Human Factors and Usability of an Incentive Spirometer Patient Reminder (SpiroTimer™)

Introduction: To address the problem of incentive spirometry (IS) noncompliance, a use-tracking IS reminder device (SpiroTimer™) was developed. In a recent randomized clinical trial, the SpiroTimer™ improved IS use compliance, length of stay, and mortality. For successful, safe, and effective implementation of a new medical device, human factors and usability must be evaluated. This study aims to evaluate the SpiroTimer™’s human factors as they pertain to intended users, use environments, and uses. Material and methods: Immediately following the completion of the randomized clinical trial of the SpiroTimer™, before the providers were informed of the results of the study, a human factors and usability survey was distributed in-person to all nurses involved in the trial. Variations in nurse user perspectives were evaluated. Results: A total of 52 nurses (100% response rate) completed the survey. In general, most nurses felt IS use compliance is poor (65%; 34/52, p = 0.0265) and should be improved (94%; 49/52, p < 0.001). Nurses agreed the SpiroTimer™ ameliorated patient IS use compliance (82%; 41/50, p < 0.001), IS effectiveness (74 %; 37/50, p < 0.001), and patient engagement in their own care (88%; 44/ 50, p < 0.001). Nurses reported the SpiroTimer™ helped remind them to work with their patients on IS (70%; 35/50, p = 0.0047) while reducing the number of times they had to remind their patients to use their IS (70%; 35/50, p = 0.0047). They felt that they would use the SpiroTimer™ with all their patients (82%; 41/50, p < 0.001) and that they would recommend the SpiroTimer™ to a colleague (74%; 37/50, p < 0.001). Ultimately, most nurses believed the SpiroTimer™ should become part of routine patient care (78%; 39/50, p < 0.001). Discussion: For a new medical technology to a medical device to be effectively implemented, human factors and usability must be demonstrated. Nurses believe the clinically effective SpiroTimer™ helps both patients and nurses and should become part of routine care.

Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial

Importance

Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined.

Objective

To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery.

Design, Setting, and Participants

This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women).

Interventions

A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants' inspiratory breaths. Patients were randomized by hourly reminder "bell on" (experimental group) or "bell off" (control group).

Main Outcomes and Measures

Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated.

Results

A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P < .001). The percentage of recorded hours with an inspiratory breath event was greater in bell on (58%; 95% CI, 51-65 vs 28%; 95% CI, 23-32; P < .001). Despite no differences in the first postoperative chest radiograph mean atelectasis severity scores (2.3; 95% CI, 2.0-2.6 vs 2.4; 95% CI, 2.2-2.7; P = .48), the mean atelectasis severity scores for the final chest radiographs conducted before discharge were significantly lower for bell on than bell off group (1.5; 95% CI, 1.3-1.8 vs 1.8; 95% CI, 1.6-2.1; P = .04). Of those with early postoperative fevers, fever duration was shorter for bell on (3.2 hours; 95% CI, 2.3-4.6 vs 5.2 hours; 95% CI, 3.9-7.0; P = .04). Having the bell turned on reduced noninvasive positive pressure ventilation use rates (37.2%; 95% CI, 24.1%-52.5% vs 19.2%; 95% CI, 10.2%-33.0%; P = .03) for participants undergoing nonelective procedures. Bell on reduced the median postoperative length of stay (7 days; 95% CI, 6-9 vs 6 days; 95% CI, 6-7; P = .048) and the intensive care unit length of stay for patients undergoing nonelective procedures (4 days; 95% CI, 3-5 vs 3 days; 95% CI, 3-4; P = .02). At 6 months, the bell off mortality rate was higher than bell on (9% vs 0%, P = .048) for participants undergoing nonelective procedures.

Conclusions and Relevance

The incentive spirometer reminder improved patient adherence, atelectasis severity, early postoperative fever duration, noninvasive positive pressure ventilation use, ICU and length of stay, and 6-month mortality in certain patients. With the reminder, IS appears to be clinically effective when used appropriately.

Trial Registration

ClinicalTrials.gov identifier: NCT02952027.

Financial Impact of Incentive Spirometry

Despite largely unproven clinical effectiveness, incentive spirometry (IS) is widely used in an effort to reduce postoperative pulmonary complications. The objective of the study is to evaluate the financial impact of implementing IS. The amount of time nurses and RTs spend each day doing IS-related activities was assessed utilizing an online survey distributed to the relevant national nursing and respiratory therapists (RT) societies along with questionnaire that was prospectively collected every day for 4 weeks at a single 10-bed cardiothoracic surgery step-down unit. Cost of RT time to teach IS use to patients and cost of nurse time spent reeducating and reminding patients to use IS were used to calculate IS implementation cost estimates per patient. Per-patient cost of IS implementation ranged from $65.30 to $240.96 for a mean 9-day step-down stay. For the 566 patients who stayed in the 10-bed step-down in 2016, the total estimated cost of implementing IS ranged from $36 959.80 to $136 383.36. Using national survey workload data, per-patient cost of IS implementation costed $107.36 (95% confidence interval [CI], $97.88-$116.98) for a hospital stay of 4.5 days. For the 9.7 million inpatient surgeries performed annually in the United States, the total annual cost of implementing postoperative IS is estimated to be $1.04 billion (95% CI, $949.4 million-$1.13 billion). The cost of implementing IS is substantial. Further efficacy studies are necessary to determine whether the cost is justifiable.

