The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts

CONCORDANCE OF RESPIRATORY CARE PLANS GENERATED BY PROTOCOLS FROM DIFFERENT HOSPITALS: A COMPARATIVE STUDY.

Lucy Kester, R.R.T., M.B.A., F.A.A.R.C., Ed Hoisington, R.R.T., Marty Lemin, R.R.T., Jim Karol, R.R.T., James K Stoller, M.D., M.Sc., F.A.A.R.C., The Cleveland Clinic Foundation, Cleveland, Ohio.

Introduction: Respiratory care protocols have gained widespread acceptance based on evidence that their use can enhance the allocation of respiratory care services. With the goal to provide appropriate, effective care, most respiratory care protocols are based on evidence-based guidelines and the Clinical Practice Guidelines (CPGs) developed by the AARC. In the context that CPG's intend to assure uniform care, it is reasonable to expect that protocols, even those from different institutions, would produce similar respiratory care plans when applied to identical patients. The current study is designed to assess whether respiratory care protocols from different hospitals produce concordant respiratory care plans when applied to standard patient vignettes. As a secondary goal, we compared the degree of concordance when therapists generated the care plans using written guidelines vs. a computer-aided approach.

Methods:
Protocols were compared by applying each of 4 hospitals' protocols to 5 patient vignettes. The 4 hospitals have experience with comprehensive protocol programs and are geographically dispersed across the United States (e.g., California, Ohio [2], South Dakota). Vignettes were developed for the following respiratory problems: pneumonia, asthma, COPD, neuromuscular disease, and abdominal surgery. Each vignette contained the clinical information needed to establish the indications for the most commonly used respiratory therapies: oxygen, aerosol, bronchopulmonary hygiene, hyperinflation, and respiratory monitoring techniques. MediServe (Tempe, Arizona) provided the platform for the computerized protocols. Respiratory care plans for each of the 5 patients were developed by each of 3 experienced respiratory therapist evaluators using two approaches: 1. a "manual" approach, which based the care plan on a hard copy written protocol, and 2. a "computer-aided" approach, which used a management information system (MediServe, Tempe, Arizona) into which the different hospitals' protocols had been programmed. Altogether, each evaluator generated 40 respiratory care plans, 20 manually and 20 with the computer-aided system. After all 3 evaluators completed all 40 care plans, a consensus care plan for each patient vignette was developed based on the majority of evaluators' choices. The primary outcome measure of the study was the percent of similar modalities that were derived for the care plans using the 4 different hospital protocols. Secondary outcomes were the degree of agreement between methods (i.e., manual vs. computer-aided) and agreement among individual evaluators.

Results: Protocols from the 4 hospitals led to similar therapeutic care plan modalities for 95% of the choices using both the manual and the computer-aided methods. The 3 evaluators disagreed on 35 (13%) of the choices with the manual method and 30 (12%) with the computer-aided method. The table presents the frequency with which specific modalities were suggested in the consensus care plans with both approaches.

TABLE:

Modality Aerosol Pulmonary Hygiene Hyperinflation Oxygen Monitoring
Manual 95% 100% 80% 100% 100%
Computer 100% 90% 100% 95% 85%

Delivery methods for bronchopulmonary hygiene therapy (e.g., postural drainage and percussion, Therapy Vest, Flutter device), and for hyperinflation therapy (e.g., incentive spirometry, PEP, IPPB) varied widely among the different hospitals' protocols.

Conclusions: Use of protocols from 4 different hospitals produced relatively consistent care plans regarding the mode of therapy (95%) using both the manual and computer-aided methods. Differences among the evaluators occurred with similar frequency using the manual and computer-aided approaches (13% and 12%, respectively). Overall, our results support the benefits of respiratory care protocols in generally encouraging consistent care, while identifying ongoing opportunities to standardize respiratory care plans.

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