The Protocol Diaries

The February 2003 issue of AARC Times introduced readers to the WellStar Health System, a five hospital group in Georgia in the process of implementing respiratory care protocols. Over the next year, we’re going to follow the system here on the Web as it proceeds through that process, checking in with RT managers every few months to see how things are going. In this installment, we pick up the thread as the first two sites take protocols from the “evaluate-and-suggest” phase to “evaluate-and-treat.”

Installment 1
The Protocol Diaries: First Sites Goes Live

January 6 was the red letter day for Cobb Hospital, WellStar’s 302-bed facility in Austell, GA. “We are currently up and running with the pilot here at Cobb,” says Site Manager Shelley Huebner, RRT. So far, she continues, “Things are going very well.”

WellStar LogoTerri Glaze, RRT, director of respiratory care for all five hospitals in the system, agrees. The site had already shown good progress during the “evaluate and suggest” phase, wherein RTs assessed patients and called physicians with their recommendations. Declines were noted in aerosol treatments and oxygen days for simple pneumonia and COPD, and the department saw a less than expected increase in MDI therapy.

Aerosol treatments per simple pneumonia admission, says the manager, went from 20.3 in July to December 2001 to 15.5 in January to June of 2002 to 12 in July through December of 2002. Figures for aerosol treatments per COPD admission dropped from 25 to 22 to 15 during those same time periods.

Oxygen days per simple pneumonia admission and COPD admission followed a similar path, from 4.07 to 3.61 to 2.38, and from 4.57 to 4.67 to 2.80, respectively.

MDI treatments per simple pneumonia admission went from 1.33 to 2.38 to 1.39, while those for COPD admission went from 1.64 to 3.59 to 2.05 Notes Glaze, “We have not increased MDI therapy as much as expected. Therefore, the 8-10 less aerosol treatment gain per patient admission is not being offset by the slight .5 or less MDI treatment increase.”

With the transition to evaluate and treat, she expects “more gains due to not having to contact the physician” — though she admits that will depend on “the number of physicians writing ‘RT by protocol’” orders. “We must keep marketing ourselves.”

Issues, issues, issues

Has it been easy? Both Glaze and Huebner acknowledge there have been issues. “When moving from the evaluate and suggest phase to the evaluate and treat phase, we made a change in the assessment form,” says Glaze. “This created staff frustration, although the physicians like the new form better.”

Huebner echoes those sentiments. “One of the biggest challenges we had was getting our staff to use new forms in December before we went live with the pilot in January. Change is hard for some and torture for others, so we really had to get involved with ensuring that staff was educated and felt supported with these new forms.”

The pilot also hit at the hospital’s busiest time of the year, which added to staff frustrations. The solution, says Huebner, was to get out and support staff as much as possible. “As far as implementing this process in the winter — well, there is not much else we can do to address this issue except support our staffing needs as much as possible to ensure the assessments all get done in a timely manner.”

The department’s education resource person, Renee Lovell, RRT, has also created story boards, held informal question and answer sessions, and provided staff with pocket handouts to ensure they are completing the forms correctly.

Seeking broader support

Eighty-three bed Paulding Hospital in Dallas, GA, is also in the evaluate and treat stage, with protocols now being piloted in the medical-surgical unit. Like her colleague at Cobb, Site Manager Dana Harris, RRT, has successfully shepherded her department through the formal classes, physician rounds, and final checkoffs.

“We have 100 percent of the staff through.”

And results have been equally positive. While hard numbers are not yet available, Terri Glaze says treatments have dropped by around two-thirds since protocols went into effect.

Still, challenges remain. Physician buy in and communications have been the biggest issues, says Harris. In particular, she’s had to address the way doctors are writing the orders, pointing out things they need to change to make the system work effectively.

Karen Sicard, RRT, RT clinical specialist for the WellStar system, says that’s to be expected. “We have had to clarify orders here and there but this is what a pilot is all about, ironing out the creases. As with any change in practice, it takes time to develop a comfort level with a new process.”

Getting the right people in the right place at the right time has been an uphill battle as well. “Another issue,” says Harris, “has been attendance at the proper meetings, where we are attempting to educate and get the word out. The nursing staff meetings have had low attendance.”

The manager says she’s mostly satisfied with how the department has addressed these concerns, although she does get frustrated at times when she can’t get good cooperation from those who should be more involved. However, she realizes, “Those things are out of my control.”

Her next step will be to “tweak the process during our pilot phase… and we have to step up our one-on-one communication with physicians and nurse staff.”

Confidence building

Steve Hilton, RRT, site manager at Douglas Hospital, a 98-bed acute care facility in Douglasville, is a few steps behind in the implementation process.

“We have completed the staff formal training and I have started the initial process of having the staff complete the assessment forms so I can review for completeness and appropriateness of suggested therapy within our protocol guidelines.”

As staff demonstrate competency, he will begin having them place the completed forms in the progress notes for the physicians. “Next step is for them to complete formal checkoff with the medical advisor.”

Hilton is trying to facilitate the process by addressing questions and concerns with his RTs on an individual basis and in monthly staff meetings, and he’s also posting a newsletter and memos from the other four sites to keep staff members abreast of what’s happening with protocols system wide.

So far, the biggest stumbling blocks have been resistance to change on the part of staff and reluctance to let go of control on the part of physicians. RTs are having a hard time breaking old habits and “seeing the benefit of protocols in helping them perform their jobs more effectively and efficiently,” says Hilton.

Finding the time to perform the assessments when the census is high, and making assessment a routine part of the job have both been a challenge.

Physicians are having to change their old ways as well, and even though they are able to change any order they are not in agreement with, Hilton says he must work continually to “build confidence of the MDs in the staff’s ability to properly assess and recommend appropriate therapy for their patients.”

Says he, “The process takes time, but it is coming along well.”

