Objectives. Background. Purpose Statement. Literature Review. Team & Support 9/30/2016

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1 Objectives Kristi Tomporowski, RN, BSN, CMSRN Surgical Care Unit 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 Discuss the next steps in the project Background St. Cloud Hospital for 4+ years The Iowa Model of Evidence Based Practice Purpose Statement 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. 4 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 Literature Review Reference Level of Evidence Evidence Branson (0) C IS, PEP, and other devices have either little support from the literature or have been shown not to be of value. Guimarães (0) C No evidence regarding effectiveness of the use of IS for preventions of PPCs in upper abdominal surgery. Overend, et al (00) A 0 studies showed no positive short term effect or treatment effect of IS following cardiac or abdominal surgery. study reported IS, DB, and IPPB were equally more effective than no treatment. Implications Additional studies required Underlines the urgent need to conduct well designed trials in this field. IS should not be used following cardiac or abdominal surgery. Restrepo RD, AARC Clinical Practice Guideline (0) 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 (0) 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. 5 6

2 Additional Evidence 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. 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. Avoid the routine use of incentive spirometers and instead focus on directed coughing and deep breathing and mobility practices to prevent postoperative pulmonary complications 7 8 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 postoperative order sets from various IS orders to Perform directed coughing and deep breathing practices every 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, s, and presentations at unit meetings 9 0 Patient Education Standard patient teaching sheet developed to provide bedside education on effective coughing and deep breathing practices and promote mobility Patient Education 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

3 Pilot Approved for a one month pilot from September 6, 04 to October 6, 04 on the Surgical Care Units 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 Pre and Post Measure Data Postoperative respiratory complication rate Postsurgical pulmonary hygiene staff survey Chart review 4 Postoperative Pneumonia Rate Pre Pilot Post Pilot Dates Data Collected 9/6/ 0// 9/6/4 0//4 Total Patients on Sur, Sur, and SPCU Met Criteria for Postoperative Pneumonia 7 8 Percentage of Occurrence.45%.6% Postoperative Respiratory Complication Rate FY4 Q.54 FY4 Q Percentage of Patients with Postoperative Respiratory Complications.84 FY4. FY5 Q.7 Practice change initiated FY5 Q.57 FY5 Q.7 FY5.46 % with complications FY6 Q. FY6 Q. FY6 Q.8 FY Staff Survey. 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? 4. Do you remind patients to use IS as frequently as ordered? 5. Is incentive spirometry effective? 6. Are cough and deep breathing techniques effective? 7. How often do patients sit up in bed, at the bedside, or in a chair when coughing/deep breathing? 8. Do you promote patient mobility? 9. Which is easier for patients to perform? 0. For what primary purpose do you promote patient mobility? 7 8

4 9 0 Documentation Results 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 Celebrating Success Pilot completion and continued practice Dissemination of results to other departments Improved documentation Decreased postoperative respiratory complication rate Decreased cost Next Steps Provide ongoing staff education and reminders Expand practice to other hospital departments Present project at a national nursing convention Publish project in a national nursing journal 4 4

5 References Agostini P, Singh S. Incentive spirometry following thoracic surgery: what should we be doing? Physiotherapy 009;95():76 8. Branson R. The scientific basis for postoperative respiratory care. Respiratory Care 0:58(): Guimarães M. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews [serial online]. February, 0;(4) Available from: Cochrane Database of Systematic Reviews, Ipswich, MA. Accessed June, 0. 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 00;0(): Restrepo RD, Wettstein R, Wittnebel L, Tracy M. AARC clinical practice guideline: Incentive spirometry: 0. Respiratory Care 0;56(0): Rupp M, Miley H, Russell Babin K. Incentive Spirometry in Postoperative Abdominal/Thoracic Surgery Patients. AACN Advanced Critical Care 0:4():55 6. 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. 0;58: