Chronic lung conditions such as asthma require aerosolized pharmacological maintenance therapy, but data suggests the frequency and dosages can often be overprescribed and based on empirical assumptions rather than clinical evidence.
By Stephen Carey, EdD, MS, RRT
We have all encountered treatments ordered for reasons we don’t quite understand. Respiratory therapists have limited time and resources to properly care for patients. It’s important that RTs and RT managers concentrate their time and effort on patients who need their care and reduce the number of cases of giving patients treatments which are unnecessary.
Unnecessary treatments do not conform to evidence-based medicine. Effective clinical practitioners focus on providing the correct therapy only for the length of time needed. Types of unnecessary treatments include therapy ordered when there is no clinical indication, therapy ordered on a Q2 schedule when Q4 or Q6, or a QID schedule is adequate, and allowing a treatment to continue when the original problem has been resolved.
Beyond inconvenience, discomfort, and expense, unnecessary treatments can pose serious risks to patients. These patients are potentially exposed to more nosocomial infections, a higher rate of potential side effects from medications, and disturbances in sleep pattern.
If unnecessary treatments can be identified and eliminated, the RT department will be more productive in providing quality care to patients; staffing costs would be reduced due to less need for overtime and adjustments to scheduling. Additionally, a workplace that values and responds to the knowledge and experiences of its employees increases morale. Respiratory therapists whose ideas and expertise are respected will therefore experience greater job satisfaction.
When RT’s have a better sense of control in the process, work flow can be improved with a greater sense of autonomy. This can give RT’s a stronger role on the healthcare team, and provides a greater sense of focus on delivering effective patient care.
The process of reducing unnecessary treatments can be as simple as working with various physicians one person at a time. While this may be the quickest approach to make small changes, this may not be the best long term solution. To enable a more comprehensive long term solution, consider using methods and suggestions from Pediatric RT managers and staff at leading hospitals who’ve already made reductions in unnecessary treatments and can speak from experience.
10 Tips to Unnecessary Pediatric MDI and Aerosol Treatments:
1. Form a Committee.
Creating a committee within the RT department will provide a space in which RTs can collaborate and generate ideas for implementing evidence-based practices and educating physicians and other staff. When ideas are generated from the ground up, it’s easier for the group to take ownership.
2. Collect Data.
Statistics will communicate the extent and details of unnecessary treatments and can help make the case to administrators and practitioners that change is needed. Bob Youst, RRT-NPS, educational coordinator, East Tennessee Children’s Hospital, found that the data collection aspect helped to illuminate the size of the problem and helped to “sell the idea” to administration that change was needed.
Youst said that it is worthwhile to “define your own departmental metrics for a given area of care, and do the research needed to substantiate changes…” Collect data that highlights information such as: the frequency of treatments, number of treatments given, location, practitioners involved, patient diagnosis, and breath sounds.
3. Find Someone to Champion Your Ideas.
Share the collected data with a physician who is responsive to RT recommendations. Youst suggested finding a physician to champion innovative ideas and to help sell them to other practitioners and administrators. According to Youst, “battles related to change” are more likely to be won if “physicians are regularly presented with statistics by one of their own.” He asserted that, “without a physician champion to handle other providers’ resistance to change, every accomplishment will be twice as hard to obtain.”
4. Adopt and Develop Protocols.
Christa Sala, MSHC, RRT, Vanderbilt Children’s Hospital’s clinical educator, suggested: “treatments for patients with asthma, croup, and bronchiolitis and airway clearance need to be reviewed for efficacy.”
There is no need to reinvent the wheel when implementing protocols; as a starting point, research protocols from the American Association of Respiratory Care (AARC) and similar organizations. Adapt these ready-made protocols as needed to best serve the needs of the specific RT department, hospital, and patients.
5. Analyze Data from the Perspective of the Hospital and the Patient.
Consider that an administrator may first look at data that reflects the hospital’s profitability. Highlight data associated with increased cost (overtime, cost shifting, duplicate therapy, and patient debt). Bringing attention to financial matters may expedite implementation of more effective and efficient hospital strategies.
6. Create Ordering Flags or ‘Pop ups’ on the
Sala suggested adopting technology to help. As physicians and others are ordering respiratory treatments, “pop ups” or flags can become visible which illuminate conditions related to the treatment protocol; this gives physicians information at the ordering stage which helps educate and direct them to the guidelines of the RT treatment protocols.
7. Increase Opportunities for Communication.
Participate in rounds and be prepared to discuss issues that arise in patient care. Deanna Clark, BSc, RRT-NPS, at Children’s Hospital at Centennial Medical Center, found that consistent communication and being “active in the care of the patient” has been their key to reducing unnecessary treatments in the workplace. RTs at her hospital stay active in the care of the patient, she said.
8. Pilot Test New Protocols.
Pilot testing helps identify unanticipated problems and correct these on a small scale before implementing protocols hospital-wide. Consider using a paradigm such as the PDCA cycle (Plan, Do, Check, and Act). This type of change dynamic has been successfully used by many industries; the cyclical approach generates reflection and continuous quality improvement.
9. Educate Practitioners Regularly.
Reducing unnecessary treatments will be an ongoing process requiring you to keep physicians and others up-to-date on evidence-based practice in respiratory therapy. Look for any and all opportunities to educate and continue to sell your ideas on what types of care for respiratory patients is most effective.
10. Celebrate Successes.
Success may come one physician at a time adopting a new approach to ordering treatments or allowing you to determine when treatments may be discontinued. Celebrate and build upon your successes on a regular basis. As your team succeeds, so do your department, your staff, and ultimately your patients.
Reducing unnecessary treatments will most likely take the form of a long term, ongoing commitment. To increase productivity and quality of care, RTs need a strategic plan to reduce the amount of unnecessary treatments. These 10 tips can be a platform for your RT department to begin implementing change. Beyond these tips, consult other respiratory departments who have successfully implemented changes. Adopt what works and discard what doesn’t fit in with your hospital when utilizing RT protocols.
The long-term process presents an opportunity to raise the profile of the respiratory therapy department in the facility while providing critically needed input to ordering physicians. Celebrate your success.
Stephen Carey, EdD, MS, RRT, is assistant professor of Cardiorespiratory Care in the College of Health Sciences at Tennessee State University. For more information, contact [email protected]