–10]. Numerous physicians acknowledge their lack of training and feel uncomfortable carrying out a chest tube insertion, particularly in a young patient [11, 12]. Furthermore, many physicians may have difficulty supervising novices while inserting a chest tube with a surgical approach . For three decades, simulation-based education has been developed, allowing learners to gain competence and develop their skills through performance in a safe environment, prior to practice in a clinical setting [14–20]. Nevertheless, no study to date has reported a rigorous evaluation of the benefit of simulation on surgical approach for chest tube insertion.
The aim of this study was to evaluate the benefit of simulation-based education on the performance and success rate of surgical insertion of a chest tube on a model of traumatic pneumothorax.
This was a prospective, randomized, controlled, bicentric study, carried out from May 2013 to October 2013 in the Simulation Laboratory of the Faculty of Medicine of Poitiers and in the Medical Center of Cayenne, French Guyana, after approval by the Institutional Research Board (Scientific Committee of the Faculty of Medicine of Poitiers, file number 11–37). All participants signed an informed consent form. Results were kept anonymous.
The primary objective was to evaluate the success rate of surgical insertion of a chest tube in a task trainer simulator of traumatic pneumothorax.
The secondary objectives were (1) to assess the performance of insertion procedure according to a performance assessment scale, (2) to measure the global procedure time and dissection time during insertion, (3) to seek out a correlation between the learner’s status, experience, and performance and success rate, and (4) to survey the learners for their evaluation of the realism of the model, self-confidence, and satisfaction after simulation experience.
Sixty-five healthcare providers (18 residents and 47 senior emergency physicians), representing two groups of registered participants (Poitiers and Cayenne) for the pediatric emergency procedure course at the University of Poitiers (carried out in Poitiers and in Cayenne), were given a chance to participate.
Since the surgical approach is rarely taught and practiced in France, all participants received a 1-h academic lesson, prior to the simulation session, on current international recommendations for surgical chest tube insertion for traumatic pneumothorax [1, 21–24]. This didactic lesson was performed by three Advanced Trauma Life Support (ATLS)-certified supervisors. The session consisted in a presentation of the currently recommended safest approach to chest tube insertion in case of traumatic pneumothorax: landmarks on the medio-axillary line, in the fourth or fifth intercostal space [21, 22, 25], use of a tube without chuck or handle, dissection of chest wall muscular layers with a Kelly clamp, followed by insertion of a gloved finger probing into the chest cavity to confirm pleural placement, and strip any adhesions facing the insertion site . In small children, it is recommended to tunnel the chest tube by a skin incision at the underlying intercostal space. This provides a subcutaneous path for securing the tube and avoids its falling out due to a thin chest wall .
Randomization was based on a list of 65 random numbers—even numbers for SIM+ and odd ones for SIM− group allocation. The SIM+ group participants (n = 34) were assigned for deliberate practice on the simulator just after the didactic lesson, whereas the SIM− group participants (n = 31) were not assigned any simulation practice. The SIM+ group participants had the opportunity to practice several times (mean = four times) on the simulator with immediate feedback from the supervisor. The SIM− group participants were exposed 5 min to the simulator and its environment (webcam, laptop, chest tube equipment) but did not perform chest tube insertions. One month later, all participants (SIM+ and SIM−) were evaluated during an assessment session on the simulator.
Every participant received a questionnaire on clinical experience in chest tube insertion—especially surgical approach—before the didactic lesson and during the month that followed prior to the assessment on the simulator. We arbitrarily distinguished experienced participants who had inserted at least five chest tubes (with a surgical approach) during the last 5 years from novices who had inserted less than five or none during the same span time.
At the end of the study, all participants were offered a chance for deliberate practice on the simulator with supervision.
