Evaluation of a Nursing Educational Intervention on the Proper Technique for Incentive Spirometry in Post-operative and Trauma Critical Care Patients

1
Evaluation of a Nursing Educational Intervention
on the Proper Technique for Incentive
Spirometry in Post-operative and Trauma Critical
Care Patients

• Sara Couch, RN,BSN,CCRN - EBPI fellow
• Laura Dibsie, RN, MSN,CCRN - EBPI mentor
• UCSD Medical Center

2
Recognition

• Financial and Logistical Support
• Juana Burkhart, RN, BSN, CCRN - SICU manager
• Mary Hackim, RN, MS Director, EDR
• UCSD Department of Nursing
• Team members
• Sue Wynn, Informatics Nurse
• Caroline Brown, RN, PhD. - Facilitator
• Helen Ogg, SICU Clinical Nurse Educator
• Mary Wickline, Librarian
• Julie Emerick, RT
• All SICU staff for their patience and
  participation!!

3
The Catalyst

• Need to understand and improve nursing role in
  care and outcome of SCI patients.
• RNs had inconsistent understanding and practice
  related to pulmonary management of SCI patients
• Desire to complete CNIII promotional process.

4
Significance

• SCI patients are often associated with a sudden
  and tragic lifestyle change, this can be further
  complicated by pulmonary issues during recovery.
• Responding to staff and patient concerns related
  to patient plan of care and desire to improve
  patient outcome.

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PICO question

• Population UCSD, SICU RNs and RTs
• Intervention Implementation of an education
  program about incentive spirometry
• Comparison Knowledge and documentation of IS
  practice with non-ventilated trauma and
  post-surgical patients.
• Outcome Improved scores in post-education
  knowledge assessment and improved documentation

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The Evidence

• No Gold Standard for acute pulmonary care of
  SCI patients.
• Limited literature available.
• In the literature, inspiratory muscle training
  (IMT) is consistently associated with improved
  patient outcome.
• Incentive spirometry is an effective IMT therapy.

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Applying Project Design

• IRB application submitted June 2007
• Revisions and approval July 2007
• 5 week study design including
• Pre-test and chart audit
• Live education to staff
• Post-test and chart audit
• Data analysis

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Methods Procedure

• Human subject approval 071124X
• Recruitment
• IRB approved email and staff meeting
  announcements, including informed consent info
• Verbal consent at time of education
• Data collection
• EMTEK query
• Pre-tests available 14 days
• Education 10 sessions/8 days (3 week span) with
  post test completion
• EMTEK query

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Methods Instruments

• Knowledge Test
• IRB approved
• Brief
• Multiple choice
• Focused on EBP found in literature review
• Same instrument used pre- and post-test
• Chart query
• 3-week time frame pre- and post-education
• All non-ventilated SICU patients

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Sample and Setting

• Convenience sample of SICU RNs and RTs
• Day and night shift career, per diem, or
  temporary/contract
• Varied experience
• Either gender
• Pre-test n 46
• Post-test n 40 (5 RTs)
• Education sessions primarily in Surgical/Trauma
  ICU of academic medical center in large
  metropolitan area

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Findings Pre/Post

• Nurses knowledge improved with education
• Knowledge of most effective treatment time more
  than doubled (almost 100)
• Pre-test About half the nurses understood
  differences in terminology between IS breath
  (Vital Capacity) and resting breath (Tidal
  Volume)
• Post-test this improved to more than
  three-quarters

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Greatest Improvement
What 3 factors determine pts goal volume?
24
88
13
Most correct answers
How long should pt hold breath?
48
98
14
Most Commonly MissedPre Post
Incentive spirometry measures what?
78
48
50
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15
Documentation Pre-

• Pre-education documentation was inconsistent
• Two options Done or Active
• Comments not detailed
• attempted
• UTA
• CDB
• 10 x 1000

16
Documentation Post-

• Definitely more detailed
• Patients effort now documented
• Computer charting that prompts intervention
• Includes target volume (to trigger RN)

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New Charting
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Similarities / Unchanged

• Some patients, including those on room air, have
  no documentation for IS therapy
• No standard for frequency of charting IS
  treatment

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Advancing and Adopting

• Laminate target volume insert information and
  post in supply area
• Follow up on obtaining insert info in several
  languages for patient and family
• Fellow follow-up with staff and SCI patients
• Summarize key findings on Hot Topics Bulletin
  Board
• Incorporate findings into standards of care

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Lessons Learned

• Clinical Project/Information
• Not the anticipated focus from initial
  application, but greater appreciation and
  understanding IMT using IS.
• EBPI Experience
• Where we started vs. where we ended up
• Empowered to ask questions and challenge current
  practice
• Tools to research and investigate the answers
• More critical of practice and literature
• Appreciate constant presence of opportunities for
  improvement

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Select References

• Royster, R.A., Barboi, C., Peruzzi, W.T.
  (2004). Critical care in the acute cervical
  spinal cord injury. Topics in Spinal Cord Injury
  Rehabilitation, 9(3), 11 32.
• Agency for Healthcare Research Quality. (2001).
  Treatment of pulmonary disease following cervical
  spinal cord injury. Summary, evidence
  report/technology assessment number 27 (AHRQ
  Publication No. 01-E013). Retrieved February 13,
  2007 from http//www.ahrq.gov/clinic/epcsums/spin
  alsum/htm
• AARC Clinical Practice Guideline Incentive
  Spirometry. Retrieved April 5, 2007 from
  http//www.rcjournal.com/cpgs/ispircpg.html

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For additional information please contact

• Sara Couch scouch_at_ucsd.edu
• Laura Dibsie ldibsie_at_ucsd.edu