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 fellowLaura Dibsie, RN, MSN,CCRN - EBPI mentor

UCSD Medical Center

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!!

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.

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.

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

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.

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

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

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

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

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

AGE GENDER HEIGHT

0 10 20 30 40 50 60 70 80 90 100

POST

PRE

% CORRECT ANSWERS

Greatest Improvement

24%

88%

What 3 factors determine pts goal volume?

3-5 Seconds

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

POST

PRE

% CORRECT ANSWERS

Most correct answers

48%

98%

How long should pt hold breath?

Most Commonly MissedPre & Post

Vital Capacity Tidal Volume

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PRE POST PRE POST

correct incorrect

Incentive spirometry measures what?

48%

78%

50%

20%

Documentation Pre-

• Pre-education documentation was inconsistent

• Two options: “Done” or “Active”

• Comments not detailed– attempted

– UTA

– CDB

– 10 x 1000

Documentation Post-

• Definitely more detailed

• Patient’s effort now documented

• Computer charting that prompts intervention

• Includes target volume (to trigger RN)

New Charting

Similarities / Unchanged

• Some patients, including those on room air, have no documentation for IS therapy

• No standard for frequency of charting IS treatment

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

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

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/spinalsum/htm

AARC Clinical Practice Guideline: Incentive Spirometry. Retrieved April 5, 2007 from http://www.rcjournal.com/cpgs/ispircpg.html

For additional information please contact:

Sara Couch – scouch@ucsd.eduLaura Dibsie – ldibsie@ucsd.edu