Management of Parapneumonic Effusions

OBJECTIVE: To evaluate physician practices in managing patients with parapneumonic effusions and the impact of practice patterns on clinical outcome. DESIGN: Case series. SETTING: Private, tertiary care medical center. PATIENTS: Thirty-nine hospitalized patients with complicated parapneumonic effusions and a separate group of 191 patients admitted with community-acquired pneumonia. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Evaluation of physician practice patterns in managing complicated parapneumonic effusion and the impact of delaying thoracentesis (> or = 2 days after pleural fluid detection) or pleural drainage (> or = 2 days after pleural fluid criteria for drainage fulfilled) on duration of hospitalization, cost of hospitalization, and need for thoracotomy. RESULTS: Thirty-eight of the 39 patients with complicated parapneumonic effusions underwent thoracentesis that was "delayed" (5.7 +/- 3.1 days) in 16 patients. Delays in thoracentesis were associated with longer hospitalizations (P = .02). Laboratory tests ordered on nonpurulent pleural fluid were incomplete for 16 of 38 patients. Chest tube or surgical pleural drainage was delayed (4.2 +/- 3.5 days) in 10 of 38 patients who underwent thoracentesis. Delays in initiating drainage were associated with prolonged hospitalization (P = .04). Delaying interventions accounted for a mean cost increment per patient of $8462 for delayed thoracentesis and $9332 for delayed drainage. Of the 191 patients with community-acquired pneumonia, 99 (52%) had pleural effusions but only 15 (15%) underwent thoracentesis. CONCLUSIONS: Physicians commonly delay thoracentesis and chest tube drainage to observe parapneumonic effusions for improvement. This practice pattern is associated with longer and more costly hospitalizations.