What’s New in the Patient Safety World

July 2013




There is a fairly substantial literature on interventions to reduce complications in intubated, mechanically ventilated patients. However, there is a much less robust literature on best practices to prevent pulmonary complications in non-ventilated patients.


Now a new multicomponent intervention bundle has been demonstrated to reduce post-operative pulmonary complications (Cassidy 2013). The “I COUGH” program was associated with a reduction in the incidence of post-op pneumonia from 2.6% to 1.6% and unplanned intubations from 2.0% to 1.2%. The acronym “I COUGH” stands for the components of the intervention bundle use:

I           Incentive spirometry

C         Coughing and deep breathing

O         Oral care (brushing teeth and using mouthwash twice daily)

U         Understanding (patient and family education)

G         Getting out of bed frequently (at least 3 times daily)

H         Head-of-bed elevation


The authors also note that postoperative pain control was a key element of the bundle. The educational piece involved not only patients and families but also physicians and nurses. They developed a standardized order set to incorporate all the key interventions. Unit-specific audit of nursing practice changes probably also played an important role.


The authors also felt that the composition of the workgroup that developed and implemented the program was extremely important. That mulitidisciplinary workgroup consisted of surgeons, nurses, internal medicine representatives, respiratory therapists, physical therapists, infection control, and quality improvement personnel. They also felt that nurse managers were especially crucial to the success of the program. The catchy acronym ICOUGH also helped staff and patients and families remember the key intervention components.






Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH. Reducing Postoperative Pulmonary Complications With a Multidisciplinary Patient Care Program. JAMA Surg. 2013; (): 1-6 Published online first June 5, 2013






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