Reference No: Title: Primary Topic: Secondary Topic: Tertiary Topic: Keywords: Authors' Names: Medical Institution:

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1 Reference No: Title: Creating a Culture of Pulmonary Hygiene to Prevent Pneumonia in the Traumatically Injured patient population at a Level 2 Rural Trauma Center Primary Topic: Performance Improvement Secondary Topic: Triage/ Transfer/ Rural Trauma Centers, Tertiary Topic: Keywords: Pulmonary Hygiene Algorithm Authors' Names: Lisa LaRock, RN,BSN, CCRN, PHRN; Mary Wenger, RN, BSN, CCRN; Alex Johnston, MD; Rob Behm, MD Medical Institution: Guthrie Robert Packer Hospital What is the problem or challenge you identified? Every trauma patient encountered, especially those with thoracic and abdominal trauma, are at an increased risk for pneumonia. The multiple insults to their normal underlying physiology require an increased alertness, surveillance, and emphasis on prophylaxis. We noted pneumonia rates at our institution the Robert Packer Hospital (RPH) was higher than other Pennsylvania trauma centers in a 2010 PTSF quarterly report. This was felt to be secondary to a lack of knowledge of techniques and a limited utilization of the already existing standards of care. Formal guidelines for pulmonary hygiene and pneumonia did not exist at the time. The goal of this project was to create a culture of pulmonary hygiene at RPH by the creation of evaluation and intervention guidelines therefore decreasing the pneumonia rates in these injured and susceptible patients. Describe the intervention you developed/change you implemented to address the problem: A literature based Pulmonary Hygiene Practice Management Guideline was developed incorporating already existing rib fracture management guidelines. A tool was developed to aid in incentive spirometry (IS) calculations along with an easy algorithm for evaluation. This was applied to the trauma patient population for risk stratification. The relevant hospital staff was educated with regards to these practice management guidelines and calculators. A standard was set for hourly intervention with the patients including IS demonstration and evaluation and Cough Cushions were provided for comfort, to aid in pulmonary hygiene and as a means for easy dissemination of information to the patient population beyond their initial education.

2 How did you measure the effects of the change? This project spanned a 6-year time frame. Rates of pneumonia as percentage of total PTOS (Pennsylvania Trauma Outcome Study) patient volume were calculated yearly. When the intervention began in 2010, the rate was 2.2. This rate has declined across the 6 year time span of the protocol. Yearly the rates were 2.2 in 2010, 2.1 in 2011, 1.5 in 2012, 0.8 in 2013, 0.5 in 2014 and 2015, and 0.3 in We also began submitting our trauma data to the American College of Surgeon Trauma Quality Improvement Project in January of Our first TQIP report was received in the Spring of We were pleased see that we were a positive outlier for the pneumonia complication thus reaffirming our PTSF PTOS reports data related to our pneumonia prevention efforts.

3 How did you sustain the change? The trauma population is at an increased risk for pneumonia and other pulmonary complications secondary to insults to their usual baseline physiology especially in thoracic and abdominal trauma. The use of a simple evaluation and intervention guideline has become a culture for pulmonary hygiene utilizing incentive spirometry for patient risk stratification leading to a measurable and significant reduction in rates of pneumonia per PTOS patient volume over a six year period. We continued to monitor PTSF and TQIP data which have demonstrated a sustained low rate of pneumonia among our trauma patient population. We have since shared our successes with both the Pennsylvania State Collaborative and our local TQIP facilities group (comprised of our Level one trauma consultant's network facilities).

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