Success was assessed on the laptop connected to the webcam using two criteria: (1) sudden loss of resistance while passing through pleural membranes (one could hear the “pop” of the penetration in the pleural space) and (2) insertion of the chest tube without resistance over at least 10 cm (at or over the third black bar). Assessment of performance was carried out by an independent observer expert in surgical approach for chest tube insertion (ATLS-certified or ATLS instructor), who was neither a supervisor nor a research investigator. He was unaware of the breakdown into two groups. Four observers participated in the assessment (two emergency physicians, one intensivist, and one pediatric intensivist). All were trained for surgical chest tube insertion assessment according to a specific scale that we had previously designed and validated . It included eight steps, detailing the procedure: asepsis, local anesthesia, cutaneous incision and dissection of the thoracic wall, confirmation of insertion, introduction of the chest tube with a Kelly clamp, securing the water seal tubing, securing the chest tube, and location of the incision site (which was examined by the observer after the procedure had been completed). Each item was ranked 1 (correctly performed) or 0 (not done or incorrectly performed). The maximum total score was over 20 points. This scale had acceptable internal coherence (Cronbach’s alpha coefficient = 0.747) and high inter-observer reproducibility (intra-class correlation coefficient = 0.966). Because of the webcam connected to a laptop inside the model, the observer could assess the performance of the extra- and intrathoracic steps of the procedure.
Timing of the different steps of the procedure was recorded. A stopwatch was started at the beginning of the procedure (t0) to record different times: beginning of the cutaneous incision (t1), chest tube passing through the skin (t2), connection of chest tube to water seal tubing (t3), and end of the procedure after securing the chest tube on the skin (t4). Dissection time was consequently defined as t2 − t1.
After each chest tube insertion, a debriefing was performed by the observer, and all the observers were trained in debriefing by good judgment . Videotape replay during debriefing could render participants aware of their gaps in performance .
After each assessment, the participant was asked to fill out a questionnaire on realism of the model, self-confidence, and overall satisfaction with simulation-based education using 10-point Likert scales.
Analysis was carried out on Biostat TGV software and Excel 2010. Descriptive analysis included percentage, mean, and standard deviation (SD) of every variable. Comparative analysis used paired Student’s t test, with an ANOVA for repeated measures when necessary. Correlation between training and performance or success rate used Spearman’s test. Correlation between success and performance used Pearson’s test. A p value of <0.05 was considered as significant.
Comparison of SIM+ and SIM− groups according to status and previous clinical experience of participants
(n = 34)
(n = 31)
8 (23 %)
10 (32 %)
26 (77 %)
21 (68 %)
Novices (<5 drains)
25 (74 %)
17 (55 %)
Experienced (≥5 drains)
9 (26 %)
14 (45 %)
Comparison of success rate, performance score, procedure time, and dissection time according to group allocation, status, and previous clinical experience
(n = 34)
(n = 31)
Success rate (%)
Performance score (M ± SD)
16.29 ± 1.82
11.39 ± 3.67
Procedure time (M ± SD)
10 min 19 s ± 2 min 19 s
10 min 7 s ± 2 min 9 s
Dissection time (M ± SD)
2 min 1 s ± 1 min 2 s
2 min 37 s ± 1 min 17 s
(n = 47)
(n = 18)
Success rate (%)
Performance score (M ± SD)
14.32 ± 3.58
13 ± 4.14
Procedure time (M ± SD)
10 min 20 s ± 2 min 17 s
9 min 57 s ± 2 min 5 s
Dissection time (M ± SD)
2 min 8 s ± 1 min 3 s
2 min 43 s ± 1 min 26 s
(n = 23)
(n = 42)
Success rate (%)
Performance score (M ± SD)
14.22 ± 3.18
13.81 ± 4.07
Procedure time (M ± SD)
10 min 13 s ± 2 min 29 s
10 min 14 s ± 2 min 5 s
Dissection time (M ± SD)
2 min 13 s ± 1 min 7 s
2 min 21 s ± 1 min 14 s
Details of the scores (mean ± standard deviation) obtained at the different steps of the performance assessment scale for the SIM+ and SIM− groups
Steps of the scale (maximum score)
n = 34
n = 31
Antiseptic procedure (3)
2.61 ± 0.65
2.36 ± 0.66
Location of incision site (1)
0.94 ± 0.23
0.69 ± 0.47
Local anesthesia (1)
0.88 ± 0.33
0.85 ± 0.37
Incision and dissection (6)
4.41 ± 0.70
2.43 ± 1.31
Confirmation of location (2)
1.62 ± 0.69
0.98 ± 0.91
Introduction of chest tube with a Kelly clamp (4)
3.28 ± 1.03
2.46 ± 1.09
Securing water seal tubing (1)
0.81 ± 0.38
0.23 ± 0.42
Securing chest tube (2)
1.74 ± 0.44
1.39 ± 0.61
16.29 ± 1.82
11.39 ± 3.67
There was no difference in the procedure time between SIM+ and SIM−, p = 0.71. By contrast, the SIM+ group had a shorter dissection time than the SIM− group, p = 0.047. There were no correlations between status and procedure time (p = 0.52) or dissection time (p = 0.16), nor between a participant’s previous experience and procedure time (p = 0.98) or dissection time (p = 0.65) (Table 2). Status was not correlated with either performance score (p = 0.24) or success rate (p = 0.94).
