The Joint Commision
In the before-and-after study “The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience,” a multidisciplinary team spearheaded by the Department of Surgery at Boston Medical Center developed tactics to reduce pulmonary complications, represented by the acronym I COUGH:
- Incenter spirometry (a breathing exercise device)
- Coughing/deep breathing
- Oral care
- Understanding (education)
- Getting out of bed
- Head of bed elevation
I COUGH is a standardized perioperative pulmonary care program that includes the formal education of patients and their families, nurses, and surgeons and their teams. The study authors created brochures, a video and posters in multiple languages with instructions that describe the techniques and value of postoperative pulmonary care and set expectations for postoperative recovery.
Researchers found that while I COUGH initially improved performance and reduced pulmonary complications, a loss of early program momentum corresponded with a return to baseline outcomes. However, an overall favorable trend resulted from a coordinated rededication to I COUGH through steadfast commitment and creative responses to cultural barriers.
For example, the absolute incidence of pneumonia fell from 3.0% pre-I COUGH to 1.8% post-I COUGH, before climbing again to 2.2% two years later. After rejuvenation efforts the rate dropped to 0.4%.
“Over the course of the 10-year period, we saw improvement from the last decile to the first for pneumonia among hospitals enrolled in the American College of Surgeons National Surgical Quality Improvement Program,” said first author Michael Cassidy, MD, a surgical oncologist at Boston Medical Center and assistant professor of Surgery at Boston University School of Medicine. “It became clear over time that sustaining outcomes requires constant assessment and dedication to care principles. We continue to look at ways to improve the program and have recently developed an application for mobile devices to help our patients comply with the I COUGH protocol.
“Not only did [the investigators] continue to monitor performance even as it drifted back to baseline performance, they remained committed to the compelling clinical benefits they had originally witnessed in the I COUGH program,” notes Kedar S. Mate, MD, in an accompanying editorial. “There are important lessons to be learned from the investigators’ experience over the course of a decade. The authors wisely note the need for critical resources such as champions, audits, and staff and patient education in making improvements.”