Incentive Spirometry Adherence: A National Survey of Provider Perspectives

BACKGROUND

Patient adherence is a critical factor for success of patient-administered therapies, including incentive spirometry (IS). Patient adherence with IS is not known, so we sought to evaluate providers' perspectives on the current state of IS adherence and elucidate possible factors hindering patient adherence.

METHODS

Respiratory therapists (RTs) and nurses across the United States were surveyed via social media and online newsletters. Surveys were distributed to the relevant national RT and nursing societies: the American Association for Respiratory Care, the Academy of Medical-Surgical Nurses, the American Society of Peri-Anesthesia Nurses, and the American Association of Critical-Care Nurses.

RESULTS

Responses from 1,681 (83.8% completion rate) RTs and nurses were received. The clear majority of all providers agreed that patient adherence is poor (86.0%; 1,416 of 1,647 respondents) and should be improved (95.4%; 1,551 of 1,626 respondents). Providers believe that IS adherence is hindered by various factors. The most common reasons cited were that patients forget to use their ISs (83.5%; 1,404 of 1,681 respondents), do not use them effectively (74.4%; 1,251 of 1,681 respondents), and do not use them frequently enough (70.7%; 1,188 of 1,681 respondents).

CONCLUSIONS

These findings from a large national survey of health care providers highlight the need for improved IS adherence and indicate that patient forgetfulness may be a large contributor to nonadherence. Efforts aimed at improving IS adherence are warranted.

Perspectives on Incentive Spirometry Utility and Patient Protocols

BACKGROUND

Incentive spirometry (IS) is widely used to prevent postoperative pulmonary complications, despite limited clinical effectiveness data and a lack of standardized use protocols. We sought to evaluate health care professionals' perspectives on IS effectiveness and use procedures.

METHODS

An online survey was distributed via social media and newsletters to relevant national nursing and respiratory care societies. Attitudes concerning IS were compared between the American Association for Respiratory Care (AARC) and the nursing societies.

RESULTS

A total of 1,681 responses (83.8% completion rate) were received. The clear majority of these respondents agreed that IS is essential to patient care (92.7%), improves pulmonary function (92.0%), improves inspiratory capacity (93.0%), helps to prevent (96.6%) and to reverse (90.0%) atelectasis, helps to prevent (92.5%) and to reverse (68.4%) pneumonia, and is as effective as early ambulation (74.0%), deep-breathing exercises (88.2%), and directed coughing (79.8%). Furthermore, most health care professionals believed that IS should be used routinely preoperatively (78.1%) and postoperatively (91.1%), used every hour (59.8%), used for an average of 9.6 (95% CI 9.3-9.9) breaths per session, used to achieve breath holds of 7.8 (95% CI 7.4-8.2) s, used to reach an initial target inspiratory volume of 1,288.5 (95% CI 1,253.8-1,323.2) mL, and used to achieve a daily inspiratory volume improvement of 525.6 (95% CI 489.8-561.4) mL. Of all respondents, 89.6% believed they received adequate IS education and training. Respondents from the AARC endorsed significantly less agreement relative to the nursing societies on most parameters for IS utility.

CONCLUSIONS

There was a major discrepancy between health care professionals' beliefs and the published clinical effectiveness data supporting IS. Despite reported adequate education on IS, variability in what health care professionals believed to be appropriate use underscores the literature's lack of standardization and evidence for specific use procedures.

Incidence of Simonsiella in the oral cavity of dogs

The gliding bacterium Simonsiella (Cytophagales, Simonsiellaceae) was found in palate samples from 66 out of 67 dogs. It is considered a common resident in the oral cavities of dogs.

Dorsal-ventral differentiation in Simonsiella and other aspects of its morphology and ultrastructure

The morphology and ultrastructure of the aerobic, Gram-negative multicellular-filamentous bacteria of the genus simonsiella were investigated by scanning and transmission electron microscopy. The flat, ribbon-shaped, multicellular filaments show dorsal-ventral differentiation with respect to their orientations to solid substrata. The dorsal surface, orientated away from the substrate, is convex and possesses an unstructured capsule. The ventral surface, on which the organisms adhere and glide, is concave and has an extracellular layer with fibrils extending at right angles from the cell wall. The cytoplasm in the ventral region contains a proliferation of intracytoplasmic membranes and few ribosomes in comparison to the cytoplasm in other parts of the cell. Centripetal cell wall formation is asymmetrical and commences preferentially in the ventral region. Quantitative differences in morphology and cytology exist among selected Simonsiella strains. Functional aspects of this dorsal-ventral differentiation are discussed with respect to the colonization and adherence of Simonsiella to mucosal squamous epithelial cells in its ecological habitat, the oral cavities of warm-blooded vertebrates.

