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Guidelines for Respiratory Care Department Protocol Program

Ford Version 11.10.2008

The American Association for Respiratory Care (AARC) is the leading national and international professional association for respiratory care. The AARC encourages and promotes professional excellence, advances the science and practice of respiratory care, and serves as an advocate for patients, their families, the public, the profession and the respiratory therapist. The AARC recognizes and supports the use of therapist implemented protocols defined as:

Initiation or modification of a patient care plan following a predetermined      structured set of physician orders, instructions or interventions in which the therapist is allowed to initiate, discontinue, refine, transition, or restart therapy as the patient’s medical condition dictates. Note: This definition should not be Confused with programs that include that includes discontinuation of therapy without a reorder, flagging therapy for physician reorder, standing orders or policies that dictate therapy durations.

Current medical literature supports the use of therapist implemented protocols as an effective tool for producing improved patient outcomes and appropriate allocation of services. Protocols have been attributed with:

  • Helping respiratory therapists deliver appropriate and efficient care under conditions of an increased workload.
  • Assuring that all treatments have established indicators.
  • Reducing the volume of unnecessary care.

Evidence based literature supports the use of protocols to minimize unnecessary treatments and provide self-administration options for patients who demonstrate their ability to do so. Based on the demonstrated efficacy of therapist implemented protocols, it is the position of the American Association for Respiratory Care that institution-approved protocols should be used by respiratory therapists as the standard of care for providing respiratory therapy services under qualified medical direction.

It is recognized that the characteristics and structure of protocol programs thoughout the country have some variability secondary to facility specific policy and practice. All programs however must comply with Federal and State regulations and standards including those published by their State Licensing Boards, The Joint Commission as well as the Centers for Medicare and Medicaid Services. The AARC recommends that a policy and procedure governing the application of therapist implemented protocols be developed. The following policy guidelines are intended to promote compliance with such standards; however each department must refine their specific programs to insure regional compliance. Those responsible for drafting protocols and related policy should incorporate the following recommendations:

  • Department policy must specify which respiratory therapists can deliver care outlined in the protocol, inclusive of the competencies required of individuals and demonstration of skills and knowledge.
  • Medical Director oversight and accountability for services provided using protocols must also be specified in department policy.
  • The protocols should be written to reflect the indications, precautions, and therapy specifics as outlined in the AARC Clinical Practice Guidelines, or other evidence based references.
  • All policies related to protocols, as well as the protocols themselves, must be approved by the appropriate institutional governing bodies.
  • Policies for protocols must be compliant with other institutional policies related to the provision of care, with specific attention to pharmacy and nursing services. Because many therapist implemented protocols involve the administration of medication, there must be a single standard throughout the facility regarding the procurement, control and administration of medications.
  • A physician order is required to implement respiratory therapy managed by protocols. The order may include a request for “Respiratory Protocol”, a specific request such as “MDI Protocol” or other order details as specified and approved by the Medical Staff. (It should be noted that this is an area of contention with some surveying agencies when they encounter a facility that does not require a physician order).
  • Protocols must include criteria, thresholds, and decision points that require the physician be notified for continuation of the protocol, options to consider including exemption from protocol with requirements for new non-protocol orders.
  • Policy should also define emergent situations in which respiratory therapists can immediately initiate protocols without a physician order. Protocols initiated in this manner shall be reviewed and authorized by physician signature within 24 hours.
  • A quality assurance mechanism should be in p lace to assess if the respiratory therapist is providing care in compliance with protocol as well as capturing adverse responses.