2004 OPEN FORUM Abstracts
IMPROVING THE TIME OF RESPIRATORY CARE PROTOCOL INITIATION IN THE POST-OPERATIVE PATIENT
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Jim Rebel
RRT, Mike Trevino RRT,
Gary L. Weinstein MD, FCCP, Presbyterian Hospital of Dallas, Dallas,
Texas
Background: Our 903-bed acute care facility has a year-to-date, 77% occupancy
rate. The respiratory care department works under a protocol driven
clinical practice model whereby the therapist evaluates, orders,
modifies, and discontinues therapy within pre-established guidelines.
Surgeons may either write an order for respiratory care or have
standing orders with our department for protocol. Both will
automatically trigger a protocol evaluation. The department is on
track to administer 9900 protocol evaluations this year. Of these,
approximately fifty percent (50%) are post-operative surgery. A
significant challenge is to evaluate these patients in a timely
manner. Our goal was to see these post-operative patients <
2 hours of receiving an order or notification of their arrival to the
nursing unit. The purpose of this study was to evaluate the
timeliness of protocol initiation, then formulate and implement
solutions.
Methods: Using the surgery schedule, we
identified patients requiring a respiratory evaluation during April
2004. Only those patients admitted to the adult general care area
were included in our assessment. Each case not seen in the two-hour
time period was analyzed for possible grounds of failure. Three main
causes were identified 1) the patient went to a different floor than
expected 2) the order was received by the department during shift
change 3) staff failed to recognize patients with surgeons who have
standing automatic orders for our protocol. Based on the root cause
analysis a list of solutions was created and introduced to the staff
1) the lead tech designed assignments which enhanced the therapists’
ability to get to protocol patients 2) therapists follow assigned
surgery patients to floors not included in their assignment 3) the
therapist is responsible for all orders in their areas up to 30
minutes prior to the end of their shift 4) therapists were reminded
that a list of all protocol doctors is included with the daily work
assignment. Clinical and charting data were again reviewed in June
2004.
Results:
| April | June | |
| Total Protocols | n=310 | n=289 |
| On Time | 71.9% (223) | 81.3% (235) |
| Late Protocols | 28.1% (87) | 18.7% (54) |
| Different Area/Floor | 26.4% (23) | 29.6% (16) |
| Shift Change Hours | 27.5% (24) | 29.6% (16) |
| Automatic Doctors | 30.1% (29) | 27.8% (15) |
Conclusions:
During the two periods of study there were 599 post-operative
patients ordered on protocol in which our completion rate was 98.4%.
Timeliness was improved as evidenced by an increase in on-time
protocols from 71.9% to 81.3% post study. Each area of focus was
equally reduced, while the proportion within each area remained
relatively constant. Overall, we were able to improve our
performance of providing timely, appropriate respiratory therapy to a
population of patients who are susceptible to atelectasis and other
post-surgical pulmonary complications. The results demonstrate the
need for 1) continuous monitoring 2) adaptable workflow processes and
3) staff involvement in problem solving.