Effectiveness Not Established

Preoperative Care Bundle

for Prevention of Infection: General

A care bundle is a set of evidence-based interventions provided simultaneously rather than as single interventions. A care bundle aimed at reducing the prevalence of postoperative pneumonia among patients undergoing surgery for esophageal cancer was tested. This bundle consisted of three breathing exercises, two oral care procedures, and nutritional care, and smoking cessation was taught to patients preoperatively for the prevention of infection.

Research Evidence Summaries

Hiramatsu, T., Sugiyama, M., Kuwabara, S., Tachimori, Y., & Nishioka, M. (2014). Effectiveness of an outpatient preoperative care bundle in preventing postoperative pneumonia among esophageal cancer patients. American Journal of Infection Control, 42, 385–388.

Study Purpose

To determine the effectiveness of a care bundle completed by patients with esophageal cancer before surgery to reduce the risk of postoperative pneumonia

Intervention Characteristics/Basic Study Process

Two groups of patients undergoing subtotal esophagectomy were compared based on their use of a daily care bundle intervention before surgery. The intervention included seven different activities: 1) deep breathing, 2) breathing exercises with an incentive spirometer, 3) respiratory muscle stretching, 4) professional oral cleaning by a dental hygienist, 5) thorough cleaning of the teeth and tongue, 6) adherence to nutrition guidelines, and 7) smoking cessation. 
 
Retrospective data were collected for patients who did not use the care bundle (precare bundle implementation). This group was compared to patients who used the care bundle. Patients who used the care bundle received instructions on each activity during a 30–60 minute outpatient session. Patients were instructed to complete the seven activities every day beginning on day 1 of instruction until the day of surgery, and they recorded adherence to each activity daily. The time from instruction until surgery ranged from 4–42 days, and the mean was 11 days.

Sample Characteristics

  • N = 240  
  • MEDIAN AGE = 64 years (range = 36–86 years)
  • MALES: 83.3%, FEMALES: 16.7%
  • KEY DISEASE CHARACTERISTICS: Esophageal cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: The comparison groups were significantly different based types of surgery. The care bundle group was 65.4% thoracotomy and 34.6% thoracoscopic versus the non-care bundle group, which was 96.7% thoracotomy and 3.3% thoracoscopic.

Setting

  • SITE: Single site    
  • SETTING TYPE: Multiple settings  
  • LOCATION: Japan

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment

Study Design

Retrospective, case-controlled study comparing two groups of patients, each from a different time period in the past.

Measurement Instruments/Methods

The definition of postoperative pneumonia was based on the Centers for Disease Control and Prevention criteria. The detection of postoperative pneumonia was based on bacteria collected from a bronchoscope within 30 days of surgery. An analysis between groups was completed using logistic regression.

Results

The control group (no care bundle) included 216 patients, and the case group (care bundle) included 26 patients. In the case group, compliance with the seven care bundle activities varied. All patients received professional oral cleaning by a dental hygienist and achieved smoking cessation. Respiratory muscle stretching, adherence to nutrition guidelines, and breathing exercises using an incentive spirometer were the activities most often missed with 62%, 69%, and 73% of patients reporting 100% adherence, respectively. 
 
In total, 20.4% of patients developed postoperative pneumonia. In the control group, 22.4% of patients developed postoperative pneumonia, and in the case group, 3.8% of patients developed postoperative pneumonia. The median day to developing pneumonia was postoperative day 5. Care bundle activities were significantly associated with a decreased incidence of postoperative pneumonia (OR = 0.16; CI = 95%; 0.01–0.94). Recurrent laryngeal nerve palsy was significantly associated with an increased incidence of postoperative pneumonia (OR = 3.18; CI = 95%, 1.44–7.11).

Conclusions

Completing daily care bundle activities before surgery for esophageal cancer may lower the risk of postoperative pneumonia. The study design and underadherence to care bundle activities limit stronger conclusions. However, most care bundle activities were inexpensive with little risk to patients, so the use of this intervention may still be warranted.

Limitations

  • Small sample (< 30): Not for study as a whole, but for the intervention group
  • Baseline sample/group differences of import: Significant difference in surgical approach (p < 0.001) and operative time (p = 0.002) between the comparison groups; variation in adherence to care bundles
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Other limitations/explanation: Although compliance rates with the care bundle activities reflect real-world applications, it makes the conclusions based on care bundle activities difficult to discern. Also, it was unclear how many days preoperatively a patient should complete the care bundle activities.

Nursing Implications

Preoperative nursing interventions and patient education may influence postoperative health outcomes. Nurses can promote smoking cessation, deep breathing, breathing exercises, oral care, and adherence to nutritional guidelines before surgery for esophageal cancer as a potential strategy to decrease the risk of postoperative pneumonia.

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