Post-Op Pneumonia Project

Abstract

Pneumonia in the post-operative setting is a challenging condition which can cause serious health complications for patients who are already recovering from a surgical procedure and can delay this process in a variety of ways. Patients face a greater risk of the disease in this setting due to their lower immunity and a limited ability to fight different types of infection during hospitalization. Advanced practice nurses who work with these patients often experience difficult challenges which can impact the course of their patient’s recovery. It is important to develop and implement targeted interventions in the immediate post-operative phase  to reduce the risk of developing pneumonia. This study explores this phenomenon to determine if targeted interventions have the desired impact on patients and can lead to improved outcomes and recovery rates using the Roy Adaptation Model of nursing practice to evaluate nurse-led interventions in the post-operative setting.

Overview of Post-Op Pneumonia

Post-operative pneumonia is defined as an infection that develops within the tissue of the lungs during hospitalization after patients have undergone a surgical procedure, and its most common symptoms include shortness of breath, cough, fever, and chest pain (Arozullah, Khuri, Henderson, & Daley, 2001). Pneumonia, along with infections of the urinary tract and in open wounds, are the most common types of infections that occur in the post-operative setting and cause serious complications for patients, along with an increased risk of higher mortality rates (Arozullah et al., 2001). However, the risk of post-operative pneumonia must be better understood and provide additional information regarding individual patient risk because the severity of the disease can contribute to a higher risk of mortality among patients (Arozullah et al., 2001). Prevention of pneumonia in the immediate post op phase is of critical importance and requires an examination of key interventions which can have a positive and lasting impact on patients, using the knowledge, experience, and resources of advanced practice nurses to accomplish these objectives. However, these interventions can pose challenges for nurses and require a targeted approach to ensure that they are successful in preventing the risk of infection among patients and will have the desired impact in reducing the risk of mortality and in improving recovery rates.

Problem Statement

In the surgical unit, there is an elevated rate of pneumonia cases in the post-operative setting, due to the risk factors and compromised immunity of patients within this environment. This phenomenon can negatively impact recovery rates and quality of life in patients and contribute to increased costs of keeping patients hospitalized for longer periods. The development of targeted interventions may provide a potential strategy for nurses who work with these patients, but the effectiveness of these interventions is not well known.

Purpose Statement

The primary objective of this research study is to examine the clinical efficacy of targeted interventions for post-op patients to prevent the risk of pneumonia in these settings. These interventions require expert knowledge and resources utilized by advanced practice nurses to facilitate patient recovery and reduce the risks of developing pneumonia in post-op patients. This quantitative research study will evaluate if targeted interventions in the post-op setting have the desired effect on patients in comparison to delayed interventions in the prevention of pneumonia. The proposed hypothesis for this quantitative research study is the following: What is the impact of a targeted intervention that includes ambulation, eating out of bed, and an incentive spirometer in the immediate post-op phase to prevent pneumonia? It is anticipated that the development of a successful intervention to prevent post-operative pneumonia requires the expert knowledge of nurses and an understanding of the key factors that will have lasting impact on the organization and on patients who face significant risk due to complications from surgery and the risk of infection. However, the chosen intervention method should encompass a variety of different perspectives based upon available evidence and provide nurses with feedback and data regarding the effectiveness of the protocol and if fewer cases of post-operative pneumonia are observed.

Health Phenomenon and Nursing Conceptual Model

The risk of post-op pneumonia is significant for patients in these settings; therefore, a multidisciplinary team-based approach is necessary to ensure that patient care is not compromised and quality of care improves with an effective cultural framework in place (Khan et al., 2016). A key component of this practice is the delivery of targeted interventions by nurses who have the knowledge, experience, and resources to minimize pneumonia risk among post-op patients and can ensure that prevention strategies are optimized in this setting to improve patient outcomes and promote greater cost efficiency (Khan et al., 2016). A structured program within the nursing practice is likely to have a positive impact on patients and provide resources that will reduce infection risk and utilize evidence-based practice tools to improve quality of life and reduce mortality rates (Talley, Lamb, Hart, Lorenz, & Green, 2016). With an increased risk of hospital-acquired pneumonia among post-op patients, preventive strategies must begin with a nursing-based framework that will have the desired impact on patients and provide sufficient resources to conduct a successful intervention (Kollef, 2007). A key factor of the intervention is understanding pneumonia risk among post-op patients and how to best accommodate their needs with a strategy that will utilize prior evidence to support an intervention to prevent additional cases of pneumonia and related complications among this patient population (Park, Kang, Moon, Yang, Kim, & Byun, 2017).

