Vol. 11 •Issue 3 • Page 45
Making Headway with Patient Driven Protocols
More than 25 patient driven protocols have been developed over the past eight years in an effort to improve the quality and reduce the costs of respiratory care at the University of California, San Diego Medical Center. UCSD’s protocols provide day-to-day refinements in care plans based on patients’ responses to ensure they get the maximum benefit from care.
Three of those protocols are specific to metered dose inhaler use. The first MDI protocol implemented at UCSD in March 1993 was developed for non-intubated adult patients. In April 1995, the department integrated the protocol program with the ICU’s care of ventilator patients. In June 2000, the protocol program was expanded even further to incorporate pediatric patients, ages 5 to 12.
It was recognized that MDIs are best utilized in those patients where there are relatively clear therapeutic indications and standardized approaches and measures for accomplishing the therapeutic objectives. As a result of the protocols, MDI utilization has gone from less than 10 percent to greater than 65 percent of total aerosol delivery.
RCPs AS EVALUATORS
All respiratory care practitioners are trained to be patient driven protocol evaluators at UCSD. They’re able to modify the plan of care per protocol during each treatment versus waiting for a “designated assessor” to alter the plan. After a physician has initiated the order for an MDI protocol, the RCP performs a patient evaluation, identifies any contraindications or hazards and then applies the clinical practice guidelines for the MDI protocol. The RCPs can initiate, alter or discontinue therapy without additional physician orders. However, the RCP must contact the physician when the patient’s condition regresses, if any adverse response is observed, or if the patient doesn’t progress through the protocol as expected.
Within the UCSD MDI protocols, RCPs are guided to select the proper dose and type of medication. Patients who have persistent diffuse wheezing are initiated on two to four puffs of albuterol. If a patient has a history of COPD, then he or she is started on albuterol/ipratropium. Physicians also could choose to use another medication, in which case the RCP converts and titrates the patient to the proper dosage.
Pre and post peak flows are obtained with each treatment. If there is no improvement in peak flow and wheezing persists, titration will continue with four additional puffs, with pre and post peak flows, until one or more of the following occurs: a decrease in wheezing, improvement in peak flow or FEV1 > 15 percent, the RCP has reached the maximum of 20 puffs (40 puffs on ventilated patients), or there is a fluctuation in heart rate > 20 percent and tremors or arrhythmias are noted. Re-evaluations are completed every 24 hours, at which time patients are assessed to determine if they are utilizing the MDI properly.
Outcomes evaluated within the MDI protocols include relief of dyspnea, reduction in expiratory wheezing, increased aeration or decrease in respiratory rate. Once a patient has been titrated to a normal level and can self-administer his or her own treatments, the RCP notifies the registered nurse to continue monitoring the patient’s MDI use. After the patient has been discontinued from the protocol, a 24-hour follow-up re-evaluation is completed to assure that an acute change has not occurred in his or her condition.
OPTIMIZING BRONCHODILATOR USE
The MDI protocols have been shown to optimize the administration of bronchodilators, in which the dose of inhaled bronchodilators is titrated by trained RCPs using measurable parameters of respiratory function. The MDI protocol for nonventilated patients allows the RCP to administer bronchodilators ranging from two to 20 puffs. In administering as many as 20 puffs through protocols, it became important to ensure that the RCP focused on minimizing any adverse affects, including heart rate.
A study was completed at UCSD to observe the effect that high dosages had on heart rate due to the recommendations and guidelines from manufacturers that have cautioned the utilization of high dose bronchodilators. From October 1998 to February 1999, data was collected on 43 patients who had received 16 to 20 puffs of either albuterol or albuterol/ipratropium. During this period, a total of 333 treatments were administered to these patients with an average dose of 17.34 puffs per treatment.
The mean heart rate among this group of patients was 100.16 pre-treatment and 102.67 post-treatment. Of the 43 men and women who received 16 to 20 puffs, only one who had a total of 47 treatments had an increase of heart rate of greater than 20 beats per minute, therefore terminating the treatment. The conclusion of this study indicated that high dosages of bronchodilators had no significant side effect on heart rate.
