The Science Journal of the American Association for Respiratory Care

1998 OPEN FORUM Abstracts

Safety and Efficacy of Alternative Strategies for the Treatment of Bronchospasm in the Emergency Room

William J. Beach MBA RRT, Jewish Hospital Heart and Lung Institute, Louisville, KY

Introduction: Jewish Hospital Respiratory Care Practitioners (RCPs) provided traditional "on demand" service to the Emergency Department (ED) until the introduction of Respiratory Care Protocols in 1997. Therapist Driven Protocols (TDPs) had been used in limited form as early as 1982 by RCPs at Jewish, and by 1995 had grown to cover all therapy outside the ED. Approximately 250 patients per month were ordered for bronchodilator treatment.

Analysis: The current system was labor intensive and tended to divert critical physician and nursing resources from other acutely ill patients, or encouraged over-treatment of those least acute. The use of structured protocols in the ED would facilitate outcomes research, as evidenced by the abstract presented at the 1996 ACCP Meeting, demonstrating the safety and efficacy of continuous nebulization of albuteral in the ED by RCPs.

Data was gathered by Respiratory Care QA on 28 consecutive patients with orders for at least 3 "back to back" treatments in the ED. Pulmonary history, SOB scores, Wheezing scores, and response to therapy data was collected on each patient. It was determined that there were three distinct groups of patients presenting to the ED that were receiving intensive respiratory treatments. These were:

* Level 1 patients without pulmonary diagnosis, or severe symptoms.

* Level 2 patients with indications for moderate therapy and teaching.

* Level 3 patients needing aggressive and immediate treatment.

Action: The Emergency Department Respiratory Care Protocol (EDRCP) was developed jointly by physicians, respiratory therapists and nurses from Pulmonary and Emergency Medicine in October of 1997. This quality improvement initiative was designed to address a number of patient care and cost containment issues.

* How can the "time to treatment" interval be reduced.

* How can "treatment time" be reduced?

* What is the best method(s) for treating patients with SOB?

* How can emergency department resources be used more efficiently?

* How can Respiratory Care Department resources be used more efficiently?

* How can data acquisition and analysis be improved?

The EDRCP was specifically designed to allow for safety and efficacy studies to be conducted comparing different modes of medication delivery, including continuous aerosol, rapid nebulization of undiluted drug, MDI, and conventional small volume nebulizers.

Results:

* 65% of all patients presenting to the ED with Respiratory Symptoms were Level 1 or Level 2. Prior to the ED / RT Protocol, these patients received approximately 3 Txs / patient. With the ED/RT Protocol these patients received an average of 1.34 Txs / patient.

* Each patient's time in the ED was reduced. The average time to treatment was reduced by 69.83 minutes compared to Pre Protocol. The average ED time for Level three patients was reduced by 47 minutes each for those on Rapid Neb Txs.

* Admissions for Asthma were down to 6.7%, compared to 24% in the 1st month of operation.

* ED /RT Protocol patients admitted with a Clin Care Diagnosis were identified to the respective ClinCare Team Leader for early intervention.

* All ED/RT Protocol patients were entered into a Microsoft Access Database for analysis. This feature, combined with the structured treatment approach, allowed for quality prospective clinical studies to be conducted, and submitted for publication.

* Safety and efficacy of rapid delivery of undiluted drug, (2 minute treatment) was demonstrated.

The 44th International Respiratory Congress Abstracts-On-DiskĀ®, November 7 - 10, 1998, Atlanta, Georgia.

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