To Use or Not to Use Digital Drains for the Standard of Care

This debate, held at the Drainology Symposium “New Perspectives in Postoperative Management of Thoracic Surgery Patients” at the AATS 2024, outlines two perspectives on adopting digital drainage systems in thoracic surgery. Dr. Mitzman advocates for them as the standard of care, citing benefits like continuous air leak monitoring, improved decision-making, and cost-effectiveness despite higher initial expenses. Dr. Crabtree, while acknowledging the advantages in reliability and patient mobility, argues that inconsistent trial evidence and challenges in proving cost-utility make it difficult to justify the shift from analog systems to administrators.

To Use or Not to Use Digital Drains for the Standard of Care:The Pro Perspective

Brian Mitzman, MD, MS

Thoracic surgeon, Huntsman Cancer Institute, University of Utah

Key Message 

Toward a Digital Standard of Care

The Case for Digital Drainage Systems as Standard of Care

Dr. Mitzman presented the favorable perspective on adopting digital drainage systems as the standard of care after thoracic surgery. He took the position that digital drains should be standard of care, they already are in parts of the EU, and that the United States is behind the rest of the world in this respect.

Reducing Interobserver Variability – Less Confusion

Digital drainage systems reduce interobserver variability,¹ which reduces staff confusion and errors. As he put it, “you can trust anyone to look at the drain and just read you back the number.” When shifts change, confusion between team members is reduced because nurses are not required to interpret a manual drawing on the side of a primitive, analog drain.

Digital Drainage Protocols – Objective Removal Criteria

With regard to air leak management objective scales and algorithms have been developed based on analog drain data.² For example, Dr. Robert Cerfolio has previously proposed criteria of air leak < 20 ml/min, no spikes over 50 ml/min in the previous 6 hours, and a negative pleural assessment. Even so, analog drains confound observer agreement and assessment typically occurs only twice per 24 hours, missing spikes. Digital systems provide quantitative, continuous flow data in ml/min, enabling objective assessment of air leak in which acute readings relate to longitudinal trends. They may be programmed to alert the team when removal criteria have been met. Dr. Mitzman says this gives him and his team greater comfort in making the decision to remove a chest tube.

Additional Benefits

Other benefits include portable, regulated suction, replacing the need for wall suction to enable earlier patient mobilization, and improved satisfaction of both staff and patients. While digital drainage systems are more expensive than analog systems, the results of a number of published studies, as well as a formal analysis by the UK National Institute for Health Excellence, have found digital drain management reduces length of stay and is cost-effective.^3‑10

To Use or Not to Use Digital Drains for the Standard of Care: The Con Perspective

Traves Crabtree, MD

Professor and Chairman, Department of Cardiothoracic Surgery

Southern Illinois University School of Medicine

Key Message

Toward a Digital Standard of Care

The Case Against Digital Drainage Systems as Standard of Care

Dr. Crabtree was tasked with arguing against digital drainage systems as a new standard of care in thoracic surgery. He noted that he was not against digital drain technology per se, but approached his position from a pragmatic point of view. He agreed with Dr. Mitzman that analog methods for air leak assessment and chest tube management yield inconsistent and highly variable results, and that digital drainage systems address this issue—in fact, he noted that he could appreciate the value of consistent, reliable readouts with trainees and less experienced staff. He also cited the built-in regulation of intrapleural pressure, without being tethered to wall suction, as a clear advantage for fostering patient mobility. All things being equal, Dr. Crabtree asserted, digital drainage systems should be standard of care.

Administrative Hurdles

From a pragmatic standpoint, however he argued that a digital standard of care was a hard case to make to administrators, given mixed evidence regarding the cost-utility of digital drainage systems. Unfortunately, there has been a great deal of inconsistency in the way that randomized controlled trials have been conducted—likely reflecting the widespread variation in chest tube management practices and the inability to blind patients or clinicians to the intervention. That inconsistency has confounded the ability to definitively determine what effect, if any, digital drainage systems have on chest tube duration and hospital length of stay. Since reduced length of stay appears to be a principal driver of cost savings, it is currently difficult to prove cost-utility.

How to Overcome Hurdles

For surgeons hoping to convince their administrators of the value of digital drainage systems, Dr. Crabtree offered the following points when asking a hospital for support:

Digital drainage systems 

• improve efficiency & consistency of chest tube care

• improve patient satisfaction

• improve staff satisfaction

• improve patient mobility

• potentially decrease length of stay, and more data are needed