Article Review on "Effectiveness of Therapist Driven Protocols"

Article Review 6 pages (1714 words) Sources: 2

[EXCERPT] . . . .

Therapist-Driven Protocols

THE BETTER OPTION

Effectiveness of Therapist-Driven Protocols

The traditional role and task of a respiratory therapist are dictated and thus limited by a physician's order. She may not accept orders to perform a controlled act from any other health professional. This order of things has been unquestioned for so long. But misallocation of respiratory care and the discovery that reducing the volume of respiratory therapy procedures through protocols demand a change of view. Therapist-driven protocols have shown to reduce the use of support equipment without producing adverse effects on patients. They better agree with clinical practice algorithms and realize more patient treatments while reducing ICU and hospital stay and total hospital costs. On top of it all, respiratory care practitioners are getting more and more trained in patient assessment. One way they prove their new capability is in appropriately performing and interpreting daily screen data more than 95% of the time without the usual physician supervision. More and more evidence is piling up that therapist-driven protocols are preferable to physician-directed orders.

Introduction

A respiratory therapist can discharge her duties traditionally only on orders from a physician or surgeon (CRTO, 2011; Hess, 1988). The practice has endured for many years without apparent issues until developments prompted a review of the situation. These developments were an over-ordering of respiratory care and misallocations. It was felt that respiratory procedures could be greatly reduced without increased adverse effects on patient outcomes (Hess). A clinical study (Kollef, 2000), which compared the clinical outcomes of patients receiving treatment by respiratory care practitioner or RCP protocols with those by physician-directed orders, found that respiratory care by RCP-directed protocols for non-ICU patients was safe, more consistent with the standard care plan of their institution, and incurred lower costs than physician-directed respiratory care. Another study (Ely, 2001) pointed to existing scientific evidence on the capability of healthcare practitioners in implementing these protocols, which improve clinical outcomes and enhance the proper allocation of respiratory-care services (Ely). More studies bolster these findings. The support and recognition of the medical director, the medical staff, the nurses and other health professionals are, however, needed.

Claim

Therapist-driven protocols provide an effective way to improve patient outcomes.

Reasons

They reduce the duration of use of support equipment without producing adverse effects on patient condition or outcome.

As compared with physician-directed respiratory care, RCP protocols exhibited greater agreement with clinical practice guideline-based algorithms.

RCPs can correctly and appropriately perform and interpret daily-screen data more than 95% of the time without need for daily supervision by a weaning physician or team.

Therapist-driven protocols result in more patient treatments and reduced ICU and hospital stay as well as lower total hospital costs.

The protocols significantly reduced ventilator weaning time and time for spontaneous breathing for pediatric ICU patients. More importantly, they enhanced patient care culture and staff relationship without negative impact.

Evidence

This prospective, randomized, controlled study (Marelich et al., 2000) examined the efficacy of a single ventilator management protocol or VMP, as administered by a respiratory care practitioner-and-registered nurse-driven VMP, on medical and surgical ICU patients. It was conducted on 385 patients receiving mechanical ventilation at the University of California, Davis Medical Center from June 1997 to May 1998. The study revealed the feasibility and effectiveness of a single, easily implemented VMP in reducing the use or application of mechanical ventilation for ICU patients. The protocol did not require additional staff and could be implemented with minimal training in a registered nurse or RCP. It required a physician's order only for discontinuation. The protocol reduced mechanical ventilation by 2.33 days without increasing ventilator discontinuation failure rate. The house staff regarded the VMP protocols helpful to their patients. The RCPs and RNS who administered it have the competence to perform weaning. Their protocols reduced the duration of use of the equipment without incurring adverse patient outcome (Marelich et al.).

