Pulmonary complications after surgery are relatively common, occurring in roughly 3% of patients who undergo non-cardiac operations. When compared with other adverse postoperative outcomes, pulmonary complications are also among the most costly. Some analyses have shown that these complications can increase hospital length of stay by as
many as 14 days when compared with a lack of these complications. “Clinicians have little guidance on how to prevent pulmonary complications after operations,” says David McAneny, MD. “Efforts to standardize care may reduce the incidence of adverse
pulmonary outcomes.”

Testing an Intervention

In a study published in JAMA Surgery, Dr. McAneny and colleagues tested an intervention designed to reduce the incidence of postoperative pulmonary complications. “Our goal was to create a simple, inexpensive pulmonary care program that was easily understood and remembered by patients, their families, and our staff,” says Dr. McAneny. “We included lung expansion exercises, early and frequent patient mobilization, oral hygiene, and education as key components of our strategy.”


In order to facilitate recall of the intervention, the acronym “I COUGH” was developed. I COUGH components included:

Incentive spirometry.

Coughing and deep breathing.

Oral care (brushing teeth and using mouthwash
twice daily).

Understanding (patient and family education).

Getting out of bed frequently (at least three times daily).

Head-of-bed elevation.

“A critical component of I COUGH is patient education, a process that begins in clinics and continues during preoperative assessments,” explains Dr. McAneny. “Brochures, a video in various languages, and posters with instructions that describe the importance of postoperative pulmonary care were developed.” The multidisciplinary program taught and reinforced principles of the I COUGH interventions. Elements of I COUGH were reinforced after operations by nursing staff, surgeons, and house staff during rounds to establish a culture that emphasized optimal postoperative pulmonary care.

“It should be noted that our hospital was a high outlier in all National Surgical Quality Improvement Program (NSQIP)-defined adverse pulmonary outcomes, but we viewed this as an opportunity to improve care,” adds Dr. McAneny. “Our goal was to motivate providers to understand the significance of quality outcomes and to embrace a higher standard of care for patients.”

Profound Effects

In the JAMA Surgery study, Dr. McAneny and colleagues found that the raw incidence of postoperative pneumonia decreased from 2.6% before implementing I COUGH to 1.6% after implementation (Figure 1). The average incidence of pneumonia at comparable NSQIP hospitals, which included academic medical centers with more than 500 beds, meanwhile declined from 1.7% to 1.4%. The risk-adjusted data for BMC improved from an observed/expected (O/E) ratio of 2.13 to an odds ratio (OR) of 1.58. The O/E ratio and OR values are statistically comparable for large sample sizes. After implementing I COUGH, the raw incidence of unplanned intubations also decreased from 2.0% before implementation to 1.2% afterward (Figure 2). The raw incidence for comparable hospitals simultaneously declined from 1.6% to 1.4%, with a risk-adjusted improvement from an O/E of 2.10 to an OR of 1.31.

“Efforts to standardize care may reduce the incidence
of adverse pulmonary outcomes.”

In a subjective review of I COUGH care patterns, patient education was inconsistent before implementation. “There was no formal preoperative education, and patients’ families were usually not included in discussions,” says Dr. McAneny. “Physicians’ orders for nurses regarding postoperative mobilization were also inconsistent.” After introducing I COUGH, the establishment of a standardized order set and nursing documentation requirements improved the education of patients and their families, making it routine in preoperative clinics, preoperative holding areas, and postoperative units. Patient mobilization also occurred in a more standardized fashion.

“By involving a multidisciplinary team in all stages of planning and development, we redefined the culture to instill commitment to and pride in reducing the incidence of pulmonary complications,” Dr. McAneny says. “This cannot be achieved by simply instituting and enforcing a policy without input from key stakeholders.” He adds that sustained efforts to reinforce the I COUGH principles are required, including continuous auditing of practices on the postoperative units and redirection of care toward quality outcomes.

Looking Forward

Fostering a culture of education and improvement is essential to the I COUGH goals, according to Dr. McAneny. “The collection of postoperative interventions in I COUGH can improve outcomes, but it starts with promoting excellence as part of the culture of the institution,” he says. “Educational efforts should be directed at both staff and patients and their families. Standardization and simplicity are other important aspects of success.”

Dr. McAneny adds that national quality improvement programs like NSQIP have empowered clinicians to redefine standards of care. “The successes of I COUGH and other postoperative care programs must be sustained with constant education and re-education of staff and patients. We also need to regularly measure performance and analyze the data. As we monitor our outcomes over a longer period of time, we are hopeful that postoperative complications may decrease by adhering to simple, inexpensive, easily performed patient care strategies like I COUGH.”