Guidelines For Preparing A Respiratory Care Protocol (RC protocol)

Goal:      To deliver individualized diagnostic and therapeutic respiratory care procedures to patients in order to improve and maintain health. These services will be delivered by members of the respiratory care department in accordance with criteria developed by the respiratory care staff, their medical director, and other appropriate individuals. All respiratory care protocols will be approved by the appropriate hospital committees and medical staff.

Objective: Specific to the care outlined in the RC protocol

Scope: Members of the respiratory care department will deliver care outlined in the RC protocol. Respiratory care practitioners (RCP) may participate in RC protocols only when defined by job description, and following individually documented education and demonstrated competency in the application and implementation of RC protocols to patient diseases and/or conditions.

Policy: A respiratory care protocol will be initiated for a patient by written order of a physician for a "Respiratory Care Evaluation and Recommendation" or for a specific therapy, such as "chest physical therapy" or "bronchodilator therapy."

Note: The medical director of the respiratory care department will ensure that the quality, safety, and appropriateness of respiratory care services are monitored and evaluated, with variances identified and appropriate action taken. Done on a timely basis, this review becomes an instrument for quality monitoring (e.g. continuing performance improvement).

  1. Perform initial patient evaluation
    1. Check physician order for respiratory care protocol
    2. Review medical records for:
      1. Admitting (and consulting) physician assessment
      2. All admitting and working diagnoses
      3. Pertinent pulmonary history
      4. Pertinent reports of diagnostic evaluations
        1. Laboratory tests (including blood, urine, sputum)
        2. Radiographs
        3. Arterial blood gases, including specific FI02 or oxygen liter flow
        4. Pulmonary function tests
        5. Vital signs
        6. Oxygen saturation by pulse oximetry, including specific FI02 or oxygen liter flow
    3. Initiate patient contact
      1. Introduction to patient
      2. Verification of patient
      3. Explanation of purpose of visit by RCP
    4. Observe universal precautions at all times
    5. Perform pertinent physical examination
      1. Vital signs
      2. Chest inspection, palpation, percussion, auscultation
      3. Spirometry
      4. Pulse oximetry
      5. Other diagnostic evaluations (e.g. arterial blood gas)
  2. Formulate appropriate management plan
    1. Indications
    2. Therapeutic objectives
    3. Therapy
    4. Precautions/contraindications
    5. Delivery method
    6. Frequency
    7. Medication dose
    8. Patient/family education where appropriate
    9. Monitor therapy (including adverse effects)
    10. Assess efficacy of therapy (patient outcomes)
    11. Modify plan to achieve optimal efficacy and outcome
    12. Discontinue therapy
    13. Identify physician and other appropriate health care personnel
    14. Integration of respiratory care protocol into overall patient management
    15. Management plan basis:
      1. AARC Clinical Practice Guidelines
      2. Other appropriate medical literature
      3. Specific institutional preferences (including inventory of available protocols)
  3. Documentation of respiratory care protocol application in medical record
    1. Date and time of protocol initiation
    2. Pertinent medical history and physical examination
    3. Pertinent diagnostic results
    4. Management plan details (as outlined in section II)
    5. Physician notification criteria -- Guidelines for physician notification of patient status change (as directed by respiratory care medical director, appropriate hospital committee and medical staff)
    6. Adverse reaction, if any, and remedial steps taken
    7. Notification of physician, nurse, and other appropriate health care professionals
    8. Required departmental documentation
    9. Signature with credential
  4. Re-evaluation
    1. Assess management plan with each treatment or at a pre-established frequency based on patient acuity
    2. Modify therapy based on:
      1. AARC Clinical Practice Guidelines
      2. Other appropriate medical literature
      3. Specific physician orders
      4. Patient report -- (Evaluation of care by RCPs, based on patient's current status and assessed at shift report.)
    3. Adjustments in therapy will be
      1. Documented in the patient record including reasons for change
      2. Communicated to the patient's physician, nurse, and other appropriate health care professionals.
  5. Discontinuation
    1. Upon discontinuation of therapy, the RCP will refer to all indications for therapy as being resolved and/or addressed, via documentation in the patient record
    2. Communicate discontinuation to the patient's physician, nurse, and other appropriate health care professional