Preventing pneumonia among post-op patients requires a theoretical framework which supports nursing-based interventions that will have the desired impact and will improve recovery rates. Specifically, the Roy Adaptation Model is applicable to this scenario because patients must learn to adapt to their surroundings with the support and guidance of nurses in their presence; therefore, nurse-led interventions can be useful in addressing these needs in an effective manner by offering tools to overcome illness and promote recovery at a high level (Phillips & Harris, 2014). When stimuli from the surrounding environment affect patients, nurses have the responsibility to investigate these issues and to establish procedures to guide patients to prevent pneumonia (Phillips & Harris, 2014). Roy’s Adaptation Model supports patients’ capacity to adapt to their surroundings, and their ability is either compromised, compensatory, or integrated, depending on the environment (Phillips & Harris, 2014). When environmental stimuli are present, patients respond via coping mechanisms which are designated as regulator (internal system functions) versus cognator (cognitive-emotive) responses (Phillips & Harris, 2014).

From an advanced practice nursing perspective, the Roy Adaptation Model serves as a “goal-oriented, problem-solving approach to guide the provision of comprehensive, competent nursing care to a person or groups of persons” (Phillips & Harris, 2014, p. 266). Therefore, several steps must be considered as critical to this process and include the following: an assessment of the behavior in question; an evaluation of the stimuli which have led to the behavior; the development of a definitive nursing diagnosis for a patient; the development of goal-setting activities to achieve the desired results; conducting the intervention with the chosen strategy in place; and evaluating the success or failure of the strategy based upon the outcomes that are generated (Phillips & Harris, 2014). These conditions are important in determining how patients can be impacted by a targeted intervention to prevent post-operative pneumonia when nurses develop the intervention using this model and determining if it is effective in preventing this risk for patients in this setting (Phillips & Harris, 2014). It is believed that “nursing theory directs the practitioner toward important aspects of assessing, planning, goal setting, implementation, and evaluation” (Phillips & Harris, 2014, p. 266). This process is essential to the success of a targeted intervention for post-operative pneumonia and in determining if this intervention will have the desired impact on patients who are recovering from surgery (Phillips & Harris, 2014). Roy’s Adaptation Model  also utilizes inherent nursing-based knowledge and resources to implement the proposed intervention and to ensure that the organization is prepared to accommodate patient care needs effectively (Philips & Harris, 2014). This Model is an important step towards understanding the key risk factors related to post-operative pneumonia risk and how patients are perceived in this setting (Phillips & Harris, 2014).

Review of Literature

Post-operative pneumonia is a serious health issue which can increase mortality rates among patients and may be identified in one of two forms: ventilator-associated pneumonia within 48-72 hours after intubation has occurred; and hospital-acquired pneumonia, which occurs within 48-72 hours after a patient has been admitted to the hospital (Chughtai et al., 2017). This condition typically requires an extended length of stay for many patients and can cost an additional $40,000 for treatment, and there are increased measures to minimize the risk of infection due to penalties associated with reduced reimbursement by Medicare when hospital readmissions occur due to pneumonia (Chughtai et al., 2017). Based upon these concepts, it is important for advanced practice nurses to develop targeted interventions to reduce the risk of infection and to improve patients’ quality of life in the process (Chughtai et al., 2017). One of the issues to consider is the following: “there may be differences between hospitals in pneumonia prevention protocols, such as frequency of incentive spirometry use, or variance in utilization of methods such as oral cleansing and suctioning (pre-operatively vs. postoperatively vs. both pre- and postoperatively)” (Chughtai et al., 2017). From this perspective, advanced practice nurses may not always agree on the appropriate intervention strategy to implement and may find it difficult to achieve consistent success with an intervention when patients still contract the infection after surgery (Chughtai et al., 2017). Therefore, identification of the appropriate intervention must serve as the first step in understanding the key risk factors that affect patients and in advancing the intervention to the next level once it has been tested on patients and is deemed successful (Chughtai et al., 2017).

