Boston Medical Center (Boston, MA) was selected as the winner of ECRI Institute's 12th Health Devices Achievement Award for its development and implementation of a mobile app designed to reduce postoperative pulmonary complications by empowering patients to take greater control of their recovery.

The app, which patients can download to their smartphones, promotes compliance with recommended postoperative pulmonary care measures using features such as audiovisual prompts, social support accountability, and game-like elements (gamification). For example, patients can earn gold stars for getting out of bed to walk around the care area, keep track of how often they've performed breathing exercises using their incentive spirometer, and compare their performance with that of other patients. A pilot study examining use of the app has yielded positive results, in terms of both patient reviews of the app and the app's ability to improve compliance with the recovery protocol without overburdening clinical staff.

The Health Devices Achievement Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. ECRI Institute announced Boston Medical Center as the winner of the 12th award in May 2018. For details about the other submissions that achieved recognition, see The Health Devices Achievement Award: Recognizing Exceptional Health Technology Management.

ECRI Institute congratulates the project team members: Andrew Chu, MD, Samir Haroon, MD, and Pamela Rosenkranz.

The Challenge

To develop a point-of-care, patient-centric mobile app that can be used to promote compliance with BMC's ICOUGH postoperative pulmonary care protocol.
 

The Landscape

1. Postoperative pulmonary complications (PPCs) are a common and costly issue.

a) Examples of PPCs include pneumonia, unplanned intubation, and failure to wean from mechanical ventilation after 48 hours.

b) As reported in Cassidy et al.,[1] such complications have been estimated to:

(1) Occur in 2.7% to 3.4% of patients who undergo noncardiac surgery

(2) Increase the length of hospital stay by an average of 14 days

2. Several years ago, BMC instituted a program to address the incidence of adverse pulmonary outcomes.

a) A review of National Surgical Quality Improvement Program (NSQIP) data indicated that BMC, the largest safety-net hospital in New England, had been a high outlier for measured PPCs.

b) In response, BMC assembled a research team to:

(1) Create a standardized suite of postoperative pulmonary care guidelines

(2) Demonstrate the efficacy of those guidelines

3. The result was the development of the "ICOUGH" protocol—a postoperative pulmonary care plan that stresses the importance of:

a) Incentive spirometry

b) Coughing and deep breathing

c) Oral hygiene

d) Understanding (i.e., patient and family education)

e) Getting out of bed at least three times daily

f) Head-of-bed elevation

4. The ICOUGH protocol was shown to be effective at both improving health outcomes for patients and reducing the hospital's costs. BMC reports that:

a) The ICOUGH protocol decreased postoperative pneumonia by 38%, unplanned intubations by 40%, and all adverse outcomes by 40%.

b) These reductions in complications resulted in a cost saving of $3 million over two years.

5. Nevertheless, BMC encountered obstacles that, over time, impeded the protocol's sustainability in an acute care, safety-net hospital setting.

a) Although nurses and ancillary staff showed great enthusiasm in educating and holding patients accountable to ICOUGH during its initial roll-out, this momentum proved difficult to sustain. Already burdened with heavy workloads, clinicians could not easily incorporate the ICOUGH protocol into their everyday workflow.

b) Acute care hospital settings face high inpatient turnover for elective surgical cases and must contend with an aging baby-boomer population. These factors translate to a higher volume of older, higher-risk patients who may require more time and attention per nurse, exacerbating the difficulty in sustaining the protocol.

c) Additionally, patients undergoing non-elective surgery, such as those from the emergency department, would not have received ICOUGH protocol education before their surgery.

6. To address these challenges and to facilitate ICOUGH protocol implementation and sustainability, BMC's research team came up with a new approach.
 

The Process

1. To achieve its objective, BMC developed a smartphone application—the ICOUGH Recovery app—that patients could use to help improve adherence to the ICOUGH protocol.

a) The app guides patients through the ICOUGH protocol, offering visual and auditory reminders for each step.

b) It functions by sending push notifications to the patients' phones, reminding them, for example, to brush their teeth, to use the incentive spirometer, to perform deep coughs, and to walk around the hospital at set time intervals.