Waiting in the wings

Wellstar’s two Marietta facilities —Windy Hill, a 115-bed long-term acute care hospital, and Kennestone, a 455-bed acute care facility — are scheduled to enter the pilot phase this month. Martha Durell-Egger, RRT, is the site manager at Windy Hill, where RTs have been doing the assessments but not yet started on the protocols. She says they’ll be entering into discussions with the medical director and in-servicing the staff, and she’s already posted a story board to help RTs, physicians, and nursing see how the program will work.

Similar plans are underway at Kennestone, the largest of the five Wellstar facilities, where a new site manager will soon be onboard to oversee the efforts.

Next up: Critical care

Karen Sicard believes the initial results at Cobb and Paulding bode well for similar success in the other facilities. “The pulmonologists at our Cobb site are being aggressive with the use of the protocols, and we expect to see the ordering of protocols increase as we move into the second month of pilot.”

Management has now made the eight-hour assessment class a part of new employee orientation as well, further ingraining the protocol philosophy into the system.

While the problems the hospitals have faced so far have been frustrating to some, Sicard believes the RTs at all five facilities are “doing a tremendous job in their new role as respiratory care assessors,” and she fully expects even greater progress in the months to come. “After that we will evaluate for any changes we need to make to the protocols.”

In the meantime, she and Terri Glaze are working ahead on the next big step for the protocol project. Says Sicard, “We are already moving into the critical care units and developing protocols for ‘liberation from mechanical ventilation’ and ‘ventilator weaning.’”

Installment 2
The Protocol Diaries: Meeting Expectations

Meeting Expectations

When we last visited with the folks at WellStar Health Systems in Georgia, two of the five hospitals in the chain were just emerging from their “evaluate and suggest” pilot programs on protocols and heading into the uncharted waters of “evaluate and treat.” Several others were getting ready to enter the pilot phase, and the rest were still training staff on the assessment forms and educating doctors and nurses on how the program would work. There were some problems—it was the busiest season of the year, a new form was causing some angst among staff, managers were having a little difficulty getting cooperation from other members of the health care team—but all in all, progress was being made.

What’s happened in the interim? “The protocols are meeting our expectations,” assures Karen Sicard, RRT, RCP, respiratory care clinical specialist and pulmonary diagnostic coordinator for the five hospital system. “We are seeing an increase in orders requesting RC by protocol, an increase in appropriate therapy ordered, an increase in therapist satisfaction with the care they are delivering, and physicians are pleased with the care that their patients are receiving.”

System-wide RT Manager Terri Glaze, RRT, agrees. “The program is meeting expectations and in some instances exceeding expectations—no unforeseen problems so far.”

Taking ownership

At Cobb Hospital in Austell, WellStar’s second largest facility at 302 beds, the transition to the full blown program in February hit when the census was especially high. RT manager Shelley Huebner, RRT, was initially concerned the larger workload could slow the program down, but that hasn’t happened. “The transition from one phase to the other has really played out better than expected.” The department benefited greatly from having a central group of physicians squarely in their corner, and staff worked overtime to make the most of that advantage.

“We knew here at Cobb that we really had a core group of doctors that were supporting us, but it suddenly became a busy two-way street in order for this program to work. Staff had to prove to the physicians that they could make good, sound decisions—and the physicians had to trust the staff to actually make those decisions based on the assessment. The fact that all of this was done during the busy season has only made our staff and the physicians more confident in knowing we can reach our goals.”

The results have been outstanding. “We more than doubled the amount of patients on protocols from February to March,” says Huebner. RTs performed 478 initial assessments, more than she ever expected, and about 40 of the hospital’s physicians and physician’s assistants were ordering RT via protocol, covering about 38 percent of eligible care.

The credit for Cobb’s success, says the manager, goes directly to her staff. “The staff has taken real ownership of the protocols and are the true reason why Cobb is benchmarking the system.” They’ve come a long way from the initial days of the program, she continues, when there was some resistance to the idea, especially implementing it when the staffing was low and counts were high. “Once they saw that they could actually impact the overall counts, then it became less of a problem and more of a habit. Time, and eventually the actual numbers, helped us overcome this obstacle.”

What about those problems Cobb was having with the new assessment form when we talked to them in February? “There is no longer a ’form issue,’” says Huebner. “Time and repeated use seem to have resolved it.” Her next order of business is to continue to educate physicians and campaign for greater use of the protocols in general care areas in anticipation of a move into critical care. “We would like to continue to perfect our assessments and see how we compare nationally. Once we have reached a good comfort zone with protocols on the floors, we then want to grow into the intensive care areas.”

On the right track

The problems that arose when 83-bed Paulding Hospital in Dallas entered the “evaluate and treat” stage also seem to be melting away—for the most part. As you’ll recall, RT Manager Dana Harris, RRT, was having some difficulty getting physicians up to speed on the order writing process, but time and continuing education have ameliorated the problem. “There has been some resolution of the physicians correctly writing the orders. We are having to discuss with them individually and on a case by case basis to help educate.”

Karen Sicard agrees there are a few issues remaining in this area, and not just with physicians. “Our current challenge is our computerized order tracking process. Respiratory depends on correct order entry and completion of orders to track current patient orders. Our initial rollout plan consisted of education of the unit secretaries and nursing…we are currently working with our information systems department to improve the process.”

Getting the right people together for necessary meetings was also a challenge at Paulding, but Harris says this is no longer of much concern. “The ’meeting phase’ has passed,” she gratefully notes. “We are marketing ourselves every chance we get with the nursing staff, physician staff, and administration. The more we talk it up, the better understanding has come from the areas outside of RT.”

Like their colleagues at Cobb, she and her staff are seeing the fruits of their labor. “We have captured physician staff that historically have been more rigid with RT. I think the more we have proven ourselves, the more they trust us.” Key physicians have provided enormous assistance by talking to their peers about the program, and both physician and nursing staff are becoming increasingly comfortable with the logistics of the program—the paperwork and stickers being used to generate orders and track patients.