Prior to the development of the MDI protocols, the department provided as many as 5,000 aerosolized bronchodilator treatments per month from 1990 to 1993. In addition, analyzed data from 1992 estimated that 25 percent of the aerosolized bronchodilator treatments were given without being medically indicated. Since the protocols have been in effect, the respiratory care department has observed a 40 percent to 50 percent reduction in the delivery of bronchodilator therapy.
PEDIATRIC PROTOCOL
The MDI protocol for pediatric patients was the first protocol to be utilized among the UCSD pediatric population. Six months prior to its integration, members of the respiratory care department met with pediatric physicians and nurses to reach a consensus to ensure the unique considerations and needs among this age group had been met. In addition, the department’s pediatric development and improvement team created an age-specific, asthma-education coloring book to help teach patients and their family members about ways to manage the disease.
In order to observe the degree of the pediatric MDI protocol’s success, data was extracted from the department’s information system on 6,557 treatments over a one-year period prior to the implementation of the pediatric protocol. This was then compared to 1,568 treatments that were given over a three-month period after the protocol was implemented. The results indicated that the use of MDIs increased from 12 percent to 20 percent of total bronchodilator delivery, demonstrating an increase of the overall utilization by 67 percent.
MDIs VERSUS NEBULIZERS
At the medical center, policies regarding the selection of MDIs versus small volume nebulizers are formed by evidence-based findings within the literature and patient response. Small volume nebulizers are only utilized at the medical center if a patient is incapable by virtue of physical or cognitive impairment of administering an MDI; the medication prescribed is not available in the MDI form; the patient has already attempted maximum dosage via MDIs; or the patient has clearly demonstrated a reactive hypersensitivity to the MDI components. In cases such as these, the patient would receive bronchodilator delivery via small volume nebulizers or when indicated, per continuous nebulization. Exceptions to this practice require the approval of the medical director of respiratory care.
MEASURING PROTOCOL EFFICACY
It’s essential to have mechanisms in place to monitor the effectiveness of protocols. At UCSD, a respiratory care management information system was integrated into the department six months after the implementation of the patient driven protocols. Prior to this, observation for protocol activity within a single unit would utilize one to two hours of the patient driven protocol coordinator’s workday. A computer-generated report now allows the same activity to be tracked within less than five minutes. As a result, the RCPs can spend more time at the patient’s bedside versus shuffling through a manual paper tracking system.
Daily reports are generated though the information system that allow the RCPs to monitor patients’ responses to bronchodilator therapy. These reports are used while assessing the patient and completing their daily evaluations. Breath sounds and heart rates are compared pre- and post-therapy. In addition, the amount of drug titration and patient outcomes are documented. If a physician ever doubts the effectiveness of the protocol, an instant report can be generated through the system to give the doctor assurance that the care provided to the patient was the actual care delivered through the guidelines of the protocol.
The respiratory care department at UCSD is now beginning its ninth year of utilizing MDIs via protocols. As a result, the department has seen a significant decrease in treatments upon early implementation, which continues to be maintained. In addition, the cost per respiratory patient has continued to decrease over this period without adversely affecting outcomes.
REFERENCES
1. Ford RM, Phillips JE, Burns DM. Implementing PDPs. Respiratory Care Clinics of North America. 1996. 2:1.
2. Ford R, Phillips J, Burns D. Early results of implementing a patient driven protocol system (abstract). Respiratory Care.1993;38:1306.
3. Phillips JE, Ford RM, Morris TA, Burns D. UCSD Patient Driven Protocols. Daedalus Enterprises Inc. 1998.
4. Herzig, S, Phillips-Clar, JE, Morris TA. The effect of high dose bronchodilators via MDI/spacer on heart rate (abstract). 2000 AARC Open Forum.
Phillips-Clar is technical director of UCSD Medical Center. Ford is director of respiratory and pulmonary services at the same facility.