A study by Kazaure, Martin, & Yoon (2014) addressed the significance of a prevention program for post-operative pneumonia in the surgical ward which encompassed the following components: education for all nurses on staff in the surgical unit; the use of an incentive spirometer to promote coughing as well as deep breathing; the use of chlorhexidine on a twice-daily basis for hygienic purposes; improved ambulation by patients post-surgery and maintaining strong control over pain episodes; sitting up to eat all meals and elevating the head at an angle of 30 degrees or more; discussing the outcomes of the program among nursing staff on a quarterly basis; recording the pneumonia bundle as part of the patient health record; and the use of an “automated computerized physician pneumonia prevention order” in the electronic ordering system. This was conducted as a quality improvement study to determine the effectiveness of the pneumonia bundle in the post-operative setting and if this process has the desired impact on patients, including any diagnoses of pneumonia that occur while this bundle was implemented (Kazaure et al., 2014). Based upon the results of this study over a five-year period, it was determined that the study was largely effective in dramatically reducing the post-operative pneumonia rate among patients and contributing to cost savings for hospitals and insurers (Kazaure et al., 2014). These characteristics demonstrate that a similar bundle implementation in another environment could have a comparable impact and reduce the risk of infections in patients in the post-operative setting (Kazaure et al., 2014).

It is known that ambulation is a critical component in the prevention of post-operative pneumonia because this process can be effective on day zero after surgery or within the first 12 hours (Currier, TeKolste, & Wheatley, 2018). It is proposed that “improved nursing staff education may be necessary to encourage adherence to ambulation protocols and policy change. Early ambulation has the potential to positively impact the patient’s physical, psychological, and social outcomes” (Currier et al., 2018, p. 5). Under these conditions, advanced practice nurses have a responsibility to make ambulation a routine practice method during the first 12 hours after surgery to ensure that patients receive the best possible options to prevent post-operative pneumonia and to improve quality of life in these patients (Currier et al., 2018). As part of a larger framework, ambulation should serve as a key factor in advancing the objectives of an intervention to prevent the disease and to facilitate the development of a protocol that will target post-operative patients to prevent further complications (Currier et al., 2018). Furthermore, assessing the protocol requires an examination of the type of surgery that was required and any other complications that have emerged which can lead to problematic circumstances for patients (Currier et al., 2018).

Boev & Xia (2015) recognized the importance of collaborative efforts between nurses and physicians to facilitate positive treatment and recovery outcomes for post-operative patients. In this context, the organization must focus on the development of different programs as created by advanced practice nurses and physicians to solve important problems such as the risk of post-operative pneumonia (Boev & Xia, 2015). Nurses are likely to experience greater satisfaction in their roles if they develop and implement procedures or protocols which are successful in the clinical setting and which translate into positive outcomes for patients (Boev & Xia, 2015). However, when nurses lack cohesion in their ideas and collaborations with physicians or do not communicate their ideas or expectations, these can cause serious complications for patients because protocols to reduce infection risk may be delayed, poorly executed, or unsuccessful within the patient care environment (Boev & Xia, 2015). Once the problem is identified, a collaborative solution is necessary to ensure that all parties contribute to solving the problem and implementing a successful strategy going forward (Boev & Xia, 2015). This exercise offers an important opportunity for an organization to consider the options that are available and to identify an effective means of disease prevention which includes the bundling of services and treatments for patients (Boev & Xia, 2015). However, perhaps the most important approach to solving the problem should be conducted by advanced practice nurses in collaboration because they are generally on the same page with the process; in addition, when physicians become involved for different reasons in an effort to solve the problem, this is not always successful and may contribute to poor patient outcomes (Boev & Xia, 2015). It is known that “Nurses, as the recipient of the orders, may find true collaboration difficult because of the inherent barriers related to the hierarchy within hospitals” (Boev & Xia, 2015, p. 71). These circumstances reflect the importance of accomplishing cohesive intervention strategies which limit communication barriers and provide the best possible resources to prevent disease (Boev & Xia, 2015).

