CLINICAL PROTOCOLS TO ENHANCE OUTCOMES, PATIENT SAFETY & OPERATIONAL EFFICIENCY

Al Heuer, PhD, MBA, RRT, RPFTProfessor & Program Director

Rutgers-SHRP

Learning Objectives

• Define a Protocol & Summarize their Evolution• Examine How Protocols Can Benefits Health Care Orgs.• Emphasize Why they are More Important than Ever!!!• Review Pre-requisites and their Basic Elements• Review a Protocol for Developing a Protocol• Examine Key Protocols Examples, both “Good & Bad”• Identify Potential Barriers & How to Overcome Them• Provide Additional Resources

Questions to Consider

• Are all patient’s getting therapy they need?

• Are some patients receiving unnecessary interventions?

• Are the “frequently fliers”….. flying tooooooo frequently to your ER?

• Are ventilator patients being weaned ASAP?

• Are RTs & RN’s doing too many “low-dividend” activities at the expense of value-added services?

Clinical Protocols can Help Address These Questions…But What’s a Protocol?

• According to the AARC: • Initiation or modification of a respiratory

interventions… • Following a pre-determined & pre-approved

inclusion/exclusion criteria• Permitting the therapist to initiate,

discontinue, refine, transition, or restart elements of the care plan.

The Evolution of Clinical Protocols• 1970’s & 1980’s: Amer. Heart Assn. introduces & refines

BLS & ACLS protocols. • 1980’s & 1990’s: Health care becomes more competitive;

research “evidence” improves, respiratory protocols gain a foothold.

• Late 1990’ and early 2000’s, certain organizations emerge as leaders in respiratory protocols• Univ. California at San Diego• The Cleveland Clinic

• Today: Their use is widespread but compliance with them and the benefit they yield are mixed.

• Ironically, the need for effective protocol use has never been greater.

Why Protocols ARE Becoming a Necessity

• Shrinking Resources in Health Care = Need for Efficiency

• Plus, Outcomes Based Reimbursement• Value-based Purchasing

• Technological Advancements = Increasing complexity of our profession (e.g., more complex ventilators & modes).

• Without “Re-engineering” resources will be further diluted & quality outcomes threatened• 30-day readmission?• HCAHPs

• Potential downward cycle can be addressed (in part) with more heavy reliance on protocols.

The Evidence

• Overall effectiveness of PDP’s -- Kester, L, et al, (2005): Protocols from 4 different hospitals produced relatively consistent care plans 95% of time. The results support the benefits of respiratory care protocols in generally encouraging consistent care, while identifying ongoing opportunities to standardize respiratory care plans.

• MDI’s versus SVN’s- -Gardenhire (2008) and Brocklebank, et al, (2001): • MDIs are at least as clinically effective as SVN/HHN’s• Cost result in a 20-40% “all-in” cost advantage.

• PEP versus CPT in Secretion Removal--Bellone, et al, (2002): • PEP can be as effective in mobilizing secretions as manual CPT.• PEP is less labor intensive than CPT

More Evidence…..

• Weaning protocols – Hooper & Girard (2011) & Nemer & Barbas (2011): • Spontaneous Breathing Trials (SBTs) = fewer ventilator days/faster

weaning.• Inhaled Flolan versus Inhaled Nitric Oxide – Wong (2009):

• Inhaled Flolan significantly reduces (40%) inhaled pulmonary vasodilator therapy cost versus INO.

• Similar clinical efficacy• Need for Readmission Prevention Protocols— Hari & Rosenweig

(2012): Appropriate Patient Education and Follow-up are essential requisites to reduce short-term re-admission

Potential Benefits-General• Cost Savings & Efficiency

• Reduce physician burden• Reduce unnecessary treatments• Optimize Treatment Delivery

• MDI versus SVN• PEP versus CPT

• Reduced LOS • Asthma• post op• vent weaning

• Reduced Exposure to Errors & Infections• Directly via standardization to best practices and reduction of variation• Indirectly via shorter LOS.

• Enhanced Therapist Morale = ↑ Patient Satisfaction• More Therapist Autonomy• Less unnecessary therapy

Economic Benefits – Cost Savings and Efficiency • One less ICU day due to rapid weaning can save $5k to

$10K/patient.• One case of VAP prevention can equal $20K to $50K• One conversion from Inhaled Nitric Oxide (INO) to Inhaled

Flolan can save $2k/day/ patient.• Flolan is $300 per day vs.• INO $1,000 to $3,000/day

• Conversion of half of bronchodilator treatments from SVN to MDI can save a 300-bed hospital approx $1,000 per day.

• One Fewer facial (or bed) sore w/declined reimbursement can equal $2k to $25K.

Qualitative Benefits• Patients: Better QOL!!

• Reduced LOS--Faster recovery• Fewer re-admissions - QOL

• Staff • More efficient use of resources • More RT engagement = ↑ employee morale = ↑ patient satisfaction

• Other:• Less variation in procedures = Fewer medical Errors• Less un-necessary therapy

Prioritize!!! Protocols to Target –Big Bang for the Buck!!!

