9/30/2016
Objectives
 Outline the process prior to implementation of the practice change
 Discuss the pilot of the practice change at the bedside
 Highlight the pre and post results
Kristi Tomporowski, RN, BSN, CMSRN
Surgical Care Unit 1
 Discuss the next steps in the project
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Background
Purpose Statement
 St. Cloud Hospital for 14+ years
 The purpose of this project was to implement an effective respiratory hygiene practice without the use of incentive spirometry in adult postoperative patients in order to maintain or decrease postoperative respiratory complications.  The Iowa Model of Evidence‐Based Practice
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Literature Review
Team & Support
 Team: Members of the Surgical Care Unit Nurse Practice and Performance Improvement Committee
 Support and input from others: Roberta Basol and Peggy Lange
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Reference
Level of
Evidence
Evidence
Implications
Branson (2013)
C
IS, PEP, and other devices have either little support from the literature or have been shown not to be of value.
Additional studies required
Guimarães (2012)
C
No evidence regarding effectiveness of the use of IS for preventions of PPCs in upper abdominal surgery.
Underlines the urgent need to conduct well‐designed trials in this field. Overend, et al (2001)
A
10 studies showed no positive short‐term effect or treatment effect of IS following cardiac or abdominal surgery. 1 study reported IS, DB, and IPPB were equally more effective than no treatment. IS should not be used following cardiac or abdominal surgery.
Restrepo RD, AARC Clinical Practice Guideline (2011)
A
IS alone is not recommended for routine use in preventing PPCs. Recommended that IS be used with DB techniques, directed coughing, early mobilization, and optimal analgesia to prevent PPCs. Suggested that DB exercises provide the same benefit as IS. Routine use of IS to prevent atelectasis in patients after upper abdominal surgery or CABG is not recommended.
Routine use of IS alone is not recommended.
Rupp, et al (2013)
A
IS is only as effective as cough/deep‐breathing regimens and other means of postoperative pulmonary prophylaxis. No single prophylactic technique clearly outperforms all others in preventing pulmonary complications. Future research is needed to determine the best method to prevent postoperative pulmonary complications.
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Additional Evidence
Practice Change
 Expert opinion obtained from multiple physicians who agreed with literature indicating little to no documented benefit of the use of incentive spirometry and that they would willingly replace incentive spirometers with directed coughing and deep breathing practices.  Avoid the routine use of incentive spirometers and instead focus on directed coughing and deep breathing and mobility practices to prevent postoperative pulmonary complications
 Zynx, who uses the latest evidence in development of their care plans, previously sent out this reminder “Avoid the routine use of incentive spirometry; if used, combine with optimal analgesia, deep breathing exercises, directed coughing, and early mobilization.”
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Practice Change
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Practice Change
 Proposal to remove incentive spirometer orders from all admission and postoperative order sets presented at department meetings of OB/GYN, Surgery, and Urology with approval to remove the pre‐check on the incentive spirometry orders and focus more on directed coughing, deep breathing, and mobility practices.  Submitted requests to change 13 postoperative order sets from various IS orders to “Perform directed coughing and deep breathing practices every 1 hour while awake.”
 “Ineffective Airway Clearance” added to the General Surgery Care Plan which also adds a “Deep‐breathing and coughing exercises” education point to the ITR
 Worklist prompt added to “Document Deep Breath and Cough Effort” on the AID flowsheet
 Staff education provided to Surgical Care Unit and Float Pool staff via poster, newsletter articles, emails, and presentations at unit meetings
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Patient Education
Patient Education
 Standard patient teaching sheet developed to provide bedside education on effective coughing and deep breathing practices and promote mobility
 Summary of the patient teaching sheet to place as a tent card on the bedside table as a visual reminder to patients to complete coughing and deep breathing exercises
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Pilot
Pre and Post Measure Data
 Approved for a one‐month pilot from September 16, 2014 to October 16, 2014 on the Surgical Care Units
 Postoperative respiratory complication rate
 Focus on effective coughing and deep breathing practices and mobility by utilizing the developed patient education, encouraging patients to complete the exercises regularly, promoting mobilization early and often postoperatively, and documenting via the Worklist, AID flowsheet, and Care Plan
 Chart review
 Postsurgical pulmonary hygiene staff survey
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Postoperative Respiratory Complication Rate
Postoperative Pneumonia Rate
Percentage of Patients with Postoperative
Respiratory Complications
Pre Pilot
Post Pilot
Dates Data Collected
9/16/13 – 10/31/13
9/16/14 – 10/31/14
Total Patients on Sur1, Sur2, and SPCU
483
492
Met Criteria for Postoperative Pneumonia
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Percentage of Occurrence
1.45%
1.63%
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2.5
2.71
2.54
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1.84
2.11
2.11
1.57
1.5
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1.72
2.31
1.46
1.38
1.04
Practice
change
initiated
0.5
0
FY14
Q2
FY14
Q3
FY14
Q4
FY15
Q1
FY15
Q2
FY15
Q3
FY15
Q4
FY16
Q1
FY16
Q2
FY16
Q3
FY16
Q4
% with complications
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Staff Survey
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9.
10.
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Survey Results
How consistently do you document incentive spirometry use and cough/deep breathe?
Do patients use IS as frequently as ordered?
Do patients cough/deep breathe as frequently as ordered?
Do you remind patients to use IS as frequently as ordered?
Is incentive spirometry effective?
Are cough and deep breathing techniques effective?
How often do patients sit up in bed, at the bedside, or in a chair when coughing/deep breathing?
Do you promote patient mobility?
Which is easier for patients to perform?
For what primary purpose do you promote patient mobility?
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Survey Results
Survey Results
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Documentation Results
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Challenges
 Incentive spirometer being a “sacred cow”
 Making coughing and deep breathing a routine practice
 Reluctance of several physicians to avoid routine use of incentive spirometers
 Length of time to make a practice change
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Celebrating Success
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Next Steps
 Pilot completion and continued practice
 Provide ongoing staff education and reminders
 Dissemination of results to other departments
 Expand practice to other hospital departments
 Improved documentation
 Present project at a national nursing convention
 Decreased postoperative respiratory complication rate
 Publish project in a national nursing journal
 Decreased cost
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References
Agostini P, Singh S. Incentive spirometry following thoracic surgery: what should we be doing? Physiotherapy 2009;95(2):76‐82.
Branson R. The scientific basis for postoperative respiratory care. Respiratory Care 2013:58(11):1974‐1984.
Guimarães M. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews [serial online]. February 22, 2012;(4) Available from: Cochrane Database of Systematic Reviews, Ipswich, MA. Accessed June 13, 2013.
Overend TJ, Anderson CM, Lucy SD, Bhatia C, Johnsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest 2001;120(3):971‐978.
Restrepo RD, Wettstein R, Wittnebel L, Tracy M. AARC clinical practice guideline: Incentive spirometry: 2011. Respiratory Care 2011;56(10):1600‐1604.
Rupp M, Miley H, Russell‐Babin K. Incentive Spirometry in Postoperative Abdominal/Thoracic Surgery Patients. AACN Advanced Critical Care 2013:24(3):255‐263.
Strickland SL, Rubin BK, Drescher GS, Haas CF, O'Malley CA, Volsko TA, et al. AARC clinical practice guideline: Effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respir Care. 2013;58:2187‐93.
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