Medicine has been moving toward protocol-driven care for a couple of decades now, and while progress has been slower than many would like, health care leaders continue to push for the concept because it results in safer and more cost-effective care.
How are RT departments using protocols, and what skills should respiratory therapists possess to participate in their delivery? The managers we spoke with have some firm ideas.
It’s all about the team
Alicia Wafer, MBA, RRT, says her hospital — Henry Ford in Detroit, MI — has a three-tiered system for protocols. System-wide protocols fall into Tier 1, multidisciplinary protocols are in Tier 2, and departmental protocols are in Tier 3.
“We are moving to Tier 2 as much as possible, as ‘team’ is where it is at,” said Wafer, the RT department director. She cites the hospital’s weaning protocol for vents as a case in point. It was developed via a keystone initiative that was then modified so that it could be used in all 170+ adult ICUs in the facility.
Wafer says getting the medical and surgical teams on board was a huge undertaking.
“Our physicians came to the table ready to hash our concerns, and we came up with a protocol we could live with,” she said. Now, nearly two years later, feedback they’ve received on the protocol is leading them into a review that they believe will improve on the process.
“This is done at the table in a controlled setting so that in the ICU at the bedside caregivers have confidence in the process for their patients,” she said.
Wafer believes the number one skill RTs need to possess to deliver care via protocols is communication.
“If RT works in a silo and the patient’s nurse and provider have no idea what they are doing, the patient isn’t as safe,” she said. “Our team has to speak in order to have the best outcomes for our patients.”
Trifecta of skills
Protocols to expedite liberation and extubation from mechanical ventilation are in place at St. Mark’s Hospital in Salt Lake City, UT, where Jack Fried, MS, BSRC, RRT, serves as director of respiratory care and neurodiagnostic services.
He cites a trifecta of skills RTs must have to deliver care via these protocols: patient assessment, teamwork, and communication.
“Assessment skills are necessary to determine appropriate ventilator settings and to determine when patients are ready for extubation,” says Fried. “Communication skills are necessary to inform physicians of patient status before rounds and to present the plan for the shift.”
He believes these skills let nurses know when sedation should be reduced or discontinued as well, and they can occasionally come in handy when a reluctant caregiver needs to be persuaded to take a more aggressive stance toward the liberation process.
Teamwork comes into play on multiple fronts.
“Team skills are critical not only in working with physicians and nurses but also in working with physical and occupational therapists to help ambulate and strengthen patients,” Fried said. “It is also critical that therapists be able to assist speech therapists with swallow studies and speaking valve trials and to assist imaging personnel in special procedures.”
Interactions make or break a program
Rick Ford, BS, RRT, FAARC, has been retired for five years now, but as department manager at the University of California at San Diego Medical Center for the bulk of his career, he was in on the ground floor of protocol development in respiratory care. He echoes many of the concerns raised by both Wafer and Fried.
“Back in the days I was collaborating with Lucy Kester, Judy Teitsort, and Dr. George Burton, it was evident that those therapists providing evaluations needed to be experts regarding the intervention being provided, but also possess an advanced knowledge of clinical evaluation and assessment,” Ford said.
He thinks those skills are a given for anyone who takes on the responsibility of protocol-driven care. But the missing link in many facilities, both then and today, is communication.
“Programs thrive or fail based on the interactions the respiratory practitioner has with other clinicians, specifically physicians and nursing partners,” Ford said. “Physicians need to feel their patients are in good hands and they are kept informed.”
Indeed, he says protocol programs that emphasize the need for less communication with the physician are missing the mark.
“There were many programs that suggested a benefit of protocols was saving time because the RT did not have to get an MD order for everything,” he said. “My position was just the opposite — that protocols result in more communication with MDs.”
Ford says UCSD built several “contact MD” steps into their protocol algorithms to ensure physicians were always being brought up to speed. It is these communication skills, he says, that ultimately make or break a program.
So, if you work in a hospital that uses therapist-driven protocols — or are seeking a new job in a facility that allows RTs to perform at this level — focus your efforts on being a safe and knowledgeable team player with good assessment skills. But remember that just having those skills will not be enough.
You will also need to be able to speak up and clearly articulate your actions and the rationale behind them to all your colleagues, inside and outside of the respiratory care profession.