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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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I COUGH provides blueprint for sustainable quality improvement

The I COUGH program, which seeks to prevent non-ventilator-associated postoperative pulmonary complications, is a model for other sustainable quality improvement initiatives.

Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCSEng(Hon), FRCSEd(Hon)

October 1, 2020

As the health care sector continues to shift toward a focus on promoting patient safety, outcome-driven practices, value, and efficiency, quality improvement (QI) projects in surgery are gaining widespread attention.* It has been difficult, however, to permanently maintain these quality improvements, as health care facilities and professionals can revert to past habits and ways of delivering care once QI projects are completed. These regressions not only have a negative impact on patient outcomes, but can lead to financial losses, as well as wasted technical and human resources.

Study reveals how change can be sustained

A study in the May issue of The Joint Commission Journal on Quality and Patient Safety details how a surgical QI initiative was developed to reduce the likelihood of postoperative pulmonary complications and assesses the results over a 10-year period.

The study authors noted that registry data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) in 2009 listed their medical site—Boston Medical Center, MA—as “a high outlier for all measured postoperative pulmonary complications, including pneumonia and unplanned intubation.”*

Noticing an opportunity for improvement, they conducted a before-and-after study—The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience.”Michael Cassidy, MD, FACS, and colleagues convened a multidisciplinary team that included representatives from the departments of surgery, nursing, anesthesia, QI, respiratory therapy, infection control, and physical therapy, as well as the ACS NSQIP team and preoperative assessment clinic staff.

The team—spearheaded by the department of surgery at Boston Medical Center—reviewed available literature about the prevention of non-ventilator-associated postoperative pulmonary complications and came up with strategies for reduction. Ultimately, they focused on the following: • Lung expansion exercises • Early and frequent patient mobilization • Oral hygiene • Education

All those elements were included in the acronym created for the study, I COUGH: • Incentive spirometry (a breathing exercise device) • Coughing/deep breathing • Oral care • Understanding (education) • Getting out of bed • Head of bed elevation

Multilayer approach needed

A major component of the I COUGH program was to educate not only patients and their families, but also the nurses, surgeons, and their teams. The study authors created brochures, a video, and posters in multiple languages that provided instructions for patients that described the techniques and value of postoperative pulmonary care. The education materials also set expectations for postoperative recovery.*

Researchers found that while I COUGH improved performance and reduced pulmonary complications immediately, the eventual loss of early program momentum corresponded with a return to baseline outcomes. A favorable trend, however, resulted from a coordinated rededication to I COUGH through institutional commitment and creative solutions to cultural barriers.*

Positive outcomes included the following:* • Absolute incidence of pneumonia fell from 3 percent pre-I COUGH to 1.8 percent post-I COUGH, before climbing again to 2.2 percent two years later. • After rejuvenation efforts, the rate dropped to 0.4 percent.

“The I COUGH protocol reduces postoperative pulmonary complications when institutional culture is optimized around adherence to its principles, but momentum can be easily lost in the absence of active program maintenance,” the study authors concluded. “The success and sustainability of the I COUGH program depends on a complex interaction of local population health concerns, dedication of stakeholders, financial support, human resources, and the organizational environment. Initiatives to limit complications must be flexible, multifaceted, and coordinated.”

The study can be accessed at www.jointcommissionjournal.com/article/S1553-7250(20)30028-3/fulltext.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*Cassidy MR, Rosenkranz P, Macht RD, Talutis S, McAneny D. The I COUGH Multidisciplinary Perioperative PulmonaryCare Program: One decade of experience. Jt Comm J Qual Patient Saf. 2020;46:241-249.

Scheirer MA. Is sustainability possible? A review and commentary on empirical studies of program sustainability. Am J Eval. 2005;26(3):320-347.