Therapist-Driven Protocols Illuminate Waste, Brighten Department

Vol. 14 •Issue 11 • Page 8
Therapist-Driven Protocols Illuminate Waste, Brighten Department

By Shawn M. Proctor

In the past few years, reams of stories have been written about Therapist-Driven Protocols (TDPs). Advocates contend every facility should try to incorporate them, but even people who support the concept often quibble over the name. They should be called Patient-Driven Protocols or Care-Driven Protocols, many argue. Support is far from unanimous, however. Many proponents face resistance from medical directors, physicians and nurses when they try to put them in place.

It is clear therapists who think TDPs are necessary and those who are reassessing protocols already in place would benefit from the guidance of two advocates who believe protocols are the only way to fly. They have seen the benefits of TDPs and believe protocols will work for other facilities too.

When Skip Bangley, BS, RRT, director of Cardiopulmonary at Rutland Regional Medical Center in Rutland, Vt., thinks back five years, he remembers wasted time and money.


Bangley was director of Respiratory Care at St. Joseph’s Health Services in Rhode Island (two hospitals in the Providence area), when he realized TDPs were desperately needed.

“When I made rounds, I noticed a third of all patients were in maintenance mode and did not need RTs involved with them at that level,” he recalled.

He could not justify asking hospital administrators to supply additional FTEs since it was obvious some of the patients “should be erased from the board.” Instead, he turned his attention to what was wrong: wasted hours and money on needless treatments.

Determined not to fall back into the ’80s dark ages of lay-offs and uncertainty, Bangley set out to eliminate waste and prove his department was worthwhile at the same time. While advocating changes, he was fearful of people being laid off and tried to take a pro-active role in simply eliminating waste and shifting staff where they could do the most good. If administration knows there is no fat to be cut and therapists are seeing only patients who actually need care, then they are less likely to cut FTEs, he said. The changes in care resulted in a decrease in the length of stay and staff ability to see more patients.


With the guidance of a book by Judy Tietsort, RN, RRT, FAARC, and George Burton, MD, Therapist-Driven Respiratory Care Protocols, Bangley and his medical department created some sample protocols and pitched the idea to administrators. The medical director, whom Bangley described as a strong pulmonologist, agreed to use the new protocols on his patients and assess the outcomes. As the results came back, he began to tout TDPs to others in the hospital.

Over the next two years, protocols slowly became an integral part of St. Joseph’s philosophy of respiratory care. In addition to cutting costs, the protocols led to therapist contentment as well, Bangley said. “Our RTs became more involved in acute aspect of care,” he explained. “We needed practitioners, not robots.”

When Bangley left for Rutland Regional in Vermont, he realized it would mean starting over. Packing samples of his TDPs, he was prepared for a long, drawn-out process at his new hospital. But he found it was easier the second time around because he did not start at square one. He started to work on them immediately.

He began as he had before. Bangley demonstrated how protocols work and showed how they reduced costs through audits. Then he kick-started an asthma protocol using national guidelines adapted for the facility.


To their credit, Rutland’s doctors did not resist change. “The asthma protocols have been a win, and doctors have seen they are working,” Bangley said. Currently, they are trying new protocols on a select patient sample.

Although patients have been the biggest beneficiaries of the change, RCPs have gained in stature too. “The facility is very proud of its therapists,” said Bangley. “They have the ability to think on their feet and adjust to different situations as they arise.”

John Burkhart, MBA, RRT, respiratory care supervisor at the Cleveland Clinic in Cleveland was a staff therapist at the facility when TDPs were on the drawing board nine years ago. The process for change started when the department began auditing unneeded respiratory treatments.

Department leaders like Lucy Kester, MBA, RRT, education coordinator, et al., created indications and contraindications for different modalities and then measured treatments against the guidelines. The results were startling.

“We found that about 25 percent of the therapies given were not indicated,” Burkhart said. “And approximately 10 percent of the patients examined had indications but were not receiving therapy.”


That first study was used to justify the need for protocols, which were provided by what the Cleveland Clinic called a Respiratory Therapy Consult Service (RTCS). The protocols were not something automatically adopted once proposed.

“Hospitals have become more of a business, so in order to sell something to administration, you have to show a need,” Burkhart said. And you also have to show you can fit the expectations.

“We pride ourselves as good patient assessors, so who better to come up with the care plan for treating respiratory patients than the person delivering the therapy?” he asked.

