The Use of Patient Audits and Nurse Feedback to Decrease Postoperative Pulmonary Complications
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1 The Use of Patient Audits and Nurse Feedback to Decrease Postoperative Pulmonary Complications Christine M. Schleider, RN, BSN Adam P. Johnson, MD, MPH Kathleen M. Shindle, RN, BSN Scott W. Cowan, MD, FACS Department of Surgery Thomas Jefferson University Hospital, Philadelphia PA
2 Disclosures None
3 Background Problem: Postoperative pulmonary complications & hospital acquired pneumonia = Morbidity & mortality Higher health care costs Increased LOS Value based purchasing 2018 study: NON-VENTILATOR Hospital Acquired Pneumonia: 21 hospitals 1300 cases 70.8% non-icu ALL PATIENTS HAVE SOME RISK MOST DID NOT HAVE FUNDAMENTAL PREVENTATIVE CARE Oral care **Frequently missed care Incentive Spirometer Mobility HOB degrees 1 1. Baker D, Quin B. Hospital acquired pneumonia prevention initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018;46:2-7. doi: /j.ajic
4 Local Problem PA NSQIP Consortium: high rates of pulmonary complications Thomas Jefferson University Hospital ACS NSQIP Data
5 Intended Improvement Objective: To implement Boston Medical Center s ICOUGH sm program to decrease postoperative respiratory complications 1. PA NSQIP Consortium (2016): formal contract with Boston Medical Center ICOUGH sm 2. Thomas Jefferson University Hospital Department of Surgery: General & Vascular Surgery 3. Back to basics bundled interventions to prevent respiratory complications I Incentive Spirometer 10x per hour while awake C Cough & deep breath every 2 hours O Oral care (brush teeth & mouthwash) 2x per day U Understand ICOUGH practices (Education) G Out of bed & ambulate at least 3x per day H Head of bed elevated 30 degrees 4. Audit & Feedback to ensure compliance with the interventions
6 Evidence-Based Practice 1. Implementing ICOUGH sm Boston Medical Center: Pneumonia rates: pre-implementation 2.6% (1569 cases) post implementation 1.6% (1542 cases) Unplanned intubation rates: pre-implementation 2% (1569 cases) post-implementation 1.2% (1542 cases) 2 2. Audit & Feedback: implications for practice Effective in improving professional practice Effective in improving patient outcomes 3 2. Cassidy MR, Rosenkranz P, McCabe K, et al. ICOUGH reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148(8): doi: /jamasurg Iver N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6:1-227 doi: / CD pub3.
7 Methods Framework: Plan Do Study Act Setting: March 2017: 3 in-patient pilot 2 hospitals & general and vascular surgery provider offices Process: 1. Pre-implementation bedside patient audits: interventions compliance 2. Staff education & pre-implementation audit feedback 3. All patients received ICOUGH interventions, brochure & incentive spirometer 4. Posters at the foot of all patients beds 5. Post-audits with feedback & coaching 6. Provider offices: Schedule surgery = ICOUGH education, incentive spirometer & brochure Evaluation: Intervention compliance: Audit data Patient outcomes: ACS NSQIP PA NSQIP Consortium: Monthly conference calls - share & learn from barriers, & successes Provider offices: Regular visits and staff coaching sessions
8 Results Figure 1. ICOUGH sm bundle performance on pilot unit s pre and post implementation. IS represents incentive spirometer. Error bars at 95% CI. Statistical significance is set at p<0.05.
9 Conclusion 1. Early compliance results encouraging! Sustainability Improving patient outcomes 2. Process measure changes & structural improvements Medical student ambulation program Improved incentive spirometer & toothbrushes Revised incentive spirometer policy to include medical patients July 2018: Hospital wide (medical & surgical) across three hospital divisions!! 3. Next steps Collaborate with Department of Nursing to monitor compliance and patient outcomes
10 Thank You!
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