The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

IMPROVING THE TIME OF RESPIRATORY CARE PROTOCOL INITIATION IN THE POST-OPERATIVE PATIENT

- 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.

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