Selected Reading List

  1. American Association for Respiratory Care. Clinical practice guidelines: incentive spirometry, pulse oximetry, oxygen therapy in the acute care hospital, spirometry, and postural drainage therapy. Respir Care 1991; 36 (12): 1398-1426
  2. American Association for Respiratory Care. Clinical practice guidelines: patient ventilator system checks, humidification during mechanical ventilation, selection of aerosol delivery device to the lower airways, nasotracheal suctioning, bronchial provocation, exercise testing for evaluation of hypoxemia and/or desaturation, sampling for arterial blood gas analysis, and oxygen therapy in the home or extended care facility. Respir Care 1992; 37(8):882-922
  3. American Association for Respiratory Care. Clinical practice guidelines: directed cough, in-vitro pH and blood gas analysis and hemoximetry, single-breath carbon monoxide diffusing capacity, and use of positive airway pressure adjuncts to bronchial hygiene therapy. Respir Care 1993; 38(5): 494-521
  4. American Association for Respiratory Care. Clinical practice guidelines: transport of the mechanically ventilated patient, fiberoptic bronchoscopy assisting, resuscitation in acute care hospitals, intermittent positive pressure breathing, and bland aerosol administration. Respir Care 1993; 38(11):1169-1200
  5. American Association for Respiratory Care. Clinical practice guidelines: ventilator circuit changes, static lung volumes, delivery of aerosols to the upper airway, neonatal assisted ventilation, application of CPAP to neonates via nasal prongs or NP tubes and surfactant replacement therapy. Respir Care 1994; 39(8):797-835
  6. Brougher LI, Blackwelder AK, Groissman GD, Straton GW. Effectiveness of medical necessity guidelines in reducing cost of oxygen therapy. Chest 1986; 90(5):646-648
  7. Browning JA, Kaiser DL, Durbin CG Jr. The effect of guidelines on the appropriate use of arterial blood gas analysis in the intensive care unit. Respir Care 1989; 34(4):269-276
  8. Burton GG, Tietsort J. Therapist-driven respiratory care protocols (TDPs): a practitioner's guide. Torrance CA: Academy Medical Systems, 1993
  9. Haney D, Orens D, Kester L, Stoller JK. Impact of a respiratory therapy consult service on inappropriateness of orders for respiratory care (abstract). Respir Care 1993; 38(11):1305
  10. Hart SK, Dubbs W, Gil A, Myers-Judy M. The effects of therapist-evaluation of orders and interaction with physician on the appropriateness of respiratory care. Respir Care 1989; 34(3):185-190
  11. Jacobs J. How are we doing with operational restructuring and therapist-driven protocols? AARC Times 1994; 18(4):66-69
  12. Kester L, Stoller JK. Ordering respiratory care services for hospitalized patients: practices of overuse and underuse. Cleve Clin J Med 1992; 59(6):581-585
  13. Kester L, Stoller JK. A primer on therapist-driven protocols. Clin Pulm Med 1994; 1(2):93-99
  14. Malloy R, Pierce M, Friel D, McElroy P. Reduction of unnecessary care through utilization of a respiratory care plan (abstract). Respir Care 1992, 37(11):1277
  15. Nielsen-Tietsort J, Pool B, Creagh CE, Repsher LE. Respiratory care protocol: an approach to in-hospital respiratory therapy. Respir Care 1981; 26(5): 430-436
  16. Professor's Rounds in Respiratory Care. James K Stoller MD. Therapist-driven protocols: implementation. March 29, 1994 (videoconference)
  17. Stoller JK. Misallocation of respiratory care services: time for a change (editorial) Respir Care 1993; 38(3):263-266
  18. Stoller JK, Haney D, Burkhart J, Fergus L, Giles D, Hoisington E, et al. Physician- ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: early experience at The Cleveland Clinical Foundation. Respir Care 1993; 38(11):1143-1154
  19. Tietsort J. The respiratory care protocol: a management tool for the '90s. AARC Times 1991; 15(5):55-62
  20. Weber K, Milligan S. Conference summary -- therapist-driven protocols: the state of the art. Respir Care 1994; 39(7): 746-756
  21. Zibrak JD, Rossetti P, Wood E. Effect of reduction in respiratory therapy on patient outcome. N Engl J Med 1986; 315(5):292-295