CLINICAL PROTOCOLS TO
ENHANCE OUTCOMES, PATIENT
SAFETY & OPERATIONAL
EFFICIENCY
Al Heuer, PhD, MBA, RRT, RPFT
Professor & Program Director
Rutgers-SHRP
Learning Objectives
• Define a Protocol & Summarize their Evolution
• Examine How Protocols Can Benefits Health Care Orgs.
• Emphasize Why they are More Important than Ever!!!
• Review Pre-requisites and their Basic Elements
• Review a Protocol for Developing a Protocol
• Examine Key Protocols Examples, both “Good & Bad”
• Identify Potential Barriers & How to Overcome Them
• Provide Additional Resources
Questions to Consider
• Are all patient’s getting therapy they need?
• Are some patients receiving unnecessary interventions?
• Are the “frequently fliers”….. flying tooooooo frequently to your
ER?
• Are ventilator patients being weaned ASAP?
• Are RTs & RN’s doing too many “low-dividend” activities at the
expense of value-added services?
Clinical Protocols can Help Address These
Questions…But What’s a Protocol?
• According to the AARC:
• Initiation or modification of a respiratory
interventions…
• Following a pre-determined & preapproved inclusion/exclusion criteria
• Permitting the therapist to initiate,
discontinue, refine, transition, or restart
elements of the care plan.
The Evolution of Clinical Protocols
• 1970’s & 1980’s: Amer. Heart Assn. introduces & refines
BLS & ACLS protocols.
• 1980’s & 1990’s: Health care becomes more competitive;
research “evidence” improves, respiratory protocols gain
a foothold.
• Late 1990’ and early 2000’s, certain organizations
emerge as leaders in respiratory protocols
• Univ. California at San Diego
• The Cleveland Clinic
• Today: Their use is widespread but compliance with
them and the benefit they yield are mixed.
• Ironically, the need for effective protocol use has never
been greater.
Why Protocols ARE Becoming a
Necessity
• Shrinking Resources in Health Care = Need for
Efficiency
• Plus, Outcomes Based Reimbursement
• Value-based Purchasing
• Technological Advancements = Increasing complexity
of our profession (e.g., more complex ventilators &
modes).
• Without “Re-engineering” resources will be further diluted
& quality outcomes threatened
• 30-day readmission?
• HCAHPs
• Potential downward cycle can be addressed (in part) with
more heavy reliance on protocols.
The Evidence
• Overall effectiveness of PDP’s -- Kester, L, et al, (2005): Protocols
from 4 different hospitals produced relatively consistent care plans
95% of time. The results support the benefits of respiratory care
protocols in generally encouraging consistent care, while identifying
ongoing opportunities to standardize respiratory care plans.
• MDI’s versus SVN’s- -Gardenhire (2008) and Brocklebank, et al,
(2001):
• MDIs are at least as clinically effective as SVN/HHN’s
• Cost result in a 20-40% “all-in” cost advantage.
• PEP versus CPT in Secretion Removal--Bellone, et al, (2002):
• PEP can be as effective in mobilizing secretions as manual CPT.
• PEP is less labor intensive than CPT
More Evidence…..
• Weaning protocols – Hooper & Girard (2011) & Nemer & Barbas
(2011):
• Spontaneous Breathing Trials (SBTs) = fewer ventilator days/faster
weaning.
• Inhaled Flolan versus Inhaled Nitric Oxide – Wong (2009):
• Inhaled Flolan significantly reduces (40%) inhaled pulmonary
vasodilator therapy cost versus INO.
• Similar clinical efficacy
• Need for Readmission Prevention Protocols— Hari & Rosenweig
(2012): Appropriate Patient Education and Follow-up are essential
requisites to reduce short-term re-admission
Potential Benefits-General
• Cost Savings & Efficiency
• Reduce physician burden
• Reduce unnecessary treatments
• Optimize Treatment Delivery
• MDI versus SVN
• PEP versus CPT
• Reduced LOS
• Asthma
• post op
• vent weaning
• Reduced Exposure to Errors & Infections
• Directly via standardization to best practices and reduction of variation
• Indirectly via shorter LOS.