“Overall,” says the manager, “I think we’re on the right track.” About 60 percent of the physician staff is currently ordering RT by protocol, accounting for about 40 percent of the department’s care. She plans to stay on target by continuing to market the program to physicians, and she’ll also be investing more time in ensuring staff hone their assessment skills and become more confident in their decision-making abilities. The goal is to see those initial numbers on physician usage take a big jump: “I would like to be at 80 percent or greater.”

Moving forward

May is shaping up to be a big month for both WellStar’s long-term acute care hospital, 40-bed Windy Hill, in Marietta, and its 98-bed acute care facility, Douglas Hospital, in Douglasville.

“We are continuing to complete the assessment forms and place them on the patients’ charts in preparation for going to our pilot of RT by protocol,” says Douglas Manager Steve Hilton, RRT. Formal medical director competency checkoffs have begun, and physicians have received a special presentation from the medical director and the system education coordinator on how the program will work and the impact it’s made on the system so far. “This should help in resolving any concerns and also make them more aware of the initiative. Once we go to the implementation phase, I will be checking with the doctors on problems and concerns and responding appropriately to their needs.”

Hilton’s biggest concern right now is continuing reluctance on the part of staff to buy into the concept. “Some staff members still haven’t made assessments a priority, in that they put off doing them in the required time frame of 48 to 72 hours for the reassessments and 24 hours for the initial assessments.”

He’s working with these individuals on a one-on-one basis, providing counseling, along with reminders during individual assessment form reviews. The problem is most acute on the weekends, and workload is the big culprit, says Hilton. “The census is still quite busy, and now pollen/allergy season and the hot weather and humidity is just starting. I have adjusted one person’s schedule to help in the middle of the week to keep the reassessments current and am looking at other ways to ease the workload so the therapists have time to do the initials and reassessments per our policy.”

At Windy Hill, Manager Martha Durell-Eggers, RRT, has a slight advantage over her peers at the other hospitals, in that her facility has been using RT protocols on a facility-specific basis for some time now in non-critical care areas. “When a patient has been off the ventilator 24 hours, we assess them and place it in the chart.”

Physicians order this protocol about 90 percent of the time on these patients, and RTs also participate in weekly team meetings where assessments are discussed. “Suggestions are made for changes there, or with the physicians while rounding.” Since physicians have long incorporated RT assessments into their plan of care, Durell-Eggers believes the live rollout of the system-wide program this month will go smoothly. “Trust in our ability to assess the patient correctly is already there…patient outcomes have attested to that ability.”

Still, they’re working to ensure a smooth transition to the system-wide protocol program, sending staff to the patient assessment classes and ensuring they have time to perform the assessments. “We also did a clinical performance lab on the patient care assessment protocol to make sure everyone was on the same page.”

Biggest site ready to go

That leaves WellStar’s largest hospital—455-bed Kennestone in Marietta. RT Medical Director Cindy Powell, MD, reports, “We have just emerged from the pilot phase of the protocol for assessing and treating our pulmonary patients, and the program has just been passed through the Medical Executive Committee…I expect it to go well and that, within the near future, hopefully, many physicians will be placing patients on protocol.”

Frances Martin, RRT, the new RT site manager at Kennestone, could not be more pleased. “This is a grand opportunity for therapists to gain autonomy and become an integral part of the health care team.” Her biggest challenge will be to convince more physicians of the merits of the program. “There are some doctors who are very accepting of the protocol and some who are not. I believe that, in time, each will see that the protocol does work and realize how it will benefit their patients in the long run.”

Terri Glaze thinks that’s already happening. In fact, one of the pulmonary groups has already decided to add the order to their admission order sheet. Staff remains her biggest concern when it comes to obstacles facing the program. “At one time I would have said physicians were the problem, but I really must say at this point we still have some staff trying to avoid the change.”

With some “tweaking,” however, she believes these challenges can be met and overcome. And she is quick to point out there are some staff who are already performing above and beyond the call of duty. “I have to complement the nightshift at Kennestone for taking such complete ownership of this project and for performing way beyond expectations.”

Dr. Powell notes it’s these kinds of therapists that are going to make or break the program. “The physicians need to have the experience of seeing the RTs doing a good job with the protocol so that they develop some trust in it. This will take time.”

On to the ICU

It all takes time, agree Glaze and Sicard, but the WellStar program appears to be marching full steam ahead, with the next step being the development of ventilator protocols for the ICU. “We have developed and presented to the System Care Management Committee our liberation from mechanical ventilation protocol,” says Sicard. “We started staff education in April, as it moved through each site’s Medical Executive Committee for approval.”

The plan is to begin implementation in June. In the meantime, she’s working with a group of pulmonologists on several additional ICU protocols, including progressive weaning, low volume mechanical ventilation, extubation, and mechanical ventilator management. “I am also looking to augment our existing acute care respiratory protocols with disease based protocols.”

Terri Glaze notes the emergency room physicians and the Global ICU Committee have both asked RC to implement the acute care protocols in their areas of care. Laura Peno-Green, MD, chair of the Global ICU group, is looking forward to their use. “The program is doing well; staff and administration have been very receptive to change and acclimation to the new trends in patient management.” With positive data on outcomes, she believes the next steps will proceed on plan. “Patient outcomes will need to be monitored between protocol and non-protocol groups.”

Just do it

Changing the practicing culture of a department is never easy, but these managers believe their experiences so far prove you can teach old dogs some new tricks. Says Karen Sicard, “It takes commitment, time, and, most importantly, team work.”

Terri Glaze has the final word for other RT managers around the country who would like to be in her shoes: “This process takes true dedication from your leadership—it can be done!”

Updated outcomes data is available from the WellStar protocol program. (20k MS Exel file)

Installment 3
The Protocol Diaries: Holding Their Own

The Protocol Diaries: Chapter 3

In the last edition of this series, respiratory therapists at WellStar Health Systems in Georgia were hard at work refining protocols in their hospitals and ensuring the ongoing success of their newly instituted “evaluate and treat” program. But labor does have its rewards! This excerpt from a letter sent to all the RTs at the five WellStar facilities from RC department management and system administration tells the story:

“Over the last two years…you have been instrumental in implementing a process that has taken many other systems 5–10 years. Each of you supported your patients by developing the skills required for the delivery of state-of-the-art care. Our organization is extremely proud that the RC department continues the ‘evaluate and treat’ program and the use of respiratory protocols to provide high quality care, control utilization, and lower cost.”

