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Original Investigation |

I COUGH:  Reducing Postoperative Pulmonary Complications With a Multidisciplinary Patient Care Program

Michael R. Cassidy, MD2; Pamela Rosenkranz, RN, BSN, MEd2; Karen McCabe, RN, BSN2; Jennifer E. Rosen, MD1; David McAneny, MD1
[+] Author Affiliations
1Section of Surgical Oncology and Endocrine Surgery, Department of Surgery, Boston University Medical Center, Boston, Massachusetts
2Department of Surgery, Boston University Medical Center, Boston, Massachusetts
JAMA Surg. 2013;148(8):740-745. doi:10.1001/jamasurg.2013.358.
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Published online

Importance  Postoperative pulmonary complications can be a devastating consequence of surgery. Validated strategies to reduce these adverse outcomes are needed.

Objectives  To design, implement, and determine the efficacy of a suite of interventions for reducing postoperative pulmonary complications.

Design  A before-after trial comparing our National Surgical Quality Improvement Program (NSQIP) pulmonary outcomes before and after implementing I COUGH, a multidisciplinary pulmonary care program.

Setting  An urban, academic, safety-net hospital.

Participants  All patients who underwent general or vascular surgery at our institution during a 1-year period before and after implementation of I COUGH.

Interventions  A multidisciplinary team developed a strategy to reduce pulmonary complications based on comprehensive patient and family education and a set of standardized electronic physician orders to specify early postoperative mobilization and pulmonary care. Designated by the acronym I COUGH, the program emphasizes incentive spirometry, coughing and deep breathing, oral care (brushing teeth and using mouthwash twice daily), understanding (patient and family education), getting out of bed at least 3 times daily, and head-of-bed elevation. Nursing and physician education promoted a culture of mobilization and I COUGH interventions. I COUGH was implemented for all general surgery and vascular surgery patients at our institution in August 2010.

Main Outcomes and Measures  The NSQIP-reported incidence and risk-adjusted ratios of postoperative pneumonia and unplanned intubation, which NSQIP reports as observed-expected (OE) ratios for the 1-year period before implementing I COUGH and as odds ratios (ORs, statistically comparable to OE ratios) for the period after its implementation.

Results  Before implementation of I COUGH, our incidence of postoperative pneumonia was 2.6%, falling to 1.6% after its implementation, and risk-adjusted outcomes fell from an OE ratio of 2.13 to an OR of 1.58. The incidence of unplanned intubations was 2.0% before I COUGH and 1.2% after I COUGH, with risk-adjusted outcomes decreasing from an OE ratio of 2.10 to an OR of 1.31.

Conclusions and Relevance  I COUGH, a standardized postoperative care program emphasizing patient education, early mobilization, and pulmonary interventions, reduced the incidence of postoperative pneumonia and unplanned intubation among our patients.

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Figures

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Figure 1.
Incidence of Pneumonia at Boston Medical Center (BMC) and at Comparable Institutions, Along With Risk-Adjusted Outcomes at BMC, During Consecutive National Surgical Quality Improvement Program (NSQIP) Reporting Periods Before, During, and After the Implementation of I COUGH

For reporting periods before calendar year (CY) 2010, NSQIP reports risk-adjusted data as observed-expected (OE) ratios. For CY 2010 and later, NSQIP reports risk-adjusted data as odds ratios (ORs). *P = .09 compared with CY 2009. See the Table footnote for the expansion of I COUGH.

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Figure 2.
Incidence of Unplanned Intubations at Boston Medical Center (BMC) and at Comparable Institutions, Along With Risk-Adjusted Outcomes at BMC, During Consecutive National Surgical Quality Improvement Program (NSQIP) Reporting Periods Before, During, and After the Implementation of I COUGH

For reporting periods before calendar year (CY) 2010, NSQIP reports risk-adjusted data as observed-expected (OE) ratios. For CY 2010 and later, NSQIP reports risk-adjusted data as odds ratios (ORs). *P = .09 compared with CY 2009. See the Table footnote for the expansion of I COUGH.

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