Standardizing thoracostomy care across a regional trauma system: Outcomes of the TrAQ-T Initiative

Background: Chest tube insertion is common in major trauma but highly variable in practice, contributing to preventable complications, patient safety events, and prolonged hospital stays. To address these gaps, we launched the Island Health Trauma Accreditation and Quality: Thoracostomy (TrAQ-T) initiative to evaluate current care patterns, synthesize evidence, offer standardized staff training, and introduce standardized guidelines supported by digital chest drainage systems. Methods: We used Davidson’s breadth-and-depth mixed-methods to analyze large volumes of unstructured safety and mortality review data, identifying patterns in chest tube–related complications. A rapid review of local, provincial, and international guidelines was synthesized using GRADE Evidence-to-Decision criteria. Implementation planning was guided by the Three Streams and Integrative Model of Innovation Diffusion frameworks. Staff interviews and pre/post surveys informed training design. Regional trauma registry data were used to compare complications, mortality, and length-of-stay. Results: Pre-implementation analysis revealed substantial variation in insertion technique, drainage management, and clinical endpoints. Failure points were concentrated in physician ordering practices and nursing monitoring, with inconsistent protocols contributing to safety events. This informed development of an evidence-based clinical practice guideline addressing tube size selection, insertion technique, prophylactic antibiotics, suction protocols, and standardized endpoints while discouraging low-value practices such as routine clamp trials and post-pull chest radiographs. Training uptake reached 68.8% among physicians and 76.4% among nurses. Pre/post surveys across 14 proficiency domains demonstrated no reductions in clinical competence and significant improvements in four: cardiopulmonary assessment (p = .011), monitoring intrathoracic negativity (p = .001), device integrity monitoring (p = .017), and management of accidental dislodgement (p = .006). Staff strongly preferred the Thopaz digital chest drainage system over analog drainage across safety, ease of use, and overall quality (all p < .001). Clinical outcomes demonstrated an 81.8% relative reduction in chest tube–related complications (47.8% to 15.5%), a 69.7% relative reduction in mortality (16.1% to 2.9%), and a 59.5% relative reduction in median length of stay (7.5 to 3.0 days) between the pre-intervention and post intervention three-month periods. These improvements aligned with previous meta-analyses demonstrating reduced complications, shorter stays, and improved workflow efficiency in post-operative patients with digital drainage. The project spread beyond trauma to critical care and pediatrics, supported by clinical governance structures. Staff acceptance, clear protocols, and strong local evidence were critical for early sustainability, with ongoing analyses evaluating long-term impact on safety events and imaging use. Implications and lessons learned: Implementing standardized chest tube guidelines and digital drainage across trauma services improved staff proficiency, reduced complications, and shortened hospital stays. The TrAQ-T initiative demonstrates that technology alone is insufficient; successful adoption requires evidence synthesis, clinician engagement, structured training, and strong social and organizational support. Our improvements in safety and efficiency suggest that the surgical literature supporting digital chest drainage may offer system-wide benefit that extends to trauma patients. Implications 1. Nurse confidence and competency in thoracostomy management is variable 2. Digital chest drainage systems support nursing practice and are preferred to traditional, analog systems 3. Our bundled thoracostomy quality improvement initiative reduced complications, mortality, and length of stay.