• Enhanced Therapist Morale = ↑ Patient Satisfaction
• More Therapist Autonomy
• Less unnecessary therapy
Economic Benefits – Cost
Savings and Efficiency
• One less ICU day due to rapid weaning can save $5k to
$10K/patient.
• One case of VAP prevention can equal $20K to $50K
• One conversion from Inhaled Nitric Oxide (INO) to Inhaled
Flolan can save $2k/day/ patient.
• Flolan is $300 per day vs.
• INO $1,000 to $3,000/day
• Conversion of half of bronchodilator treatments from SVN
to MDI can save a 300-bed hospital approx $1,000 per
day.
• One Fewer facial (or bed) sore w/declined reimbursement
can equal $2k to $25K.
Qualitative Benefits
• Patients: Better QOL!!
• Reduced LOS--Faster recovery
• Fewer re-admissions - QOL
• Staff
• More efficient use of resources
• More RT engagement = ↑ employee morale = ↑ patient satisfaction
• Other:
• Less variation in procedures = Fewer medical Errors
• Less un-necessary therapy
Prioritize!!! Protocols to Target –Big Bang
for the Buck!!!
• High Frequency
• Bronchodilators – MDI should be default, mode
• Secretion Mobilization- Consider PEP versus manual CPT
• Education & Referral Protocols – Asthma, COPD, CHF
• High Cost
• Vent weaning – Wean unless proven otherwise.
• Flolan versus Nitric Oxide for Pul HTN
• 30 Day Re-admission Prevention
• VAP and BiPAP Facial Sore Prevention
Desired Features
• Evidence Based
• Clin. Practice Guidelines
• KISS Principle: Keep It Simple…….!
• Streamlined paperwork and use!!!
• Developed with Input from Multiple Stakeholders.
• End-users should participate in development and beta-testing.
• Practical within the Organizational Structure!
• Compatible with paperless/computerized charting system
• If MDIs are the default mode, make sure MDIs are available!
• RTs Must be Trusted by MDs & Prescribing Professionals
• Tried & True is OK – Outreach to other organizations
effectively using protocols, and ask to use/modify.
• Univ. of California at San Diego
A Protocol for Developing Protocol
1. Identify Need/benefits & Key Focus Areas
• Greatest Bang for the Buck (high volume activities)
• Limit Initial Scope—Start small then expand
2. Establish a Protocol Team (RTs, Mgr, MD, RN?)
3. Initial Research & Review
• Research Evidence
• “Best practices” of similar Institutions
4. Gain Initial Top-level Support
• Medical Director
• Pulmonary Section
5. Expand Research & Review
• Establish/Expand Collaborations
Development (Cont.)
6. Draft initial Protocol
• Procedures
• Algorithm
7. Team Review
8. Beta test by Team & End Users
9. Refine and Finalize
10. Educate RT’s, RN’s and Other Stakeholders (MD’s)
11. Implementation
• Gradual – new Starts Only
• Threshold - Convert all existing patient to Protocol
12. Monitor Impact and Compliance & Evaluate
13. Refine & Revise Based on Feedback
14. Periodic Review, Re-education & Reinforcement
Elements of the Protocol &
Documentation
• Policy - States in detail:
• Purpose/objectives
• Step-by-step how to proceed
• Monitoring mechanism
• Signed by Med. Dir.
• The assessment tool/form
• The algorithm/flowchart
• The oversight/measurement/compliance method
• Feedback/improvement method/plan
General Categories of Protocols
• Umbrella Protocols
• “Respiratory Therapy Consult” ordered by MD.
• Patient is assessed by RT in light of criteria
• Care plan devised & appropriate therapy is initiated
• Therapy-Specific Protocols
• Pertains only to a specific therapy “Bronchodilator Protocol”
• Tag-On: May Focus on Hazard Prevention
• ZAP-VAP
• BiPAP facial sores.
• Condition/Disease-Specific
• Asthma, CF, Post-open heart
• Pulseless V-Fib. - Amer. Heart Assn.
