The Protocol Diaries: Chapter 3
In the last edition of this series, respiratory therapists at WellStar Health Systems in Georgia were hard at work refining protocols in their hospitals and ensuring the ongoing success of their newly instituted “evaluate and treat” program. But labor does have its rewards! This excerpt from a letter sent to all the RTs at the five WellStar facilities from RC department management and system administration tells the story:
“Over the last two years...you have been instrumental in implementing a process that has taken many other systems 5–10 years. Each of you supported your patients by developing the skills required for the delivery of state-of-the-art care. Our organization is extremely proud that the RC department continues the ‘evaluate and treat’ program and the use of respiratory protocols to provide high quality care, control utilization, and lower cost.”
Administrators also touted the program for helping them achieve the AARC’s Quality Respiratory Care Recognition. Says the letter, “Today, May 21, 2003, we were notified that we, WellStar Respiratory Care Services, had received the ‘Quality Respiratory Care Recognition’ (QRCR) from the AARC...the QRCR is the highest commendation in the field of respiratory care at this time and is an excellent marketing tool.”
All these glowing words are backed up by solid numbers too. “The adult care protocols have gone live and we are currently completing about 900 assessments per month system-wide,” says System Administrative Director Terri Glaze, RRT, RPFT. “We continue to see 10–15 fewer aerosol treatments delivered per patient visit for our COPD population, average length of stay has not increased but has decreased, and O2 days have decreased by 2—and that is a lot of O2!”
Holding their own
Managers at the five sites agree the program is slowly but surely becoming standard operating procedure in their hospitals. At 83-bed Paulding Hospital in Dallas, Manager Dana Harris, RRT, says the department has managed to maintain initial coverage since the early days of implementation last spring, despite an extremely busy month in June and the loss of one of the department’s biggest sources of support.“We had record numbers for procedures done in the month of June and we were still able to keep our percentage numbers (60 percent of docs ordering the protocols on about 40 percent of care) about the same.” Fears that the departure of a key physician would throw a screw in the works didn’t materialize either. “We thought that might hurt us, especially in the transition period, but we were able to avoid much of a drop in protocols being initiated.”
RTs at 302-bed Cobb Hospital in Austell are having a similar experience. In April, the department had about 40 doctors using the program on about 38 percent of eligible care, and the same is true today. “Our numbers have remained fairly steady, and that may be because our workload has been steady,” says Manager Shelley Huebner, RRT. “For the most part everyone is very trusting—since June I am only aware of one physician that has raised some concern. He continues to grumble, although someone from education will be meeting with him one-on-one very soon.”
Things are going even more smoothly at WellStar’s long-term acute care hospital, 40-bed Windy Hill in Marietta. “The transition has been easier here than in the rest of the hospitals because of our weekly, multidisciplinary team meetings,” says Manager Martha Durrell-Eggers, RRT. “One hundred percent of our doctors are using the program for 95 percent to 97 percent of the care.”
Lingering issues
Of course, each of the facilities still has a few lingering issues. At Paulding, Harris says the biggest obstacle this summer has been the desire of physician staff to use Xoponex instead of albuterol for some patients, which causes the patient to drop out of the protocol. “We are having to call the physician and discuss the different perspectives on which drug to use.”At Windy Hill, Durrell-Eggers says the main problem they’ve faced is physicians neglecting to sign off on the respiratory care protocol request. But she’s quick to note that’s generally remedied by a simple reminder to the doctor in question. “If we see a doctor has not signed off, we ask why, and he then signs off.”
Cobb’s most significant challenge now is getting new hires up to speed on the program. Says Huebner, “That will always be a never-ending battle.” But she sees an upside as well in terms of recruiting new people to the department, noting the protocol program may appeal to RTs looking to work in a more “hands-on” department.
Karen Sicard, RRT, WellStar’s respiratory care clinical specialist/pulmonary diagnostic coordinator, notes physician understanding of the program continues to be somewhat of an issue system-wide, although she believes progress is steadily being made. “Outcomes and education with other physicians are what we are using to overcome these obstacles. I believe by the end of 2003, the respiratory department as a system will have their arms completely around protocol care and will have changed their approach to patient care. This will improve the physician comfort with protocol therapy and increase its use across the system.”