There was no difference between experienced participants and novices regarding performance score (p = 0.66) or success rate (p = 0.54) (Table 2).
Comparison of the assessment of realism of the model, gain in self-confidence, and global satisfaction according to the group (on a 0–10 scale). Mean ± standard deviation
(n = 34)
(n = 31)
Realism of the model
7.65 ± 1.01
6.97 ± 0.83
Gain in self-confidence
7.94 ± 0.69
7.55 ± 0.93
8.21 ± 0.88
7.71 ± 0.74
On a traumatic pneumothorax model, simulation-based education was associated with higher success rate and performance score. These results were directly due to the simulation training, with no influence of status or previous clinical experience in surgical chest tube insertion. To our knowledge, this is the first study reporting the benefit of simulation-based education on success rate and performance for a surgical chest tube insertion.
This study nevertheless presented some limitations. All participants were registered for the pediatric emergency procedure university course, which could have represented a confounding factor. The SIM− participants were exposed to the model only 5 min prior to the evaluation. Therefore, on evaluation day, they might have been surprised and experienced a lack in confidence, higher stress, and poorer performance due to ignorance of how the model would respond to their approach . Nevertheless, the fact that assessment was performed 1 month after initial didactic and training reduced this déjà-vu phenomenon in the SIM+ group and might have counterbalanced the lack of familiarity with the task trainer of the SIM− group.
Discussion about the primary objective
The results of the present study on the benefit of simulation-based education for surgical chest tube insertion are similar to those reporting the increase of success rate for non-surgical chest tube insertion after simulation training [15–17, 19]. One distinctive feature of the present study is to have reported that simulation increased not only the success rate but also the performance assessment score . This approach could reveal that, as expected, the specific “surgical” steps of the procedure were those that benefit the most from simulation training. In fact, there was a high correlation between success and performance score. During the validation process of the performance assessment scale, a score ≥14 was always found to be associated with a functional chest tube .
Discussion about secondary objectives
Simulation-based education was not associated with a decrease in procedure time for surgical chest tube insertion, as one would have expected. However, dissection time—the crucial step of the surgical procedure—significantly decreased in the SIM+ group. This implied that failure of surgical chest tube insertion was associated with poor mastery of this major step of the procedure [20–22].
Surprisingly, there was no effect of status or previous experience on the performance or success rate of surgical chest tube insertion [5, 30]. This fact might be related to the rarity of this technique (surgical approach) in France and a consequent need for adequate training, according to the recommendations . Besides that, it underlines the fact that only simulation-based training was responsible for the gain in performance and success rate.
Compared with SIM− participants, SIM+ group participants judged the training model more realistic (with more anatomic features), probably because they had been trained on it repeatedly a month earlier. Similarly, there was a higher gain in self-confidence in the SIM+ group. But these differences were minimal. Indeed, self-confidence is a major issue in the performance of a stressful procedure or when the practitioner is uncomfortable with the procedure because of his/her scarce experience [11, 12]. The satisfaction rate was high in both groups—more pronouncedly in SIM+—thereby implying that participants are particularly receptive and attracted to simulation-based education as a means of improving technical skills [14, 26, 30, 31].
