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Respiratory Therapist-driven Protocol for Non-ICU Surgical Patients Reduces ICU Use and Decreases Costs
Abstract & Commentary
By David J. Pierson, MD, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle. Dr. Pierson reports no financial relationships relevant to this field of study. This article originally appeared in the September 2009 issue of Critical Care Alert. It was edited by William Thompson, MD. Dr. Thompson is Staff Pulmonologist, VA Medical Center; Associate Professor of Medicine, University of Washington; he reports no financial relationships relevant to this field of study.
Synopsis: Initiation of a respiratory therapist-driven protocol for assessment and management of risk for respiratory complications in the study hospital's neurosurgery step-down, trauma/surgery step-down, and trauma/surgery general units was followed by an increase in the number of patients receiving respiratory treatments, but decreases in ICU and hospital stays and overall hospital costs.
Source: Harbrecht BG, et al. Improved outcomes with routine respiratory therapist evaluation of non-intensive-care-unit surgery patients. Respir Care 2009;54: 861-867.
Harbrecht et al, at the University of Pittsburgh, studied the effects of a targeted protocol for respiratory assessment and management in patients admitted to the hospital's neurosurgery step-down, trauma/surgery step-down, and trauma/surgery general units. The protocol, which did not require a physician's order, focused on early identification of patients at risk for pulmonary complications and provision of respiratory therapy and bronchodilator aerosol. Patients admitted to the study units were evaluated by a respiratory therapist (RT) using a standardized assessment tool, by means of which they were assigned a risk score from 0 to 4. Based on the score assigned, patients then could automatically receive therapy according to one or more standardized protocols (bronchodilator therapy, hyperinflation therapy, or secretion management), with the responses assessed by the RT and adjustments to therapy made as deemed necessary according to the protocol. The investigators collected data on all patients admitted to the study units for eight months prior to and eight months after initiation of the protocol.
Patient admissions to the three units were 2,230 during the control period prior to implementation of the RT-driven protocol and 2,805 in the following eight months. During the second period, the units' patients were slightly older and had somewhat greater comorbidities according to Charlson score, but the groups were otherwise similar. There were no significant differences in overall mortality or in the proportion of patients (about 3%) who required transfer to the ICU. However, after protocol initiation, a greater number and proportion of patients received respiratory treatments (48% vs. 30%, respectively; p < 0.01), and patients receiving respiratory treatments had shorter ICU (2.3 vs. 3.6 days; p < 0.002) and hospital (6.8 vs. 7.8 days; p < 0.02) stays and decreased total hospital costs ($17,000 vs. $20,300; p < 0.01).
Previous studies have shown that RT-driven protocols shorten weaning time and prevent ventilator-associated pneumonia in the ICU. Outside the ICU, such protocols have also been shown to improve the process of care increasing adherence to hospital standards and decreasing inappropriate therapy but there has been little evidence of a positive effect on patient outcomes. Although the effects of protocol implementation in this study were modest, a positive impact on potentially important outcomes time spent in the ICU and in the hospital, and overall hospital costs was demonstrated.
Implementation of RT-driven protocols in the ICU and elsewhere in the hospital are sometimes met with resistance on the part of physicians. Typical objections are that protocols "take patient management out of my hands," or "don't apply to my patients," or interfere with the teaching of students and residents. As intuitive as they appear on the surface, however, these objections are not valid. An appropriately devised protocol, duly tailored to the institution's patient population, and reflective of local practice patterns, actually improves the delivery of care as physicians say they want it done. Effective protocols are developed locally, with allowance for local preferences. Although many protocols have been developed around the world, and many templates are available for use in developing local versions, those that prove most effective are individualized to the patients and practice in the specific institution or unit. In addition, protocols have generally been shown to improve, rather than impede, medical education, through their consistency and the application of best evidence in bedside care. A lot of clinicians, like people in general, tend to be resistant to change. Formal studies and experience alike show that staff participation and satisfaction with protocols tend to increase over time once they are in place and their benefits begin to become apparent.