Getting up to speed
The last of the facilities to transition to the “evaluate and treat” phase of the program, 98-bed Douglas Hospital in Douglasville, and 455-bed Kennestone in Marietta, are hoping to cash in on the success the other facilities are having.“Protocols were started here on May 1,” says Kennestone Manager Frances Martin, RRT. “Initially, there were quite a few questions, but having the pilot in place answered a good number of them.” Since going to “evaluate and treat,” she says the department has slowly been improving on utilization numbers as more and more doctors sign on to the program. “It is running smoother now that staff and physicians have become more comfortable with it.”
She continues to work both sides of the equation, utilizing feedback from therapists and physicians alike to identify and remedy any remaining or new issues. “We’re checking orders that have been changed or discontinued to find out why. Was there something missed? What was the preferred treatment? Asking questions that will aid in giving better care.”
The biggest challenge has simply been getting information out to everyone involved in a timely fashion. “Keeping everyone up to par on changes, especially in a large facility, can be difficult. We have used inservices, story boards, flyers, posters, emails, and announcements—this is an ongoing process.” But she emphasizes her staff is up to the challenge. “Everyone understands that the protocols are now a part of their job responsibilities. Both shifts have been working together to help our department become stronger and do our best to make our place a pulmonary center of excellence.”
Catching up quickly
As the final facility to transition to protocols, Douglas is a little behind the others, but catching up quickly. The “evaluate and suggest” phase began in late May-early June, with good initial results. “For the month of June a total of 153 initial assessments were done and 60 patients were ordered on protocol, for a rate of 39 percent,” says Manager Steve Hilton, RRT. “The staff also did 135 reassessments during this period. This was in addition to delivery of therapy, ABGs, ER treatments, etc.—so as you can see, they have stayed busy.”The transition to “evaluate and treat” came in early July, and so far Hilton is pleased with the progress, though he notes utilization fluctuates on a day-to-day basis. Some physicians are still unaware the program exists, and some staff continue to drag their feet when it comes to total buy-in. “I feel that the staff genuinely wants to make the program work, but some are having a hard time breaking old habits and ways of doing things.” He’s working one-on-one with the physicians to get them up to speed on the program and continuing to review staff worksheets and suggest ways RTs can improve their assessments and recommendations for therapy.
A welcomed boost has come from nursing, which is now requesting that RT evaluate some of their patients before they call the physician to assist them in better understanding the patient’s respiratory care needs. Specifically, Hilton says the RTs found some patients who were on home respiratory care treatments but had no MD order for the treatments on admission. “We were able to start them on their home regimens, which prevented them from having other complications with their breathing.”
Since these were patients admitted for problems that were other than respiratory in nature, it also helped sell the idea of respiratory care protocols to several physicians who might otherwise have remained unaware of their existence.
Opening the lines of communication
The next phase at all the hospitals will be a move into the critical care units. Terri Glaze is hoping to jump start this part of the program by running the ICU therapists through the FCCS course, and plans are well underway to implement the liberation from mechanical ventilation protocol before the end of the summer.Several additional ICU protocols are under development as well, but Karen Sicard emphasizes management will ease into them slowly, ensuring staff is not overwhelmed. “We are working carefully on a timeline to move through these critical care protocols so as not to overload the RTs with new processes. One thing we have learned is to give yourself time for a new process to become part of your practice.”
In the meantime, managers at all the facilities continue to chip away at remaining areas of resistance and work with staff to keep them moving in the right direction. For the most part, the latter is becoming easier and easier as they go along.
As Dana Harris notes, protocols have done more than anything she has ever seen to open up the lines of communication between therapists and physicians, and the result is a working environment that would be the envy of all. “The impact on morale is outstanding. My staff feels like, ‘We are taking the skills we learned in school and putting them to use in the workplace.’”
Look for the fourth and final edition of the Protocol Diaries series this fall.
