First Sites Goes Live
January 6 was the red letter day for Cobb Hospital, WellStar's 302-bed facility in Austell, GA. “We are currently up and running with the pilot here at Cobb,” says Site Manager Shelley Huebner, RRT. So far, she continues, “Things are going very well.”
Terri Glaze, RRT, director of respiratory care for all five hospitals in the system, agrees. The site had already shown good progress during the “evaluate and suggest” phase, wherein RTs assessed patients and called physicians with their recommendations. Declines were noted in aerosol treatments and oxygen days for simple pneumonia and COPD, and the department saw a less than expected increase in MDI therapy.
Aerosol treatments per simple pneumonia admission, says the manager, went from 20.3 in July to December 2001 to 15.5 in January to June of 2002 to 12 in July through December of 2002. Figures for aerosol treatments per COPD admission dropped from 25 to 22 to 15 during those same time periods.
Oxygen days per simple pneumonia admission and COPD admission followed a similar path, from 4.07 to 3.61 to 2.38, and from 4.57 to 4.67 to 2.80, respectively.
MDI treatments per simple pneumonia admission went from 1.33 to 2.38 to 1.39, while those for COPD admission went from 1.64 to 3.59 to 2.05 Notes Glaze, “We have not increased MDI therapy as much as expected. Therefore, the 8-10 less aerosol treatment gain per patient admission is not being offset by the slight .5 or less MDI treatment increase.”
With the transition to evaluate and treat, she expects “more gains due to not having to contact the physician” — though she admits that will depend on “the number of physicians writing 'RT by protocol'” orders. “We must keep marketing ourselves.”
Issues, issues, issues
Has it been easy? Both Glaze and Huebner acknowledge there have been issues. “When moving from the evaluate and suggest phase to the evaluate and treat phase, we made a change in the assessment form,” says Glaze. “This created staff frustration, although the physicians like the new form better.”Huebner echoes those sentiments. “One of the biggest challenges we had was getting our staff to use new forms in December before we went live with the pilot in January. Change is hard for some and torture for others, so we really had to get involved with ensuring that staff was educated and felt supported with these new forms.”
The pilot also hit at the hospital’s busiest time of the year, which added to staff frustrations. The solution, says Huebner, was to get out and support staff as much as possible. “As far as implementing this process in the winter — well, there is not much else we can do to address this issue except support our staffing needs as much as possible to ensure the assessments all get done in a timely manner.”
The department’s education resource person, Renee Lovell, RRT, has also created story boards, held informal question and answer sessions, and provided staff with pocket handouts to ensure they are completing the forms correctly.
Seeking broader support
Eighty-three bed Paulding Hospital in Dallas, GA, is also in the evaluate and treat stage, with protocols now being piloted in the medical-surgical unit. Like her colleague at Cobb, Site Manager Dana Harris, RRT, has successfully shepherded her department through the formal classes, physician rounds, and final checkoffs.“We have 100 percent of the staff through.”
And results have been equally positive. While hard numbers are not yet available, Terri Glaze says treatments have dropped by around two-thirds since protocols went into effect.
Still, challenges remain. Physician buy in and communications have been the biggest issues, says Harris. In particular, she’s had to address the way doctors are writing the orders, pointing out things they need to change to make the system work effectively.
Karen Sicard, RRT, RT clinical specialist for the WellStar system, says that’s to be expected. “We have had to clarify orders here and there but this is what a pilot is all about, ironing out the creases. As with any change in practice, it takes time to develop a comfort level with a new process.”
Getting the right people in the right place at the right time has been an uphill battle as well. “Another issue,” says Harris, “has been attendance at the proper meetings, where we are attempting to educate and get the word out. The nursing staff meetings have had low attendance.”
The manager says she’s mostly satisfied with how the department has addressed these concerns, although she does get frustrated at times when she can’t get good cooperation from those who should be more involved. However, she realizes, “Those things are out of my control.”
Her next step will be to “tweak the process during our pilot phase... and we have to step up our one-on-one communication with physicians and nurse staff.”
Confidence building
Steve Hilton, RRT, site manager at Douglas Hospital, a 98-bed acute care facility in Douglasville, is a few steps behind in the implementation process.“We have completed the staff formal training and I have started the initial process of having the staff complete the assessment forms so I can review for completeness and appropriateness of suggested therapy within our protocol guidelines.”
As staff demonstrate competency, he will begin having them place the completed forms in the progress notes for the physicians. “Next step is for them to complete formal checkoff with the medical advisor.”
Hilton is trying to facilitate the process by addressing questions and concerns with his RTs on an individual basis and in monthly staff meetings, and he’s also posting a newsletter and memos from the other four sites to keep staff members abreast of what’s happening with protocols system wide.
So far, the biggest stumbling blocks have been resistance to change on the part of staff and reluctance to let go of control on the part of physicians. RTs are having a hard time breaking old habits and “seeing the benefit of protocols in helping them perform their jobs more effectively and efficiently,” says Hilton.
Finding the time to perform the assessments when the census is high, and making assessment a routine part of the job have both been a challenge.
Physicians are having to change their old ways as well, and even though they are able to change any order they are not in agreement with, Hilton says he must work continually to “build confidence of the MDs in the staff’s ability to properly assess and recommend appropriate therapy for their patients.”
Says he, “The process takes time, but it is coming along well.”
Waiting in the wings
Wellstar’s two Marietta facilities —Windy Hill, a 115-bed long-term acute care hospital, and Kennestone, a 455-bed acute care facility — are scheduled to enter the pilot phase this month. Martha Durell-Egger, RRT, is the site manager at Windy Hill, where RTs have been doing the assessments but not yet started on the protocols. She says they’ll be entering into discussions with the medical director and in-servicing the staff, and she’s already posted a story board to help RTs, physicians, and nursing see how the program will work.Similar plans are underway at Kennestone, the largest of the five Wellstar facilities, where a new site manager will soon be onboard to oversee the efforts.
Next up: Critical care
Karen Sicard believes the initial results at Cobb and Paulding bode well for similar success in the other facilities. “The pulmonologists at our Cobb site are being aggressive with the use of the protocols, and we expect to see the ordering of protocols increase as we move into the second month of pilot.”Management has now made the eight-hour assessment class a part of new employee orientation as well, further ingraining the protocol philosophy into the system.
While the problems the hospitals have faced so far have been frustrating to some, Sicard believes the RTs at all five facilities are “doing a tremendous job in their new role as respiratory care assessors,” and she fully expects even greater progress in the months to come. “After that we will evaluate for any changes we need to make to the protocols.”
In the meantime, she and Terri Glaze are working ahead on the next big step for the protocol project. Says Sicard, “We are already moving into the critical care units and developing protocols for ‘liberation from mechanical ventilation’ and ‘ventilator weaning.’”
Installment 2: Meeting Expectations.
