When data showed that Boston Medical Center (BMC) had higher than expected postoperative pulmonary complications in its patients, the hospital mobilized, assembled a multidisciplinary team, and undertook an intervention – named I COUGH – that reduced the postoperative complications while saving money.
I COUGH program emphasizes Incentive spirometry, Coughing and deep breathing, Oral care (brushing teeth and using mouthwash twice daily), Understanding (patient and family education), Getting out of bed at least 3 times daily, and Head-of-bed elevation. (An incentive spirometer is a relatively simple and inexpensive device. A patient breathes in from the device, slowly and deeply, and an indicator gauge on the spirometer measures the patient’s progress.
While many of the above practices were stressed by caregivers, under I COUGH they were combined into a single, comprehensive protocol designed to mitigate the most common risk factors for non-ventilator hospital-acquired pneumonia and other complications. Along with the I COUGH checklist of interventions, BMC nurses and doctors worked to control pain in patients, which was essential to helping them take deep breaths, cough, and get out of bed to sit in chair and walk through hospital hallways.
I COUGH was first implemented for all general and vascular surgery patients at the hospital in August 2010, and then expanded to include all surgery specialties soon after. And the positive results soon followed.
Incidences of postoperative pneumonia fell by a full percent and unplanned intubations fell by 0.8%. Prior to implementation, only 19.6% of 250 patients were in chair or walking at the time of audit; afterwards, 69.1% were out of bed. Before I COUGH, only 52.8% of patients had incentive spirometer within reach, while after implementation 77.2% did. BMC estimates that its relative simple and inexpensive program that used a $1.50 incentive spirometer and other interventions saved at least $3 million over two years, given that the average pulmonary complications costs between $20,000 and $52,000.
BMC says to ensure the program works, patients and family members have to take an active part in the recovery process; the hospital provided lots of educational materials in multiple languages.
Staff across all levels – leadership, physicians, house staff, and nurses – have to be well educated on the program and committed to its success. BMC tried to make I COUGH “part of the culture” and solicited feedback from frontline caregivers and patients on it so that adjustments could be made.
BMC also undertook regular audits to ensure compliance with the program. So after surgeries, patients were visited to check on whether they were in bed, sitting in a chair or walking at time of visit; whether the incentive spirometer was within reach; and whether the head of the bed was elevated more than 30 degrees.
Given the success of I COUGH, hospitals in the US, UK and Canada contacted BMC to learn about how they could implement I COUGH. As a result, BMC developed an I COUGH implementation toolkit and toolbox to help other medical centers use I COUGH in their facilities.
For its success in reducing postoperative pulmonary complications by creating a relatively simple, but innovative, I COUGH program, BMC was a winner in the first annual MHA Accountable Care Compass Awards.