A multidisciplinary postoperative care program of patient and staff education, early patient mobilization, and pulmonary interventions has begun to reduce the excessive rate of postsurgical pulmonary complications at a large urban safety-net hospital, according to a report published online June 5 in JAMA Surgery (formerly Archives of Surgery).
"We are eager to monitor our outcomes over a longer period, and we are stimulated by the possibility that postoperative complications may be diminished by adherence to simple, inexpensive, easily performed patient care strategies," said Dr. Michael R. Cassidy of the department of surgery, Boston University Medical Center, and his associates.
When data collected in the National Surgical Quality Improvement Program (NSQIP) revealed that their center "was a high outlier for all measured postoperative pulmonary complications," the investigators formed a multidisciplinary group to address the problem.
BUMC is the largest safety-net facility in New England. The annual income of more than half of its patients is below $20,420, approximately 25% of its patients do not speak English, and 70% belong to racial or ethnic minorities, the investigators noted.
The committee included representatives from the hospital’s departments of surgery, nursing, and quality improvement, as well as from the units on respiratory therapy, preoperative assessment, infection control, and physical therapy. To devise a program to reduce the incidence of adverse pulmonary complications, these members reviewed the sparse literature regarding prevention of postoperative pneumonia and audited postsurgical pulmonary practices at their medical center.
The audit found that patients received no formal preoperative education about the importance of lung expansion, mobility, and other strategies to prevent pulmonary complications, and that families usually weren’t included in whatever minimal education did take place. In addition, physicians’ orders for nurses regarding postoperative pulmonary care "were irregular or absent."
The program that was then developed was given the acronym "I COUGH" to help physicians, nurses, patients, and families remember its key principles: Incentive spirometry, Coughing and deep breathing, Oral care, Understanding, Getting out of bed frequently, and Head-of-the-bed elevation. It was intended for all patients on the general surgery and vascular surgery services.
I COUGH included brochures, a video, and posters to educate patients, families, nurses, and physicians about the importance of pulmonary care. Proper use of incentive spirometry was demonstrated, the use of mouthwash and toothbrushing was recommended at least twice a day, and elevation of the head of the bed to at least 30 degrees was advocated. All this information was reinforced at preoperative clinic visits and in the preoperative holding area just before surgery. Nursing staff also reiterated the information after the procedures, as did surgeons, attending physicians, and house staff during rounds.
The effort also included standardized electronic physician order sets with "specific and detailed orders for all elements of the I COUGH program." These included instructions for patients to perform deep breathing and coughing every 2 hours; for patients to perform incentive spirometry 10 times every hour while awake; for nurses to document incentive spirometry volume every 4 hours and to ensure that the head of the patient’s bed was elevated to at least 30 degrees; for patients to walk at least once on the day of operation unless contraindicated; and for patients to get out of bed and sit in a chair for a while at least 3 times per day.
Dr. Cassidy and his associates then compared data collected during the year before I COUGH was implemented to that collected during the year afterward.
Before I COUGH, 80% of 250 patients were in bed at the time of the audit, with only 19.6% seated in a chair or walking. After I COUGH, 69.1% of 250 patients were out of bed. Before I COUGH, only 52.8% of patients had an incentive spirometer within reach and an unknown number were using it appropriately, whereas afterward 77.2% of patients had the device within reach and were using it appropriately. Both findings were statistically significant.
The incidence of postoperative pneumonia was 2.6% before I COUGH, which dropped to 1.6% in the year afterward (P = .09). Similarly, the incidence of unplanned intubations was 2.0% before I COUGH, which decreased to 1.2% afterward, the authors reported (JAMA Surg. 2013 June 5 [doi: 10.1001/jamasurg.2013.358]).
These successes are due in part to the involvement of the multidisciplinary team at all stages of development of the I COUGH program, the investigators said.
"We have not imposed a standard of care by mandate, but instead have involved nursing leadership and practicing ward and ICU nurses in the process of redefining the culture.