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Reducing PPC's in Surgical ICU Patients

Lisa Kerigan, Specialist Physiotherapist at Manchester Royal Infirmary shares the implementation of their Enhanced Recovery After Surgery + (ERAS+) pathway, which has reduced post-operative pulmonary complications for elective major surgery patients on ICU from 18.7% to 8.7% since implementation in September 2014.

A prevalence audit at Central Manchester Foundation NHS Trust in 2013 revealed a post- operative pulmonary complication rate (PPC) of 18.3% in patients following elective major surgery on critical care. As a result of this a quality improvement team was set up with the aim of reducing PPC’s in patients following elective major surgery, incorporating elements of Enhanced recovery and specific measures to reduce the rates of PPC’s thus formulating Enhance Recovery After Surgery + (ERAS+).

The team comprises of consultant anaesthetists/intensivists, physiotherapy staff, enhanced recovery nursing staff, critical care nursing staff and administration. This involved weekly meetings for the MDT for approximately one hour during the development of ERAS+ and therapy staff being involved in the development of patient education videos and in the on-going support and education of nursing staff. Members of the MDT disseminated the information and relevant training to individual teams as appropriate. There was no additional staffing to complete this project during the development and implementation stage although the project is now accepted as custom and practice within the critical care units. However, now the project is up and running it is primarily nurse driven on critical care and formal therapy input is for one hour a week at surgery school. Patients still receive individualised therapy on critical care however therapy incorporates as much as is appropriate of the ICOUGH UK concept.

ERAS+ was implemented in September 2014 with the introduction of ICOUGH UK and surgery school as two specific measures to help reduce PPC’s. The project has seen involvement from the wider MDT including the surgical teams, medical, nursing and therapy staff. ERAS+ incorporates multiple specialities including vascular, urology, HPB, colorectal, Upper GI, head and neck and major gynaecological surgery. However, the principles of ERAS+ and ICOUGH UK are widely utilised by non-surgical specialities with good effect.

A therapist is present for approximately one hour a week to present during Surgery school which is an educational session for patients and their families. This session includes advice on pre-operative breathing exercises with incentive spirometry, how to improve activity levels and exercise before surgery, what to expect after an operation, diet and lifestyle advice. Patients and their relatives are also given the opportunity to look around critical care after surgery school.

ICOUGH UK is a collaboration between Boston Medical Centre USA and the Manchester Royal Infirmary. ICOUGH stands for Incentive Spirometry, Coughing and deep breathing, Oral health care, Understanding, Getting out of bed and Head of the bed elevated. Patients are taught about ICOUGH UK prior to surgery when attending surgery school. They are issued with incentive spirometers either at pre-op clinic or at surgery school and taught how to use them. Patients are advised to use their incentive spirometers 4 x day pre-op and 1hourly post-op.

During the implementation of ERAS+ to 1 year post implementation the rate of PPC’s in elective major surgery patients with planned critical care admission fell from 18.7% to 10.4%. Sustained improvement was seen at 1 year post implementation with the rate of PPC’s dropping to 8.7%

The use of ICOUGH UK on critical care is prescribed and adherence to the ICOUGH care bundle is continually measured and audited. The prescription includes the use of incentive spirometers, mobilisation to a chair 2 x day, the use of mouth wash 2 x day and brushing teeth 2 x day. This is in addition to the measurement of other standard outcomes including unit length of stay and severity of illness scores (ICNARC).


Lisa Kerigan, Specialist Physiotherapist, Manchester Royal Infirmary

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