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RT STAT: IS Q2 for post-op prevention of atelectasis

By Shawna Strickland posted 03-06-2014 09:38

  
Standing orders have been a part of the RT's work life for a very long time. Have asthma? Standing order for Q2 albuterol x 24 hours. Just have surgery? IS Q2 hours and PRN until discharge. I am a total advocate for standardizing care across the continuum but we can't forget that the "asthmatic" is really an individual and that surgical patients have unique challenges that can't be addressed by a standing order. Now, don't get me wrong...I'm a big fan of protocols. But a standing order isn't a protocol. A standing order is a set of orders that direct care for all individuals admitted with a certain diagnosis with no room for individualization.

How do we individualize care, then? First, we can't forget to assess the patient on a regular basis. Does the patient wheeze? It might not hurt to try a bronchodilator. But we can't simply administer a medication and not look at outcomes. Did it improve patient condition? Does the patient feel better? Are we achieving our desired clinical outcomes? Is the answer yes? Great! Let's continue the therapy. Is the answer no? Then let's stop this therapy and find something else that works.

Second, we have to know the evidence. It would help my patient if I were to find evidence that showed other patients with similar conditions responded well (or didn't respond) to certain therapies. But where do I find that evidence? As a respiratory therapist, my first step should be the AARC clinical practice guidelines webpage. Some CPGs are related to condition, some are related to therapy. CPGs "are statements that includes recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options" (Institutes of Medicine, 2011). Basically, these recommendations are based entirely on the evidence available. A good, trustworthy CPG is based on the systematic review, considers all patient groups, manages conflicts of interest, and has a transparent process.

Think back to the last time you were asked to administer Incentive Spirometry Q2 post-op CABG to prevent atelectasis. Did you grumble to yourself that this wasn't effective? Complain to a co-worker that the ordering physician was mistaken in his/her belief that IS did any good? Did you know that the AARC published a CPG in 2011 that specifically does not recommend "routine use of incentive spirometry to prevent atelectasis after coronary bypass graft surgery"? (Don't believe me? Check out page 1603, item 14.5: http://www.rcjournal.com/cpgs/pdf/10.11.1600.pdf). Instead of complaining about the ineffective order, perhaps we should take a more proactive approach to educating our colleagues and sharing the evidence.

I'm not saying that every physician will accept a CPG at face value during the first discussion. We're hardwired to be critical of studies and CPGs...as well we should. However, the goal of a good CPG is to make sure we're delivering effective care and reducing unnecessary treatment (which saves overall healthcare costs, too). Seriously, it's all about the patient. Delivering ineffective and unnecessary care isn't just an annoyance to the RT...it's also a potential source of preventable harm and excessive cost to the patient, too.

By the way...if you haven't done so already, check out the AARC's CPG webpage. It not only has the CPGs produced by the AARC, but also provides access to CPGs from other organizations such as the NAEPP EPR-3, ATS/ERS spirometry guidelines, CFF pulmonary guidelines, NCP palliative care guidelines, and much more. http://www.rcjournal.com/cpgs/index.cfm
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