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Use of a Trauma Service Clinical Pathway to Improve Patient Outcomes for Retained Traumatic Hemothorax



Early evacuation of retained hemothorax (RHTX) has been shown to improve clinical outcomes. In 2006, our trauma surgery service instituted a clinical pathway for management of RHTX that was designed to decrease time to operation and improve patient outcomes. We report our experience with early evacuation of posttraumatic RHTX after instituting a service-wide clinical pathway.


From 2006 to 2007, 29 operations were performed by the trauma surgery service for RHTX. Using the clinical pathway, if patients had a persistent effusion on hospital day 2, the patient underwent thoracoscopic (VATS) evacuation of the hemothorax. A case control cohort (24 patients) was generated from 2003 to 2005 of operations for retained hemothorax before implementation of this pathway.


The mean age was 33.2 years. There was no difference in ISS between groups (p = 0.14). The study group had significantly decreased time to operating room (3.0 ± 0.33 days vs. 9.9 ± 2.0 days, P = 0.002) and shorter hospital stays (10.8 ± 0.8 days vs. 30.5 ± 5.8 days, P = 0.003). All 29 study patients had their hemothorax evacuated by VATS, whereas 14 of 29 control patients had evacuation attempted by VATS (P = 0.0003). There were no differences in complications or reoperation between groups. Total hospital charges for the study group were $46,471 in the study group compared with $126,221 in the control group (P = 0.03).


Implementation of a clinical pathway for early evacuation of retained hemothorax can significantly improve patient outcomes and decrease hospital costs. Furthermore, trauma surgeons are capable of safely performing thoracic surgery for evacuation of retained hemothorax.

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  1. Clarke DE, Fantus RJ et al (2007) National Trauma Data Bank 2007 annual report. American College of Surgeons.

  2. Mancini MC, Eggerstedt JM (2006) Hemothorax. e-Medicine website. Accessed 28 June 2006

  3. Hanley ME, Gruber MP (2003) Pneumothorax/hemothorax. In: Hanley ME, Welsh CH (eds) Current diagnosis and treatment in pulmonary medicine. McGraw-Hill

  4. Milfield DJ, Mattox KL, Beall AC (1978) Early evacuation of clotted hemothorax. Am J Surg 136:686–692

    Article  Google Scholar 

  5. Graham JM, Mattox KL, Beall AC (1979) Penetrating trauma of the lung. J Trauma 19:665–669

    PubMed  CAS  Article  Google Scholar 

  6. Coselli JS, Mattox KL, Beall AC (1984) Reevaluation of evacuation of clotted hemothorax. Am J Surg 148:786–790

    PubMed  Article  CAS  Google Scholar 

  7. Heniford BT, Carrillo EH, Spain DA et al (1997) The role of thoracoscopy in the management of retained thoracic collections after trauma. Ann Thorac Surg 63:940–943

    PubMed  Article  CAS  Google Scholar 

  8. Knottenbelt JD, van der Spuy JW (1994) Traumatic haemothorax: experience of a protocol for rapid turnover in 1845 cases. S Afr J Surg 32:5–8

    PubMed  CAS  Google Scholar 

  9. Abolhoda A, Livingston DH, Donahoo JS, Allen K (1997) Diagnostic and therapeutic video assisted thoracic surgery (VATS) following chest trauma. Eur J Cardiothorac Surg 12:356–360

    PubMed  Article  CAS  Google Scholar 

  10. Velhamos GC, Demetriated D, Chan L et al (1999) Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient. J Trauma 46:65–70

    Article  Google Scholar 

  11. Vassiliu P, Velhamos GC, Toutouzas KG (2001) Timing, safety, and efficacy of thoracoscopic evacuation of undrained post-traumatic hemothorax. Am J Surg 67:1165–1169

    CAS  Google Scholar 

  12. Meyer DM, Jessen ME, Wait MA, Estrera AS (1997) Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective randomized trial. Ann Thorac Surg 64:1396–1401

    PubMed  Article  CAS  Google Scholar 

  13. Navsaria PH, Vogel RJ, Nicol AJ (2004) Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg 78:282–286

    PubMed  Article  Google Scholar 

  14. Morales Uribe CH, Villegas Lanau MI, Petro Sanches RD (2008) Best timing for thoracoscopic evacuation of retained post-traumatic hemothorax. Surg Endosc 22:91–95

