Standardising Pleural Management in Suspected Malignant Pleural Effusion Using a Structured Pre-Test Probability and RED Score-Guided Proforma: A Single-Centre Before-and-After Quality Improvement Project

BackgroundThe management of suspected malignant pleural effusion (MPE) is often variable, with many patients undergoing repeated pleural aspirations before a definitive management decision is made.The RED (respiratory rate, effusion depth and dyspnoea) score is a recently derived and validated tool that predicts the time to the next pleural fluid drainage procedure.We describe a single-center, before-and-after quality improvement project (QIP) evaluating the introduction of a structured proforma incorporating clinical pretest probability and the RED score into routine pleural clinic assessment. MethodsA retrospective baseline cycle (Cycle 1, n=48) was compared with a prospective intervention cycle (Cycle 2, n=26) following the implementation of a structured assessment pro forma.The primary outcome was the proportion of patients experiencing unplanned emergency admission or earlier-than-planned pleural clinic review within three months of the index pleural procedure.Secondary outcomes included the proportion of patients requiring more than two pleural procedures and the proportion of patients achieving definitive pleural management within three months.Categorical variables were compared using Fisher's exact test given the small sample sizes; results are presented with risk differences, 95% confidence intervals, and odds ratios where calculable.No a priori power calculation was performed, and this exploratory before-and-after design does not permit causal inferences. ResultsIn Cycle 1, 16/48 patients (33.3%) experienced an emergency admission or unplanned pleural clinic review, compared with 2/26 (7.7%) in Cycle 2 (Fisher's exact test, P=0.021; risk difference -25.6%, 95% CI -42.5 to -8.8; odds ratio 6.0).The proportion of patients requiring more than two pleural procedures fell from 33.3% to 22.7% (P=0.415,not statistically significant).Cytology was positive in 24/48 (50.0%)Cycle 1 patients and 10/26 (38.5%)Cycle 2 patients.The two cohorts differed descriptively in performance status (Eastern Cooperative Oncology Group (ECOG) ≥2:41.7% vs. 87.5%,P<0.001) and malignancy type distribution.RED scores were documented only anecdotally within free-text clinical notes for a subset of Cycle 2 patients and were not systematically recorded or analyzed as a distribution. ConclusionsA structured pleural assessment pathway was associated with a statistically significant reduction in emergency presentations and a non-significant reduction in repeated procedures.However, given the small, single-center, non-randomised, uncontrolled before-and-after design, differing case mix between cohorts, and incomplete RED score documentation, these findings should be regarded as preliminary and hypothesis-generating.They support further, larger, multicenter evaluations rather than immediate wider adoption.