2. The ICOUGH Recovery app incorporates:

a) An in-depth educational video: The video provides instruction on the ICOUGH protocol and on how to perform each action, allowing patients and caregivers to learn at their own convenience and refresh their memory as needed.

b) Gamification and benchmarking features:

(1) The app gives users gold stars for ambulation. Ambulation is measured using a tablet placed at the nurses' workstation; patients have to walk to the tablet and check in.

(2) The app tracks both ambulation and incentive spirometry data via an intuitive point system on the main dashboard.

(3) It allows patients to access a summary page that lets them see how well they are performing relative to other patients in the care area who are using the app.

c) A "Care Coach" feature: This functionality allows patients to automatically send updates on their adherence status to a designated protocol accountability partner, or Care Coach. The coach would typically be a family member or friend. Updates are sent via text messages, adding an additional level of accountability.

d) Bilingual language support: The app incorporates both English- and Spanish-language options to accommodate the two languages spoken most often at BMC.

3. Before deploying the app in a pilot project, the research team:

a) Conducted pre-pilot preparations, meeting with physicians and unit nurses to:

(1) Review baseline pulmonary outcomes data

(2) Reinforce the importance and benefits of ICOUGH principles

(3) Educate clinical staff about how the app would work and how they could incorporate patient education about the app into their typical clinical workflow

b) Recruited patients for the study

(1) Patients received verbal education from physicians about the ICOUGH protocol during preoperative assessment clinic visits, and they were informed about the research study.

(2) If patients agreed to learn more, they would be visited by the research team to discuss the ICOUGH Recovery app.

(3) Patients who were eligible and interested, and who consented to participate, then downloaded the app and completed the onboarding process with the research staff.

4. Patients who agreed to participate in the pilot project would use the ICOUGH Recovery app while on the inpatient floor following their surgery.

a) Surgery residents and the research team were available to address questions and problems.

b) The patient was encouraged to select a friend or family member to serve as the patient's Care Coach.

(1) As detailed above, this Care Coach would receive periodic updates on the patient's protocol adherence level. If the patient was adhering poorly, the coach could take action to help the patient stay accountable to the protocol through texts, phone calls, or hospital visits.

(2) BMC notes that the Care Coach concept is unique to the application and not part of the typical standard of care.

5. Patients continued to use the app until discharged from the hospital. Duration of participation was dependent on each patient's type of surgery, surgery outcome, and development of complications.

6. Upon discharge, the patients completed a brief qualitative survey and an audio-recorded interview regarding their experiences with the app.
 

The Results

1. The study had a sample size of 17 patients (14 female and three male).

2. Analysis of the post-use interview transcripts showed that all patients liked the app and found it easy to use.

a) Patients said the app was motivating and gave them something to do during their recovery period.

b) They cited the regular notifications, competition, Care Coach, and star-reward system as essential to motivation.

c) Some patients also remarked that the app was empowering, stating that it allowed them to take the recovery process into their own hands.

3. Additionally, quantitative measurements of the usability of the tool corroborated these subjective assessments.

4. Although the sample size was small, BMC identified meaningful differences between app users and non-app users. For instance:

a) App users were found to walk more than non-app users (when comparing usage data against baseline, standard-of-care data).

b) On average, patients who used the app walked 9.2 times per day, which is three times the minimum number of recommended walks per day.
 

Key Takeaways

1. The ICOUGH Recovery app transferred more responsibility and accountability for recovery to the patient, while providing the patient with the knowledge and tools needed to succeed. This combination has helped increase adherence to the protocol, and it has done so in a way that BMC expects will be easier to sustain than its previous approach, which put more of the responsibilities on clinical staff.

2. Features of the app that helped improve knowledge retention and protocol adherence include its use of audiovisual notifications, bedside education, gamification, benchmarking of adherence levels, and social support accountability.

3. The BMC team found the ICOUGH Recovery app to be:

a) A highly cost-effective method of reducing postoperative pulmonary complications

b) Easily implementable, as well as scalable for use throughout the hospital, and potentially at other institutions

4. Such uses of mainstream technology to empower patients to engage in recovery, to improve adherence to postsurgery protocols, and to reduce burden on medical staff can have significant benefits for both health outcomes and costs to hospitals.

________________________________

[1] Cassidy MR, Rosenkranz P, McCabe K, et al. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013 Aug;148(8):740-5. Available from: https://jamanetwork.com/journals/jamasurgery/fullarticle/1693122.