IText For ICOUGH: Improving Ambulation of Surgical Patients Through Text Messaging
| Status: | Enrolling by invitation |
|---|---|
| Conditions: | Orthopedic |
| Therapuetic Areas: | Orthopedics / Podiatry |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 3/27/2019 |
| Start Date: | March 21, 2019 |
| End Date: | August 2019 |
The investigators plan to conduct a study that evaluates if text messaging increases
patients' adherence to ambulation (specifically reminding patients to get out of bed three or
more times daily) which is one component of a protocol called ICOUGH, which is a mnemonic
that stands for: Incentive spirometry (a breathing device that expands the lungs), Coughing
and deep breathing, Oral hygiene (using a toothbrush for example),Understanding (patient and
family education), Getting out of bed at least three times daily, and Head-of-bed elevation
to prevent choking; each letter representing steps of a protocol developed at Boston Medical
Center (BMC) shown to decrease lung-related complications of surgery. Other outcomes,
including frequency of ambulation, pain score, number of visitors per day, head-of-bed
elevation, education on importance of ambulation, and falls will also be assessed. The
hypothesis is that a reminder text message to ambulate will improve these outcomes over time.
While beneficial to patients and health care facilities, the ICOUGH protocol is sometimes
both difficult to implement and sustain at an acute care hospital, because: (1) patient
motivation fluctuates and is the key determinant of patient ambulation (2) it relies heavily
on nurses to both educate patients and then keep them accountable to the protocol, (3) an
unfavorable nurse-to-patient ratio, (4) high inpatient turnover for elective surgical cases,
and (5) an aging baby boomer population—a higher volume of older, higher- risk patients will
require more time and attention per nurse. Therefore, utilization of text message reminders
may promote better patient, family, and provider engagement and adherence to ambulation which
can improve outcomes and decrease healthcare spending.
patients' adherence to ambulation (specifically reminding patients to get out of bed three or
more times daily) which is one component of a protocol called ICOUGH, which is a mnemonic
that stands for: Incentive spirometry (a breathing device that expands the lungs), Coughing
and deep breathing, Oral hygiene (using a toothbrush for example),Understanding (patient and
family education), Getting out of bed at least three times daily, and Head-of-bed elevation
to prevent choking; each letter representing steps of a protocol developed at Boston Medical
Center (BMC) shown to decrease lung-related complications of surgery. Other outcomes,
including frequency of ambulation, pain score, number of visitors per day, head-of-bed
elevation, education on importance of ambulation, and falls will also be assessed. The
hypothesis is that a reminder text message to ambulate will improve these outcomes over time.
While beneficial to patients and health care facilities, the ICOUGH protocol is sometimes
both difficult to implement and sustain at an acute care hospital, because: (1) patient
motivation fluctuates and is the key determinant of patient ambulation (2) it relies heavily
on nurses to both educate patients and then keep them accountable to the protocol, (3) an
unfavorable nurse-to-patient ratio, (4) high inpatient turnover for elective surgical cases,
and (5) an aging baby boomer population—a higher volume of older, higher- risk patients will
require more time and attention per nurse. Therefore, utilization of text message reminders
may promote better patient, family, and provider engagement and adherence to ambulation which
can improve outcomes and decrease healthcare spending.
Pulmonary complications (e.g., pneumonia, unplanned intubation, and prolonged duration of
ventilatory support) occur after about 1-2% of operations in the United States, leading to
significant morbidity, lengths of hospital stay and cost, perhaps as much as $50,000 in
expenses for the necessary additional care. However, many of these complications are
preventable and the ICOUGH protocol has been demonstrated to impact pulmonary post operative
complications. It has been shown to improve patient outcomes by decreasing postoperative
pneumonia by 38%, unplanned intubations by 40%, and all adverse outcomes by 40%; over $5
million in cost savings for BMC in a two-year period has accompanied improved patient
outcomes.
But despite its efficacy, the acute care hospital setting, specifically a safety-net hospital
setting, presents challenges to ICOUGH protocol sustainability. ICOUGH requires education of
patients over a number of time points and holds them accountable to adhere to the protocol.
