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Sustaining momentum in quality improvement: Lessons from a postoperative pulmonary care program
Michael R Cassidy, MD, Pamela Rosenkranz, RN, BSN, MEd, David McAneny, MD, FACS
Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA

Background: After NSQIP data revealed that our hospital was a high outlier for postoperative pulmonary outcomes, we created a standardized program to reduce pulmonary complications. We present the natural course of many quality improvement projects and lessons learned. Methods: A multidisciplinary team developed a strategy to reduce pulmonary complications, designated by the acronym ICOUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (patient/family education), Getting out of bed, and Head of bed elevation. We performed audits of practices before and after ICOUGH implementation and tracked risk-adjusted outcomes.

Results: Before ICOUGH, compliance with patients being out of bed (at select times) was 20%. This improved to 69% immediately after ICOUGH introduction, but two years later fell again to 29%. Similarly, compliance with incentive spirometry was 53% before ICOUGH, 77% following implementation, but 41% two years later. The O/E ratio for pneumonia was 2.13 before ICOUGH, 1.58 (Odds Ratio) at peak compliance, and OR 1.87 later. Unplanned intubations fell from O/E 2.10 before ICOUGH, to OR 1.31 after ICOUGH, before rising to OR 1.64. Conclusion: ICOUGH, a standardized program emphasizing education, mobilization, and pulmonary interventions, resulted in immediate improvements in care and reduced risk-adjusted pulmonary complications among our patients. As program support and infrastructure waned, the incidence of adverse outcomes increased once more. These data suggest that changes in practices can improve outcomes, although early success may be difficult to sustain. Momentum must be actively supported by regular performance evaluations and a culture of education (staff, patient and family) that we are restoring.

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