From Task Oriented Therapy to Protocols and Respiratory Therapy Care Plans Jane Reynolds, MS, RN,...

From Task Oriented Therapy From Task Oriented Therapy to Protocols and Respiratory to Protocols and Respiratory

Therapy Care PlansTherapy Care Plans

From Task Oriented Therapy From Task Oriented Therapy to Protocols and Respiratory to Protocols and Respiratory

Therapy Care PlansTherapy Care Plans

Jane Reynolds, MS, RN, RRT

ProtocolsProtocolsProtocolsProtocols

• 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 PlansProtocols and Care PlansProtocols and Care PlansProtocols 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


Value Respiratory TherapistsValue Respiratory Therapists as

“The Experts”

in knowing the indications for therapies and assessing the efficacy

of the therapy for the patients receiving respiratory care


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

Top Ten Reasons why patients get albuterol


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 And the # 1 reason # 1 reason

why patients get why patients get albuterol IS . . .albuterol IS . . .

It won’t It won’t hurt !hurt !

It won’t It won’t hurt !hurt !


QUESTION:

What is the last thing most patients taste or smell, if they die in the hospital?

Answer:

Albuterol!


WWords of wisdom when ords of wisdom when studying for your your studying for your your boards . . .boards . . .

“Don’t approach the questions the way you would at work; think about what you learned in school.”


AARC Clinical Practice Guidelines have AARC Clinical Practice Guidelines have been available for over 20 years.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


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

A visit to WWW. AARC.org on line provides all the tools needed

Position StatementsThe AARC has adopted a number of statements regarding the provision of services or the practice of respiratory care.

http://evolvotron.sourceforge.net/a000003.gif




Services offered by Respiratory Care: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

Date

Time RCP Name

Eval completed properly ?

DxAppro-priate ?

S&S

Appro-priate ?

Indication for Tx Clear?

Is tx appro-priate

?

Goal achieved

?

Is there reason to call MD ?

If yes, was MD contact-

ed ?

Was the

order changed ?

Comments for

other Rx ?

1

2

3

4

Quality Assessment for the Respiratory Care Evaluation FormQuality Assessment for the Respiratory Care Evaluation Form

Protocols and Care PlansProtocols and Care Plans

Quality Assessment for the Respiratory Care Quality Assessment for the Respiratory Care Evaluation FormEvaluation Form

Quality Assessment for the Respiratory Care Quality Assessment for the Respiratory Care Evaluation FormEvaluation Form

% of % of Unnecessary Unnecessary TreatmentsTreatments

4%4%

# of Pts / Asthma 18 0

% of unnecessary changed to PRN

50%

# of Pts / COPD

6 2

# D/C

11

# of Pts / Pneumonia

5 3

# of patients who received treatments

5

# of Pts / CHF

1 4

# changed back to frequency

0

Protocols and Care PlansProtocols and Care Plans

Protocols and Care PlansProtocols and Care PlansProtocols and Care PlansProtocols and Care PlansRespiratory Care - Process Improvement

Not Indicated Therapy 2004

0%

5%

10%

15%

20%

25%

30%

35%

Januar

y

Febru

ary

Mar

ch

AprilM

ayJu

neJu

ly

August

Septe

mber

October

Novem

ber

Decem

ber


“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 1Case Study 1Case Study 1Case 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 1Case Study 1Case Study 1Case 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 PlanRespiratory Care PlanRespiratory Care PlanRespiratory Care Plan• Oxygenation

• Ventilation

• Bronchodilator Rx

• Steroids

• Mucus mobilization

• Smoking cessation

• PFT

• Pulmonary Rehabilitation

• Home O2

Case Study 2Case Study 2Case Study 2Case 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.


• 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 PlanRespiratory Care PlanRespiratory Care PlanRespiratory 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 3Case Study 3Case Study 3Case 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.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


• 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

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From Task Oriented Therapy to Protocols and Respiratory Therapy Care Plans Jane Reynolds, MS, RN,...

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