2019 Research Forum

Team Lead: Lindsee Handel RN; Jessica J. Williams RN; Gloria Baez RN; James Gisborn RN; Andy del Valle RN Kern Medical Intensive Care Unit and Designated Observation Unit Increasing Incentive Spirometer Usage in the Acute Care Setting

Conclusions

Introduction

In order to establish a baseline assessment, an audit tool was created with the purpose of tracking the use of Incentive Spirometry (IS) in individual patients at Kern Medical (Figure 2.). A study of 24 patients was conducted in order to assess both the use of Incentive Spirometer (IS) and the extent of patient education pertaining to IS. The audit tool included the patient’s age, sex, and height; IS proximity to patient; the volume currently set; and the goal volume. Throughout this study, patient education by nurses was evaluated using the audit tool. In efforts to improve patient education, nurses were taught how to use the inspiratory capacity guide provided in the IS package. The guide included a table indicating proper inspiratory lung capacity based on age and height (Figure 1.). Nurses were taught to set an inspiratory lung capacity volume goal based on the guide. Nurses attempted to raise the volume line to reach the goal volume throughout their shift. Raising the volume line was done at the discretion of the nurses for individual patients. The implementation of proper IS usage was left to the discretion of the nurse in care of the patient. The same audit tool was used to collect data after educating the nurses to assess how education impacted the proper usage of IS. Materials and Methods

• Current review of the literature indicates Early Mobility improves patient outcomes more than use of the incentive spirometer. Kern Medical is already supporting this initiative. • Limit the use of the IS to identified patients with compromised mobility (for example pelvic and/or lumbar trauma). Recommend PT evaluation for these patients. Continue to reinforce the proper use of the IS in this patient population. • Add use of IS to the hourly rounding mobility flowsheet. This action would ensure that nurses place proper importance on hourly IS usage. • Recommend nursing reevaluate all policies related to use of the 1. Fayyaz, A., Dr., Furqan, A., Dr., Ammar, A., Dr., Ahmad, R. A., Prof., & Ahmad, S., Dr. (2016). Pre-Operative Incentive Spirometry; effectiveness to improve post-operative oxygenation in patients undergoing CABG surgery. The Professional Medical Journal, 1368-1372. doi:10.17957/TPMJ/16.3579 2. Kumar, A., Alaparthi, G., Augustine, A., Pazhyaottayil, Z., Ramakrishna, A., & Krishnakumar, S. (2016). Comparison of Flow and Volume Incentive Spirometry on Pulmonary Function and Exercise Tolerance in Open Abdominal Surgery: A Randomized Clinical Trial. Journal of Clinical and Diagnostic Research,10 , KC01-KC06. doi:10.7860/JCDR/2016/16164.7064 3. Mitchell, M., Dr., Lavenberg, J., Dr, RN, Trotta, R., Dr, RN, & Umscheid, C., Dr. (2015). Hourly Rounding to Improve Nursing Responsiveness: A Systematic Review. HHS Public Access, 462-472. doi:10.1097/NNA.0000000000000101 4. Narayanan, A., PT, Hamid, S., Dr., & Supriyanto, E., Dr. (2016). Evidence regarding patient compliance with incentive spirometry interventions after cardiac, thoracic and abdominal surgeries: A systematic literature review. Can J Respiratory Therapy, 17-26. 5. Omuwa, C. A., GBIRI, Oluwatobiloba, T., & Rufus, S., AKINBO. (2016). Efficacy Of Chest- Physiotherapy And Incentive-Spirometry In Improving Cardiovascular And Pulmonary Functional Performances In Individuals Post-Thoraco-Abdominal Surgery: A Randomised Comtrolled Study. International Journal of Therapies and Rehabilitation Research, 1-8. doi:10.5455/ijtrr.000000118 Acknowledgements We would like to thank the staff of the ICU and DOU who participated in our evidence based practice project. Facilitator: Laronda Dillard-Smith, RN, BSN Director of Acute Care Services at Kern Medical: Cindy R. Norville, RN, BSN ICU/DOU Clinical Supervisor: Kathleen Kearney, RN Director of Cardiopulmonary Services at Kern Medical – Don Bull, RRT NRP Coordinator: Pamela Gavin, RN, BSN • In collaboration with Kern Medical respiratory therapy staff, the use of IS was not supported with valid data. They do agree with the studies of Early Mobility is more beneficial in improving patient outcomes. • The need for float nurses on our units made it difficult to properly educate and reinforce proper IS usage due to the short amount of time on the unit. Recommendations incentive spirometer. References While our study gave us insight about the use of IS at Kern Medical, the extent of the study is somewhat inconclusive in regards to improving patient outcomes due to the multiple factors involved. After researching multiple articles we found that the researchers ran into the similar difficulties. “There is a scarcity and inconsistency of evidence regarding IS compliance. Compliance data should be obtained using reliable and standardized methods to facilitate comparisons between and among trials. These should be reported comprehensively to facilitate valid inferences regarding IS intervention effectiveness.” (4) Some beneficial outcomes of this study included: • we were able to educate our staff on how to properly use the instructional guide included in the IS package • setting a new and improved standard of care for educating patients properly • established the importance of IS usage of immobilized patients at Kern Medical. Challenging outcomes of this study included: • Lack of current research less than 5 years.

Kern Medical’s acute care clinical director noted that Incentive Spirometry (IS) usage was decreasing and requested this study be completed to find a solution. In the ICU, DOU, and PACU setting there are many postoperative patients that are hospitalized for extended periods without having the ability to mobilize. “A basic postoperative complication is a lack of lung inflation which results from a change in breathing to a shallow, monotonous pattern without periodic sighs and temporary diaphragmatic dysfunction...Incentive Spirometry (IS) is a lung expansion technique. It is designed to induce sighing or yawning by making the patient take long, slow deep breaths. It prevents and treats atelectasis in alert patients who have a predisposition for shallow breathing. It is a simple and relatively safe method for doing so.” (2) Implementing the use of IS would be a cost effective way to manage patient healthcare in both the hospital and home health care settings. The use of IS would decrease possible pulmonary postoperative complications. “Triggered by shallow breaths, lung atelectasis and pulmonary dysfunction, PPCs can lead to increased rates of morbidity, mortality and health care costs.” (4) What we found from conducting the study was that most patients were not being adequately educated on proper IS usage nor being given an Incentive Spirometer with correct settings. These findings guided our study and determined what we needed to focus on in order to improve patient outcomes.

Figure 2: Audit tool

Figure 1: Predictive Inspiratory Capacity. Tool used to determine patient’s goal.

Results

Results In the graph below, Comparison of IS Usage Before and After Nursing Education, show improvements in all areas after education to the nursing staff, with biggest gain in proper goal setting (20% to 68% after training). Recommend more education to the nursing staff to meet compliance goal of 90%.

Objectives

• Research and consolidate relevant clinical data in efforts to educate nurses to implement proper IS usage at Kern Medical • Educate nurses how to properly determine patient IS goals by using the goal form provided for eligible IS patients. • Establish a standard of care for IS education for nurses to use while teaching patients about the usage of IS. • Educate patients about the importance of IS, especially when the patient is immobilized.

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