Administrators also touted the program for helping them achieve the AARC’s Quality Respiratory Care Recognition. Says the letter, “Today, May 21, 2003, we were notified that we, WellStar Respiratory Care Services, had received the ‘Quality Respiratory Care Recognition’ (QRCR) from the AARC…the QRCR is the highest commendation in the field of respiratory care at this time and is an excellent marketing tool.”

All these glowing words are backed up by solid numbers too. “The adult care protocols have gone live and we are currently completing about 900 assessments per month system-wide,” says System Administrative Director Terri Glaze, RRT, RPFT. “We continue to see 10–15 fewer aerosol treatments delivered per patient visit for our COPD population, average length of stay has not increased but has decreased, and O2 days have decreased by 2—and that is a lot of O2!”

Holding their own

Managers at the five sites agree the program is slowly but surely becoming standard operating procedure in their hospitals. At 83-bed Paulding Hospital in Dallas, Manager Dana Harris, RRT, says the department has managed to maintain initial coverage since the early days of implementation last spring, despite an extremely busy month in June and the loss of one of the department’s biggest sources of support.

“We had record numbers for procedures done in the month of June and we were still able to keep our percentage numbers (60 percent of docs ordering the protocols on about 40 percent of care) about the same.” Fears that the departure of a key physician would throw a screw in the works didn’t materialize either. “We thought that might hurt us, especially in the transition period, but we were able to avoid much of a drop in protocols being initiated.”

RTs at 302-bed Cobb Hospital in Austell are having a similar experience. In April, the department had about 40 doctors using the program on about 38 percent of eligible care, and the same is true today. “Our numbers have remained fairly steady, and that may be because our workload has been steady,” says Manager Shelley Huebner, RRT. “For the most part everyone is very trusting—since June I am only aware of one physician that has raised some concern. He continues to grumble, although someone from education will be meeting with him one-on-one very soon.”

Things are going even more smoothly at WellStar’s long-term acute care hospital, 40-bed Windy Hill in Marietta. “The transition has been easier here than in the rest of the hospitals because of our weekly, multidisciplinary team meetings,” says Manager Martha Durrell-Eggers, RRT. “One hundred percent of our doctors are using the program for 95 percent to 97 percent of the care.”

Lingering issues

Of course, each of the facilities still has a few lingering issues. At Paulding, Harris says the biggest obstacle this summer has been the desire of physician staff to use Xoponex instead of albuterol for some patients, which causes the patient to drop out of the protocol. “We are having to call the physician and discuss the different perspectives on which drug to use.”

At Windy Hill, Durrell-Eggers says the main problem they’ve faced is physicians neglecting to sign off on the respiratory care protocol request. But she’s quick to note that’s generally remedied by a simple reminder to the doctor in question. “If we see a doctor has not signed off, we ask why, and he then signs off.”

Cobb’s most significant challenge now is getting new hires up to speed on the program. Says Huebner, “That will always be a never-ending battle.” But she sees an upside as well in terms of recruiting new people to the department, noting the protocol program may appeal to RTs looking to work in a more “hands-on” department.

Karen Sicard, RRT, WellStar’s respiratory care clinical specialist/pulmonary diagnostic coordinator, notes physician understanding of the program continues to be somewhat of an issue system-wide, although she believes progress is steadily being made. “Outcomes and education with other physicians are what we are using to overcome these obstacles. I believe by the end of 2003, the respiratory department as a system will have their arms completely around protocol care and will have changed their approach to patient care. This will improve the physician comfort with protocol therapy and increase its use across the system.”

Getting up to speed

The last of the facilities to transition to the “evaluate and treat” phase of the program, 98-bed Douglas Hospital in Douglasville, and 455-bed Kennestone in Marietta, are hoping to cash in on the success the other facilities are having.

“Protocols were started here on May 1,” says Kennestone Manager Frances Martin, RRT. “Initially, there were quite a few questions, but having the pilot in place answered a good number of them.” Since going to “evaluate and treat,” she says the department has slowly been improving on utilization numbers as more and more doctors sign on to the program. “It is running smoother now that staff and physicians have become more comfortable with it.”

She continues to work both sides of the equation, utilizing feedback from therapists and physicians alike to identify and remedy any remaining or new issues. “We’re checking orders that have been changed or discontinued to find out why. Was there something missed? What was the preferred treatment? Asking questions that will aid in giving better care.”

The biggest challenge has simply been getting information out to everyone involved in a timely fashion. “Keeping everyone up to par on changes, especially in a large facility, can be difficult. We have used inservices, story boards, flyers, posters, emails, and announcements—this is an ongoing process.” But she emphasizes her staff is up to the challenge. “Everyone understands that the protocols are now a part of their job responsibilities. Both shifts have been working together to help our department become stronger and do our best to make our place a pulmonary center of excellence.”

Catching up quickly

As the final facility to transition to protocols, Douglas is a little behind the others, but catching up quickly. The “evaluate and suggest” phase began in late May-early June, with good initial results. “For the month of June a total of 153 initial assessments were done and 60 patients were ordered on protocol, for a rate of 39 percent,” says Manager Steve Hilton, RRT. “The staff also did 135 reassessments during this period. This was in addition to delivery of therapy, ABGs, ER treatments, etc.—so as you can see, they have stayed busy.”

The transition to “evaluate and treat” came in early July, and so far Hilton is pleased with the progress, though he notes utilization fluctuates on a day-to-day basis. Some physicians are still unaware the program exists, and some staff continue to drag their feet when it comes to total buy-in. “I feel that the staff genuinely wants to make the program work, but some are having a hard time breaking old habits and ways of doing things.” He’s working one-on-one with the physicians to get them up to speed on the program and continuing to review staff worksheets and suggest ways RTs can improve their assessments and recommendations for therapy.