We think that simulation-based education for surgical chest tube insertion can be spread to other groups of learners with the same results, in initial learning (residents) as well as continuous education (emergency physicians, intensivists) [5, 6, 13–15]. We observed that one simulation attempt did not suffice to achieve 100 % success for the whole group. This observation underscores the great interest of repeated simulation training for low-volume/high-stake procedures [20–22]. Finally, the assessment session was scheduled 1 month after the initial didactic session in both groups and simulation training in the SIM+ group. This delay might have been short as regards the occurrence of clinical surgical chest tube insertion (in our occupational field) and performance scores may have been better in simulation than in reality [16, 20, 30, 32]. Future studies should investigate if practicing on a task trainer improves the performance of the technique when performed on human subjects.
Simulation-based education significantly improved the success rate and performance of surgical chest tube insertion on a traumatic pneumothorax model. This benefit was explained by a better mastery of the chest wall dissection step. It was accompanied by an increase in self-confidence contributing to performance and success. Such training appears well suited to an infrequent, difficult procedure, responsible for potential severe complications if poorly performed.
Future studies should investigate the frequency of repetition of simulation sessions as a way of sustaining the benefit of simulation-based education.
We are grateful to our colleague—Dr Paul Contal—who consented for the publication of his picture while using our model for chest tube insertion (Fig. 1). Furthermore, we would like to thank Jeffrey Arsham, an American medical translator, for having reviewed the English-language text.
DO is responsible for the content of the manuscript, including the data analysis. DO had the idea of the project and supervised the whole process of research and writing. AL and AG contributed substantially to the study design, analyzed the literature, and wrote the text. AG supervised the data management. FP, YG, and ABV contributed substantially to the assessment phase. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Alrahbi R, Easton R, Bendinelli C, Enninghorst N, Sisak K, Balogh ZJ. Intercostal catheter insertion: are we really doing well? ANZ J Surg. 2012;82:392–4.View ArticlePubMedGoogle Scholar
- Cullinane DC, Morris JA JR, Bass JG, Rutherford EJ. Needle thoracostomy may not be indicated in the trauma patient. Injury. 2001;32:749–52.View ArticlePubMedGoogle Scholar
- Millikan JS, Moore EE, Ateiner E, Aragon GE, Van Way III CW. Complications of tube thoracostomy for acute trauma. Am J Surg. 1980;140:738–41.View ArticlePubMedGoogle Scholar
- Bailey R. Complications of tube thoracostomy in trauma. J Accid Emerg Med. 2000;17:111–4.View ArticlePubMedPubMed CentralGoogle Scholar
- Sethuraman KN, Duong D, Mehta S, Director T, Crawford D, ST George J, et al. Complications of tube thoracostomy placement in the emergency department. J Emerg Med. 2011;40:14–20.View ArticlePubMedGoogle Scholar
- Chan I, Reilly KM, Henderson C, Kahn F, Salluzzo RF. Complication rates of tube thoracostomy. Am J Emerg Med. 1997;15:368–70.View ArticlePubMedGoogle Scholar
- Meisel S, Ram Z, Priel I, Nass D, Lieberman P. Another complication of thoracostomy—perforation of the right atrium. Chest. 1990;98:772–3.View ArticlePubMedGoogle Scholar
- Fraser RS. Lung perforation complicating tube thoracostomy: pathologic description of three cases. Hum Pathol. 1988;19:518–23.View ArticlePubMedGoogle Scholar
- Osinowo O, Softah A, Eid Zahrani M. Ectopic chest tube insertions: diagnosis and strategies for prevention. Afr J Med Med Sci. 2002;31:67–70.PubMedGoogle Scholar
- Remerand F, Luce V, Badachi Y, Lu Q, Bouhemad B, Rouby JJ. Incidence of chest tube malposition in the critically ill: a prospective computed tomography study. Anesthesiology. 2007;106:1112–9.View ArticlePubMedGoogle Scholar
