Year of Publication

2017

Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Carol Thompson

Clinical Mentor

Dr. Lacey Buckler

Committee Member

Dr. Chizimuzo Okoli

Abstract

Abstract

BACKGROUND: This paper outlines the steps taken for a quality improvement study that investigated the development of postoperative respiratory failure (PORF) at University of Kentucky Chandler Medical Center (UKCMC). The first paper describes the influence of an interprofessional education (IPE) pilot program on doctoral nursing students and the experiences gained while working on a process improvement project. The second paper is a literature review on predictors for PORF. The third paper is a case control study that investigated the effects of pain management modalities on the development of PORF.

OBJECTIVES: To outline the process for developing a practice improvement project. The purpose of the practice improvement project is to understand factors associated with PORF among surgical patients. Specifically the goal of the study was to understand if the type of postoperative pain management provided to surgical patients is associated with the development of PORF. There are four objectives to this project report: 1. To compare demographic, type of surgery, type of pain management, and discharge disposition differences between patients with and without PORF; 2. Among those who develop PORF to examine differences in demographic, type of surgery, and discharge disposition by type of pain management; 3. Examine the relationship between cause for reintubation and pain management type; 4. To determine the predictors of mortality in those with PORF.

METHODS: First a practice improvement project was completed using the skills gained during and IPE pilot program. Then a search of the literature was completed to determine the risk factors involved with the development of PORF. Then a retrospective chart review of PORF cases (n=108) matched to controls (n=107) was done at the University of Kentucky Chandler Medical Center for the years 2010-2015.

FINDINGS: The skills learned in IPE and the knowledge gained during the literature review culminated in a process improvement project with the following findings. As compared to controls, cases were significantly more likely to be smokers (36.1% vs 21.5%), to use intermittent intravenous dosing (IID) (47.2% vs 16.8%) and intravenous patient controlled analgesia (IVPCA) (26.9% vs 15.9%), have abdominal surgery (42.6%vs 29.9%), and to have longer lengths of surgery (mean length =334.6min vs 256.8min) and were less likely to be discharged home (42.6% vs 88.8%). Abdominal surgeries were more likely to receive IVPCA (47.8%) and epidural patient controlled analgesia (EPCA) (19.6%). Genitourinary surgery patients were more likely to receive IID (78.6%); head/neck and neuro/spine only received IDD (66.7%) or oral (PO) pain medication (33.3%); orthopedic surgery patients were most likely to receive IVPCA (37.5%); and thoracic and vascular surgery were primarily likely to receive IDD (63.6%). Individuals who expired were most likely to receive IID (42.9%). Primary causes for reintubation were atelectasis (34.3%) and fluid overload/pulmonary edema (25.0%). There were no statistically significant differences in causes for reintubation by pain management type. The only salient predictor of mortality was American Society of Anesthesia score >3.

CONCLUSION: Interprofessional education (IPE) is a valuable tool that should be incorporated in the curriculum of doctoral education. The literature review is an essential step to guide scholarly inquiry into evidence-based practice. An investigation of the association of pain management modalities on the development of PORF at UKCMC found that there is a need for a multi-disciplinary approach to decrease the risk associated with PORF. Enhanced recovery after surgery (ERAS) pathways incorporate multidisciplinary strategies to address the primary variables associated with PORF. By implementing these multidisciplinary strategies, UKCMC can decrease the risk of PORF in abdominal surgery patients.

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