Have you read this yet? http://rc.rcjournal.com/content/62/3/259 or https://www.ncbi.nlm.nih.gov/pubmed/28028189
"Implementation of a β-Agonist/Airway Clearance Protocol in a Pediatric ICU" was published in the March 2017 Respiratory Care Journal. The main discussion identifies areas in which a change in provider often means a change in therapy, seemingly arbitrarily at times, and how respiratory therapists can ameliorate this problem.
Respiratory therapists possess the skills to evaluate a patient and can determine when prescribed therapy is inappropriate, and are potentially being underutilized as part of the diagnostic care team or used inefficiently. In this article by Lowe et al,1 the authors guide the reader through one institution’s strategic implementation of a therapist-driven protocol to provide more consistent care to patients, increase the perceived value of RT staff, and address an area in which data is often insufficient.
Although it’s not the focus of their study, the data from Lowe et al’s survey reveals a difference in opinion regarding appropriate frequency of therapies between LIP and RT. While both groups agreed that the objective scoring system provided by the new protocol delivered more consistent care to patients, LIP’s were more likely to believe that patients were not receiving therapies often enough compared to RT’s being more likely to believe that patients were still being given treatment too often (nevertheless, the majority of both groups reported that they believed the treatment frequencies were adequate).1
Perhaps because the side effects of the therapies provided by RT generally tend to be relatively benign and infrequent, many providers are perceived to adopt a “Why not?” approach to ordering respiratory treatments such as bronchodilators and mucus clearance adjuncts and are ordering these therapies at a higher frequency than may be necessary. Many providers will agree that they are ordering a therapy that isn’t necessarily indicated, but they know that placing the order ensures that their patient will be seen by an RT. Surely their hope is that their patient is assigned the RT who adopts a communicative team approach to patient treatment and isn’t afraid to talk to the provider about alternatives if needed. If the RT has the mindset that they are only there to do as they’re told and to follow orders, this results in the patient potentially receiving unnecessary or inappropriate treatments. This is when therapist-driven protocols are perhaps the most valuable.
The RT’s responsibility after receiving a new order has been addressed before. Dr. Op’t Holt’s editorial published in the March 2016 issue of RCJ discusses how RT’s need to pay more attention to the big picture instead of just carrying out an order. “As therapists, we need to ensure that when we give an aerosol treatment, it’s not just because it was ordered, but rather with attention to whether the aerosol actually makes it to the airway, whether it’s indicated, and whether we have assessed the patient before and after the treatment to see if it was effective.”2
Speculation into possible rationale for orders as well as suggestions for alternatives and methods to approaching this topic with providers can be found on the AARConnect discussion boards. “[The providers] have to try something, and they want another set of eyes watching their patient,” wrote Brian Pruss, staff therapist and HBO Tech at Avera McKennan Hospital in Sioux Falls, SD. “If the neb truly isn’t indicated, educate them on why but you’ve got to have good reasoning and an alternative recommendation.”3
Marc Blanchard, a respiratory educator at Munroe Regional Medical Center in Ocala, FL, pointed out that this can be a great opportunity for RT’s to demonstrate their value in a busy inpatient setting by taking a more active role in assisting the diagnostic team with their input, which increases the perceived value of the respiratory care profession. Even though doing one treatment may help rule out a disease process or identify previously undiagnosed reversible obstruction, “sometimes doing nothing is just as valuable as doing something, and diminishes risk to the patient,” wrote Blanchard.4
Brian Walsh, a research coordinator at Boston Children’s Hospital, contributed that administering unnecessary therapies increases the cost of care and is a source of risk that should be considered carefully, especially when that risk hasn’t been proven to be of any benefit, despite the “it can’t hurt” attitude of many ordering providers. “Just because we can doesn’t mean we should,” wrote Walsh. He speculates that while providers may appear to be placing inappropriate orders for reasons unknown, “I find often that physicians or NPs want you to reassure them that you will work on the specific outcome they desire,” and suggests offering an appropriate alternative after showing the provider that their concern is being taken seriously.5
Are providers wrong to think “it can’t hurt” when ordering respiratory treatments? Well, yes! Like any therapy, there are side effects and risks that should be carefully considered. Singer et al6 reveal how bronchodilator use is associated with an increased requirement for more aggressive interventions and monitoring in patients with heart failure and no history of pulmonary disease, and “bronchodilators may be harmful in patients with heart failure or ischemic heart disease.” When a patient presents with respiratory distress, treating dyspnea with bronchodilators without determining the cause of the dyspnea is often a knee-jerk response from providers who may feel obligated to fix the patient’s most concerning symptoms as quickly as possible. Although the rapid effects of short-acting beta-agonists can be tempting, they should not be given unless the patient has a history that suggests reversible obstruction or other indication for therapy; shortness of breath is not an indication for bronchodilators.7
In addition to the potential for iatrogenic harm, unnecessary orders can have detrimental financial effects (Table 1). As Lowe et al indicate, eliminating unnecessary treatments is economically wise, not only for saving costs for the patient and payer but for the often-overlooked benefit of using an RT’s time more efficiently.1 The “Choosing Wisely” initiative is one resource to help determine when an order is appropriate based on a patient’s unique condition and prevent unnecessary or inappropriate tests, procedures, and medications from being ordered.8 While “Avoid administering beta-agonists to patients complaining of shortness of breath or cough unless patient exhibits signs of bronchoconstriction or has a history of reactive airway disease” isn’t a recommendation on their website yet, over 70 specialty societies have contributed lists of guidelines.
So, why not? Why not give patients a more consistent therapeutic approach to interventions? There is a clear need for more therapist-driven protocols in more areas, and any chance to improve and evolve the field of respiratory care should not be ignored. By becoming more valuable to the provider through accurate patient assessments and evaluations coupled with respectful and intelligent communication, RT’s can prepare their workplace to accept a more independent RCP role which may eventuate in smoother transitions when changes occur.
The next time you see an order that seems unnecessary or inappropriate, make it a priority to talk to the provider. Discuss the objective of the treatment, and suggest appropriate alternatives to the ordered therapy if needed.
It can’t hurt.
Please refer to the following for further reading:
First, do no (financial) harm
Waste: Unnecessary overuse of medical care causes both waste and harm
The Perfect Storm of overutilization
Choosing Wisely
Bibliography available on request.