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CommentaryRespiratory Therapist-Driven Protocols

Rationale and EfficacyJAMES K. STOLLER, MD, Cleveland, Ohio

T herapist-driven protocols, also known as respiratorycare- or patient-driven protocols, are prescribed

plans for a specific respiratory care service that areimplemented under respiratory care practitioners' super-vision. The protocol is often a guideline or a branching-logic algorithm that is developed collaboratively by themedical director of respiratory care and respiratory carepractitioners with the goal of assuring the appropriateallocation of these services.

As an extension of a single therapist-driven protocol,a respiratory therapy consult service, also known as anevaluate-and-treat program, is a program in which respi-ratory care is directed by respiratory care practitionersbased on a menu of protocols for individual respiratorycare services. Thus, in a respiratory therapy consult ser-vice, respiratory care practitioners bear the additionalresponsibility of applying sign- and symptom-based pro-tocols to ascertain which services are needed and thenimplementing those services under protocol guidance.After initial therapy is implemented, protocols generallyallow therapy to be titrated by either escalating or reduc-ing the number and intensity of respiratory care servicesas patients' clinical needs dictate.

See Editorial, pages 440-441

As suggested by their widespread adoption and grow-ing attention in the literature, therapist-driven protocolshave attained widespread popularity. For example, a pollof 32 attendees at the 1994 American Association forRespiratory Care House of Delegates indicated that 13(41%) were currently using therapist-driven protocolsand 5 (16%) were planning their use. Similarly, a 1995poll of respiratory care managers in the CaliforniaSociety of Respiratory Care showed that 50% were cur-rently using protocols and 42% were planning to do so.

Therapist-driven protocols have been proposed as away to improve the allocation of respiratory care ser-vices, and several lines of evidence suggest their effica-cy in enhancing appropriate allocation. That a new strat-egy may help is suggested by the widespread misalloca-

tion of respiratory care services under the traditional,physician-directed approach to prescribing respiratorycare. Table 1 summarizes the frequency with which res-piratory care services have been misallocated-eitherprescribed when not likely to offer clinical benefit("overordering") or not prescribed when indicated("'underordering").' As shown, rates of overorderingfor a variety of respiratory care services range from 32%to 72%, and the rates of underordering (which is lesswell-studied) range from 7% to 21%.

As further supportive evidence, a growing number ofstudies have shown that implementing therapist-drivenprotocols can lessen the misallocation of respiratory careservices, thereby improving clinical outcomes and main-taining the cost of providing care. Such advantages oftherapist-driven protocols have been demonstrated in avariety of clinical services. For example, in one study ofintensive care units, it was shown that implementingappropriate guidelines for measuring arterial blood gasvalues lessened the rate of the inappropriate use of arte-rial blood gases from 43% to 33% and that respiratorycare practitioners were far less likely than other healthcare professionals to measure arterial blood gases inap-propriately (3% inappropriate rate versus 45%).7Another study showed that a therapist-driven protocolfor weaning patients who have had open-heart opera-tions from mechanical ventilation was associated with aslight decrease in the total duration of mechanical venti-lation (mean, 18.6 to 16.8 hours) without adverse events(such as higher reintubation rate or higher rate of initialweaning failure).8 Recently, a report of a randomizedcontrolled trial of a therapist-directed weaning protocolin 357 patients showed that the rate of successful wean-ing was higher in the protocol-directed weaning group(relative risk, 1.31; P < 0.04).9 Also, the duration ofweaning was shorter (median, 35 versus 44 hours) andthe hospital charges were lower (mean, $3,866 perpatient) with no higher mortality in the protocol-direct-ed group.

In non-intensive care unit inpatient care, favorableexperience with therapist-driven protocols also supportstheir use.1s'2 For example, a review of respiratory care

(Stoller JK. Respiratory therapist-driven protocols: rationale and efficacy. West j Med 1997; 167:408-410)

From the Section of Respiratory Therapy, Cleveland Clinic Foundation, Department of Pulmonary and Cntical Care Medicine, Cleveland, Ohio.Reprint requests to James K. Stoller, MD, Department of Pulmonary and Critical Care Medicine, A90, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH

44105.

1997-Vol 167, No. 6 Commentary-Stoller 409

orders by respiratory care practitioners found that thevolume of many respiratory care services was substan-tially reduced (up to 17%), with concomitant savings($16.35 per patient).'2 In our experience with theRespiratory Therapy Consult Service at the Cleveland(Ohio) Clinic Foundation, implementing a protocol fortitrating supplemental oxygen in postoperative patientssubstantially shortened the total duration of oxygen ther-apy and the number of pulse oximetry measurements,with concomitant cost savings of $21.73 per patient.Extrapolated to all adult inpatients receiving supplemen-tal oxygen at our institution in 1995 (n = 12,119), theprojected aggregate annual savings is $263,346. Finally,in a recently reported observational cohort study com-paring respiratory care that was directed by the respira-

tory therapy service with that directed by physicians in98 patients," despite caring for sicker patients withlonger lengths of stay and higher total hospital charges,the respiratory therapy service generated fewer inappro-priate orders than physicians and provided a similarnumber of total respiratory treatments at slightly lowercost without any excess adverse respiratory events.

