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.

5. 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

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. Greatest Improvement 24% 88% What 3 factors determine pts goal volume?

13. Most correct answers 48% 98% How long should pt hold breath?

14. Most Commonly Missed Pre & Post Incentive spirometry measures what? 48% 78% 50% 20%

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 Patient’s effort now documented Computer charting that prompts intervention Includes target volume (to trigger RN)

17. New Charting

18. Similarities / Unchanged Some patients, including those on room air, have no documentation for IS therapy No standard for frequency of charting IS treatment

19. 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

20. 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

21. 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 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 http://www.rcjournal.com/cpgs/ispircpg.html

22. For additional information please contact: Sara Couch – scouch@ucsd.edu Laura Dibsie – ldibsie@ucsd.edu