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OVERVIEW
In an effort to improve the quality and reduce the costs of the respiratory care at UCSD Medical Center, the Respiratory Care Department has developed a number of Patient-Driven Respiratory Care Protocols. These protocols have been developed for those areas of respiratory care where there are relatively clear therapeutic indications and standardized approaches and measures for accomplishing the therapeutic objectives.
The goals of this effort are multiple and are directed at the following problems:
1. Respiratory care is often ordered by the least experienced members of the health care delivery team who are less likely to be aware of the most effective approaches.
2.We are currently mandated to document in the medical record the indications and therapeutic goals for respiratory care procedures and lack an effective mechanism for fulfilling this requirement.
3.A fraction of the routine care delivered at the Medical Center is delivered without adequate indication or is continued after the therapeutic goals have been met.
Patient-driven protocols are intended to improve care by: (top)
1.defining the indications and standards of care agreed upon by the medical staff of UCSD Medical Center,
2.training respiratory care practitioners to apply those criteria to individual patients and to present them to the ordering physician,
3.documenting the indication and therapeutic objectives as a part of the initial ordering process, and
4.tapering or discontinuing treatments once the indication for treatment changes.
The protocols do not supersede physician orders and are intended to aid physicians in selecting appropriate therapeutic approaches and in documenting indications and goals for treatments. Specific physician orders that deviate from protocols will continue to override the protocols and define the care delivered to the patient.
The Medical Center is developing Critical Paths and a Patient Focused approach. PDPs for the delivery of Respiratory Care will contribute to the development of both these processes/programs. In addition, several studies have indicated that the consistent use of formal clinical guidelines for the provision of Respiratory Care can result in cost reductions.
PATIENT DRIVEN PROTOCOLS (PDP) (top)
The following Patient Driven Protocols have been developed for all areas of patient care:
Oxygen
Oximetry
Prophylaxis for Pulmonary Complications
Secretion Management
Secretion Management for Artificial Airways
Percussionaire
Flutter Valve
Autogenic Drainage
Positive Expiratory Pressure Therapy
ThAIRapy Vest
Meter Dose Inhaler
Small Volume Nebulizer
Therapeutic Effective Dosage
Acute Maximum Dosage
Intermittent Positive Pressure Breathing
Thoracoscopy
To meet the special requirements of the ICU patient:
Extubation
Post-Op Laparotomy
Prophylaxis Protocol Addendum
for Rib Fractures/Chest Trauma
Secretion Management Addendum
for Ventilated Head Trauma Patients
Secretion Management for Ventilated Patients
Meter Dose Inhaler for Ventilated Patients
Volume Reduction Lung Surgery
BiPAP for Volume Reduction Lung Surgery
The key steps for each PDP have been flowcharted (algorithms) and support documents developed.
Rational for PDP (top)
- Continuous Quality Improvement
- Cost containment
- Facilitate physician education
- Ensure state-of-the-art care
- Standardize care
- Enhance continuity
- Utilization review
- Timely intervention
Operational Structure
The PDP Program is overseen by the PDP Coordinator/Clinical Resource Manager. The PDP Coordinator oversees PDP development, performs evaluations, and coordinates activities related to PDP with team members. A PDP facilitator assists the PDP Coordinator to maintain statistics, train staff, and troubleshoot situations.
Patient Evaluation
Each patient with an order for "RC Protocol" or any request for any Respiratory Care service will trigger a PDP Evaluation. All evaluations will be performed by designated Respiratory Care Practitioners who have been specially trained. The same evaluation tool will be utilized for all PDP initial and follow-up assessments.
If for any reason an evaluation cannot be performed in a timely basis the RCP will contact the MD for order specifics and provide requested therapy until the formal evaluation can be performed.
If the patient does not meet any PDP entry criteria, demonstrates an adverse response, or an acute deterioration in condition, the RCP will abort any further treatment, provide supportive therapy and contact the physician for recommendations.
PDP Initiation (top)
If the physician had requested RC Protocol, the RCP will place a summary of the evaluation and care plan in the medical chart for MD review and proceed with the care plan outlined in the PDP.
If the physician had specified a care plan that differs from the PDP, the RCP will deliver the requested therapy and then contact the MD to review recommendations.
If the PDP recommendation is not in accord with the physician's request, the therapy rationale and desired outcomes of the therapy will be documented in the progress notes within 24 hours. The RCP may place a therapeutic objective sticker in the progress notes to help facilitate the physician's documentation.
Discontinuing Therapy
Therapy will be discontinued as per PDP criteria or achievement of the physician specified outcomes. In addition, the patient will be re-evaluated within 24 hours. (top)
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