Therapist-driven protocols appear to be effectivestrategies for improving the allocation and provision ofrespiratory care services in the current cost-attentive era.Their implementation requires a committed and collab-orative interaction among respiratory care practitioners,medical directors of respiratory care services, physi-cians, and nurses, as has been achieved in a growingnumber of institutions and settings.

TABLE 1.-Frequency of the Misallocation of Respiratory Care Services in Selected Series*

Patient Type No. of Patients Frequency of Overordering Frequency of Underordering

Supplemental oxygen

Zibrak et al, 19861 .......

Brougher et al, 19862...

Small et al, 1992 ........

Kester and Stoller, 19924 .

Albin et al, 19925 .........

Adult

Adult,non-ICU inpatientsAdult,non-ICU inpatients

Adult,non-ICU inpatientsAdult,

non-ICU inpatients

NS 55% reduction in incentive spirometryafter therapist supervision begun

77 38% ordered to receive oxygen

despite adequate oxygenation47 72% of those checked had PaO2

>60 mm of mercury or SaO2>90% but were prescribed oxygen

230 25.2% overall for 5 respiratory care

services; 28% for supplemental oxygen

274 61% ordered to receive supplementaloxygen despite SaO2 >92%

NA

NA

NA

10.5% overall for 5 respiratory care

services, 8% for supplemental oxygen

21% underordered, including 19%prescribed to receive inadequate

oxygen flow rates

Bronchial hygienetechniquesZibrak et al, 19861 ......e

Shapiro et al, 19886 ..

Kester and Stoller, 1 9924

Zibrak et al, 19861 ........

Kester and Stoller, 1 992

Intermittent positivepressure breathing (IPPB)Zibrak et al, 19861 ........

Kester and Stoller, 1 9924

Arterial blood gases (ABGs)Browning et al, 19897 .....

Adult

Adult,

non-ICU inpatientsAdult,non-ICU inpatientsAdult

Adult,

non-ICU inpatients

Adult

Adult,

non-ICU inpatients

SICU inpatients

NS 55% reduction in incentive spirometryafter therapist supervision begun

3,400 61% reduction of bronchial hygieneevaluations

230after system implemented32%

NS 50% reduction in aerosolized medicationafter therapist supervision begun

230 12%

NS 92% reduction in IPPB after therapistsupervision begun

230 40%

724 ABGs 42.7% inappropriately ordered before

guidelines implemented

NA

NA

8%

NA*

12%

NA

6.7%

NA

ICU - intensive care unit, NA not assessed, PaO2 = partial pressure of arterial oxygen, SaO, = saturation of arterial blood with oxygen, SICU = surgical intensive care unit.

From Stoller.

Types of Service11

WJM, December 1997-Vol 167, No. 6 Commentary-Stoller 409

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REFERENCES

1. Zibrak JD, Rossetti P, Wood E. Effect of reductions in respiratory therapy onpatient outcome. N Engl J Med 1986; 315:292-295

2. Brougher LI, Blackwelder AK, Grossman GD, Straton GW. Effectivenessof medical necessity guidelines in reducing cost of oxygen therapy. Chest 1986;90:646-648

3. Small D, Duha A, Wieskopf B, et al. Uses and misuses of oxygen in hospi-talized patients. Am J Med 1992; 92:591-595

4. Kester L, Stoller JK. Ordering respiratory care services for hospitalizedpatients: practices of overuse and underuse. Cleve Clin J Med 1992;59:581-585

5. Albin RJ, Criner GJ, Thomas S, Abou-Jaoude S. Pattern of non-ICU inpa-tient supplemental oxygen utilization in a university hospital. Chest 1992;102:1672-1675

6. Shapiro BA, Cane RD, Peterson J, Weber D. Authoritative medical direc-tion can assure cost-beneficial bronchial hygiene therapy. Chest 1988;93:1038-1042

7. Browning JA, Kaiser DL, Durbin CG Jr. The effect of guidelines on the ap-propriate use of arterial blood gas analysis in the intensive care unit. Respir Care1989; 34:269-276

8. Wood G, MacLeod B, Moffalt S. Weaning from mechanical ventilation:physician-directed vs a respiratory therapy-directed protocol. Respir Care 1995;40:219-224

9. Kollef MH, Shapiro SD, Silver P, St John RE, et al. A randomized controlledtrial of protocol-directed versus physician-directed weaning from mechanical ven-tilation. Crit Care Med 1997; 4:567-574

10. Stoller JK. A rationale for therapist-driven protocols. Respir Care ClinNorth Am 1996; 2:1-14

11. Stoller JK, Haney D, Fergus L, Meredith R, Giles D, Kester EL, et al, andthe Section of Respiratory Therapy. Physician-ordered respiratory care versusphysician-ordered use of a respiratory therapy consult service: results of a prospec-tive observational study. Chest 1996; 110:422-429

12. Shrake K, Scaggs JE, England KR, Henkle JQ, Eagleton LE. A respiratorycare assessment-treatment program: results of a retrospective study. Respir Care1996; 41:703-713

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