A welcomed boost has come from nursing, which is now requesting that RT evaluate some of their patients before they call the physician to assist them in better understanding the patient’s respiratory care needs. Specifically, Hilton says the RTs found some patients who were on home respiratory care treatments but had no MD order for the treatments on admission. “We were able to start them on their home regimens, which prevented them from having other complications with their breathing.”

Since these were patients admitted for problems that were other than respiratory in nature, it also helped sell the idea of respiratory care protocols to several physicians who might otherwise have remained unaware of their existence.

Opening the lines of communication

The next phase at all the hospitals will be a move into the critical care units. Terri Glaze is hoping to jump start this part of the program by running the ICU therapists through the FCCS course, and plans are well underway to implement the liberation from mechanical ventilation protocol before the end of the summer.

Several additional ICU protocols are under development as well, but Karen Sicard emphasizes management will ease into them slowly, ensuring staff is not overwhelmed. “We are working carefully on a timeline to move through these critical care protocols so as not to overload the RTs with new processes. One thing we have learned is to give yourself time for a new process to become part of your practice.”

In the meantime, managers at all the facilities continue to chip away at remaining areas of resistance and work with staff to keep them moving in the right direction. For the most part, the latter is becoming easier and easier as they go along.

As Dana Harris notes, protocols have done more than anything she has ever seen to open up the lines of communication between therapists and physicians, and the result is a working environment that would be the envy of all. “The impact on morale is outstanding. My staff feels like, ‘We are taking the skills we learned in school and putting them to use in the workplace.’”

Installment 4
The Protocol Diaries: The Final Edition

The Protocol Diaries: The Final Edition

It’s been nearly a year now since we first visited with the folks at WellStar Health Systems in Georgia about their entry into the brave new world of respiratory care protocols. Launched in 2001 after an audit revealed a high volume of misallocated therapy and other problems, the program started with an 18-month-long development phase requiring not only writing the protocols themselves, but gaining approval for the program from 22 pulmonologists, a Care Management Committee, and five different Medical Executive Committees. Along the way 177 individual therapists at five facilities scattered across the state had to be trained as well.

But 2003 has been the real proving ground for protocols at WellStar. This year, each of the five facilities has transitioned from “evaluate and suggest” pilots initiated early in the year to full blown “evaluate and treat” programs. They’ve all had their ups and downs, of course, but system-wide managers Terri Glaze, RRT, RPFT, administrative director, and Karen Sicard, RRT, respiratory care clinical specialist, are happy to report everyone’s on track and thriving.

On solid ground

“We have made great strides in delivering the kind of respiratory care our RTs are trained to deliver,” says Sicard. “We are still in the infant stages of this program, but feel that we have laid the strong groundwork that will enable us to continue building on it.”

Glaze agrees. “Protocols will stay and continue to grow. We will see RT moving forward with new skills sets, such as artline insertion and conscious sedation, and we are already moving forward with the Mini BAL by RT process.”

The program is also forging ahead with implementation of an ICU protocol for “Liberation from Mechanical Ventilation,” which is now being used with a physician’s order in several of the facilities. Development of a “Low Volume Ventilation” protocol that follows the ARDSNet protocol is up next, along with a “Weaning Protocol” for the long-term ventilation patient. “This is going well at the sites,” says Glaze. “It is just another piece of the puzzle fitting into place.”

While both managers admit to lingering issues—the size of the health system itself makes it difficult to keep everyone on the same page and motivated, says Glaze—the remaining glitches aren’t likely to slow things down now. “We refer to it as ‘completion of the process,’” says Sicard. “Taking the paperwork from the assessment all the way through initiating the protocols, there is anywhere from four to six steps, depending on how the order is written. We continue to work on improving our outcomes on RT performance in this area.”

New way of life

The bottom line, says Glaze, is “RT by protocol is an accepted ‘way of life’” for therapists at WellStar. System-wide outcomes back that statement up.

“As a system we are averaging 37 percent of our patients on protocol therapy. Our goal is to be at 50 percent protocol care by this time next year,” says Sicard. Statistics on nebulizer and MDI treatments, oxygen days, and length of stay for pneumonia and COPD cases at each of the facilities show significant cost savings, and system administration is also tracking missed medication delivery.

“In 2002, the system respiratory department had reported that 5 percent of the ordered therapy was not delivered due to assignment/therapist ratio,” continues Sicard. “So far in 2003, protocols have made our assignments more manageable, with minimal missed therapy. The therapy reported as missed is due to emergencies that have pulled the RTs from their assignment.”

Site managers have the last word

These outcomes bode extremely well for the program’s future and stand as testament to all the hard work and effort the two managers have put into the program over the past couple of years. Of course, they’ll be the first to tell you most of the credit has to go to the individual site managers and staff therapists at each of the five WellStar facilities. After all, they’re the folks who took the ball and ran with it, trouble-shooting problems and turning theory into bedside practice.

So, as we wrap up this foray into one system’s adventures with respiratory care protocols, let’s let them have the last word. Take a look at what they had to say when we asked them to complete key sentences based on their protocol experiences over the past year:

WellStar Kennestone: Frances Martin, RRT, site manager
  • The biggest roadblock to getting protocols implemented in my department was…physician buy-in.
  • If I had to do it all over again, the one thing I’d do differently is…provide more staff education.
  • The most effective ways I found to communicate the need for protocols to my staff were…PCA classes that included reviewing how to do patient interviews, physical exams, chest X-ray interpretation, information gathering, and decision making skills.
  • The most effective ways I found to communicate the need for protocols to nurses were…story boards and meetings to review information so that the nursing staff knew what to expect. An important group to include was the unit secretaries.
  • The biggest “selling point” for protocols in my hospital has been the fact that they… would reduce the number of unnecessary treatments and the number of missed treatments.
  • The biggest “negative” aspect of protocols I had to overcome was…getting all the changes and information out to everyone. There were hundreds of questions asked, and getting everyone to answer questions with the same information after changes had occurred was difficult.
  • The best advice I could give another RC manager just now embarking on a protocol program would be to…make sure that there is a plan in place to follow up on all problems. Conduct audits and physician reviews, and educate, educate, educate.

