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

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

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