Surgical patients under the care of clinicians at the University of Colorado Department of Surgery are at lower risk of complications brought on by an aspiration event, thanks to a new patient safety protocol led by the Office of Quality & Clinical Effectiveness of the Department of Surgery, as reported by Viviane Leite Abud, MD, a quality and executive leadership resident in the department.
Aspiration events — which happen when food, liquid, saliva, vomit, or other material enters the airway and lungs by accident — are a significant risk for patients recovering from surgery, especially those who have previously had a stroke, have acid reflux, have a history of radiation to the neck and throat, or have trouble swallowing. Aspiration can cause pneumonia, respiratory failure, and in some cases death.
“It’s when something ‘goes down the wrong pipe,’ is how people say it in lay terms,” Abud says. “Sometimes a patient is eating, and they have a problem with swallowing, and the food ends up going into their lungs or their airway. A lot of times after surgery, patients will have problems with their bowels not moving very well and things start getting backed up. And then when they throw up because of that, sometimes part of that vomit will go into their lungs.”
In an effort to put a stop to aspiration events at the CU Department of Surgery, Abud met with a multidisciplinary team of CU faculty and administrators, nurses and administrators from UCHealth, and other medical professionals who are part of a patient’s journey through surgery. Paying special attention to surgeries in the stomach and esophagus — as well as neurosurgery and thoracic surgery — the team put together a set of interventions that can change the course of treatment for patients at risk of an aspiration event. For some patients, that risk is determined before surgery even begins; for others, clinicians were made aware of signs to look out for as a patient is recovering.
“Our aspiration prevention order set — which is basically a bundle of orders that the provider can put in automatically for patients at risk — was not as comprehensive as we wanted it to be,” Abud says. “In addition to the orders that were already in place, we added that the patient must sit upright for 30 minutes after meals. We were already sitting patients up for meals, because we knew that patients eating while they were laying down was a risk for aspiration. But what we didn’t recognize was that a lot of patients were laying down immediately after meals.”
Other additions to the order set include brushing patients’ teeth after meals to reduce bacterial burden in the mouth; letting nurses know when a meal is delivered so they can supervise patients while they eat; creating door signs for patients at higher risk of aspiration; and educating patients about aspiration and instructing them to tell a nurse if they are experiencing symptoms.
“We created a handout to give directly to patients so they will know exactly what aspiration is, what it means if they’re at risk, and to call their nurse right away to report these problems,” Abud says.
Screenings and successes
Launched in spring 2022, the new protocol also includes instructions for patients and their caregivers when they return home after recovery, as aspiration is still a risk as patients continue to heal. The overall goal of the interventions, Abud says, is to avoid an increased length of stay in the hospital due to an aspiration event, and to avoid the need for re-intubation due to aspiration.
In addition to monitoring patients during recovery, the new aspiration protocol also emphasizes screening them prior to surgery to identify those at higher risk. As part of their standard pre-screening for surgery, patients are now asked a series of questions to identify their potential for aspiration, including their history of stroke, acid reflux, and radiation to the head and neck.
Already the team has seen a reduction in the number of aspiration events after surgery. That’s mostly due to the protocol, Abud says, but it’s also due to the fact that helping to develop the intervention put aspiration top of mind for nurses, surgeons, and other clinicians. It was a true multidisciplinary effort that is making a difference in the lives of patients.
“We started the process with a survey, and one of the questions asked if we can do better with post-operative aspirations,” she says. “And it was almost unanimous that we should do better. Everyone was on board.”