Assessing Compliance of Incentive Spirometry in Hospitalized Patients with Acute Sickle Cell Crisis

Introduction:

Sickle cell disease (SCD) and its complications span multiple organ systems, including but not limited to cardiac, pulmonary, bone and so forth (Field, Desai). Pulmonary complications such as acute chest syndrome (ACS) can occur in up to 50% of patients. Oftentimes the exact trigger for ACS is not clear; the most common etiology is due to pneumonia. Other pulmonary complications include asthma, chronic dyspnea and pulmonary hypertension (Klings). Bellet's NEJM trial studied the use of incentive spirometry (IS) in helping to prevent such pulmonary complications. The study analyzed hospitalized acute sickle cell crisis (SCC) patients, who presented with chest or back pain, and the role of IS in decreasing the incidence of atelectasis and pulmonary infiltrates. Bellet's study had demonstrated that pulmonary complications were decreased in the treatment group (i.e. patients who received IS) for both patients presenting with acute chest/back pain and in those patients who had evidence of thoracic bone infarction (Bellet).

With this background, we aimed to study the compliance and use of IS in our hospitalized SCD patients at NBI.

Methods:

45 SCD patients who were admitted to medical surgical units were identified between August 2023 to May 2024. These patients were admitted for vaso-occlusive disease, were at least > 18 years or older, included all SCD genotypes (including SS, SC, sickle beta thal..etc) and included both complicated and uncomplicated SCC.

Surveys were collected from the medical surgical nursing staff caring for these patients and the nursing staff were specifically surveyed on the use of IS in these admitted patients. The survey consisted of 5 questions assessing the compliance and use of IS among nursing staff.

Each question was given a scale of 100%, 75-100%, 50-75% and < 50% as to how often each task was seen or done. For example, question 1 asked how often nursing staff saw IS ordered for their patients. Was it 100% of the time vs 75-100% of the time and so forth. Questions 3-5 addressed other aspects such as how often (IS) was given to patients, if patients were appropriately taught to use the (IS) and whether or not additional time was taken to ensure patients understood proper use. Question 2 was a yes or no question regarding whether or not nursing staff desired physicians communicate about the IS order being placed. Using this survey and the scale for these questions, nursing answered as below.

Results:

For the 45 patients, 26% of the nursing staff saw IS ordered in less than 50% of their patients. Nursing staff noted that only 17/45 or 37% of their patients usually had IS ordered or in other words had IS ordered at least 75-100% of the time. Majority of the nursing staff, 91%, desired that physicians would communicate about IS orders being placed.

46% of nursing staff caring for these SCC patients always (or 100% of the time) provided IS to patients and another 33% usually (or in 75-100% of the time) provided IS to patients when they saw IS ordered.

46% (21/45) of the nursing staff who took time to give patients the IS always made sure to take time to teach patients on proper use of the IS. And 48% (22/45) always spent additional time making sure patients understood proper use.

Discussion:

Incentive Spirometry can be beneficial in hospitalized patients presenting in acute SCC especially in prevention of further pulmonary complications (Klings). However implementation of IS within a healthcare network can be difficult, and additional factors such physician nursing staff communication, physician compliance/awareness, appropriate technique and ability to teach patients proper technique are also important to monitor. From our study, we noted issues on multiple layers, first not all SCD patients had IS ordered on admission by physicians. In some cases, even though IS was ordered, nurses did not provide IS to patients. And finally for those patients who had IS given to them, nursing staff and/or providers did not educate and show proper use of IS. With the information from this study, we plan to re-educate both nursing staff as well as the hospitalists on the importance of both ordering the IS but also in educating admitted SCD patients on proper IS use and how IS affects patient outcomes. Additionally, we plan to further improve care by adding the IS order as part of the SCD order set to increase physician compliance with ordering IS.

No relevant conflicts of interest to declare.