Using protocols has allowed this emergency department to fulfill its medical center’s mission
Over the course of the 1990s, the clinical and financial achievements of respiratory care-driven protocols forever changed the concepts by which respiratory therapies would be administered in the future. At the beginning of the new millennium, an estimated 98% of all respiratory care practitioners were employing respiratory protocols in their daily practice.1 The evolving art and science of respiratory protocols are now positively influencing such specialty care settings as the intensive care unit, recovery room, and the increasingly patient-congested emergency department (ED).
At Memorial Medical Center in Springfield, Ill, the great success of the institution’s respiratory protocol program promoted a novel ED procedure to meet the demands of a growing respiratory patient population.2,3 The need for a viable protocol arose with the recognition that the emergency department could not always assess, test, and treat respiratory complaints in a timely fashion without diverting care and services from other admitted patients. Clinically, any delay defeats the purpose of triaging respiratory presentations into the main ED ahead of lesser category cases. Concerns were further based on the changing ED role within the surrounding Springfield community.
Memorial Medical Center, located at the heart of the Illinois capital city, is challenged by the an ever-rising consumption of emergency department resources. National statistics indicate the trend extends across the country as a whole. Too many people—uninsured, underinsured, and those lacking a primary care physician (PCP)—rely upon their local ED for access to health care.4 From the same patient group, a large percentage present with acute or chronic exacerbations of respiratory diseases and disorders. In particular, some 2 million asthmatic ED visits are annually accounted for in the United States.5 Incapable of altering the current social climate, ED medical director David Griffin, MD, FACEP, requested an emergency respiratory protocol from Memorial’s Department of Pulmonary Medicine.
After careful consideration, it was decided not to employ the popular algorithm design, but instead to employ a coordinated combination of check-mark identifications with limited diagnostic and therapy selections. Complexity was strongly avoided, while efficiency and expediency were stressed. The resulting protocol provided a methodical RCP assessment of a patient’s immediate respiratory signs and symptoms, history, and home medications followed by an array of possible diagnostic tests and therapeutic interventions. All aspects of the respiratory therapist’s evaluation and decision-making, including the patient’s diagnostic results and reactions to therapy, are documented on a single page report. The policy dictating the protocol’s clinical use is precise, yet remains flexible for ease of execution (see Diagram).
In practice, the ED triage nurse pages the respiratory supervisor for every patient admitted with a respiratory complaint who cannot be promptly evaluated by the assigned physician. Upon assessing the patient, the responding RCP first decides whether a physician intervention is immediately required. Though fortunately a rare event, there are occasions when a patient entering the ED is so respiratory compromised that the protocol must be suspended and an appropriate physician is summoned STAT.
The therapist then proceeds through the “Respiratory Therapy/Emergency Department Protocol” by first identifying and documenting the patient’s pertinent pulmonary disease/disorder, patient pulmonary history, pulmonary presentation, and breath sounds, checking every applicable value contained in each care category at the time of the initial assessment. The derived information is used toward selecting specific tests and/or treatment options, if any, under the “Pulmonary Therapy/Diagnostics” category. The adjacent “Pulmonary Medication” category lists the medications approved for administration.
If respiratory treatment is decided upon, the “Assessment & Treatment Record” sheet provides space for recording patient responses with an additional comments section where further observations may be included. Once the evaluation, diagnostic results, and therapies are completed and documented, a verbal report is made to the assigned nurse. The Assessment & Treatment Record face sheet is then attached to the patient’s ED chart awaiting physician review. An underlying copy page is retained for holding and charge purposes in the respiratory care department, pending the patient’s admission or discharge from the hospital.
Under no circumstances does the protocol process circumvent or replace the primary assessment and care offered by the attending ED physician. Should the therapist’s evaluation conclude ahead of the physician’s appearance at the bedside, the documented report serves to further develop the respiratory complaint. If the physician arrives while the therapist is still serving the patient, any new orders are simply entered into the evolving protocol. In a final example of clinical flexibility, ED patients who admit to the hospital often continue within the respiratory protocol system once their baseline evaluations are forwarded to the receiving unit.
Two years have passed since the inception of the Respiratory Therapy/Emergency Department Protocol. Whether the ED is very busy or not, at any given moment patients arriving in the throes of dyspnea are assured a rapid, expedient care response. Equally vital, the protocol has proved popular among the emergency nurses and staff, respiratory therapists, and associated physicians. To the institute as a whole, the emergent policy is helping fulfill Memorial Medical Center’s self-proclaimed mission of providing Springfield with a “FastER, SmartER, GreatER” emergency department.
John E. Scaggs, RRT, is clinical supervisor of respiratory care, Division of Pulmonary Medicine, Memorial Medical Center, Springfield, Ill.
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4. Northrop D, Conyers D. Providing timely respiratory care via urgent protocol in the emergency department. AARC Times. 2004; 28(3):40-4.
5. Myers TR. The benefits of asthma care protocols in acute care. Presented at: 50th International Respiratory Congress of the American Association for Respiratory Care. December 2004; New Orleans.