Protocol Diaries



		The Protocol Diaries: The Final Edition It’s been nearly a year now since we first visited with the folks at WellStar Health Systems in Georgia about their entry into the brave new world of respiratory care protocols. Launched in 2001 after an audit revealed a high volume of misallocated therapy and other problems, the program started with an 18-month-long development phase requiring not only writing the protocols themselves, but gaining approval for the program from 22 pulmonologists, a Care Management Committee, and five different Medical Executive Committees. Along the way 177 individual therapists at five facilities scattered across the state had to be trained as well. But 2003 has been the real proving ground for protocols at WellStar. This year, each of the five facilities has transitioned from “evaluate and suggest” pilots initiated early in the year to full blown “evaluate and treat” programs. They’ve all had their ups and downs, of course, but system-wide managers Terri Glaze, RRT, RPFT, administrative director, and Karen Sicard, RRT, respiratory care clinical specialist, are happy to report everyone’s on track and thriving. On solid ground “We have made great strides in delivering the kind of respiratory care our RTs are trained to deliver,” says Sicard. “We are still in the infant stages of this program, but feel that we have laid the strong groundwork that will enable us to continue building on it.” Glaze agrees. “Protocols will stay and continue to grow. We will see RT moving forward with new skills sets, such as artline insertion and conscious sedation, and we are already moving forward with the Mini BAL by RT process.” The program is also forging ahead with implementation of an ICU protocol for “Liberation from Mechanical Ventilation,” which is now being used with a physician’s order in several of the facilities. Development of a “Low Volume Ventilation” protocol that follows the ARDSNet protocol is up next, along with a “Weaning Protocol” for the long-term ventilation patient. “This is going well at the sites,” says Glaze. “It is just another piece of the puzzle fitting into place.” While both managers admit to lingering issues—the size of the health system itself makes it difficult to keep everyone on the same page and motivated, says Glaze—the remaining glitches aren’t likely to slow things down now. “We refer to it as ‘completion of the process,’” says Sicard. “Taking the paperwork from the assessment all the way through initiating the protocols, there is anywhere from four to six steps, depending on how the order is written. We continue to work on improving our outcomes on RT performance in this area.” New way of life The bottom line, says Glaze, is “RT by protocol is an accepted ‘way of life’” for therapists at WellStar. System-wide outcomes back that statement up. “As a system we are averaging 37 percent of our patients on protocol therapy. Our goal is to be at 50 percent protocol care by this time next year,” says Sicard. Statistics on nebulizer and MDI treatments, oxygen days, and length of stay for pneumonia and COPD cases at each of the facilities show significant cost savings, and system administration is also tracking missed medication delivery. “In 2002, the system respiratory department had reported that 5 percent of the ordered therapy was not delivered due to assignment/therapist ratio,” continues Sicard. “So far in 2003, protocols have made our assignments more manageable, with minimal missed therapy. The therapy reported as missed is due to emergencies that have pulled the RTs from their assignment.” Site managers have the last word These outcomes bode extremely well for the program’s future and stand as testament to all the hard work and effort the two managers have put into the program over the past couple of years. Of course, they’ll be the first to tell you most of the credit has to go to the individual site managers and staff therapists at each of the five WellStar facilities. After all, they’re the folks who took the ball and ran with it, trouble-shooting problems and turning theory into bedside practice. So, as we wrap up this foray into one system’s adventures with respiratory care protocols, let’s let them have the last word. Take a look at what they had to say when we asked them to complete key sentences based on their protocol experiences over the past year: WellStar Kennestone: Frances Martin, RRT, site manager The biggest roadblock to getting protocols implemented in my department was...physician buy-in. If I had to do it all over again, the one thing I’d do differently is...provide more staff education. The most effective ways I found to communicate the need for protocols to my staff were...PCA classes that included reviewing how to do patient interviews, physical exams, chest X-ray interpretation, information gathering, and decision making skills. The most effective ways I found to communicate the need for protocols to nurses were...story boards and meetings to review information so that the nursing staff knew what to expect. An important group to include was the unit secretaries. The biggest “selling point” for protocols in my hospital has been the fact that they... would reduce the number of unnecessary treatments and the number of missed treatments. The biggest “negative” aspect of protocols I had to overcome was...getting all the changes and information out to everyone. There were hundreds of questions asked, and getting everyone to answer questions with the same information after changes had