Nurse-led modified respiratory care bundle for post-bariatric surgery patients cuts complications, hospital stay.
A new Singapore General Hospital (SGH) respiratory focused care bundle known as COUGH was found to benefit obese patients after bariatric surgery. They needed less oxygen therapy and a shorter hospital stay, and fewer needed close monitoring in high dependency, leading to lower costs overall.
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The COUGH respiratory care bundle is an innovative strategy that basically addresses some clinical issues in the post-anaesthesia care unit (PACU, where patients are monitored closely after surgery),” said Dr Yang Jumei, Nurse Clinician (Advanced Practice Nurse), SGH. “Obesity commonly affects post-surgical pulmonary outcomes and is associated with increased oxygen usage, length of recovery and hospital stay, discharge to high levels of care, cost, morbidity, and mortality.”
In a Quality Improvement project involving 151 patients at PACU from June 2022 to March 2023, 71 post-bariatric surgery patients underwent the COUGH care bundle. It found that 37 per cent of COUGH patients needed a high-dependency bed after leaving PACU, compared to 58 per cent of those not on the programme. COUGH patients needed just 45 minutes of oxygen therapy at PACU, significantly shorter than 143 minutes needed by non-COUGH patients. With a shorter hospital stay as well, overall costs for the COUGH group were lower.
Under the COUGH package, which began to be used on obese patients in November 2022, patients are taught and encouraged to perform deep diaphragmatic breathing and coughing exercises to expand their lung capacity. They are gradually weaned off oxygen therapy until their oxygen saturation level rises to normal levels.
Oxygen is needed for the body’s cells and tissues to function properly. Healthy pulse oximeter values range from 95 to 100 per cent. For patients with levels below 95 per cent, a condition known as hypoxemia, oxygen is administered via nasal prongs or face masks. “Generally, it’s harder for obese people to breathe because the fat stored in their chest and abdomen can restrict their lungs’ ability to expand, even during rest. This can alter how they breathe regularly, and create a persistent shallow breathing pattern,” said Dr Yang.
A five-prong approach, COUGH stands for ‘Coughing and deep breathing exercises for at least 10 times per hour, guided Oxygen protocol to titrate the patient’s oxygen therapy according to their oxygen saturation, patient’s Understanding and education of the interventions, Gargling of the patient’s mouth with 20mL of 0.2 per cent chlorhexidine mouthwash solution, and Head-of-bed elevation to 30–45 degrees.’
The bundle was based on the iCOUGH — Incentive spirometry, Coughing and deep breathing, Oral care, patient’s Understanding, Getting out of bed and Head of bed elevation — respiratory care programme developed by Boston Medical Center doctors and healthcare workers. Dr Yang adapted it to local hospital conditions for her Doctor of Nursing Practice Programme — for instance, the programme is led by nurses locally, and the incentive spirometry was removed as evidence did not show increased effectiveness for preventing pulmonary complications after surgical procedures.
According to Ministry of Health data, 30 per cent of Singaporeans are overweight and 10 per cent are obese or have a body mass index (BMI) of at least 30. At that level, the person is at greater risk of serious health problems such as heart disease, diabetes, high cholesterol, sleep apnoea, and some cancers. A BMI of 18.5 to 22.9 is considered healthy, and over 23 indicates the person’s health is at risk.
Dietary changes and exercise are usually recommended to manage obese patients’ weight, with bariatric surgery considered if the changes do not work, or for those with BMI of at least 35 and have serious weightrelated health problems.
Dr Yang said that the hospital plans to roll out the COUGH bundle this year to patients coming out of other types of surgery after more nurses have been trained to guide them in applying the bundle.
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