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 PARTICIPANTSThis 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 MEASURESIncentive 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-torecover 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 RELEVANCEThe incentive spirome...

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Objectives Emergency medicine has a demanding work environment. Characteristics influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) released a policy statement in 2009 suggesting accommodating emergency physicians in preretirement years. We engaged emergency physicians to determine awareness of the ACEP policy and issues faced in preretirement years. Methods We conducted a series of online focus group discussions with a purposive sample of emergency physicians, age ≥ 50 years. The discussion guide was developed from the ACEP policy statement and relevant literature. Groups were audio recorded, transcribed, and analyzed with a thematic coding system developed iteratively by the 4‐person team. Emerging themes were identified, organized, and presented with illustrative quotations. Results A total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These physicians had between 17 and 35 years of clinical experience (median = 27), 6 were female (21%), and the majority (n = 26, 93%) worked in academic emergency medicine. Only 1 emergency physician was fully aware of the ACEP policy. Three principal content areas were identified: workload demands that change as physicians age, wellness and physician social equity, and senior emergency physician value. Interwoven across all of these was the focus on leadership and solutions to issues. Issues facing emergency physicians in their preretirement years were identified; commitment from emergency medicine site and national leadership and buy‐in from junior colleagues was emphasized. Generational conflicts in recognizing the contribution and needs of preretirement emergency physicians was a major barrier to solutions. Conclusions Workload demands, wellness and physician social equity, and concerns about value as a senior physician are major themes confronting preretirement emergency physicians. Generational divides, deficits in local and national leadership, and the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.