• Process Oriented
• Short term readmission prevention
• Education: Asthma, COPD
Umbrella Protocol Example – Applies to Several Therapies
Specific Therapy Protocol – Applies
only to MDI Conversion
The Algorithm/Flowchart Shouldn’t
Look Like This!
A Oxygen Therapy Protocol – Gone Bad?
Oxygen Therapy Algorithm - Streamlined
Oxygen Titration Protocol-Steamlined
Medication Device Protocol-Streamlined
Secretion Clearance Protocol-Streamlined
Flolan Substitution Protocol
Patient has Acute Pulmonary Hypertension: ARDS and/or CHF
Physician considering INO , inhaled Flolan or alternative tx.
Indications and Contraindications (Bleeding) Considered.
Computerized Physician Order Entry (CPOE) System Directs
Physician to Inhaled Flolan Therapy
Other disciplines notified (Pharmacy, Respiratory Care, Nursing)
Inhaled Flolan Initated at 10 mcg/Ml, * mls/hr, via mini-heart neb.
Patient Closely Monitored for Desired and Negative effects.
Underlying Cause (ARDS, CHF) Resolved, Flolan Weaned (5.0
mcg/ml, 2.5 mcg/ml, discontinued).
Ventilator Weaning Protocol
VAP Prevention Bundle/Protocol
HOB-30-45
Degrees
Sub-Glottic
Suction
ZAP
VAP!!!
Sedation
vacation
Mouth Care/Oral
Antiseptics
Fewer Circuit
Changes
BiPAP Pressure Sore Prevention Bundle
Facial Skin
Cushion/Barrier
Wean Off
BiPAP ASAP
Prevent
Facial
Pressure
Sores!!!
Frequent Facial
Checks/Inspection
Appropriate
Interface Fit
Proper Fitting
Interface
Short-term Readmission Prevention Protocol
General Process Improvement Protocol Algorithm
Potential Barriers & Their Solutions
Barrier/Problem
Solution/Corrective Action
• Don’t Know where to Start
• Research “best practices” & evidence
• Lack of Initial Top-level & MD
• Enlist MD’s in process, market
Support
benefits
• Outdated/obsolete protocol
• Update using latest evidence
• Lack of Initial bottom-up support by
• Develop a user-friendly & practical
RT’s
• Low Compliance with Existing
Protocols
• Insufficient ongoing compliance by
RT’s or other stakeholders
protocol, w/RT input! Review benefits
• Decode via Root-cause analysis, ask
RT staff, devise plan
• Monitoring & Re-education,
Refine/Revise Protocol
Take Home Points
• Protocols can be valuable tools, especially with limited
resources.
• Efficiency
• Effectiveness
• Proper planning and implementation takes time.
• Front-end loaded, requiring careful advance planning,
Implementation and Follow-up.
• Ongoing monitoring and reinforcement also important.
• Protocols do not need to be original, they just need to
work.
• There’s many resources out there, use them!!!
Selected References
• UCSD Respiratory Services, Respiratory Care Patient
•
•
•
•
Driven Protocols, 3rd ed, Daedalus Enterprises Inc.,
Dallas, TX, 2005
Ford, R, AARC Guidelines for Respiratory Care
Department Protocol Program Structure, 2008
Kacmarek, R; Stoller, J & Heuer AJ, Egan’s Fundamentals
of Respiratory Care, ed 10, 2012
Hermeto F, et al, Implementation of a Respiratory
Therapist-Driven Protocol for Neonatal Ventilation,
Pediatrics, 2009
AARC.com-CPG and Protocol Resources
One Last Protocol Algorithm
General Troubleshooting Protocol Algorithm
Yes
Does it
work?
No
Don’t Mess
With It!
Bad
News!!!
Yes
Did you mess
with it?
No
Hide It
Yes
Does
anyone
know?
No
Yes
You Poor
Bucko!
Will you get
Blamed?
Yes
Can you Blame
Someone else?
Yes
No
Problem!
Ditch It!