From Task Oriented Therapy to
Protocols and Respiratory
Therapy Care Plans
Jane Reynolds, MS, RN, RRT
Protocols
• 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 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
Protocols and Care Plans
Value Respiratory Therapists as
“The Experts”
in knowing the indications for
therapies and assessing the efficacy
of the therapy for the patients
receiving respiratory care
Protocols and Care Plans
Top Ten Reasons why patients get albuterol
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
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
And the
# 1 reason
why patients get
albuterol IS . . .
It won’t
hurt !
Protocols and Care Plans
QUESTION:
What is the last thing most
patients taste or smell, if they
die in the hospital?
Answer:
Albuterol!
Protocols and Care Plans
Words
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.”
Protocols and Care Plans
AARC Clinical Practice Guidelines have
been available for over 20 years.
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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
Protocols and Care Plans
A visit to WWW. AARC.org on line provides all the tools needed
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
Position Statements
The AARC has adopted a
number of statements
regarding the provision of
services or the practice of
respiratory care.
Protocols and Care Plans
Services offered by Respiratory Care:
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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
Protocols and Care Plans
Quality Assessment for the Respiratory Care Evaluation Form
D
a
t
e
1
2
3
4
Time
RCP
Name
Eval
completed
properly ?
Dx
Appropriate ?
S&S
Appropriate ?
Indication
for Tx
Clear?
Is tx
appropriate
?
Goal
achieved
?
Is there
reason
to call
MD ?
If yes,
was MD
contacted ?
Was
the
order
chan
ged ?
Comm
ents
for
other
Rx ?
Protocols and Care Plans
Quality Assessment for the Respiratory Care
Evaluation Form
% of
Unnecessary
Treatments
# of Pts /
Asthma
4%
18
0
% of unnecessary changed to
PRN
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
# of Pts / COPD
50%
Protocols and Care Plans
Respiratory Care - Process Improvement
Not Indicated Therapy 2004
35%
30%
25%
20%
15%
10%
5%
0%
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
Protocols and Care Plans
Protocols and Care Plans
Protocols and Care Plans
Protocols and Care Plans
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 O2 therapy via nasal cannula at 2 lpm.
Case 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 Plan
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Oxygenation
Ventilation
Bronchodilator Rx
Steroids
Mucus mobilization
Smoking cessation
PFT
Pulmonary Rehabilitation
Home O2
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 FiO2.
Case Study 2
• 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 Plan
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Oxygenation
Ventilation
Monitoring
Bronchodilator Rx
Steroids
Asthma Action Plan
Patient Education
Smoking cessation
PFTs
Allergy Testing Anti IGE Rx?
Home Environment Assessment
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 O2 therapy via nasal cannula at
4 LPM. He has never been hospitalized before
and states he has had a ‘cold’ for two weeks.
_____________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________
Case Study 3
• 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