The Science Journal of the American Association for Respiratory Care

1999 OPEN FORUM Abstracts


Theresa Ryan Schultz, BA, RRT, CPFT, P/P Spec. Ann Marie Wallack, AS, RRT, P/P Spec., Linda Allen Napoli, BS, RRT, RPFT, P/P Spec. The Children's Hospital of Philadelphia, Philadelphia, PA

Background: Traditionally, bronchiolitis management of patients admitted to our institution began with a physician order to deliver nebulized medication and chest physiotherapy at a frequency. Respiratory care administered nebulized therapy and monitored its effectiveness. The remainder of patient monitoring and delivery of chest physiotherapy was done by nursing. Bronchiolitis season has always been a busy time, where up to five therapists per eight-hour shift, each administered as many as thirty-five nebulizer treatments, in addition to meeting all other respiratory needs of these non-intensive care patients. This left little to no time for close observation or evaluation of appropriateness of care. Stoller has established a method to enhance appropriate prescription of respiratory care services as the main impetus for respiratory protocols.1

Methods: A multidisciplinary team within our institution developed protocols to manage bronchiolitis. The goal of these protocols was to minimize misallocation of respiratory care services. These protocols included a system of evaluating and appropriating all therapies ordered for the patient admitted with bronchiolitis, including ventolin, racemic epinephrine, oxygen, chest physiotherapy and nasopharyngeal (NP) suction as needed. Only those therapies yielding positive responsiveness were used in the continuum of care. Implementation of protocols were expanded to include not only a care plan based on severity of illness and responsiveness to therapies, but also a revised model of care delivery. Competency-based cross training for all practitioners was done prior to the start-up of this program. The physician orders ?begin bronchiolitis pathway?. This initiates a Respiratory Care assessment of the patient and evaluation of therapies outlined in the protocol. This included ventolin treatment (dose by weight) Q1 hr. ´ 2, followed-by racemic epinephrine (dose by weight) Q1 hr. ´ 2. NP suctioning, oxygen therapy and chest physiotherapy was administered and evaluated as well. Given the results of this protocolized respiratory evaluation, the patient ultimately received all indicated therapies Q2 hr. when assessed as severe, Q4 hr. when assessed as moderate and Q6 hr. when assessed as mild. The care delivery model was then agreed upon. Patients assessed and treated as severe were managed by respiratory care. Mild and moderate pathway patients were managed by nursing. Patients moved within the pathway based on established guidelines for a child assessed as mild, moderate or severe.

Results: The initial assessment and care of these patients was clearly escalated for Respiratory Care Practitioners.

Total # tx. by RN by RRT
December 11-31 4171 2162 (52%) 2009 (48%)
January 1-31 6929 3477 (50%) 3452 (50%)
February 1-28 6827 2770 (41%) 4057 (59%)
March 1-6 1335 671 (50%) 664 (50%)

The number of practitioners needed to execute this level of care never called for an increase in fulltime employees, Respiratory Care or Nursing. This was made possible only because the model of care also changed, leaving the respective discipline responsible for the care of the patient, to provide comprehensive care. Coordination of the care provided was elicited subjectively as a positive outcome among staff therapists and nurses.

Conclusions: The implementation of the bronchiolitis protocol/pathway seemed to enable appropriateness of care without increasing the number of care providers for the bronchiolitis population. Financial analysis of the program will give further insight to this pilot program.

1. Stoller JK. The Rationale for Therapist-Driven Protocols: An Update. Respiratory Care 1998; 2(1):1-14.


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