    PubMed  Article  Google Scholar 

  15. Condon R (1968) Spontaneous resolution of experimental clotted hemothorax. Surg Gynecol Obstet 126:505–515

    PubMed  CAS  Google Scholar 

  16. Livingston DH, Hauser CJ (2008) Chest wall and lung. In: Feliciano DV, Mattox KL, Moore EE (eds) Trauma, 6th edn. McGraw-Hill

  17. Smith RS, Fry WR, Tsoi AKM et al (1993) Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury. Am J Surg 166:690–695

    PubMed  Article  CAS  Google Scholar 

  18. Potaris K, Mihos P, Gakidis I, Chatziantoniou C (2007) Video-thoracoscopic and open surgical management of thoracic empyema. Surg Infect 8:511–517

    Article  Google Scholar 

  19. Davies CWH, Kearney SE, Gleeson FV, Davies RJO (1999) Predictors of outcome and long-term survival in patients with pleural infection. Am J Respir Crit Care Med 160:1682–1687

    PubMed  CAS  Google Scholar 

  20. Roberts JR (2003) Minimally invasive surgery in the treatment of empyema: intraoperative decision making. Ann Thoac Surg 76:225–230

    Article  Google Scholar 

  21. Cassina PC, Hauser M, Hilleja L et al (1999) Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome. J Thorac Cardiovasc Surg 117:234–238

    PubMed  Article  CAS  Google Scholar 

  22. Scherer LA, Battistella FD, Owings JT, Aguilar MM (1998) Video-assisted thoracic surgery in the treatment of posttraumatic empyema. Arch Surg 133:637–642

    PubMed  Article  CAS  Google Scholar 

  23. Liu DW, Liu HP, Lin PJ, Chang CH (1997) Video-assisted thoracic surgery in treatment of chest trauma. J Trauma 42:670–674

    PubMed  Article  CAS  Google Scholar 

  24. Lowdermilk GA, Naunheim KS (2000) Thoracoscopic evaluation and treatment of thoracic trauma. Surg Clin North Am 80:1535–1542

    PubMed  Article  CAS  Google Scholar 

  25. Velhamos GC, Demetriades D (1999) Early thoracoscopy for the evacuation of undrained haemothorax. Eur J Surg 165:924–929

    Article  Google Scholar 

  26. Villavicencio RT, Aucar JA, Wall MJ (1999) Analysis of thoracoscopy in trauma. Surg Endosc 13:3–9

    PubMed  Article  CAS  Google Scholar 

  27. Wong MS, Tsoi EK, Henderson VJ, Hirvela ER, Forest CT, Smith RS et al (1996) Videothoracoscopy an effective method for evaluating and managing thoracic trauma patients. Surg Endosc 10:118–121

    PubMed  CAS  Google Scholar 

  28. Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients’ care. Lancet 362:1225–1230

    PubMed  Article  Google Scholar 

  29. Lomas J, Sisk JE, Stocking B (1993) From evidence to practice in the United States, the United Kingdom, and Canada. Milbank Q 71:405–410

    PubMed  Article  CAS  Google Scholar 

  30. Cabana MD, Rand SC, Powe NR et al (1999) Why don’t physicians follow clinical practice guidelines? JAMA 282:1458–1465

    PubMed  Article  CAS  Google Scholar 

  31. Davis DA, Taylor-Vaisey A (1997) Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 157:408–416

    PubMed  CAS  Google Scholar 

  32. Grol R (2001) Successes and failures in the implementation of evidence-based guidelines for clinical practice. JAMA 286:2578–2585

    PubMed  Article  CAS  Google Scholar 

  33. Whitman G, Cowell V, Parris K et al (2008) Prophylactic antibiotic use: hardwiring of physician behavior, not education, leads to compliance. JACS 207:88–94

    Article  Google Scholar 

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Correspondence to C. Anne Morrison.

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Morrison, C.A., Lee, T.C., Wall, M.J. et al. Use of a Trauma Service Clinical Pathway to Improve Patient Outcomes for Retained Traumatic Hemothorax. World J Surg 33, 1851–1856 (2009).

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  • Improve Patient Outcome
  • Clinical Pathway
  • Tube Thoracostomy
  • Chest Tube Placement
  • Thoracoscopic Procedure