• High Frequency• Bronchodilators – MDI should be default, mode• Secretion Mobilization- Consider PEP versus manual CPT• Education & Referral Protocols – Asthma, COPD, CHF

• High Cost• Vent weaning – Wean unless proven otherwise.• Flolan versus Nitric Oxide for Pul HTN• 30 Day Re-admission Prevention• VAP and BiPAP Facial Sore Prevention

Desired Features• Evidence Based

• Clin. Practice Guidelines

• KISS Principle: Keep It Simple…….!• Streamlined paperwork and use!!!

• Developed with Input from Multiple Stakeholders.• End-users should participate in development and beta-testing.

• Practical within the Organizational Structure!• Compatible with paperless/computerized charting system• If MDIs are the default mode, make sure MDIs are available!• RTs Must be Trusted by MDs & Prescribing Professionals

• Tried & True is OK – Outreach to other organizations effectively using protocols, and ask to use/modify. • Univ. of California at San Diego

A Protocol for Developing Protocol1. Identify Need/benefits & Key Focus Areas

• Greatest Bang for the Buck (high volume activities)• Limit Initial Scope—Start small then expand

2. Establish a Protocol Team (RTs, Mgr, MD, RN?)

3. Initial Research & Review• Research Evidence• “Best practices” of similar Institutions

4. Gain Initial Top-level Support• Medical Director• Pulmonary Section

5. Expand Research & Review• Establish/Expand Collaborations

Development (Cont.)6. Draft initial Protocol

• Procedures• Algorithm

7. Team Review

8. Beta test by Team & End Users

9. Refine and Finalize

10. Educate RT’s, RN’s and Other Stakeholders (MD’s)

11. Implementation• Gradual – new Starts Only• Threshold - Convert all existing patient to Protocol

12. Monitor Impact and Compliance & Evaluate

13. Refine & Revise Based on Feedback

14. Periodic Review, Re-education & Reinforcement

Elements of the Protocol & Documentation

• Policy - States in detail:• Purpose/objectives• Step-by-step how to proceed• Monitoring mechanism• Signed by Med. Dir.

• The assessment tool/form• The algorithm/flowchart• The oversight/measurement/compliance method• Feedback/improvement method/plan

General Categories of Protocols• Umbrella Protocols

• “Respiratory Therapy Consult” ordered by MD.• Patient is assessed by RT in light of criteria• Care plan devised & appropriate therapy is initiated

• Therapy-Specific Protocols• Pertains only to a specific therapy “Bronchodilator Protocol”• Tag-On: May Focus on Hazard Prevention

• ZAP-VAP• BiPAP facial sores.

• Condition/Disease-Specific • Asthma, CF, Post-open heart• Pulseless V-Fib. - Amer. Heart Assn.

• Process Oriented• Short term readmission prevention• Education: Asthma, COPD

Umbrella Protocol Example – Applies to Several Therapies

Specific Therapy Protocol – Applies only to MDI Conversion

The Algorithm/Flowchart Shouldn’t Look Like This!

A Oxygen Therapy Protocol – Gone Bad?

Oxygen Therapy Algorithm - Streamlined

Oxygen Titration Protocol-Steamlined

Medication Device Protocol-Streamlined

Secretion Clearance Protocol-Streamlined

Flolan Substitution Protocol

Ventilator Weaning Protocol

VAP Prevention Bundle/Protocol

BiPAP Pressure Sore Prevention Bundle

Short-term Readmission Prevention Protocol

General Process Improvement Protocol Algorithm

Potential Barriers & Their SolutionsBarrier/Problem

• Don’t Know where to Start

• Lack of Initial Top-level & MD Support

• Outdated/obsolete protocol

• Lack of Initial bottom-up support by RT’s

• Low Compliance with Existing Protocols

• Insufficient ongoing compliance by RT’s or other stakeholders

Solution/Corrective Action

• Research “best practices” & evidence

• Enlist MD’s in process, market benefits

• Update using latest evidence

• Develop a user-friendly & practical protocol, w/RT input! Review benefits

• Decode via Root-cause analysis, ask RT staff, devise plan

• Monitoring & Re-education, Refine/Revise Protocol

Take Home Points• Protocols can be valuable tools, especially with limited

resources.• Efficiency• Effectiveness

• Proper planning and implementation takes time.• Front-end loaded, requiring careful advance planning,

Implementation and Follow-up.• Ongoing monitoring and reinforcement also important.

• Protocols do not need to be original, they just need to work.

• There’s many resources out there, use them!!!

Selected References• UCSD Respiratory Services, Respiratory Care Patient

Driven Protocols, 3rd ed, Daedalus Enterprises Inc., Dallas, TX, 2005

• Ford, R, AARC Guidelines for Respiratory Care Department Protocol Program Structure, 2008

• Kacmarek, R; Stoller, J & Heuer AJ, Egan’s Fundamentals of Respiratory Care, ed 10, 2012

• Hermeto F, et al, Implementation of a Respiratory Therapist-Driven Protocol for Neonatal Ventilation, Pediatrics, 2009

• AARC.com-CPG and Protocol Resources

One Last Protocol AlgorithmGeneral Troubleshooting Protocol Algorithm

Yes

No

Yes

No Yes

No

Yes

Yes

Yes

No Problem!

Did you mess with it?

Does it work?

Bad News!!!

Does anyone know?

Will you get Blamed?

Hide It

Don’t Mess With It!

You Poor Bucko!

Can you Blame Someone else?

Ditch It!