Meeting Expectations
When we last visited with the folks at WellStar Health Systems in Georgia, two of the five hospitals in the chain were just emerging from their “evaluate and suggest” pilot programs on protocols and heading into the uncharted waters of “evaluate and treat.” Several others were getting ready to enter the pilot phase, and the rest were still training staff on the assessment forms and educating doctors and nurses on how the program would work. There were some problems—it was the busiest season of the year, a new form was causing some angst among staff, managers were having a little difficulty getting cooperation from other members of the health care team—but all in all, progress was being made.
What’s happened in the interim? “The protocols are meeting our expectations,” assures Karen Sicard, RRT, RCP, respiratory care clinical specialist and pulmonary diagnostic coordinator for the five hospital system. “We are seeing an increase in orders requesting RC by protocol, an increase in appropriate therapy ordered, an increase in therapist satisfaction with the care they are delivering, and physicians are pleased with the care that their patients are receiving.”
System-wide RT Manager Terri Glaze, RRT, agrees. “The program is meeting expectations and in some instances exceeding expectations—no unforeseen problems so far.”
Taking ownership
At Cobb Hospital in Austell, WellStar’s second largest facility at 302 beds, the transition to the full blown program in February hit when the census was especially high. RT manager Shelley Huebner, RRT, was initially concerned the larger workload could slow the program down, but that hasn’t happened. “The transition from one phase to the other has really played out better than expected.” The department benefited greatly from having a central group of physicians squarely in their corner, and staff worked overtime to make the most of that advantage.“We knew here at Cobb that we really had a core group of doctors that were supporting us, but it suddenly became a busy two-way street in order for this program to work. Staff had to prove to the physicians that they could make good, sound decisions—and the physicians had to trust the staff to actually make those decisions based on the assessment. The fact that all of this was done during the busy season has only made our staff and the physicians more confident in knowing we can reach our goals.”
The results have been outstanding. “We more than doubled the amount of patients on protocols from February to March,” says Huebner. RTs performed 478 initial assessments, more than she ever expected, and about 40 of the hospital’s physicians and physician’s assistants were ordering RT via protocol, covering about 38 percent of eligible care.
The credit for Cobb’s success, says the manager, goes directly to her staff. “The staff has taken real ownership of the protocols and are the true reason why Cobb is benchmarking the system.” They’ve come a long way from the initial days of the program, she continues, when there was some resistance to the idea, especially implementing it when the staffing was low and counts were high. “Once they saw that they could actually impact the overall counts, then it became less of a problem and more of a habit. Time, and eventually the actual numbers, helped us overcome this obstacle.”
What about those problems Cobb was having with the new assessment form when we talked to them in February? “There is no longer a ’form issue,’” says Huebner. “Time and repeated use seem to have resolved it.” Her next order of business is to continue to educate physicians and campaign for greater use of the protocols in general care areas in anticipation of a move into critical care. “We would like to continue to perfect our assessments and see how we compare nationally. Once we have reached a good comfort zone with protocols on the floors, we then want to grow into the intensive care areas.”
On the right track
The problems that arose when 83-bed Paulding Hospital in Dallas entered the “evaluate and treat” stage also seem to be melting away—for the most part. As you’ll recall, RT Manager Dana Harris, RRT, was having some difficulty getting physicians up to speed on the order writing process, but time and continuing education have ameliorated the problem. “There has been some resolution of the physicians correctly writing the orders. We are having to discuss with them individually and on a case by case basis to help educate.”Karen Sicard agrees there are a few issues remaining in this area, and not just with physicians. “Our current challenge is our computerized order tracking process. Respiratory depends on correct order entry and completion of orders to track current patient orders. Our initial rollout plan consisted of education of the unit secretaries and nursing...we are currently working with our information systems department to improve the process.”
Getting the right people together for necessary meetings was also a challenge at Paulding, but Harris says this is no longer of much concern. “The ’meeting phase’ has passed,” she gratefully notes. “We are marketing ourselves every chance we get with the nursing staff, physician staff, and administration. The more we talk it up, the better understanding has come from the areas outside of RT.”
Like their colleagues at Cobb, she and her staff are seeing the fruits of their labor. “We have captured physician staff that historically have been more rigid with RT. I think the more we have proven ourselves, the more they trust us.” Key physicians have provided enormous assistance by talking to their peers about the program, and both physician and nursing staff are becoming increasingly comfortable with the logistics of the program—the paperwork and stickers being used to generate orders and track patients.
“Overall,” says the manager, “I think we’re on the right track.” About 60 percent of the physician staff is currently ordering RT by protocol, accounting for about 40 percent of the department’s care. She plans to stay on target by continuing to market the program to physicians, and she’ll also be investing more time in ensuring staff hone their assessment skills and become more confident in their decision-making abilities. The goal is to see those initial numbers on physician usage take a big jump: “I would like to be at 80 percent or greater.”