James K. Stoller, MD, medical director, (See Side Bar) saw virtue in the results and began looking into implementing the consult service during weekly management meetings. The Cleveland Clinic decided to use sign and symptom based protocols.

For example, “If a patient has wheezing, we would most likely deliver a bronchodilator treatment,” explained Burkhart. The consult service created protocols for aerosol therapy, bronchlopulmonary hygiene, hyperinflation and oxygen therapy.

By the end of the following year, all the elements of the RTCS were implemented. Burkhart admits as a staff therapist he was not involved with the leadership that brought the protocols to fruition. However, he can attest to the positive results.


“It immediately changed our everyday work practice,” he said. “We went from just taking orders to evaluating the patient, coming up with and implementing a care plan and assessing the patient response. We became professionals who assess and treat. Right away it made a big difference.”

To critics who claim it might be too much responsibility for already overloaded RTs, Burkhart said: “It adds to your job satisfaction quite a bit. We have done surveys. That is why we are able to recruit and retain staff,” he said. “They feel they are doing what they have been trained to do in school.”

According to Burkhart, it is a simple equation: Responsibility plus autonomy equals job satisfaction. “You have a responsibility for that patient’s health and that is a motivator. You are patient-focused rather than task-oriented,” he said.

To other critics who believe nurses and physicians will revolt, he noted a little communication goes a long way. “The protocol service is an evolving animal, so if physicians and nurses wanted to make changes to the protocols, we listened,” he said. Still others have a voice as well. “Many changes were actually proposed by therapists.”


TDPs can increase a department’s respect around the facility. “We are freed up because we are not doing some of the ‘Mickey Mouse stuff,’” Bangley said. “That has increased our respect among the nurses, because in the past when we were called, we were tied up doing spot checks on another floor.”

Work-place politics can play a major role in the process as well. According to Bangley, it requires a considerable amount of skill to coordinate concepts with a medical director, hospital administration and various interested subcommittees. They all want to be educated and involved with the decision. It takes skill and care to be persuasive without trying to “shove new ideas down their throats,” he said

Know your own hospital’s politics, and play the game, Bangley advised. “That’s the homework you have to do up front.”

Payoff for the extra work is substantial. Cleveland Clinic’s results speak for themselves. Between 1993 and 1998, the protocols have decreased the number of annual therapies from over 202,700 to under 170,000. The total savings amounted to $327,000.

That’s quite a boon.


Burkhart and Bangley have a few tips for departments looking to light the way to a TDP-charged future:

• Prove an efficiency problem by auditing treatments;

• Create protocols and estimate the amount of saved money;

• Search for a physician to champion the idea. Face it. Physicians listen more closely to peers;

• Work to convince the medical director to take a strong role and sell the concept to administration, otherwise it will be an uphill battle;

• Know your workplace’s politics and work within the system;

• Once you get TDPs in place, review them regularly and remain open to changes;

• Think of services therapists can expand into, like pulmonary rehab, because TDPs may create free time.

“We need to do things so we are involved more in total patient care. We have lost the big picture a little bit. I think TDPs are the only way to go,” Bangley said.

Departments without TDPs need to start thinking about them, because waste puts a facility at a huge financial disadvantage, according to Bangley. “Unless you have put them in place or you are looking at them, you really need to be uncomfortable,” he said. “Hospitals are still closing.”

Shawn M. Proctor can be reached at [email protected].

Expert Forges Respiratory Believers

Facilities and caregivers who still believe therapists are useful only for nebulizer treatments clearly did not sit in on Dr. James K. Stoller’s Donald F. Egan Lecture October in Cincinnati.

Therapists looking to create a powerful argument for TDPs need look no further than Stoller’s pro-respiratory comments.

“In the current cost-attentive health care climate, the effectiveness of various providers in delivering care is being examined closely,” Stoller said in his presentation, ”Are Respiratory Therapists Effective? Assessing the Evidence.”

His talk showed therapists are extremely effective and cost efficient.


According to the medical literature Stoller cited, the answer to the speech’s question may surprise even the most hardened physician-only supporter. “Trials found in the context of a protocol service [in non-ICU care], RT-directed care allows better allocation of respiratory care services than physician-directed care.”

In closing his presentation, he spoke to his therapist-dominated audience directly: ”You are effective and you add great value to current health care.” But he admitted more work is still on the table. “Close collaboration with physicians (medical directors) who have appropriate expertise in pulmonary/critical care medicine and/or anesthesiology is needed.”

–By Shawn M. Proctor