Scanning electron microscopy of fruiting body formation by myxobacteria

Scanning electron microscopy was used to follow fruiting body formation by pure cultures of Chondromyces crocatus M38 and Stigmatella aurantica. Vegetative cells were grown on SP agar and then transferred to Bonner salts agar for fructification. Fruiting in both species commences with the formation of aggregation centers which resemble a fried egg in appearance. In Chondromyces the elevated center or "yolk" region of the aggregation enlarges into a bulbous structure under which the stalk forms and lengthens. At maximum stalk height the bulb extends laterally as bud-like swellings appear. These are immature sporangia and are arranged in a distintive radial pattern around the top of the stalk. This symmetry is lost as more sporangia are formed. Stigmatella does not form a bulb; rather the yolk region of the aggregation center projects upward to form a column-like stalk which is nearly uniform in diameter throughout its length. At maximum stalk height, the terminus of the stalk develops an irregular pattern of bud-like swellings. These differentiate into sporangia. Stalks of 2-week-old mature fruiting bodies of both species appear to be cellular in composition. Stereomicrographs suggest orientation of these cells parallel to the long axis of the stalk. Stalks of 8-week-old fruiting bodies of Chondromyces were acellular and consisted of empty tubules, suggesting that the cells undergo degeneration with aging of the fruiting body.

Filamentous cells of Escherichia coli formed in the presence of mitomycin

The effects of mitomycin C on cell elongation of Escherichia coli B were studied. Filament formation was most marked in cultures treated with a moderate level (1 mug/ml) of the antibiotic, becoming less obvious at higher levels (10 mug/ml). Cells treated with a bacteriostatic concentration (0.1 mug/ml or less) of mitomycin C were also significantly elongated. The filamentous or elongated cells appeared to lack septa, since their spheroplasts were considerably larger than those formed from normal cells. The appearance of empty spheres also indicated some defects in the surfaces of the filamentous cells. Electron micrographs of the filaments revealed a characteristic difference in the arrangement of the nuclei in the filaments formed in the presence of low (0.1 mug/ml) and high (5 mug/ml) concentrations of mitomycin C. The filaments formed by the low level of mitomycin C had normal well-defined nuclear bodies distributed along the long axis, whereas those formed by the elevated level of the antibiotic contained smaller nuclei. The latter were characteristically confined to the center of the cells and did not extend out to the tips of the filaments.

Ultrastructure of Lampropedia hyalina

Pangborn, Jack (University of California, Davis), and Mortimer P. Starr. Ultrastructure of Lampropedia hyalina. J. Bacteriol. 91:2025-2030. 1966.-In an effort to learn more about the structural bases for the sheeting format of Lampropedia hyalina, ultrathin sections were cut which were precisely oriented either parallel to or perpendicular to the plane of growth; these were examined by electron microscopy. Lampropedia cells show cytological features typical of gram-negative bacteria. In addition, three uniquely structured layers are found exterior to the cell walls. Details are presented regarding the fine structures and geometric relationships of these layers; their probable origins and involvements in the characteristic cellular juxtaposition are discussed.

Studies on the release of lysosomal enzymes from kidney lysosomes

Incubation of kidney lysosomes at 37 degrees results in a graded release of lysosomal enzymes. The release of enzyme occurs in two stages. First the enzymes become available to the substrate but remain sedimentable. Later the amount of soluble enzyme increases and eventually is almost equal to that of the available enzyme. Morphological studies of lysosomes showed that during the process involving increasing availability of enzymes, the lysosomes remained intact. Release of the soluble enzymes was characterized ultrastructurally by a complete loss of the electron-opaque matrix contained within the lysosomal membrane. The increased release of soluble enzymes was concomitant with an increase in the number of individual lysosomes showing complete loss of contents, rather than a gradual loss or dilution of matrix density. Lysosomes which had lost their electron-opaque contents retained their outer membrane intact and were seen to contain numerous internal membranes and small vesicles.

LOCALIZATION OF RESPIRATORY ENZYMES IN INTRACYTOPLASMIC MEMBRANES OF AZOTOBACTER AGILIS

Pangborn, J. (University of California, Davis), Allen G. Marr, and S. A. Robrish. Localization of respiratory enzymes in intracytoplasmic membranes of Azotobacter agilis. J. Bacteriol. 84:669-678. 1962.-Thin sections of the cells of Azotobacter agilis which have been disrupted by sonic treatment, by osmotic shock, or by ballistic disintegration reveal a network of internal membranes in the form of vesicles and tubules. The internal membranes are attached to the envelope. Treatment in a Mickle disintegrator of envelopes emptied of cytoplasm by osmotic shock results in the loss of the internal membranes and a concomitant release of reduced diphosphopyridine nucleotide oxidase from the envelopes. Thus, the intracytoplasmic membranes are the probable locus of the respiratory enzymes of the cell. Thin sections of whole cells show tubular intracytoplasmic membranes which are obscured by ribosomes and other dense cytoplasmic constituents.