From Task Oriented Therapy to Protocols and Respiratory Therapy Care Plans Jane Reynolds, MS, RN, RRT
Protocols • Scientific basis for ordering respiratory therapy provided with AARC Clinical Practice Guidelines When respiratory therapists are allowed to provide respiratory therapy via protocols: • Clinical outcomes improve, • Misallocation of respiratory therapy services decreases • Costs associated with respiratory therapy are reduced
Protocols and Care Plans • Protocols allow for clinical decision making in a real time basis • Control of ordering therapies thus better matching demand to supply of therapists • Promotes critical thinking and assessment skills • Match respiratory resources to those patients who really need respiratory therapy
Protocols and Care Plans Value Respiratory Therapists as “The Experts” in knowing the indications for therapies and assessing the efficacy of the therapy for the patients receiving respiratory care
Protocols and Care Plans Top Ten Reasons why patients get albuterol 10. Because the patient has lots of secretions 9. Because the patient is intubated 8. Because the patient is going to surgery 7. Because his attending, Dr. _ _ _ _ said so
Protocols and Care Plans Top Ten . . . 6. Because the pt’s cousin has asthma 5. Because the patient is desaturating 4. “It is my philosophy” 3. The patient is DNR. 2. The patient has terminal CA
And the # 1 reason why patients get albuterol IS . . .
Protocols and Care Plans QUESTION: What is the last thing most patients taste or smell, if they die in the hospital? Answer: Albuterol!
Protocols and Care Plans Words of wisdom when studying for your your boards . . . “Don’t approach the questions the way you would at work; think about what you learned in school.”
Protocols and Care Plans AARC Clinical Practice Guidelines have been available for over 20 years. AARC recommendations are made as to: • Appropriateness • Monitoring • Evaluation • Adjustments to therapy are made based • outcomes & efficacy • Documentation • Equipment & Personnel best suited for therapeutic modalities determined by evidence based research
Protocols and Care Plans A visit to WWW. AARC.org on line provides all the tools needed Protocol ResourcesThis is a collection of all resources provided by the AARC on helping you establish protocols. It includes a bibliography of peer-reviewed articles, a bank of algorithms and protocols to use as models, and a story about one health system's implementation of protocols. Clinical Practice GuidelinesThese AARC's guidelines enhance respiratory practice and provide a framework for RT protocols Position StatementsThe AARC has adopted a number of statements regarding the provision of services or the practice of respiratory care.
Protocols and Care Plans Services offered by Respiratory Care: • Bronchoscopic procedures • Pulmonary Function Testing • Smoking Cessation • Sleep Studies • Asthma and COPD disease management and patient education • Metabolic Testing • Therapeutic Treatments • Cardio – Pulmonary Stress Testing
Protocols and Care Plans Quality Assessment for the Respiratory Care Evaluation Form
Quality Assessment for the Respiratory Care Evaluation Form Protocols and Care Plans
Protocols and Care Plans Respiratory Care - ProcessImprovement Not IndicatedTherapy2004 35% 30% 25% 20% 15% 10% 5% 0% July May April June March January August October February November December September
Protocols and Care Plans “Not indicated therapy” • Estimated to be 40% nationally • 32% at our institution • Decreased to a sustained average rate of about 8% to date • Many treatments that were not discontinued were changed to PRN and no therapy was ever given
Case Study 1 A 50-year old white male was admitted to a telemetry unit from the ED at 0430 with a chief complaint of severe shortness of breath. He is 5 feet 10 inches tall and weighs 185 lbs. His vital signs on admission are: T 101.1, P 114, RR 26, B/P is 166/110. He has digital clubbing and cyanosis of his extremities. He has pedal edema and JVD is also noted. He uses pursed lip breathing and is audibly wheezing. He has a productive cough of small amounts of thick yellowish green sputum. Auscultation reveals bilateral wheezing with decreased aeration in both bases. He states he has been taking antibiotics for almost a week. He was not feeling any better so he came to the ED because ‘he couldn’t take it any more.’ He is receiving O2 therapy via nasal cannula at 2 lpm.
Case Study 1 • Arterial blood gases: PCO2 70, pH 7.31 PO2 50, HCO3 35, HB 20 Gm% HBO2 Sat 71%, CaO2 19.4 Vol %. • CBC: RBC 6.5, HB 20.1, HCT 61, WBC 18,000 • Electrolytes: Na 141, K 3.8, Cl 84, BUN 17, Cr 1.2, HCO3- 38, Glucose 108 • Two days later the patient requests information on smoking cessation. • The night shift therapist also notes the patient snores very loudly and appears to have OSA. • MD ordered albuterol Q4 hours around the clock
Respiratory Care Plan • Oxygenation • Ventilation • Bronchodilator Rx • Steroids • Mucus mobilization • Smoking cessation • PFT • Pulmonary Rehabilitation • Home O2
Case Study 2 A well known asthmatic 20 year old white female is admitted to the ED in a severely agitated state. She is 5 feet 6 inches tall and weighs 120 lbs. Her vital signs are: T 97.4, P 110, RR is 32, B/P is 98/50. Her respirations are shallow and her chest appears hyperinflated. Breath sounds reveal minimal wheezing and decreased aeration in both lungs. She is receiving oxygen therapy via venturi mask, 0.4 FiO2.
Case Study 2 • Arterial blood gases: PCO2 67, pH 7.26, PO2 150 , HCO3 22, HB 12 Gm%, HBO2 Sat 98%, CaO2 13.9 Vol % • CBC: RBC 4, HB 12, HCT 36, WBC 15,000 • Electrolytes: Na 141, K 4.9, Cl 94, BUN 13, Cr 0.8, HCO3 25, Glucose 88 • Peak Flow: 162 LPM • MD orders Xopenex 0.63mg Q 4 hours
Respiratory Care Plan • Oxygenation • Ventilation • Monitoring • Bronchodilator Rx • Steroids • Asthma Action Plan • Patient Education • Smoking cessation • PFTs • Allergy Testing Anti IGE Rx? • Home Environment Assessment
Case Study 3 A 49-year old African American male was brought to the ED at 0500 with a chief complaint of shortness of breath. He is 5 feet 10 inches tall and weighs 180 lbs. Vital signs on admission: T 99.3, P 124, RR 14, B/P 160/90. Breath sounds are markedly reduced bilaterally with some high pitched wheezing. He is using inspiratory and expiratory accessory muscles of ventilation. He is receiving O2 therapy via nasal cannula at 4 LPM. He has never been hospitalized before and states he has had a ‘cold’ for two weeks. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Case Study 3 • Arterial blood gases: PCO2 55, pH 7.34 PO2 55, HCO3 23, HB 15 Gm% HBO2 Sat 81%, CaO2 16.52 Vol %. • CBC: RBC 5.5, HB 15.1, HCT 46, WBC 18,000 • Electrolytes: Na 137, K 4.4, Cl 104, BUN 25, Cr 1.5, HCO3- 26, Glucose 91 • MD order Albuterol 2.5 mg Q 6 hours