QI initiative reduces post-operative pneumonia
Focus on nurses as most active frontline providers
Researchers at the Veterans Affairs Palo Alto Health Care System (PAVAHCS) and Stanford University School of Medicine have employed an eight-step process improvement intervention to significantly reduce the incidence of pneumonia in post-operative patients on the surgical ward.
The study was published in the April issue of the Journal of the American College of Surgeons.1
The intervention began in April 2007, with baseline incidence of inpatient ward pneumonia calculated from the Veterans Administration National Quality Improvement Program (VA-NSQIP). There was a decrease in pneumonia incidence from 0.78% in the pre-intervention group to 0.18% in the post-intervention group. What's more, the reduced levels of pneumonia have been maintained even after the interventions formally concluded.
"Even though the data collection technically ended in 2008, we actually haven't had a bad month yet," says Sherry M. Wren, MD, FACS, professor of surgery and associate dean, academic affairs, at Stanford University School of Medicine; chief of general surgery at PAVAHCS; and lead author of the study.
Wren undertook the initiative as part of a faculty development program, during which she was required to take on a leadership project. "I thought we should do one involving surgical QI," she recalls. "We had already seen progress on VAP [ventilator-associated pneumonia], so I saw this as another opportunity to prevent pneumonia."
The eight steps of the intervention were:
- education of all surgical and ward nursing staff about their role in pneumonia prevention;
- cough and deep-breathing exercises with incentive spirometer;
- twice-daily oral hygiene with chlorhexidine swabs;
- ambulation with good pain control;
- head-of-bed elevation to at least 30 degrees and sitting up for all meals ("up to eat");
- quarterly discussion of the progress of the program and results for nursing staff;
- pneumonia bundle documentation in the nursing documentation;
- computerized physician pneumonia prevention order set in the physician order entry system.
Nurse education critical
Wren says that among the keys to the success of the program were nurse education and leadership from the nurse managers. "The success or death of a program like this lies in nursing," she asserts. "They are the people who were doing the bulk of the interventions, with the exception of placing the orders for those interventions."
Initially, she says, she and the nursing leadership met with the ward staff and told them about the program and why it was being undertaken. The project also was covered as part of orientation why the program was being implemented, the key steps, and the importance of compliance. "Now, we also talk about how successful it is," adds Wren.
But perhaps the most important element of the program, she continues, was the monthly pneumonia statistics for the ward. "We have a NSQIP nurse who runs the data, so if a pneumonia case comes in and if it's in the sample group, we know about it," says Wren.
The monthly data have value whether they are positive or negative, she notes. "The nurse manager sees them every month, so it's an ongoing process," Wren explains. "If there is a 'zero' month, that can be discussed in meetings as a positive; it continues to motivate the staff, because they are getting the feedback that what they are doing is making a real difference to the patients. That motivation really helps."
Fortunately, Wren continues, she has never seen a big spike in pneumonia cases. "If I did, I would get together with the nurse manager, look at the cases, and figure out the cause i.e., a lot of new staff, or an influx of patients who are travelers," Wren offers.
Since part of the standard nursing documentation in the pneumonia bundle requires the nurse to say whether they performed the required steps, tracking compliance is not a challenge. "But honestly, when I get a zero rate most months, there's no need to check compliance," Wren asserts.
Keeping the momentum
Wren continues to communicate with nursing leadership on a regular basis. "Basically, the nurse manager, the NSQIP nurse, and myself share the statistics, so if we saw a blip we'd be able get on it right away; our nursing management knows everything that's going on," she notes.
"The nice thing for me is [the elements of the program] continue to go on, and we still see the benefit; the standard number I see is zero," she adds. "I really think it's due to the feedback. When the paper came out, we put it up in a visible place on the ward where you can put up [important information], and the ward has taken real pride in it."
Wren adds that she can see the difference just by walking the floor. "I just finished ward rounds, and you can see the heads of the beds up; people are not lying flat," she says. "You also see more people walking." Wren says she had to hire another nursing assistant to be able to get more people up and walking, and received budget approval from management.
Management buy-in was definitely critical to the success of the program, she continues, as was staff leadership. "You've got to have some sort of champion who owns the process initially until everyone can see the benefits," she explains.
Could her success be replicated in any facility? "Absolutely," Wren concludes.
[For additional information, contact: Sherry M. Wren, MD, FACS. Phone: (650) 849-0107.]
Reference
- Wren SM, Martin M, Yoon JK, and Bech F. Postoperative Pneumonia-Prevention Program for the Inpatient Surgical Ward. J Am Coll Surg; April 2010, Vol. 210, Issue 4: 491-495.
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