Postoperative Pneumonia Prevention Program Results
Original Investigation Research
Invited Commentary
Preventing Postoperative Pneumonia Catherine E. Lewis, MD
While pneumonia is a common postoperative complication, there is a paucity of literature on pneumonia prevention outside of the intensive care unit. Wren and colleagues designed and implemented a wardbased pneumonia prevenRelated article page 914 tion program at the Veterans Affairs Palo Alto Health Care System in 2007. They previously reported an initial 81% decrease in the incidence of ward-acquired pneumonia1 and now report a significant long-term decrease when compared both with preintervention rates and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).2 Although encouraging, these findings should be interpreted with caution. The preintervention rate of pneumonia was 0.78% in the Veterans Affairs Palo Alto Health Care System and 2.56% in ACS-NSQIP—a difference of 328% that is already of statistical significance. This remarkably low rate of pneumonia calls into question the adequacy of detection and reporting of pneumonia on their ward and also makes their finding of a significant difference between their postintervention and ACS-NSQIP rate of somewhat less consequence. A second concern is that the authors’ previous article reported that the overall rate of postoperative non– ventilator-associated pneumonia did not change with implementation of their program. Although the number of ward cases decreased from 13 to 3, the number of non– ventilator-associated pneumonia intensive care unit cases ARTICLE INFORMATION Author Affiliations: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; Department of Trauma and Acute Care Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; Department of Surgical Critical Care, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles. Corresponding Author: Catherine E. Lewis, MD, Departments of Surgery, Trauma and Acute Care Surgery, and Surgical Critical Care, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 72-256 CHS, Los Angeles, CA 90095-6904 ([email protected]).
inc reased from 4 to 17, and therefore, the reported decrease could be due to redistribution in the location of patients. A third concern is that the authors did not evaluate changes in patient care or surgical technique that could have altered the incidence of postoperative pneumonia. A systematic review of strategies to reduce postoperative pulmonary complications 3 found that choice of neuraxial blockade over general anesthesia led to a significant reduction in the rate of postoperative pneumonia (odds ratio = 0.61; 95% CI, 0.48-0.76), as did selective nasogastric decompression (odds ratio = 0.49; P < .001). Moreover, the authors’ program was implemented and evaluated over a period in which there was an ongoing shift from open to laparoscopic or robotic surgical techniques, which has been shown to significantly decrease the rates of postoperative pneumonia, partic ularly in colorec tal and prostate operations.4,5 Without collecting and analyzing such data, it is impossible to know if any of them contributed to their findings. Despite these concerns, the authors should be commended for the development and implementation of a quality improvement measure aimed at decreasing the rate of postoperative pneumonia in a Veterans Affairs population. The 8 interventions used in their program are not particularly costly or time-consuming and serve to increase awareness and education of all health care professionals caring for postoperative patients.
Published Online: July 23, 2014. doi:10.1001/jamasurg.2014.1249. Conflict of Interest Disclosures: None reported. REFERENCES 1. Wren SM, Martin M, Yoon JK, Bech F. Postoperative pneumonia-prevention program for the inpatient surgical ward. J Am Coll Surg. 2010; 210(4):491-495. 2. Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward [published online July 23, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.1216. 3. Lawrence VA, Cornell JE, Smetana GW; American College of Physicians. Strategies to
jamasurgery.com
reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144(8):596-608. 4. Grailey K, Markar SR, Karthikesalingam A, Aboud R, Ziprin P, Faiz O. Laparoscopic versus open colorectal resection in the elderly population. Surg Endosc. 2013;27(1):19-30. 5. Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol. 2012;62(1):1-15.
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
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Original Investigation Research
Invited Commentary
Preventing Postoperative Pneumonia Catherine E. Lewis, MD
While pneumonia is a common postoperative complication, there is a paucity of literature on pneumonia prevention outside of the intensive care unit. Wren and colleagues designed and implemented a wardbased pneumonia prevenRelated article page 914 tion program at the Veterans Affairs Palo Alto Health Care System in 2007. They previously reported an initial 81% decrease in the incidence of ward-acquired pneumonia1 and now report a significant long-term decrease when compared both with preintervention rates and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).2 Although encouraging, these findings should be interpreted with caution. The preintervention rate of pneumonia was 0.78% in the Veterans Affairs Palo Alto Health Care System and 2.56% in ACS-NSQIP—a difference of 328% that is already of statistical significance. This remarkably low rate of pneumonia calls into question the adequacy of detection and reporting of pneumonia on their ward and also makes their finding of a significant difference between their postintervention and ACS-NSQIP rate of somewhat less consequence. A second concern is that the authors’ previous article reported that the overall rate of postoperative non– ventilator-associated pneumonia did not change with implementation of their program. Although the number of ward cases decreased from 13 to 3, the number of non– ventilator-associated pneumonia intensive care unit cases ARTICLE INFORMATION Author Affiliations: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; Department of Trauma and Acute Care Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles; Department of Surgical Critical Care, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles. Corresponding Author: Catherine E. Lewis, MD, Departments of Surgery, Trauma and Acute Care Surgery, and Surgical Critical Care, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 72-256 CHS, Los Angeles, CA 90095-6904 ([email protected]).
inc reased from 4 to 17, and therefore, the reported decrease could be due to redistribution in the location of patients. A third concern is that the authors did not evaluate changes in patient care or surgical technique that could have altered the incidence of postoperative pneumonia. A systematic review of strategies to reduce postoperative pulmonary complications 3 found that choice of neuraxial blockade over general anesthesia led to a significant reduction in the rate of postoperative pneumonia (odds ratio = 0.61; 95% CI, 0.48-0.76), as did selective nasogastric decompression (odds ratio = 0.49; P < .001). Moreover, the authors’ program was implemented and evaluated over a period in which there was an ongoing shift from open to laparoscopic or robotic surgical techniques, which has been shown to significantly decrease the rates of postoperative pneumonia, partic ularly in colorec tal and prostate operations.4,5 Without collecting and analyzing such data, it is impossible to know if any of them contributed to their findings. Despite these concerns, the authors should be commended for the development and implementation of a quality improvement measure aimed at decreasing the rate of postoperative pneumonia in a Veterans Affairs population. The 8 interventions used in their program are not particularly costly or time-consuming and serve to increase awareness and education of all health care professionals caring for postoperative patients.
Published Online: July 23, 2014. doi:10.1001/jamasurg.2014.1249. Conflict of Interest Disclosures: None reported. REFERENCES 1. Wren SM, Martin M, Yoon JK, Bech F. Postoperative pneumonia-prevention program for the inpatient surgical ward. J Am Coll Surg. 2010; 210(4):491-495. 2. Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward [published online July 23, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.1216. 3. Lawrence VA, Cornell JE, Smetana GW; American College of Physicians. Strategies to
jamasurgery.com
reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144(8):596-608. 4. Grailey K, Markar SR, Karthikesalingam A, Aboud R, Ziprin P, Faiz O. Laparoscopic versus open colorectal resection in the elderly population. Surg Endosc. 2013;27(1):19-30. 5. Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol. 2012;62(1):1-15.
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/13/2015
919