Nurses represent one source of education, although other clinical demands compete for nurses'
time and attention. Acute care hospitals face high inpatient turnover for elective operations
and must contend with an aging population that translates to a higher volume of older,
higher-risk patients who may require more time and attention per nurse. Additionally,
non-elective surgery patients, such as those admitted from the emergency department, would
not have received ICOUGH protocol education. However, patients who are admitted to the
hospital after emergency and trauma operations are at greatest risk of suffering pulmonary
complications and stand to benefit the most from these interventions. These patients are not
always optimized for surgery due to their acute circumstances, and they do not ordinarily
receive the ICOUGH education that patients have prior to elective operations. In addition,
patients also lack significant motivation due to the seriousness of their presentation and
pain level to ambulate unless reminded.
To address these challenges within BMC and facilitate ambulation protocol implementation,
sustainability, and scaling in other institutions, the research team developed a
point-of-care, patient-centric way to promote better patient, family, and provider engagement
with and adherence to the ICOUGH protocol, specifically ambulation. In this pilot study,
patients will be randomized to receive a text message once a day to remind them to ambulate
three or more times each day in addition to the ICOUGH education or to receive the ICOUGH
education without text reminders. All participants will be contacted daily by a research team
member to collect data on the outcome measures and each participant in the experimental text
message arm will be interviewed at hospital discharge to solicit their opinion abut the text
message reminders.
ventilatory support) occur after about 1-2% of operations in the United States, leading to
significant morbidity, lengths of hospital stay and cost, perhaps as much as $50,000 in
expenses for the necessary additional care. However, many of these complications are
preventable and the ICOUGH protocol has been demonstrated to impact pulmonary post operative
complications. It has been shown to improve patient outcomes by decreasing postoperative
pneumonia by 38%, unplanned intubations by 40%, and all adverse outcomes by 40%; over $5
million in cost savings for BMC in a two-year period has accompanied improved patient
outcomes.
But despite its efficacy, the acute care hospital setting, specifically a safety-net hospital
setting, presents challenges to ICOUGH protocol sustainability. ICOUGH requires education of
patients over a number of time points and holds them accountable to adhere to the protocol.
Nurses represent one source of education, although other clinical demands compete for nurses'
time and attention. Acute care hospitals face high inpatient turnover for elective operations
and must contend with an aging population that translates to a higher volume of older,
higher-risk patients who may require more time and attention per nurse. Additionally,
non-elective surgery patients, such as those admitted from the emergency department, would
not have received ICOUGH protocol education. However, patients who are admitted to the
hospital after emergency and trauma operations are at greatest risk of suffering pulmonary
complications and stand to benefit the most from these interventions. These patients are not
always optimized for surgery due to their acute circumstances, and they do not ordinarily
receive the ICOUGH education that patients have prior to elective operations. In addition,
patients also lack significant motivation due to the seriousness of their presentation and
pain level to ambulate unless reminded.
To address these challenges within BMC and facilitate ambulation protocol implementation,
sustainability, and scaling in other institutions, the research team developed a
point-of-care, patient-centric way to promote better patient, family, and provider engagement
with and adherence to the ICOUGH protocol, specifically ambulation. In this pilot study,
patients will be randomized to receive a text message once a day to remind them to ambulate
three or more times each day in addition to the ICOUGH education or to receive the ICOUGH
education without text reminders. All participants will be contacted daily by a research team
member to collect data on the outcome measures and each participant in the experimental text
message arm will be interviewed at hospital discharge to solicit their opinion abut the text
message reminders.
Inclusion Criteria:
- Patients of all genders on any surgical service at Boston Medical Center
- English speaking
- Ability to read at 5th grade level
- Able to ambulate, with or without assistance
- Possession of a personal cell phone that can receive text messages
Exclusion Criteria:
- Visually impaired or blind
- Presence of neuromuscular disease or inability to perform all the measures in the
ICOUGH protocol
- Prisoners
- Pregnant women
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