Simple Actions May Reduce Postop Pulmonary Complications

Troy Brown

June 05, 2013

A postoperative care program focused on simple interventions and multidisciplinary care may reduce common pulmonary complications, according to a before-after trial.

Michael R. Cassidy, MD, from the Department of Surgery at Boston University Medical Center, Massachusetts and colleagues report their findings online June 5 in JAMA Surgery.

The study compared pulmonary outcomes from the National Surgical Quality Improvement Program (NSQIP) before and after implementation of I COUGH. I COUGH is a multidisciplinary program consisting of Incentive spirometry, Coughing and deep breathing, Oral care (brushing teeth and using mouthwash twice daily, Understanding (patient and family education), Getting out of bed frequently (at least 3 times daily), and Head-of-bed elevation.

"Ultimately, our aim was not to demonstrate the superior efficacy of a solitary intervention but rather to support the concept that a multidisciplinary standard of care, encompassing multiple interventions, can have a positive effect on patient outcomes," the authors write.

The researchers compared outcomes for all patients who underwent vascular or general surgery at their institution before I COUGH implementation (January 1 to December 31, 2009) and after (July 1, 2010, to June 30, 2011).

According to a pre–I COUGH nursing practice audit, 80.4% of 250 patients were in bed during the visit, and 19.6% of patients were in a chair or walking. Post–I COUGH audits showed a significant difference, with 69.1% (P < .001) of 250 patients out of bed. Before implementation, most patients had the head of their bed elevated, and that remained the case after implementation (82.7% and 91.5%, respectively; P = .40).

The nursing audit also showed that just over half (52.8%) of patients had an incentive spirometer nearby before I COUGH. After I COUGH, 77.2% of patients had one nearby and used it with appropriate frequency (P < .001).

The incidence of postoperative pneumonia was 2.6% (1569 cases) during the year before implementation of I COUGH; this was similar to the period recorded previously. During the year after I COUGH implementation, the incidence of pneumonia decreased to 1.6% (1542 cases; P = .09). Incidence rates of pneumonia at similar hospitals during the same periods range from 1.4% to 1.7%.

Before I COUGH, the observed-to-expected (OE) ratio for pneumonia (based on risk-adjusted NSQIP data) was 2.13 (95% confidence interval [CI], 1.52 - 2.90), which was similar to prior years. This fell to an odds ratio of 1.58 (95% CI, 1.06 - 2.36) after I COUGH implementation.

Before I COUGH, the incidence of unplanned intubations was 2.0% (1569 cases), a rate similar to that in the previous period. This fell to 1.2% (1542 cases; P = .09) after I COUGH implementation. At similar hospitals, that figure ranged from 1.4% to 1.6%. According to risk-adjusted NSQIP data, the OE ratio of unplanned intubations decreased from 2.10 (95% CI, 1.42 - 2.98) before I COUGH to an odds ratio of 1.31 (95% CI, 0.87 - 1.97) after I COUGH implementation.

"Despite not reaching clinical significance, this study has many positive outcomes. Cassidy and his colleagues have shown that creating a multidisciplinary team that implements simple measures involving the pulmonary care of the surgical patient can improve outcomes and lower medical costs," writes Bruce J. Leavitt, MD, from the Department of Surgery at Fletcher Allen Health Care in Burlington, Vermont, in an invited commentary. Dr. Leavitt was not involved in the study.

The authors and Dr. Leavitt have disclosed no relevant financial relationships.

JAMA Surg. Published online June 5, 2013.

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