IText For ICOUGH: Improving Ambulation of Surgical Patients Through Text Messaging

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.

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