occurred was difficult. The best advice I could give another RC manager just now embarking on a protocol program would be to...make sure that there is a plan in place to follow up on all problems. Conduct audits and physician reviews, and educate, educate, educate. Kennestone is a 455-bed acute care facility located in Marietta, GA. WellStar Paulding: Dana Harris, RRT, site manager The biggest roadblock to getting protocols implemented in my department was...there was a significant learning curve that we had to overcome, and that took effort and patience, but we did it. But I would have to say that the physician buy-in was probably the biggest challenge, along with having to “prove ourselves.” If I had to do it all over again, the one thing I’d do differently is...not implement during our busiest season. That was somewhat frustrating to the staff at first because they had a tendency to feel like it was just extra work. But after they realized that we could affect our workload by doing the “right treatments and the right time” it seemed to ease their pain. The most effective—and least effective—ways I found to communicate the need for protocols to my staff were...most effective was doing rounds with my staff and working with them to find “the right treatment at the right time.” We worked together and I would explain why I would do a certain thing and the rationale behind my decision. I got to work one-on-one with my staff, and I think we all grew because of the interaction. They loved the idea that “we are using our skills we learned in school and not just following orders.” It gave them a feeling of pride in themselves, our department, and our profession. We became decision-makers, not treatment jockeys. That is what sold protocols ultimately to the staff. Least effective was trying to communicate to them how protocols would affect our workload. That was hard to see at first, especially when we were busy and the staff knew they “had” to do assessments on the patients as well as the treatments too. Like I said before, they thought it was extra work. The most effective—and least effective—ways I found to communicate the need for protocols to physicians were...I think we just had to be given a chance to prove ourselves by doing the protocol a couple of times on one of their patients and then they built up trust in our decision making ability. Communicating one-on-one with them and then having them give us a chance was our best approach. Least effective was that the physician staff did not respond well to any of our story boards, memos, or flyers at first. We had to communicate verbally with them, then it seems like they started signing our stickers to approve the protocols. The most effective—and least effective—ways I found to communicate the need for protocols to nurses were...most effective was getting out on the floors and talking to them about what we were doing and how we were trying to “deliver the right treatment at the right time.” Least effective, again, was that I don’t think we communicated well with story boards or flyers. I don’t think they took interest until it affected their patient. The best help I got from system-wide administration was...support and encouragement during management meetings with other departments—nursing and ancillary departments. The one thing I could have used from system-wide administration but didn’t receive was...I can’t really think of anything. I felt fully supported. The biggest “selling point” for protocols in my hospital has been the fact that they...really deliver the “right therapy at the right time.” Our numbers are reflecting that we are doing things correctly, the staff is confident and really feel like they are doing what they are suppose to be doing, and our interaction with the physician staff has benefited greatly throughout this process. The biggest “negative” aspect of protocols I had to overcome was...that the assessments were extra work for us. The best advice I could give another RC manager just now embarking on a protocol program would be to...realize that you really have to sell the change in attitude and culture associated with how you work now and how you will have to work after you implement protocols. It is not extra work but rewarding work. You become a decision-maker in that patient’s care—you don’t just follow orders anymore. It will take time and effort to implement them but it is well worth it. Paulding is an 83-bed acute care facility located in Dallas, GA. WellStar Douglas: Steve Hilton, RRT, site manager The biggest roadblock to getting protocols implemented in my department was...the buy-in by both the staff (time constraints worry due to treatment loads) and physicians (giving up some of their control). If I had to do it all over again, the one thing I’d do differently is...spend more time on the one-to-one, hands-on training of staff, especially the patient interview portion. I’d have more face-to-face meetings with individual physicians prior to implementation to alleviate their concerns, fears, etc. The most effective—and least effective—ways I found to communicate the need for protocols to my staff were...staff meetings, story boards with post-tests, and one-to-one conversations/reviews were most effective. Memos and newsletters were least effective. The most effective—and least effective—ways I found to communicate the need for protocols to physicians were...speaking directly with the physicians themselves and answering any questions/concerns, explaining the process and how it works, was most