Respiratory Therapist: A Literature Review

Andrew Bogenschutz
Professor Rafaei
ENGL 2089
Literature Review
July 22, 2015

“Optimizing Utilization of the Respiratory Therapist”
Traditionally the role of the respiratory therapist has been heavily dictated and rather limited by the physician’s orders. For seemingly as long a respiratory therapy has been a recognized medical discipline, therapist have had to endure working under this physician-directed approach, until recent developments prompted an in-depth look into the overall efficiency of such physician-driven protocols. These developments were an over-utilization of respiratory care and misallocations. It was felt that respiratory procedures could be greatly reduced without increased adverse effects on patient outcomes. (Hess, D.
R. 1998) A clinical study, compared clinical outcomes of patients receiving treatment by respiratory care practitioner protocols with those by physician-directed orders, found that respiratory care by RCP-directed protocols for non-ICU patients were safe, more consistent with the standard care plan of their institution, and incurred lower costs than physician-directed respiratory care. (Kollef, 2000)

Literature Review Articles
A randomized study examined the efficacy of a single ventilator management protocol, as administered by a respiratory care practitioner-and-registered nurse-driven VMP, on medical and surgical ICU patients. (Marelich et al, 2000) It was conducted on 385 patients receiving mechanical ventilation at UC, Davis Medical Center from June 1997 to May 1998. The study revealed the viability and effectiveness of a single, easily implemented VMP in reducing the use or application of mechanical ventilation for ICU patients. The protocol did not require additional staff and could be implemented with minimal training in a registered nurse or RCP. It required a physician’s order only for termination. The protocol reduced mechanical ventilation by 2.33 days without increasing ventilator discontinuation failure rate. The house staff regarded the VMP protocols helpful to their patients. The RCPs and RNS who administered it have the competence to perform weaning. Their protocols reduced the duration of use of the equipment without incurring adverse patient outcome. (Marelich et al, 2000)

Another randomized study assessed respiratory care for adult non-ICU patients provided by a respiratory therapy consult service with that by a managing physician. The respiratory therapy consult service evaluated the volunteer patients based on sign/symptom algorithms patterned after the AARC clinical practice guidelines. Agreement between the algorithm-based standard care plan by an expert therapist and the respiratory care plan was in terms of appropriateness. This study found no differences between them on hospital mortality rate, hospital length of stay, total number of treatments delivered or days of dare. However, it did find that the respiratory therapy consult service care matched up with that of the standard care plan versus the physician-directed respiratory care. Moreover, the RTCS costs were slightly lower than the physician-directed respiratory care and thus realized slight saving without incurring adverse effects. The results suggest that an RTCS can improve the appropriateness of respiratory care orders when compared with the traditional physician-directed respiratory care. (Stoller et al, 1999) In this study, a team of researches examined the large-scale use and effectiveness of an RT-driven protocol on 1,067 patients with respiratory failure as against 9,048 patient days of mechanical ventilation. The study was conducted over a period of 12 months. The protocol included a daily screen or DS with spontaneous breathing trials, and physician prompt without a physician’s daily input. The RCPs achieved a 95% correct interpretation of the DS. Barriers were identified through a questionnaire and these were physician unfamiliarity with the protocol, RCP inconsistency for seeking an SBT for the physician, the physician’s reason for not advancing the patient to a SBT, and a lack of stationary unit assignments by RCP’s performing the protocol. The study concluded that the validated weaning strategy is feasible without the daily supervision of a weaning physician or team. RCPs proved capable of interpreting and performing DS data more than 95% of the time. The barriers can be dealt with by periodic reinforcement to improve compliance with the protocol. (Ely et al, 1999)

Conclusion:
In conclusion, the evidence has been mounting on the need to recognize the importance of therapist-driven protocols in improving patient outcomes. They reduce the length of time in the use of support equipment without the risk of adverse patient outcome. They have shown to be in greater agreement with clinical practice guideline-based algorithms as compared with physician-directed respiratory care. In terms of capability, RCPs have proved that they can correctly and appropriately perform and interpret daily-screen data more than 95% of the time without need for daily supervision by a weaning physician or team. These protocols may increase patient treatments but they may also reduce ICU and hospital stay and ventilator weaning time and time for spontaneous breathing as well as lower total hospital costs. More importantly, they enhanced patient care culture and staff relationship without negative impact. Therapists have also been receiving increased training in patient assessment to qualify them for the expanded role.

Works Cited:

Ely, E.
W., et al (1999). Large-scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Vol 159 American Journal of Respiratory Critical Care Medicine

Harbrecht, B. G., et al (2009). Improved outcomes with routine respiratory therapist evaluation of non-intensive care unit surgery patients. Vol 54 # 7, Respiratory Care: Daedalus Enterprises. Retrieved on November 23, 2012 from
http://www.upmc.com/careers/pathways/allied-health/respiratory/Documents/ImprovedOutcomes_NICU_Patients.pdf

Hess, D.
R.(1998). Professionalism, respiratory care practice and physician acceptance of a respiratory consult service. Vol 43 # 7, Respiratory Care: American Association of Respiratory Care. Retrieved on November 23, 2012 from http://aarc.org/daz/rcjournal/rcjournal/x.RCJOURNAL.COM02.21.07/content

Kollef, M. H., et al (2000). The effect of respiratory therapist-initiative treatment protocols on patient outcomes and resource utilization. Vol 117, Chest: Clinical Investigations in Critical Care. Retrieved on November 23, 2012 from http://journal.publication.chestnet.org

Marelich, G. P., et al (2000). Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses. Vol 118, Chest: Clinical Investigations on Critical Care.

Restrepo, R. D, et al (2004). Protocol-driven ventilator management in children: comparison to non-protocol care. Journal of Intensive Care Medicine: Sage Publications

Stoller, J. K., et al (1999). Randomized controlled trial of physician-directed versus respiratory therapy consult service-directed respiratory care to adult non-ICU inpatients. Vol 158, American Journal of Respiratory Critical Care
Medicine: