Challenges of Sustaining Momentum in Quality Improvement: Lessons from a Multidisciplinary Postoperative Pulmonary Care Program

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1 Challenges of Sustaining Momentum in Quality Improvement: Lessons from a Multidisciplinary Postoperative Pulmonary Care Program Michael R Cassidy, MD Pamela Rosenkranz, RN, BSN, MEd, and David McAneny MD, FACS ACS NSQIP National Conference San Diego, California July 14, 2013

2 We have no relevant financial relationships to disclose Michael R Cassidy, MD Pamela Rosenkranz, RN, BSN, MEd David McAneny MD, FACS

3 Postoperative Pulmonary Complications NSQIP definition includes Postoperative pneumonia Unplanned intubation Failure to liberate from mechanical ventilation Morbid Costly Some have estimated attributable cost at $52,466 per occurrence Ventilator-associated pneumonia is well described, but there is paucity of literature about prevention of non-vap postoperative pulmonary complications Smetana, G.W., Postoperative pulmonary complications: an update on risk assessment and reduction. Cleve Clin J Med, Suppl 4: p. S60-5. Dimick, J.B., et al., Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg, (4): p

4 Pneumonia Calendar Year 2009 Observed Rate: 2.55% O/E Ratio: 2.13 Status: Needs Improvement

5 Unplanned Intubation Calendar Year 2009 Observed Rate: 1.98% O/E Ratio: 2.10 Status: Needs Improvement

6 Objective To design, implement, and determine the efficacy of a standardized suite of To link outcomes to performance interventions for reducing postoperative measures over time pulmonary complications

7 Setting Boston Medical Center Merger of Boston City Hospital and Boston University Hospital An urban, academic, safety-net hospital 509 licensed beds One-quarter of patients do not speak English Racial and ethnic minorities constitute 70% of all patients

8 Pulmonary Care Working Group Composition Surgery (Attending Surgeons and Residents) Nursing (ICU and Ward Nurses) Quality Improvement NSQIP Team Respiratory Therapy Internal Medicine Preoperative Assessment Clinic Infection Control Physical Therapy Goals Consensus Lung expansion exercises Early frequent mobilization Oral hygiene Education Understand hospital practices Review literature on postoperative pulmonary care Multidisciplinary approach Bundled interventions Establish a simple, inexpensive suite of pulmonary care guidelines

9 I COUGH Incentive spirometry Cough and deep breathe Oral care (brushing teeth and using mouthwash twice daily) Understanding (patient, family, staff, nursing, and physician education) Get out of bed Head of bed elevation I COUGH SM is a registered service mark of Boston Medical Center Corporation

10 I COUGH Elements Preoperative and postoperative education of patients and families Brochures Videos Posters Multiple language translations IS demonstration Simple instructions Multiple settings Ongoing education & feedback for multi-disciplinary staff Performance assessment data Outcomes data Need for improvement Rationale for I COUGH interventions Standardized order sets

11 Nursing Audits Nursing practice was audited before and after implementation of I COUGH, with particular attention to Patients being out of bed Head of bed elevation Incentive spirometry availability Audits were performed three times daily by QI staff Nurses were unaware of initial audits

12 Pulmonary Care Trends Care Standard Pre-ICOUGH Percent Compliance Immediately Post- ICOUGH Out of Bed 20% 69% HOB > 30 o 91% 83% Incentive Spirometry 53% 77%

13 Postoperative Pneumonia 3 Before I COUGH I COUGH Transition After I COUGH Raw Data (%) 2 2 Risk Adjusted Ratio (O/E or OR) Pneumonia Raw Data BMC (%) Pneumonia Raw Data Comparable Hospitals (%) Pneumonia Risk Adjusted BMC (O/E or OR) July 08-June 09 CY 2009 July 09-June 10 CY 2010 July 10-June 11 1

14 Unplanned Intubation 2.3 Before I COUGH I COUGH Transition After I COUGH 2.3 Raw Data (%) Risk Adjusted Ratio (O/E or OR) Unplanned Intubation Raw Data BMC (%) Unplanned Intubation Raw Data Comparable Hospitals (%) Unplanned Intubation Risk Adjusted BMC (O/E or OR) July 08-June 09 CY 2009 July 09-June 10 CY 2010 July 10-June Cassidy MR, et al. I COUGH: Reducing Postoperative Pulmonary Complications with a Multidisciplinary Patient Care Program. JAMA Surgery, August 2013.

15 Pulmonary Care Trends Care Standard Pre-ICOUGH Percent Compliance Immediately Post- ICOUGH Two Years Post-ICOUGH Out of Bed 20% 69% 29% HOB > 30 o 91% 83% 74% Incentive Spirometry 53% 77% 41%

16 Postoperative Pneumonia 3.5 Before I COUGH I COUGH Transition After I COUGH Raw Data % Risk Adjusted Ratio BMC Pneumonia % Raw Data Comparable Hospitals % Raw Data BMC Risk Adjusted Data July 2008-June 2009 CY 2009 July 2009-June 2010 CY 2010 July 2010-June 2011 CY 2011 July 2011-June

17 Unplanned Intubation 3 Before I COUGH I COUGH Transition After I COUGH Raw Data % Risk Adjusted Ratio BMC Unplanned Intubation % Raw Data Comparable Hospitals % Raw Data BMC Risk Adjusted Data July 2008-June 2009 CY 2009 July June 2010 CY 2010 July 2010-June 2011 CY 2011 July 2011-June

18 Initial Keys to Success Involvement of multidisciplinary team Standardization of care Simplicity Education of patients and families Education of nurses, physicians, and staff

19 Failure of Momentum Loss of institutional support of audits and patient/family education Loss of QI Department support Inability to initially establish as standard of care across all subspecialty surgery services Failure to provide continuous performance feedback Misinterpretation of performance feedback as confrontational rather than collegial Loss of novelty; redirection of priorities

20 Rejuvenation of I COUGH Data collection, analysis, and presentation Control of pre-procedure clinic Risk assessment at every pre-procedure visit Smoking cessation support Respiratory therapy consults for high-risk patients Grants for AV support ICU efforts Mobilization Sedation vacations RN/RT initiated ventilator weans Biweekly ICU meetings

21 Pulmonary Care Trends Percent Compliance Care Standard Pre-ICOUGH Immediately Post-ICOUGH Two Years Post-ICOUGH NOW Out of Bed 20% 69% 29% 60% HOB > 30 o 91% 83% 74% 99% Incentive Spirometry 53% 77% 41% 94%

22 Strategies for Sustaining Momentum Continuous performance evaluation, along with continuous and constructive performance feedback to nurses and physicians Linking performance to outcome measures Ongoing education about quality principles Uniform standards across all subspecialties Personnel and leadership support Establishing commitment to quality as the essence of culture

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