effective. Having the information disseminated via the medical advisor at monthly MD staff meetings was least effective. The most effective—and least effective—ways I found to communicate the need for protocols to nurses were...use of story boards with inservices was the most effective way to disseminate the information, along with follow-up of any questions. The least effective method was word of mouth via the staff and/or resource person. The best help I got from system-wide administration was...their support of protocols to include prompt approval at all five hospital sites by the medical boards, along with the endorsement of the project by top level administration. The one thing I could have used from system-wide administration but didn’t receive was...better support from our medical advisor in training of staff, adhering to the protocols, and being a positive voice for the protocols to fellow MDs. The biggest “selling point” for protocols in my hospital has been the fact that they...have helped maintain/return patients on their home regimen (numerous patients were found to have home therapy without any orders for therapy on admission except 02).The protocols enabled these patients to receive therapy in a more timely manner instead of their need for therapy being discovered due to a crisis. They also allow my staff to triage patients during busy times to ensure those patients who need our services the most are seen on a priority basis. The biggest “negative” aspect of protocols I had to overcome was...physicians giving up their old ways of ordering therapy and relying/trusting the RT staff to properly assess their patients. (Note: MDs have the option to change any protocol orders that they are not in agreement with at any time). With my staff, I had to overcome the attitude of “we already have enough work to do, this only adds to it, and besides the doctors will never accept it.” The best advice I could give another RC manager just now embarking on a protocol program would be to...1. Work with your medical advisor/director to formulate the assessment form/frequencies/standards to ensure he or she will be a leader among the MD staff in supporting the protocols. 2. Ensure the staff have adequate one-to-one, hands-on training after attending the assessment class to ensure they know where to look for information in the chart and how to ask questions in a way to get accurate information from the patient/family. 3. Be sure the medical advisor has contact with each staff member prior to their Grand Rounds checkoff so they can benefit from the director’s insight on how to treat various patients, including medications, frequencies, and modalities indicators. 4. Meet with as many other MDs as possible and present the protocols to them individually. This will result in more overall support before implementation by explaining how they will work, the scoring system etc. 5. Share with your staff the impact that protocols are actually having on the work, patient outcomes, etc. Douglas is a 98-bed acute care facility located in Douglasville, GA. WellStar Windy Hill: Martha Durrell-Eggers, RRT, site manager The biggest roadblock to getting protocols implemented in my department was...protocols were done promptly during the week, which left my weekend staff with little opportunity to do them. The staff during the week did a great job with them. If I had to do it all over again, the one thing I’d do differently is...I would leave some assessments for the weekend staff to do. The most effective—and least effective—ways I found to communicate the need for protocols to my staff were...Most effective were poster story boards. Least effective were memos. The most effective—and least effective—ways I found to communicate the need for protocols to physicians were...Most effective were story boards. Least effective were memos. The most effective—and least effective—ways I found to communicate the need for protocols to nurses were...Most effective were inservices. Least effective were staff meetings. The best help I got from system-wide administration was...help with story boards and inservices with nurses and physicians. The biggest “selling point” for protocols in my hospital has been the fact that they...work! They show the respiratory therapists as the professionals they are. The biggest “negative” aspect of protocols I had to overcome was...failure of physicians to sign on the protocol request. The best advice I could give another RC manager just now embarking on a protocol program would be to...realize that good preparation (inservices with all disciplines and assessment classes for all staff) makes the program successful. Windy Hill is a 40-bed long-term acute care facility located in Marietta, GA. WellStar Cobb: The RT Staff* Shelley Huebner, RRT, site manager at Cobb during our year-long series, has stepped down to a staff role. In lieu of her participation, five members of the RT staff stepped in with the following responses. The biggest roadblock to getting protocols implemented in my department was... RT No. 1: Being timely. RT No. 2: Time between treatments. RT No. 3: Employees who had been working in the field for awhile and were initially unwilling to change. RT No. 4: Lack of respiratory staff ownership for their own part in the process, physicians who didn’t respond to our requests to request or decline protocols in a timely manner, staff who thought protocols could eliminate respiratory positions. RT No. 5: Treatment loads, plus trying to do assessments. The one thing I think we