Plan for Assessment of the Problem

Implementing an intervention to prevent post-operative pneumonia requires an examination of key factors which may be useful in addressing this issue and in providing sufficient options for patients to prevent the disease and to promote recovery. Therefore, quality improvement programs in this area must include collaborative efforts between Advanced Practice Nurses and physicians to ensure that all possible options are explored to improve quality of care and patient treatment strategies (Moore, Conway, Thomas, Cummings, & Atkinson, 2017). There is a risk of complications up to 40 percent in patients who have had surgery; therefore, it is necessary to identify specific prevention mechanisms that will target prevention and limit complications (Moore et al., 2017). In examining the problem and the interventions that appropriate, advanced practice nurses must demonstrate their understanding of the condition and how they can be effective in improving recovery rates for patients while using specific intervention bundles (Moore et al., 2017). Assessing the problem supports a greater understanding of the impact of the intervention and how it can contribute to effective outcomes for patients and allow advanced practice nurses to utilize their skills and experience for the greater good of their patients who are at risk of the disease after surgery (Moore et al., 2017).

Clinical Implementation and Assessment Methods

Implementing a nursing-based protocol to prevent post-operative pneumonia requires the integration of vital signs, including measurement and documentation of incentive spirometry and progress as well as monitoring lab values and adequate pain assessment including a function assessment of pain and adequate pain management.  The current nursing practice data will be collected and then compared to the immediate post -op targeted interventions to be implemented. With the protocol in place, the clinical needs of each patient must be considered and the practice should stimulate rather than deter recovery. Furthermore, this process requires nurses’ continuous feedback to improve the protocol and to make any changes that will positively impact patients. At the same time, implementing a protocol in the surgical environment requires a pilot period whereby each step of the protocol is implemented and feedback is provided to determine if the process is effective in preventing post-operative pneumonia in a larger group of patients.

The development of an assessment tool is required to ensure that advanced practice nurses can evaluate the intervention tool and determine if is effective in reducing pneumonia risk. This requires the collection of patient data to identify the number of cases of pneumonia that occurred prior to the implementation of the protocol and after the protocol has been used. A comparison of this data is necessary to determine if the protocol is successful and if it accomplishes the necessary goals and objectives in preventing post-operative pneumonia. As part of their training and in gaining new experience, the implementation tool must be evaluated and any changes must be made which indicate that part of the protocol has not been successful. Nurses will acquire additional knowledge and a critical understanding of the impact of pneumonia on surgical patients. The assessment tool must demonstrate that the organization has the appropriate tools in place to prevent pneumonia and to encourage employees to adhere to all steps of the protocol in a timely manner. This process is important because patients rely on care and treatment mechanisms which will aid in the prevention of disease and reduce the number of hospital readmissions in the future.

Post-operative pneumonia is a very serious health condition which is acquired during hospitalization and after surgery, requiring an extended length of stay and additional costs for treatment. Advanced practice nurses must develop opportunities to conduct interventions among this population group to prevent the risk of developing post-operative pneumonia in patients and provide them with the best possible resources to maximize their survival, reduce mortality rates, and improve recovery times. It is important for Advanced Practice Nurses to conduct interventions which involve the use of ambulation, eating out of bed, and an incentive spirometer to prevent post-operative pneumonia in the immediate post-op phase. This implementation should be based upon the characteristics of the Roy Adaptation Model to ensure that patients receive the targeted intervention as instructed and are evaluated in accordance with the intervention to determine its overall effectiveness. This process is critical in determining how to implement this type of intervention on a widespread basis and to facilitate outcomes that will be favorable for patients and which will prevent post-operative pneumonia and related complications.

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