1997 OPEN FORUM Abstracts
A RANDOMIZED CONTROLLED TRIAL OF RESPIRATORY THERAPY CONSULT SERVICE-DIRECTED vs. PHYSICIAN-DIRECTED RESPIRATORY CARE TO ADULT NON-ICU INPATIENTS.
James K. Stoller, M.D., Ed Mascha, M.S., David Haney, R.R.T. and the Section of Respiratory Therapy, Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, Ohio.
Introduction: Although available evidence suggests that respiratory care (RC) protocols can enhance allocation of RC services while conserving costs, a randomized trial is needed to address shortcomings of available studies. We therefore conducted a randomized controlled trial comparing respiratory care directed by a Respiratory Therapy Consult Service (RTCS) vs. by managing physicians to adult non-ICU inpatients. Methods: Eligible subjects were adult non-ICU inpatients whose physicians had prescribed specific respiratory care services. Consecutive eligible patients (pts) were approached for consent, after which a blocked randomization strategy was used to assign pts to: Physician-directed RC, in which the prescribed physician respiratory care orders were maintained (n=74), or 2. RTCS-directed respiratory care, in which the physician's respiratory care orders were pre-empted by a RC plan generated by the RTCS (n=71). Specifically, these pts were evaluated by an RTCS therapist evaluator, whose RC plan was based on sign-symptom-based algorithms drafted to comply with AARC Clinical Practice Guidelines. Appropriateness of respiratory care orders was assessed as agreement between the prescribed RC plan and an algorithm-based "standard care plan" generated by an expert therapist who was blind to the actual patient's orders. Results: The compared groups were similar at baseline regarding demographic features, admission diagnostic category, smoking status, and Triage Score (mean 3.8 ± 0.9 (S.D.) [RTCS] vs. 3.7 ± 1.0). Similarly, no differences were observed between RTCS-directed and physician-directed RC regarding hospital mortality rate (5.7% vs. 5.6%), hospital length of stay (7.9 ± 9.0 vs. 7.7 ± 7.3 days), total number of RC treatments delivered (30.3 ± 30 vs. 31.6 ± 30.5), or days requiring respiratory care (4.2 ± 5.2 vs. 4.1 ± 3.6). Notably, using both a stringent (S) and a liberal (L) criterion for agreement, RTCS-directed respiratory care demonstrated better agreement with the "standard care plan" (82 ± 17% [S] and 86 ± 16% [L]) than did physician-directed RC (64% ± 21% [S] and 72 ± 23% [L], p < 0.001). Finally, the true costs of RC treatments was slightly lower with RTCS-directed RC (mean $235.70 vs. $255.70/pt, p=0.61). Conclusions: We conclude: 1. Compared to physician-directed respiratory care, the Respiratory Therapy Consult Service prescribed a similar number and duration of respiratory care services at a slight savings and without any increased adverse events. 2. Respiratory Therapy Consult Service-directed respiratory care showed greater agreement with Clinical Practice Guideline-based algorithms, suggesting decreased misallocation of respiratory care services. 3. In showing that length of stay is equal between compared groups when similar baseline Triage Scores are assured by randomization, the current randomized trial addresses some of the important methodologic shortcomings of prior observational studies.