Another randomized controlled trial compared respiratory care for adult non-ICU patients provided by a respiratory therapy consult service or RTCS with that by a managing physician (Stoller et al., 1999). The RTCS evaluated the volunteer patients based on sign/symptom algorithms patterned after the American Association for Respiratory Care clinical practice guidelines. Agreement between the algorithm-based standard care plan by an expert therapist and the respiratory care plan was in terms of appropriateness. The study found no differences between them on hospital mortality rate, hospital length of stay, total number of treatments delivered or days of dare. But it found that the RTCS-directed respiratory care agreed more closely with the standard care plan than did the physician-directed respiratory care. Furthermore, the RTCS costs were slightly lower than the physician-directed respiratory care and thus realized slight saving without incurring adverse effects. The results suggest that an RTCS can improve the appropriateness of respiratory care orders when compared with the traditional physician-directed respiratory care. Earlier similar findings made RTCS mandatory in most adult non-ICU inpatients at the Cleveland Clinic Hospital (Stoller et al.).

A research team (Ely et al., 1999) studied the large-scale use and effectiveness of an RT-driven protocol on 1,067 patients with respiratory failure as against 9,048 patient days of mechanical ventilation. It was administered by 117 respiratory care practitioners or RCPs for 12 months. The protocol incuded a daily screen or DS with spontaneous breathing trials or SBTs and physician prompt without a physician's daily input. The RCPs achieved a 95% correct interpretation of the DS. Barriers were identified through a questionnaire and these were physician unfamiliarity with the protocol, RCP inconsistency for seeking an SBT for the physician, the physician's reason for not advancing the patient to a SBT, and a lack of stationary unit assignments by RCP's performing the protocol. The study concluded that the validated weaning strategy is feasible without the daily supervision of a weaning physician or team. RCPs proved capable of interpreting and performing DS data more than 95% of the time. The barriers can be dealt with by periodic reinforcement to improve compliance with the protocol (Ely).

A research team (Harbrecht et al., 2009) initiated an RT-driven evaluate-and-treat protocol with an RT-driven patient-assessment scale to determine their effect on mortality. It involved 2,230 patients before and 2,805 after who were assessed by a physician or an RT. They had low risk of pulmonary complications and thus did not require respiratory treatment. The number of respiratory treatments increased after the administering of the protocol. But those who received treatments after the start of the protocol had shorter ICU and hospital stay as well as lower total hospital costs than those who got treatments before the initiation of the protocol. The study concluded that therapist-driven protocols result in more patient treatments but reduced ICU and hospital stay as well as lower total hospital costs (Harbrecht et al.).

This last study compared ventilator weaning time with time to spontaneous breathing, and overall ventilator duration using a VMP against the standard care in a pediatric ICU (Restrepo et al., 2004). It involved 187 patients, 89 in the non-protocol group and 98 for the VMP group. A multidisciplinary task force evolved a comprehensive protocol for ventilator management with four phases, such as initial ventilator set up and adjustment, weaning, minimal settings, and spontaneous mode prior to extubation. Results showed that the introduction of a VMP into the unit improved patient weaning time and improved spontaneous breathing. The protocols significantly reduced ventilator weaning time and time for spontaneous breathing for pediatric ICU patients. More importantly, they enhanced patient care culture and staff relationship without negative impact. It was also noted that interaction and the relationship between the hospital's physicians and therapists somewhat improved as a consequence of their developing, implementing and reviewing the VMP together (Restrepo et al.).

Discussion

Evidence has been mounting on the need to recognize the importance of therapist-driven protocols in improving patient outcomes. They reduce the length of time in the use of support equipment without the risk of adverse patient outcome. They have shown to be in greater agreement with clinical practice guideline-based algorithms as compared with physician-directed respiratory care. In terms of capability, RCPs has proved that they can correctly and appropriately perform and interpret daily-screen data more than 95% of the time without need for daily supervision by a weaning physician or team. These protocols may increase patient treatments but they may also reduce ICU and hospital stay and ventilator weaning time and time for spontaneous breathing as well as lower total hospital costs. More importantly, they enhanced patient care culture and staff relationship without negative impact. Therapists have also been receiving increased training in patient assessment to qualify them for the expanded role.

Physicians may finally give an ear to these increasing findings and reality when respiratory therapists come to a partnership with physicians. More importantly, physicians may feel inclined to recognize the expanded role and capability of RTs if and when they show the professionalism at the bedside where respect is earned.

BIBLIOGRAPHY

CRTO (2011). Orders for medical care. Professional Practice Guidelines. College of Respiratory Therapies of Ontario.… READ MORE

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