The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience.

BACKGROUND: Surgical quality improvement programs can provide meaningful benefits for patient outcomes, but sustainability of initial success is rarely described. In response to data that revealed a greater than predicted likelihood of postoperative pulmonary complications in one hospital, the study team designed a standardized program to improve care. This study offers a long-term perspective of the effort, including special challenges and lessons learned about sustaining success. METHODS: A before-after study was conducted at an academic safety-net hospital. A multidisciplinary team developed tactics to reduce pulmonary complications, designated by the acronym I COUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (education), Getting out of bed, and Head of bed elevation. Clinical practices were audited and compared to actual and risk-adjusted pulmonary outcomes. RESULTS: Improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes have inversely correlated with process adherence in "sawtooth" patterns. Rejuvenation efforts have successively extended beyond the literal principles of the acronym to foster broader institutional commitment to perioperative pulmonary care, restoring favorable trends in both process and outcomes. A more comprehensive I COUGH program now extends beyond the acronym, applying numerous concepts to support the original program. CONCLUSION: I COUGH, a standardized perioperative pulmonary care program, initially improved performance and reduced pulmonary complications. However, loss of early program momentum corresponded with a return to baseline outcomes. Fortunately, an overall favorable trend has resulted from a coordinated rededication to I COUGH that requires steadfast commitment and creative responses to numerous cultural barriers.

Socially Responsible Surgery: Building Recognition and Coalition.

IMPORTANCE: Socially responsible surgery (SRS) integrates surgery and public health, providing a framework for research, advocacy, education, and clinical practice to address the social barriers of health that decrease surgical access and worsen surgical outcomes in underserved patient populations. These patients face disparities in both health and in health care, which can be effectively addressed by surgeons in collaboration with allied health professionals. OBJECTIVE: We reviewed the current state of surgical access and outcomes of underserved populations in American rural communities, American urban communities, and in low- and middle-income countries. EVIDENCE REVIEW: We searched PubMed using standardized search terms and reviewed the reference lists of highly relevant articles. We reviewed the reports of two recent global surgery commissions. CONCLUSION: There is an opportunity for scholarship in rural surgery, urban surgery, and global surgery to be unified under the concept of SRS. The burden of surgical disease and the challenges to management demonstrate that achieving optimal health outcomes requires more than excellent perioperative care. Surgeons can and should regularly address the social determinants of health experienced by their patients. Formalized research and training opportunities are needed to meet the growing enthusiasm among surgeons and trainees to develop their practice as socially responsible surgeons.

Patterns of Failure of a Standardized Perioperative Venous Thromboembolism Prophylaxis Protocol.

BACKGROUND: Venous thromboembolism (VTE) is a leading contributor to morbidity after operations. We previously implemented a standardized VTE risk assessment, based on the Caprini score, along with risk-stratified prophylaxis. This system reduced the odds ratio of a VTE event from 3.02 to 0.75. We investigated patterns of failure to determine characteristics of patients in whom VTE develops despite the protocol. METHODS: We reviewed all nontrauma general surgery patients with evidence of VTE after the inception of a VTE risk assessment and prophylaxis program. Characteristics were recorded, including demographics, diagnoses, operations, risk profile, prophylaxis prescribed, and regimen compliance. RESULTS: Twenty-seven patients failed the protocol and manifested VTE, representing an overall VTE rate of 0.3%. Of these patients, 63% had emergency operations and 52% underwent multiple operations, compared with 13% and 2.0% of the nontrauma general surgery population in whom VTE did not develop, respectively (p < 0.001). Of patients with VTE, 52% had pre-existing or postoperative infections, 22% had malignancies, but only 15% had missed 1 or more doses of pharmacologic prophylaxis during hospitalization. Five VTEs manifested after discharge; one of those patients was prescribed extended prophylaxis beyond hospitalization, and an extended course was not provided to 3 who were eligible. One patient had underestimation of the Caprini score due to lack of awareness of a family history of VTE. CONCLUSIONS: Emergency and multiple operations seem to confer dramatic hazards for VTE, despite standard prophylaxis. These factors are not currently captured in the Caprini model, but might be significant modifiers of risk that should prompt reassessment, perhaps with a weighted numeric value along with enhanced prophylaxis. It is encouraging that most patients received appropriate prophylaxis in compliance with the protocol.