Kennestone is a 455-bed acute care facility located in Marietta, GA.

WellStar Paulding: Dana Harris, RRT, site manager
  • The biggest roadblock to getting protocols implemented in my department was…there was a significant learning curve that we had to overcome, and that took effort and patience, but we did it. But I would have to say that the physician buy-in was probably the biggest challenge, along with having to “prove ourselves.”
  • If I had to do it all over again, the one thing I’d do differently is…not implement during our busiest season. That was somewhat frustrating to the staff at first because they had a tendency to feel like it was just extra work. But after they realized that we could affect our workload by doing the “right treatments and the right time” it seemed to ease their pain.
  • The most effective—and least effective—ways I found to communicate the need for protocols to my staff were…most effective was doing rounds with my staff and working with them to find “the right treatment at the right time.” We worked together and I would explain why I would do a certain thing and the rationale behind my decision. I got to work one-on-one with my staff, and I think we all grew because of the interaction. They loved the idea that “we are using our skills we learned in school and not just following orders.” It gave them a feeling of pride in themselves, our department, and our profession. We became decision-makers, not treatment jockeys. That is what sold protocols ultimately to the staff. Least effective was trying to communicate to them how protocols would affect our workload. That was hard to see at first, especially when we were busy and the staff knew they “had” to do assessments on the patients as well as the treatments too. Like I said before, they thought it was extra work.
  • The most effective—and least effective—ways I found to communicate the need for protocols to physicians were…I think we just had to be given a chance to prove ourselves by doing the protocol a couple of times on one of their patients and then they built up trust in our decision making ability. Communicating one-on-one with them and then having them give us a chance was our best approach. Least effective was that the physician staff did not respond well to any of our story boards, memos, or flyers at first. We had to communicate verbally with them, then it seems like they started signing our stickers to approve the protocols.
  • The most effective—and least effective—ways I found to communicate the need for protocols to nurses were…most effective was getting out on the floors and talking to them about what we were doing and how we were trying to “deliver the right treatment at the right time.” Least effective, again, was that I don’t think we communicated well with story boards or flyers. I don’t think they took interest until it affected their patient.
  • The best help I got from system-wide administration was…support and encouragement during management meetings with other departments—nursing and ancillary departments.
  • The one thing I could have used from system-wide administration but didn’t receive was…I can’t really think of anything. I felt fully supported.
  • The biggest “selling point” for protocols in my hospital has been the fact that they…really deliver the “right therapy at the right time.” Our numbers are reflecting that we are doing things correctly, the staff is confident and really feel like they are doing what they are suppose to be doing, and our interaction with the physician staff has benefited greatly throughout this process.
  • The biggest “negative” aspect of protocols I had to overcome was…that the assessments were extra work for us.
  • The best advice I could give another RC manager just now embarking on a protocol program would be to…realize that you really have to sell the change in attitude and culture associated with how you work now and how you will have to work after you implement protocols. It is not extra work but rewarding work. You become a decision-maker in that patient’s care—you don’t just follow orders anymore. It will take time and effort to implement them but it is well worth it.

Paulding is an 83-bed acute care facility located in Dallas, GA.

WellStar Douglas: Steve Hilton, RRT, site manager
  • The biggest roadblock to getting protocols implemented in my department was…the buy-in by both the staff (time constraints worry due to treatment loads) and physicians (giving up some of their control).
  • If I had to do it all over again, the one thing I’d do differently is…spend more time on the one-to-one, hands-on training of staff, especially the patient interview portion. I’d have more face-to-face meetings with individual physicians prior to implementation to alleviate their concerns, fears, etc.
  • The most effective—and least effective—ways I found to communicate the need for protocols to my staff were…staff meetings, story boards with post-tests, and one-to-one conversations/reviews were most effective. Memos and newsletters were least effective.
  • The most effective—and least effective—ways I found to communicate the need for protocols to physicians were…speaking directly with the physicians themselves and answering any questions/concerns, explaining the process and how it works, was most effective. Having the information disseminated via the medical advisor at monthly MD staff meetings was least effective.
  • The most effective—and least effective—ways I found to communicate the need for protocols to nurses were…use of story boards with inservices was the most effective way to disseminate the information, along with follow-up of any questions. The least effective method was word of mouth via the staff and/or resource person.
  • The best help I got from system-wide administration was…their support of protocols to include prompt approval at all five hospital sites by the medical boards, along with the endorsement of the project by top level administration.
  • The one thing I could have used from system-wide administration but didn’t receive was…better support from our medical advisor in training of staff, adhering to the protocols, and being a positive voice for the protocols to fellow MDs.
  • The biggest “selling point” for protocols in my hospital has been the fact that they…have helped maintain/return patients on their home regimen (numerous patients were found to have home therapy without any orders for therapy on admission except 02).The protocols enabled these patients to receive therapy in a more timely manner instead of their need for therapy being discovered due to a crisis. They also allow my staff to triage patients during busy times to ensure those patients who need our services the most are seen on a priority basis.
  • The biggest “negative” aspect of protocols I had to overcome was…physicians giving up their old ways of ordering therapy and relying/trusting the RT staff to properly assess their patients. (Note: MDs have the option to change any protocol orders that they are not in agreement with at any time). With my staff, I had to overcome the attitude of “we already have enough work to do, this only adds to it, and besides the doctors will never accept it.”
  • The best advice I could give another RC manager just now embarking on a protocol program would be to…1. Work with your medical advisor/director to formulate the assessment form/frequencies/standards to ensure he or she will be a leader among the MD staff in supporting the protocols. 2. Ensure the staff have adequate one-to-one, hands-on training after attending the assessment class to ensure they know where to look for information in the chart and how to ask questions in a way to get accurate information from the patient/family. 3. Be sure the medical advisor has contact with each staff member prior to their Grand Rounds checkoff so they can benefit from the director’s insight on how to treat various patients, including medications, frequencies, and modalities indicators. 4. Meet with as many other MDs as possible and present the protocols to them individually. This will result in more overall support before implementation by explaining how they will work, the scoring system etc. 5. Share with your staff the impact that protocols are actually having on the work, patient outcomes, etc.

