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Quality improvement program curbs postoperative pneumonia

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – A nursing intervention in a surgical ward reduced postoperative pneumonia rates – admittedly low to start with — by 77% over an 18-month period, investigators report.

The rate of pneumonia fell from 13 of 1,668 inpatient admissions (0.78%) in the preintervention period to 3 of 1651 (0.18%) afterward (p = 0.006).

“We thought pneumonia was a project we could tackle since prevention measures had worked across the country in ICU’s to diminish ventilator associated pneumonias (VAP),” lead author Dr. Sherry M. Wren told Reuters Health by e-mail.

Dr. Wren and her colleagues note in the April Journal of the American College of Surgery that while most cases of postoperative pneumonia are related to mechanical ventilation, they also occur on regular surgical wards.

The researchers, all from the VA Palo Alto Health Care System, California, developed eight evidence-based prevention strategies:

— Staff education
— Cough and deep-breathing exercises with incentive spirometry
— Twice daily mouth care with chlorhexidine swabs
— Good pain control so that patients could walk around
— Elevating the head of the bed at least 30 degrees and having patients sit up for meals
— Ongoing feedback with quarterly staff discussion
— Documentation of interventions in nursing reports
— Computerized pneumonia-prevention orders for physicians.

The researchers then documented all inpatient surgical ward pneumonia cases for the 18 months prior to the implementation date (October 2005 to March 2007) and the 18 months afterward (April 2007 to September 2008). They excluded patients who had cardiac surgery.

The authors observe that “nursing education and leadership for the nurse managers were key to the program’s success… because all of the interventions were implemented by the nursing staff.” The ongoing feedback also served as an important motivator.

The intervention is very inexpensive, Dr. Wren noted. “The most expensive item would be ward staff time to make sure patients are ambulating and out of bed,” which is offset by the decreased costs associated with reduced hospital stays by avoiding pneumonia.

In retrospect, she thinks the intervention should have been extended to include nonintubated patients in the ICU. “Since they were not intubated, they did not fall under VAP prevention protocols and also did not get covered by the surgical ward protocol since they were not present on the ward.” In fact, pneumonia rates actually increased during the study period in this population.

“This program, if expanded to other VA or private hospitals, could help improve patient care and lower morbidity, mortality, and overall health care costs,” the authors conclude.

Reference:

J Am Coll Surg 2010;210:491-495.