title: I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program.
abstract: OBJECTIVE
  Postoperative pulmonary complications can be a devastating consequence of surgery. Validated strategies to reduce these adverse outcomes are needed.
  
  
  OBJECTIVE
  To design, implement, and determine the efficacy of a suite of interventions for reducing postoperative pulmonary complications.
  
  
  METHODS
  A before-after trial comparing our National Surgical Quality Improvement Program (NSQIP) pulmonary outcomes before and after implementing I COUGH, a multidisciplinary pulmonary care program.
  
  
  METHODS
  An urban, academic, safety-net hospital.
  
  
  METHODS
  All patients who underwent general or vascular surgery at our institution during a 1-year period before and after implementation of I COUGH.
  
  
  METHODS
  A multidisciplinary team developed a strategy to reduce pulmonary complications based on comprehensive patient and family education and a set of standardized electronic physician orders to specify early postoperative mobilization and pulmonary care. Designated by the acronym I COUGH, the 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. Nursing and physician education promoted a culture of mobilization and I COUGH interventions. I COUGH was implemented for all general surgery and vascular surgery patients at our institution in August 2010.
  
  
  METHODS
  The NSQIP-reported incidence and risk-adjusted ratios of postoperative pneumonia and unplanned intubation, which NSQIP reports as observed-expected (OE) ratios for the 1-year period before implementing I COUGH and as odds ratios (ORs, statistically comparable to OE ratios) for the period after its implementation.
  
  
  RESULTS
  Before implementation of I COUGH, our incidence of postoperative pneumonia was 2.6%, falling to 1.6% after its implementation, and risk-adjusted outcomes fell from an OE ratio of 2.13 to an OR of 1.58. The incidence of unplanned intubations was 2.0% before I COUGH and 1.2% after I COUGH, with risk-adjusted outcomes decreasing from an OE ratio of 2.10 to an OR of 1.31.
  
  
  CONCLUSIONS
  I COUGH, a standardized postoperative care program emphasizing patient education, early mobilization, and pulmonary interventions, reduced the incidence of postoperative pneumonia and unplanned intubation among our patients.
authors.affiliation: Department of Surgery, Boston University Medical Center, Boston, Massachusetts.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Cassidy
authors.forename: Pamela
authors.initials: P
authors.lastname: Rosenkranz
authors.forename: Karen
authors.initials: K
authors.lastname: McCabe
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Rosen
authors.forename: David
authors.initials: D
authors.lastname: McAneny
mesh_terms: D015331:Cohort Studies; D003191:Comprehensive Health Care / Q000458:organization & administration*; D003371:Cough; D005260:Female; D006760:Hospitalization; D006801:Humans; D007442:Intubation, Intratracheal; D008171:Lung Diseases / Q000517:prevention & control*; D008297:Male; D010348:Patient Care Team / Q000458:organization & administration*; D011182:Postoperative Care; D011183:Postoperative Complications; D015397:Program Evaluation; D012121:Respiration, Artificial