I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program

JAMA Surg. 2013 Aug;148(8):740-5. doi: 10.1001/jamasurg.2013.358.


Importance: Postoperative pulmonary complications can be a devastating consequence of surgery. Validated strategies to reduce these adverse outcomes are needed.

Objectives: To design, implement, and determine the efficacy of a suite of interventions for reducing postoperative pulmonary complications.

Design: A before-after trial comparing our National Surgical Quality Improvement Program (NSQIP) pulmonary outcomes before and after implementing I COUGH, a multidisciplinary pulmonary care program.

Setting: An urban, academic, safety-net hospital.

Participants: All patients who underwent general or vascular surgery at our institution during a 1-year period before and after implementation of I COUGH.

Interventions: A multidisciplinary team developed a strategy to reduce pulmonary complications based on comprehensive patient and family education and a set of standardized electronic physician orders to specify early postoperative mobilization and pulmonary care. Designated by the acronym I COUGH, the program emphasizes incentive spirometry, coughing and deep breathing, oral care (brushing teeth and using mouthwash twice daily), understanding (patient and family education), getting out of bed at least 3 times daily, and head-of-bed elevation. Nursing and physician education promoted a culture of mobilization and I COUGH interventions. I COUGH was implemented for all general surgery and vascular surgery patients at our institution in August 2010.

Main outcomes and measures: The NSQIP-reported incidence and risk-adjusted ratios of postoperative pneumonia and unplanned intubation, which NSQIP reports as observed-expected (OE) ratios for the 1-year period before implementing I COUGH and as odds ratios (ORs, statistically comparable to OE ratios) for the period after its implementation.

Results: Before implementation of I COUGH, our incidence of postoperative pneumonia was 2.6%, falling to 1.6% after its implementation, and risk-adjusted outcomes fell from an OE ratio of 2.13 to an OR of 1.58. The incidence of unplanned intubations was 2.0% before I COUGH and 1.2% after I COUGH, with risk-adjusted outcomes decreasing from an OE ratio of 2.10 to an OR of 1.31.

Conclusions and relevance: I COUGH, a standardized postoperative care program emphasizing patient education, early mobilization, and pulmonary interventions, reduced the incidence of postoperative pneumonia and unplanned intubation among our patients.

MeSH terms

  • Cohort Studies
  • Comprehensive Health Care / organization & administration*
  • Cough
  • Female
  • Hospitalization
  • Humans
  • Intubation, Intratracheal
  • Lung Diseases / prevention & control*
  • Male
  • Patient Care Team / organization & administration*
  • Postoperative Care*
  • Postoperative Complications*
  • Program Evaluation
  • Respiration, Artificial