- Elsayed H, Rebecca R, Emadi M, Whittle I, Shackcloth M. Chest drain insertion is not a harmless procedure—are we doing it safely? Interact Cardiovasc Thorac Surg. 2010;11:745–8.View ArticlePubMedGoogle Scholar
- Maritz D, Wallis L, Hardcastle T. Complications of tube thoracostomy for chest trauma. South Afr med J. 2009;99:114–7.Google Scholar
- Ball CG, Lord J, Laupland KB, Gmora S, Mulloy RH, Ng AK, et al. Chest tube complications: how well are we training our residents? Can J Surg. 2007;50:450–8.PubMedPubMed CentralGoogle Scholar
- Park CS, Rochlen LR, Yaghmour E, Higgins N, Bauchat JR, Wojciechowski KG, et al. Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training. Anesthesiology. 2010;112:202–11.View ArticlePubMedGoogle Scholar
- Yoshimura A, Kosaihira S, Morimoto T, Kim C, Tsueshita T, Adachi K, et al. An effective training program for chest tube drainage for medical interns in a clinical simulation laboratory. J Nippon Med Sch. 2012;79:403–8.View ArticlePubMedGoogle Scholar
- Homan CS, Viccellio P, Thode HC, Fisher W. Evaluation of an emergency-procedure teaching laboratory for the development of proficiency in tube thoracostomy. Acad Emerg Med. 1994;1:382–7.View ArticlePubMedGoogle Scholar
- Hishikawa S, Kawano M, Tanaka H, Konno K, Yasuda Y, Kawano R, et al. Mannequin simulation improves the confidence of medical students performing tube thoracostomy: a prospective, controlled trial. Am Surg. 2010;76:73–8.PubMedGoogle Scholar
- Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004;13:417–21.View ArticlePubMedPubMed CentralGoogle Scholar
- Hutton IA, Kenealy H, Wong C. Using simulation models to teach junior doctors how to insert chest tubes: a brief and effective teaching module. Intern Med J. 2008;38:887–91.View ArticlePubMedGoogle Scholar
- Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. Jama. 2011;306:978–88.PubMedGoogle Scholar
- American College of Surgeons. Chapter 4 Thoracic trauma, skill station VII: chest trauma management, skill VII-b chest tube insertion. In: advanced trauma life support, student course manual. 9th ed. Chicago: American College of Surgeons; 2012. p. 119–20.Google Scholar
- Kathleen M, Terndrup C, Terndrup T. Tube thoracostomy and needle decompression of the chest. In: King C, Henretig FM, editors. Textbook of pediatric emergency procedures. Baltimore: Williams & Wilkins; 2007. p. 389–407.Google Scholar
- Kirmani B, Zacharias J. Insertion of a chest drain for pneumothorax. Anaesth Intensive Care Med. 2013;14:163–5.View ArticleGoogle Scholar
- Durai R, Ng PCH. How to insert a perfect chest drain. Acta Chir Belg. 2009;109:652–4.View ArticlePubMedGoogle Scholar
- Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58 suppl 2:ii53–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Ghazali A, Brèque C, Léger A, Scépi M, Oriot D. Testing of a complete training model for chest tube insertion in traumatic pneumothorax. Sim Healthcare. 2015;10:239–44.View ArticleGoogle Scholar
- Ghazali A, Léger A, Petitpas F, Guéchi Y, Boureau-voultoury A, Oriot D. Development and validation of a performance assessment scale for chest tube insertion in traumatic pneumothorax. J Pulm Respir Med. 2016;6:346. doi:10.4172/2161-105x.1000346.Google Scholar
- Rudolph JW, Simon R, Raemer DB, Eppich WJ. Debriefing as formative assessment: closing performance gaps in medical education. Acad Emerg Med. 2008;15:1010–6.View ArticlePubMedGoogle Scholar
- Seagull FJ, Mackenzie CF, Xiao Y, Bochicchio GV. Video-based ergonomic analysis to evaluate thoracostomy tube placement techniques. J Trauma. 2006;60:227–32.View ArticlePubMedGoogle Scholar
- Jiang G, Chen H, Wang S, Zhou Q, Li X, Chen K, et al. Learning curves and long-term outcome of simulation-based thoracentesis training for medical students. Bmj Med Educ. 2011;11:39–42.View ArticleGoogle Scholar
- Carter YM, Wilson BM, Hall E, Marshall MB. Multipurpose simulator for technical skill development in thoracic surgery. J Surg Res. 2010;163:186–91.View ArticlePubMedGoogle Scholar
- Cumin D, Weller JM, Henderson K, Merry AF. Standards for simulation in anaesthesia: creating confidence in the tools. Br J Anaesth. 2010;105:45–51.View ArticlePubMedGoogle Scholar