Respiratory Therapy

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Respiratory Therapy is a dynamic area within healthcare. Below are some of the topics with which many organizations struggle. The HMCwiki contains free and open content that allows you and others to collaborate on important issues surrounding these and other topics so contribute your thoughts on these topics and feel free to introduce new ideas on this page.

Contents 1 Protocol utilization 2 Developing models of care 3 Ventilator weaning protocols 4 Respiratory care staffing considerations

Protocol utilization

Respiratory Therapy protocols are designed to provide the most effective and efficient treatment based on patient needs. The outcomes of a fully implemented protocol are enhanced patient care and reduced costs as a result of more efficient practice patterns. In addition, by utilizing evidence-based practice, redundancy of resources is minimized and length of stay is reduced.

• Protocol development - Involve all clinical disciplines when developing protocols. Securing physician compliance to respiratory therapy protocols is an important factor in controlling expenses because respiratory therapy protocols are often less costly than physician order preferences. Some facilities have found great success in using Therapist-Driven Protocols (TDPs), which take advantage of the fact that Respiratory Therapists are often more aware of hour-to-hour changes in patients than the physician. TDPs allow Respiratory Therapists to give therapy without waiting for a physician to call or make rounds.

• Practice consistency - Protocols can assist in reducing drug and supply costs by minimizing variation in practice patterns. Consistent practice patterns among physicians create economies of scale, allowing reduced unit purchase price of drugs and supplies by leveraging volume discounts.

• Pharmacist's role - Involving the Pharmacist in developing respiratory therapy protocols can pay dividends. Pharmacists are critical in determining the proper utilization of medications and corresponding titration levels. The Pharmacist can identify over utilization issues that would otherwise lead to excessive costs. In addition, because pharmacists generally have established relationships with physicians, they may be a good ally for coaching physicians into protocol compliance.

Developing models of care

The service delivery models for Respiratory Care in the acute care hospital setting vary widely. And even the best therapy protocols will fall short of excellent patient care, if the delivery model is not optimized. The combinations of skill mix, protocol compliance, management of non-billable activities and the management of vent protocols, have dramatic effects on quality and cost outcomes. The first steps in model of care design are to determine what services will be provided, how patients entering the system will be screened, and who will participate in the delivery of care.

• Centralization vs decentralization - Decentralized models of care can be more expensive and sometimes more difficult to manage than a centralized model. A decentralized model allocates fixed staff to geographic locations or lines of services. A classic example is when a Respiratory Therapist is assigned to the Intensive Care Unit (ICU), or to Pulmonary Function Tests (PFT), regardless of ICU census or how many PFTs are performed on any given day. Volumes of activity are rarely distributed evenly throughout lines of service, or geographic locations, concurrently. An alternative is a fully cross-trained staff, providing maximum flexibility, reducing costs and avoiding missed treatments. Be prepared to go where the work is (centralized model), rather than wait for the work to come to you (decentralized model). The hospital's decision to use or not to use concurrent therapy will have an impact on how Respiratory Care work is delivered throughout the hospital.

• Specialization - Models of care that assign the development of treatment plans and patient assessment activities to more "experienced" staff can sometimes limit the potential of "less experienced" staff. Consider a model that engages all levels of staff by participating in all aspects of a treatment plan, including patient assessment and treatment plan development. Cross training can be the best defense against fixed staff positions, which can lead to increased costs. Organizations that offer greater cross training sometimes experience less turnover.

• Metered-dose inhaler utilization - Take a close look at patients that are screened at admission for metered-dose inhaler (MDI) home use, and have an initial order for nebulizer treatments. Perhaps you could avoid having to convert the patient to an MDI during his/her stay if the initial order was modified for an MDI with an RT algorithm at admission. Investigate the re-use of MDI canisters with your pharmacy and consider the trade-offs of an increased labor cost with potential reduced drug costs.

• Leverage the RN-RT team - Nursing can be cross-trained on most Respiratory Therapy activities. While treatments should be primarily assigned to one group or another (for example, MDI, incentive spirometery, O2 checks and/or clearing of airways), a team-based approach would dramatically reduce missed treatments during periods of unexpected changes in volume by providing a back-up plan.

• Neonatal Intensive Care Unit Dedicated Respiratory Therapists - Dedicating Respiratory Therapists to the 'Neonatal Intensive Care Unit (NICU) is often regarded as "good" for patients.

Ventilator weaning protocols

There is data to suggest that reduction in length of invasive mechanical ventilation reduces risk of ventilator complications. Combined with aggressive use of intermediate care, timely discontinuation of mechanical ventilation can have significant impact on quality and resource utilization (i.e reduced infections, reduced length of stay.)

• Protocol compliance - There are numerous versions of ventilator weaning protocols in use at hospitals throughout the country. Most are restricted in use to a small subset of patients. Try to develop a pathway with different pathway components to enable the best choice either by physician preference or patient condition.

• Physician engagement - Include physicians in the initial discussion of ventilator protocols, draft protocol development and committee presentation of the weaning protocol. Presenting the "final draft" to a physician audience for the first time, after months of independent work, may not encourage approval or compliance.

• The RN-RT team - If an Respiratory Therapist needs to be stationed in the ICU in the presence of a patient being ventilated, then integrate the Respiratory Therapist into the nursing team. They should learn to do conventional ICU nursing tasks as pressure-line set-ups, angioplasty catheter insertions, and intravenous (IV) starts. Some can even assist in performing electrocardiograms.

Respiratory care staffing considerations

• Core staffing levels - Set core staffing levels to a point where utilization of PRN staff is required when volumes increase and when core staff take vacations. This approach serves two purposes:
  • Valuable PRN staff are utilized throughout the year, maintaining constant contact and preservation of the float pool
  • Core staff gain more flexibility over their vacation choices.

Both outcomes can increase employee satisfaction and reduce staff turnover.

• Posting of hours - Consider the use of 32 and 24 hour weekly positions. Employees with these schedules can be encouraged to increase hours to 40 during peak volumes without incurring overtime costs. Add flexibility by creating a weekly schedule of 32 and 24 hour positions, rather than trying to create a weekly schedule of 40 and 16 hour (weekend only) positions.

• Shift design - In some settings, 12 hour shifts are less efficient than 8 hour shifts. Hospital activity frequently drops off between 11 pm to 7 am versus the 3 pm to 11 pm shift. 12 hour shifts get caught in the middle between these high and low volume periods, making it difficult to flex staff hours to volume of activity.