Douglas is a 98-bed acute care facility located in Douglasville, GA.

WellStar Windy Hill: Martha Durrell-Eggers, RRT, site manager
  • The biggest roadblock to getting protocols implemented in my department was…protocols were done promptly during the week, which left my weekend staff with little opportunity to do them. The staff during the week did a great job with them.
  • If I had to do it all over again, the one thing I’d do differently is…I would leave some assessments for the weekend staff to do.
  • The most effective—and least effective—ways I found to communicate the need for protocols to my staff were…Most effective were poster story boards. Least effective were memos.
  • The most effective—and least effective—ways I found to communicate the need for protocols to physicians were…Most effective were story boards. Least effective were memos.
  • The most effective—and least effective—ways I found to communicate the need for protocols to nurses were…Most effective were inservices. Least effective were staff meetings.
  • The best help I got from system-wide administration was…help with story boards and inservices with nurses and physicians.
  • The biggest “selling point” for protocols in my hospital has been the fact that they…work! They show the respiratory therapists as the professionals they are.
  • The biggest “negative” aspect of protocols I had to overcome was…failure of physicians to sign on the protocol request.
  • The best advice I could give another RC manager just now embarking on a protocol program would be to…realize that good preparation (inservices with all disciplines and assessment classes for all staff) makes the program successful.

Windy Hill is a 40-bed long-term acute care facility located in Marietta, GA.

WellStar Cobb: The RT Staff*

*Shelley Huebner, RRT, site manager at Cobb during our year-long series, has stepped down to a staff role. In lieu of her participation, five members of the RT staff stepped in with the following responses.

  • The biggest roadblock to getting protocols implemented in my department was…
    RT No. 1: Being timely.
    RT No. 2: Time between treatments.
    RT No. 3: Employees who had been working in the field for awhile and were initially unwilling to change.
    RT No. 4: Lack of respiratory staff ownership for their own part in the process, physicians who didn’t respond to our requests to request or decline protocols in a timely manner, staff who thought protocols could eliminate respiratory positions.
    RT No. 5: Treatment loads, plus trying to do assessments.
  • The one thing I think we should have done differently is…
    RT No. 1: Distribute the precepting among more people.
    RT No. 2: Started protocols earlier.
    RT No. 3: Introduce the paperwork to staff earlier so they could review it and be more familiar with it.
    RT No. 4: Implement the training process a little faster.
    RT No. 5: Have a core group of people to do just assessments.
  • The most effective—and least effective—ways the need for protocols was communicated to staff were…
    RT No. 1: Most effective: Protocols raise professional respect and decrease treatments not required.
    RT No. 2: Most effective: Protocols save you extra work. Least effective: Protocols save the hospital money.
    RT No. 3: Most effective: Face-to-face conversations. Least effective: Notes/messages left.
    RT No. 4: Most effective: Marketing protocols as a tool to make the respiratory care profession more competitively professional (many perceived that we were overstepping our boundaries initially). Choosing positive staff to orient to the program initially to motivate staff. Least effective: To threaten that all must do—and like it.
    RT No. 5: Most effective: Protocols decrease treatment load.
  • The most effective—and least effective—ways the need for protocols was communicated to physicians were…
    RT No. 1: Most effective: Protocols get the patients on the right track – faster.
    RT No. 2: Most effective: It will save you extra work. Least effective: It gets the patient out quicker.
    RT No. 3: Most effective: Finding the physicians who were most receptive to ideas and change, and talking to them first. Least effective: Telling them that this was something that they needed to do rather than making them see the positives for patient care.
    RT No. 4: Most effective: Best asset was getting the pulmonary group (a large pulmonary practice) to buy into the advantages of protocols to ensure therapy is individually adapted to the patient’s needs. Such a large group ensures success, since they have seen a large patient population. Least effective: Being discouraged by the physicians who were negative and felt threatened.
    RT No. 5: Most effective: It lessens their amount of work.
  • The most effective—and least effective—ways the need for protocols was communicated to nurses were…
    RT No. 1: Most effective: To make sure all the patient’s respiratory needs are met, such as overlooked, underlying asthma, etc.
    RT No. 2: Most effective: Protocols improve the appropriate care for patients and decrease hospital time.
    RT No. 3: Most effective: Talking with the charge nurse and letting her know what we were planning and how it would affect them. Least effective: Trying to explain the changes with staff nurses who were unfamiliar with the process.
    RT No. 4: Most effective: I think nurses were receptive since protocols are something they can relate to since they have been doing them for a long time.
    RT No. 5: Most effective: Getting them to call us before they call the MD for orders on respiratory distress patients.
  • The best help I got from system-wide administration was…
    RT No. 1: Education.
    RT No. 2: The same protocols across the board at each hospital—unified hospital care.
    RT No. 3: Numbers/data on therapies being done and the diagnoses of the patients receiving them.
    RT No. 4: Positive feedback from management—frequent.
    RT No. 5: The push to get them going.
  • * The one thing I could have used from system-wide administration but didn’t receive was…
    RT No. 1: No answer
    RT No. 2: Nothing
    RT No. 3: More help/support in getting the process “advertised“ through all of the nursing units and doctors’ offices.
    RT No. 4: Not applicable
    RT No. 5: Extras
  • The biggest “selling point“ for protocols in my hospital has been the fact that they…
    RT No. 1: Decreased length of stay for patients.
    RT No. 2: Decreased length of patient stay.
    RT No. 3: Having the capability for reducing the workload during the busy season and slow seasons.
    RT No. 4: Endorsed by the pulmonary group.
    RT No. 5: They have decreased the workload.
  • The biggest “negative“ aspect of protocols I had to overcome was…
    RT No. 1: The time was not originally factored in for re-assessments. Not everyone understood/performed assessments the same.
    RT No. 2: Employees performing re-assessments.
    RT No. 3: Getting all of the staff inserviced and assessing the patients appropriately.
    RT No. 4: Some staff’s lack of ownership in doing the assessments completely, follow up, changing etc. Other staff often had to rework, redo assessments, or complete the process.
    RT No. 5: Trying to initially get the staff on board.
  • The best advice I could give an RC manager just now embarking on a protocol program would be to…
    RT No. 1: Present it as a positive for the profession. Emphasize “professional.” Be patient and offer lots of answers. (Roundtable in the beginning.)
    RT No. 2: Guide each employee to make sure the assessments are done correctly to avoid future bad habits.
    RT No. 3: Start teaching, inservicing, and getting staff acquainted with the process at least six months before the process begins.
    RT No. 4: Make sure you educate, orient, and “win” the program to your staff and the physicians you work with.
    RT No. 5: Give it a chance, but you have to be 100 percent committed with the right numbers and staff.

