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

2. ProtocolsProtocols 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

3. 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

4. Protocols and Care Plans V alue Respiratory Therapists as “The Experts” in knowing the indications for therapies and assessing the efficacy of the therapy for the patients receiving respiratory care

5. Protocols and Care Plans 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

6. 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

7. A nd the # 1 reason why patients get albuterol IS...

8. It won’t hurt !

9. Protocols and Care Plans QUESTION: What is the last thing most patients taste or smell, if they die in the hospital? Answer: Albuterol!

10. Protocols and Care Plans W ords 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.”

11. Protocols and Care Plans AARC Clinical Practice Guidelines have been available for over 20 years. 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

12. Protocols and Care Plans Protocol Resources This 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 Guidelines These 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 Statements The AARC has adopted a number of statements regarding the provision of services or the practice of respiratory care.

13. 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

15. DateDate TimeRCP Name Eval completed properly ? Dx Appro- 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 chan ged ? Comm ents for other Rx ? 1 2 3 4 Quality Assessment for the Respiratory Care Evaluation Form Protocols and Care Plans

16. Quality Assessment for the Respiratory Care Evaluation Form % of Unnecessary Treatments 4% # of Pts / Asthma 180 % of unnecessary changed to PRN 50% # of Pts / COPD 62 # D/C 11 # of Pts / Pneumonia 53 # of patients who received treatments 5 # of Pts / CHF 14 # changed back to frequency 0 Protocols and Care Plans

17. Respiratory Care - Process Improvement Not Indicated Therapy 2004 0% 5% 10% 15% 20% 25% 30% 35% January February March April May June July August September October November December

18. 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

19. Protocols and Care Plans

23. 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 O 2 therapy via nasal cannula at 2 lpm.

24. Case Study 1 Arterial blood gases: PCO 2 70, pH 7.31 PO 2 50, HCO 3 35, HB 20 Gm% HBO 2 Sat 71%, CaO 2 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, HCO 3 - 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

25. Respiratory Care Plan Oxygenation Ventilation Bronchodilator Rx Steroids Mucus mobilization Smoking cessation PFT Pulmonary Rehabilitation Home O 2

26. 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 FiO 2.

27. Case Study 2 Arterial blood gases:PCO 2 67, pH 7.26, PO 2 150, HCO 3 22, HB 12 Gm%, HBO 2 Sat 98%, CaO 2 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, HCO 3 25, Glucose 88 Peak Flow: 162 LPM MD orders Xopenex 0.63mg Q 4 hours

28. 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

29. 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 O 2 therapy via nasal cannula at 4 LPM. He has never been hospitalized before and states he has had a ‘cold’ for two weeks. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

30. Case Study 3 Arterial blood gases:PCO 2 55, pH 7.34 PO2 55, HCO 3 23, HB 15 Gm% HBO 2 Sat 81%, CaO 2 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