Presenter Status
Fellow
Abstract Type
QI
Primary Mentor
Joel Thompson
Start Date
8-5-2023 12:45 PM
End Date
8-5-2023 1:00 PM
Presentation Type
Oral Presentation
Description
Problem Statement/Question: Acute chest syndrome (ACS) is one of the leading causes of morbidity and mortality in patients with sickle cell disease. Patients are at higher risk for this complication during hospital admission due to limited mobility leading to decreased lung inflation. The National Heart, Lung, and Blood Institute (NHLBI) recommends providing ten breaths of incentive spirometry (IS) every two hours while awake for patients admitted to the hospital with sickle cell disease to help prevent development of acute chest syndrome. Without this intervention, patients are more likely to develop ACS requiring increased level of care, prolonged hospital stays, and potential long-term pulmonary complications.
Background/Project Intent (Aim Statement): We reviewed provision of IS to sickle cell patients at Children’s Mercy over a three-month span (08/01/2021 to 11/01/2021) which revealed 0% of hospital days with recommended frequency of IS (offered every two hours while awake). For our first PDSA cycle, our aim was to increase this frequency from 0% to 10% between 12/21/22 and 3/14/22.
Methods (include PDSA cycles): Data was collected from 08/01/2021 to 11/01/2021 and the target population was identified via a report generated from the electronic medical records. Of those patients admitted with sickle cell vaso-occlusive crisis (the most common indication for inpatient hospitalization), we reviewed the frequency that IS was offered each hospital day, excluding admission and discharge days. During this three-month period, no patients were offered IS at the frequency recommended by the NHLBI. Meetings with stakeholders identified that orders were not consistent with current NHLBI recommendations and conflicted between Cerner powerplans. To address this potential root cause, orders were updated to match NHLBI recommendations. We supported this intervention with education for nurses and residents. We reviewed provision of IS following implementation of standardized IS orders between 12/21/22 and 3/14/22 with improvement to 2%. We collected a second data set 08/01/2022- 10/31/2022 to evaluate the impact of our intervention over time.
Results: Following PDSA cycle 1, between 08/01/2022 and 10/31/2022, there were 167 hospital days with patients admitted to CMH with a sickle cell-associated diagnosis, excluding admission and discharge days. Of 167 hospital days, 25.7% (43/167) had IS documented at all. When IS was documented, 12% of patients were offered the recommended frequency of IS and the median time between IS was 3 hours (compared to 2% and 5.9 hours, respectively, immediately post- PDSA cycle 1).
Conclusions: Our goal with this project is to increase the frequency at which IS is offered to patients with sickle cell disease admitted to the hospital for vaso-occlusive pain crisis in order to meet NHLBI guidelines. Further meetings with stakeholders revealed barriers with the task of offering IS in addition to other duties. Nursing proposed coordinating the task and its documentation with the existing, required task of patientcontrolled analgesia (PCA) assessment every two hours. With the second PDSA cycle, we aim to improve this frequency from 12 to 25% over a three-month period from 02/06/2023 to 04/30/2023.
MeSH Keywords
sickle cell disease; acute chest syndrome; quality improvement
Increasing incentive spirometry use in patients with sickle cell disease: Longer follow-up of PDSA Cycle 1
Problem Statement/Question: Acute chest syndrome (ACS) is one of the leading causes of morbidity and mortality in patients with sickle cell disease. Patients are at higher risk for this complication during hospital admission due to limited mobility leading to decreased lung inflation. The National Heart, Lung, and Blood Institute (NHLBI) recommends providing ten breaths of incentive spirometry (IS) every two hours while awake for patients admitted to the hospital with sickle cell disease to help prevent development of acute chest syndrome. Without this intervention, patients are more likely to develop ACS requiring increased level of care, prolonged hospital stays, and potential long-term pulmonary complications.
Background/Project Intent (Aim Statement): We reviewed provision of IS to sickle cell patients at Children’s Mercy over a three-month span (08/01/2021 to 11/01/2021) which revealed 0% of hospital days with recommended frequency of IS (offered every two hours while awake). For our first PDSA cycle, our aim was to increase this frequency from 0% to 10% between 12/21/22 and 3/14/22.
Methods (include PDSA cycles): Data was collected from 08/01/2021 to 11/01/2021 and the target population was identified via a report generated from the electronic medical records. Of those patients admitted with sickle cell vaso-occlusive crisis (the most common indication for inpatient hospitalization), we reviewed the frequency that IS was offered each hospital day, excluding admission and discharge days. During this three-month period, no patients were offered IS at the frequency recommended by the NHLBI. Meetings with stakeholders identified that orders were not consistent with current NHLBI recommendations and conflicted between Cerner powerplans. To address this potential root cause, orders were updated to match NHLBI recommendations. We supported this intervention with education for nurses and residents. We reviewed provision of IS following implementation of standardized IS orders between 12/21/22 and 3/14/22 with improvement to 2%. We collected a second data set 08/01/2022- 10/31/2022 to evaluate the impact of our intervention over time.
Results: Following PDSA cycle 1, between 08/01/2022 and 10/31/2022, there were 167 hospital days with patients admitted to CMH with a sickle cell-associated diagnosis, excluding admission and discharge days. Of 167 hospital days, 25.7% (43/167) had IS documented at all. When IS was documented, 12% of patients were offered the recommended frequency of IS and the median time between IS was 3 hours (compared to 2% and 5.9 hours, respectively, immediately post- PDSA cycle 1).
Conclusions: Our goal with this project is to increase the frequency at which IS is offered to patients with sickle cell disease admitted to the hospital for vaso-occlusive pain crisis in order to meet NHLBI guidelines. Further meetings with stakeholders revealed barriers with the task of offering IS in addition to other duties. Nursing proposed coordinating the task and its documentation with the existing, required task of patientcontrolled analgesia (PCA) assessment every two hours. With the second PDSA cycle, we aim to improve this frequency from 12 to 25% over a three-month period from 02/06/2023 to 04/30/2023.