Cobb is a 302-bed acute care facility located in Austell, GA.
The AARC thanks all the WellStar RTs who made this series possible by taking time out of their very busy schedules over the past year to answer questions regarding the implementation of protocols in their facilities.

 

Your Responses

Congratulations to the Terri and her crew with the Wellstar Health Group on taking the professional leap into protocol land. We too survived and now thrive in a fully implemented automatic assess and treat protocol program. We are in year 6 of our process and are housewide, including the intensive care units (minus NICU). Almost all of our 300+ physicians love the program and rely on us to have their patient’s respiratory status maximized. Our biggest hurdle was our own staff resisting making the change from task performers to decision makers. Medical Exec committee passed our protocol program as an automatic with any respiratory order written by the physician about 3 years ago. We do allow the physician to “opt out” of protocols but they have to write an order to do so, otherwise we write orders for their patients.

Keep up the good work. The key for us it is taking care of the little stuff—putting out the fires with unhappy physicians or nurses and making sure our staff know that 99% of the time, the physicians love what we do. We encourage our staff to not focus on the 1% or less who disagree with what we’ve done. I remind physicians, our staff and administration often of the $350,000 per year that we are saving by not doing therapy without indications.

Ruth Krueger


I would like to say — WOW! It sounds like this theory, which is being implemented across several hospitals, is starting to work. Congratulations. I am a respiratory therapist in Duluth, MN, at a 200+ bed facility. We are in the primary stages of discussing TDP’s for several of our duties within our hospital. Last July, we finally hired a pulmonologist, and this spring, we are adding a sleep lab to our facility. My hopes, in assisting our nurse manager (who oversees the respiratory department), is to convince her that we can use TDP’s in our hospital. I am using you as a first example. We currently attain 20 or so therapists instead of the 177 combined that you have in your facilities, so I am hoping that the training won’t be as time-consuming. Our pulmonologist seems excited to move forward as well.  The issue lies in someone to help redo/revise our policies (I am the only ‘volunteer’ so far).  If you could e-mail me with any examples of your protocols so I can show them how this is working in other hospital/clinic settings, I feel that it may be the push to get the wheel rolling. Again, I am sincerely happy that respiratory therapists are starting to be recognized professionally as part of the medical team that can contribute efficiently and effectively with patients who require our assistance. Thank you for your time.

Debbie Leland, BA, BAS, CRT


We implemented a pilot Respiratory Care Protocol Service as of August of 2002 on our Skilled/Rehab floors. The Respiratory Medical Director and the respective Medical Directors of both areas has encouraged and supported us from the start. This was a smaller area but had been pin-pointed as an area for possible large savings.

We held meetings for the nursing staff involved to explain and answer questions about the program. Our director also outlined the protocols and its benefits to our senior medical committee. The department also inserviced the Respiratory staff not directly involved with the pilot program to educate them on respiratory protocols.

We chose to start with a small core group of staff that showed an interest to do the evaluations. We had extensive training and practice evaluations for 3 plus months before initiation. Education also included a 5 hr education assessment course and a skills check off sheet.

We based the majority of our protocols on Cleveland Clinics program. JK Stoller MD and L Kester RRT FAARC both were extremely helpful in helping get our program off to a solid start. All this led to an interest in having a website that has an area dedicated to protocol information as a starting point for other respiratory programs interested in protocols. http://www.iowarespiratory.com/

We have passed our six month of protocol services and the results have been outstanding. We are doing follow up on hospital savings and patient outcomes. We have an on-going QA program to check for errors/problems, to educate staff and for possible protocol changes.

We hope to follow this up by introducing this service to the general hospital floors.
8/01/02 to 02/01/02
(Six Month Respiratory Protocol Summary)
Total patients – 130
Total evaluations – 169
Total initial evaluations with decrease in TX freq – 81
Total initial evaluations with increase in TX freq – 13
Total initial evaluations that stayed the same – 41
Total decrease in number of treatments – 205
Average length of stay of patients followed in Skilled/Rehab – 11 days
Average cost per TX – $40.00 X 1.58 TX PER DAY SAVINGS
Average per day/per patient savings – $63.20
Savings per patient times average length of stay – $695.20
Total 6 month savings – $ 90,376
Anticipated savings for 1 year – $180,752
Percent of treatment decline per the protocol – 47% decrease in treatments
QA/Comments
Total mistakes by evaluators — 5 — a 2.9% error rate

We continue to see the same results as mentioned in our 2 month report on patient safety, patient outcomes and the protocols effectiveness. So far physician acceptance has been extremely encouraging in Skilled/Rehab.

Ken Darby RRT