Moving forward
May is shaping up to be a big month for both WellStar’s long-term acute care hospital, 40-bed Windy Hill, in Marietta, and its 98-bed acute care facility, Douglas Hospital, in Douglasville.“We are continuing to complete the assessment forms and place them on the patients’ charts in preparation for going to our pilot of RT by protocol,” says Douglas Manager Steve Hilton, RRT. Formal medical director competency checkoffs have begun, and physicians have received a special presentation from the medical director and the system education coordinator on how the program will work and the impact it’s made on the system so far. “This should help in resolving any concerns and also make them more aware of the initiative. Once we go to the implementation phase, I will be checking with the doctors on problems and concerns and responding appropriately to their needs.”
Hilton’s biggest concern right now is continuing reluctance on the part of staff to buy into the concept. “Some staff members still haven’t made assessments a priority, in that they put off doing them in the required time frame of 48 to 72 hours for the reassessments and 24 hours for the initial assessments.”
He’s working with these individuals on a one-on-one basis, providing counseling, along with reminders during individual assessment form reviews. The problem is most acute on the weekends, and workload is the big culprit, says Hilton. “The census is still quite busy, and now pollen/allergy season and the hot weather and humidity is just starting. I have adjusted one person’s schedule to help in the middle of the week to keep the reassessments current and am looking at other ways to ease the workload so the therapists have time to do the initials and reassessments per our policy.”
At Windy Hill, Manager Martha Durell-Eggers, RRT, has a slight advantage over her peers at the other hospitals, in that her facility has been using RT protocols on a facility-specific basis for some time now in non-critical care areas. “When a patient has been off the ventilator 24 hours, we assess them and place it in the chart.”
Physicians order this protocol about 90 percent of the time on these patients, and RTs also participate in weekly team meetings where assessments are discussed. “Suggestions are made for changes there, or with the physicians while rounding.” Since physicians have long incorporated RT assessments into their plan of care, Durell-Eggers believes the live rollout of the system-wide program this month will go smoothly. “Trust in our ability to assess the patient correctly is already there...patient outcomes have attested to that ability.”
Still, they’re working to ensure a smooth transition to the system-wide protocol program, sending staff to the patient assessment classes and ensuring they have time to perform the assessments. “We also did a clinical performance lab on the patient care assessment protocol to make sure everyone was on the same page.”
Biggest site ready to go
That leaves WellStar’s largest hospital—455-bed Kennestone in Marietta. RT Medical Director Cindy Powell, MD, reports, “We have just emerged from the pilot phase of the protocol for assessing and treating our pulmonary patients, and the program has just been passed through the Medical Executive Committee...I expect it to go well and that, within the near future, hopefully, many physicians will be placing patients on protocol.”Frances Martin, RRT, the new RT site manager at Kennestone, could not be more pleased. “This is a grand opportunity for therapists to gain autonomy and become an integral part of the health care team.” Her biggest challenge will be to convince more physicians of the merits of the program. “There are some doctors who are very accepting of the protocol and some who are not. I believe that, in time, each will see that the protocol does work and realize how it will benefit their patients in the long run.”
Terri Glaze thinks that’s already happening. In fact, one of the pulmonary groups has already decided to add the order to their admission order sheet. Staff remains her biggest concern when it comes to obstacles facing the program. “At one time I would have said physicians were the problem, but I really must say at this point we still have some staff trying to avoid the change.”
With some “tweaking,” however, she believes these challenges can be met and overcome. And she is quick to point out there are some staff who are already performing above and beyond the call of duty. “I have to complement the nightshift at Kennestone for taking such complete ownership of this project and for performing way beyond expectations.”
Dr. Powell notes it’s these kinds of therapists that are going to make or break the program. “The physicians need to have the experience of seeing the RTs doing a good job with the protocol so that they develop some trust in it. This will take time.”
On to the ICU
It all takes time, agree Glaze and Sicard, but the WellStar program appears to be marching full steam ahead, with the next step being the development of ventilator protocols for the ICU. “We have developed and presented to the System Care Management Committee our liberation from mechanical ventilation protocol,” says Sicard. “We started staff education in April, as it moved through each site’s Medical Executive Committee for approval.”The plan is to begin implementation in June. In the meantime, she’s working with a group of pulmonologists on several additional ICU protocols, including progressive weaning, low volume mechanical ventilation, extubation, and mechanical ventilator management. “I am also looking to augment our existing acute care respiratory protocols with disease based protocols.”
Terri Glaze notes the emergency room physicians and the Global ICU Committee have both asked RC to implement the acute care protocols in their areas of care. Laura Peno-Green, MD, chair of the Global ICU group, is looking forward to their use. “The program is doing well; staff and administration have been very receptive to change and acclimation to the new trends in patient management.” With positive data on outcomes, she believes the next steps will proceed on plan. “Patient outcomes will need to be monitored between protocol and non-protocol groups.”
Just do it
Changing the practicing culture of a department is never easy, but these managers believe their experiences so far prove you can teach old dogs some new tricks. Says Karen Sicard, “It takes commitment, time, and, most importantly, team work.”Terri Glaze has the final word for other RT managers around the country who would like to be in her shoes: “This process takes true dedication from your leadership—it can be done!”
Updated outcomes data is available from the WellStar protocol program. (20k MS Exel file)
Check back in late July for the next installment of the Protocol Diaries series.