should have done differently is... RT No. 1: Distribute the precepting among more people. RT No. 2: Started protocols earlier. RT No. 3: Introduce the paperwork to staff earlier so they could review it and be more familiar with it. RT No. 4: Implement the training process a little faster. RT No. 5: Have a core group of people to do just assessments. The most effective—and least effective—ways the need for protocols was communicated to staff were... RT No. 1: Most effective: Protocols raise professional respect and decrease treatments not required. RT No. 2: Most effective: Protocols save you extra work. Least effective: Protocols save the hospital money. RT No. 3: Most effective: Face-to-face conversations. Least effective: Notes/messages left. RT No. 4: Most effective: Marketing protocols as a tool to make the respiratory care profession more competitively professional (many perceived that we were overstepping our boundaries initially). Choosing positive staff to orient to the program initially to motivate staff. Least effective: To threaten that all must do—and like it. RT No. 5: Most effective: Protocols decrease treatment load. The most effective—and least effective—ways the need for protocols was communicated to physicians were... RT No. 1: Most effective: Protocols get the patients on the right track - faster. RT No. 2: Most effective: It will save you extra work. Least effective: It gets the patient out quicker. RT No. 3: Most effective: Finding the physicians who were most receptive to ideas and change, and talking to them first. Least effective: Telling them that this was something that they needed to do rather than making them see the positives for patient care. RT No. 4: Most effective: Best asset was getting the pulmonary group (a large pulmonary practice) to buy into the advantages of protocols to ensure therapy is individually adapted to the patient’s needs. Such a large group ensures success, since they have seen a large patient population. Least effective: Being discouraged by the physicians who were negative and felt threatened. RT No. 5: Most effective: It lessens their amount of work. The most effective—and least effective—ways the need for protocols was communicated to nurses were... RT No. 1: Most effective: To make sure all the patient’s respiratory needs are met, such as overlooked, underlying asthma, etc. RT No. 2: Most effective: Protocols improve the appropriate care for patients and decrease hospital time. RT No. 3: Most effective: Talking with the charge nurse and letting her know what we were planning and how it would affect them. Least effective: Trying to explain the changes with staff nurses who were unfamiliar with the process. RT No. 4: Most effective: I think nurses were receptive since protocols are something they can relate to since they have been doing them for a long time. RT No. 5: Most effective: Getting them to call us before they call the MD for orders on respiratory distress patients. The best help I got from system-wide administration was... RT No. 1: Education. RT No. 2: The same protocols across the board at each hospital—unified hospital care. RT No. 3: Numbers/data on therapies being done and the diagnoses of the patients receiving them. RT No. 4: Positive feedback from management—frequent. RT No. 5: The push to get them going. The one thing I could have used from system-wide administration but didn’t receive was... RT No. 1: No answer RT No. 2: Nothing RT No. 3: More help/support in getting the process “advertised“ through all of the nursing units and doctors’ offices. RT No. 4: Not applicable RT No. 5: Extras The biggest “selling point“ for protocols in my hospital has been the fact that they... RT No. 1: Decreased length of stay for patients. RT No. 2: Decreased length of patient stay. RT No. 3: Having the capability for reducing the workload during the busy season and slow seasons. RT No. 4: Endorsed by the pulmonary group. RT No. 5: They have decreased the workload. The biggest “negative“ aspect of protocols I had to overcome was... RT No. 1: The time was not originally factored in for re-assessments. Not everyone understood/performed assessments the same. RT No. 2: Employees performing re-assessments. RT No. 3: Getting all of the staff inserviced and assessing the patients appropriately. RT No. 4: Some staff’s lack of ownership in doing the assessments completely, follow up, changing etc. Other staff often had to rework, redo assessments, or complete the process. RT No. 5: Trying to initially get the staff on board. The best advice I could give an RC manager just now embarking on a protocol program would be to... RT No. 1: Present it as a positive for the profession. Emphasize “professional.” Be patient and offer lots of answers. (Roundtable in the beginning.) RT No. 2: Guide each employee to make sure the assessments are done correctly to avoid future bad habits. RT No. 3: Start teaching, inservicing, and getting staff acquainted with the process at least six months before the process begins. RT No. 4: Make sure you educate, orient, and “win” the program to your staff and the physicians you work with. RT No. 5: Give it a chance, but you have to be 100 percent committed with the right numbers and staff. Cobb is a 302-bed acute care facility located in Austell, GA. The AARC thanks all the WellStar RTs who made this series possible by taking time out of their very busy schedules over the past year to answer questions regarding the implementation of protocols in their facilities.

The Protocol Diaries: The Final Edition