Prevention of Acute Chest Syndrome By Implementing a Standardized Process to Improve Incentive Spirometry Use in Hospitalized Patients with Sickle Cell Disease

Background

Acute chest syndrome (ACS) is the second most common cause of admission and the main cause of death in patients with sickle cell disease (SCD). Nearly half of ACS cases develop during hospitalizations. Incentive spirometry (IS) use decreases the incidence of ACS during hospitalization. The 2014 NHLBI guidelines for the management of SCD encouraged the use of incentive spirometry in hospitalized patients to prevent the development of ACS (strong recommendation, moderate-quality evidence). Despite the available evidence and recommendations, IS is underutilized and the use of this simple, inexpensive, and effective intervention in hospitalized patients with SCD is inconsistent. We sought to develop and implement a standardized process to ensure a reliable use of IS in hospitalized patients with SCD and measure its effect on the occurrence of ACS.

Methods

Based on the model for improvement, we implemented a standard process that involved several interventions to improve the use of IS in all hospitalized children and young adults with SCD at Cincinnati Children's Hospital Medical Center. Interventions included the development of an electronic medical record-based order set to standardize IS orders, supplying inpatient units with incentive spirometers for timely delivery, increasing awareness through education of staff, patients and families, discussing IS use during daily rounds, and standardization of the nursing documentation of IS use. The primary outcome was the percent ACS diagnosis per inpatient encounters per month.

Results

We analyzed all SCD inpatient encounters one year before (April 2015-April 2016; n=224) and one year after (May 2016-May 2017; n=214) the implementation of the new process. The frequency of ACS diagnosis was reduced from 22% (50/224) pre-intervention to 12% (25/214) post-intervention (P=0.002). The median rate of ACS diagnosis per month was reduced from 23% to 12% and this reduction was maintained over one year post intervention. There was an improvement in the reliability of all measurable key processes targeted during this initiative. The percent of inpatient encounters with accurate IS orders increased from 28% to 88% and the percent of encounters with documented actual IS use by the patient improved from 41% pre-intervention to 81% post-intervention. There also was a trend of decreased length of stay from an average of 3.3 days in the 12 months preceding intervention to an average of 3.1 days in the year following the implementation of the new process. Possibly due to increased awareness for ACS among the clinical staff, there also was an unintended increase in the number of chest radiographs (CXR) performed from 16% pre-intervention (35 total CXR) to 37% post- intervention (70 total CXR). Despite this increase in the number of CXR performed, the diagnosis of ACS was still decreased by nearly half.

Discussion

Through the implementation of a standard process, reliable and sustained use of IS in hospitalized patients with SCD was associated with a decrease in the frequency of ACS diagnosis. Identifying and reliably executing key processes through a multidisciplinary approach was associated with an improved outcome and was maintained over a 12-month period. Automation of the new process will further improve its reliability and sustainability and allow for better assessment of its impact on morbidity, cost, and length of stay over a longer duration.