Although every hospital provides a different set of practice guidelines, health care workers agree that consistency is key.
When it comes to determining whether respiratory care clinical and patient guidelines provide optimum care at the lowest cost, there appears to be a blurred definition of the guidelines or protocols that are in use. Many respiratory care professionals interchange the two words, causing uncertainty about what is actually being followed. It is a situation that Loren Greenway, MBA, PhD, RRT, administrative director of pulmonary services at Salt Lake Valley Hospitals in Salt Lake City, comes across frequently. “People ought to stop talking about guidelines when they’re really not guidelines, or protocols,” he points out. “When we talk about using protocols, I have a hard time talking to other people who say they use protocols because in fact what they do is not much of anything. They have a flow diagram written, they may or may not follow it, it’s not evidence-based, and there are no rules. As far as I’m concerned, that’s not a protocol, it’s a guideline. Until we start speaking the same language, we’re not going to get anywhere in respiratory care, and medicine is just going to move on without us.”
The American Association for Respiratory Care (AARC) has established clinical practice guidelines that provide individual hospitals with standards that are flexible enough to be molded to meet specific facility needs. The guidelines also bring accountability and consistency to health care. “The definition of a clinical practice guideline is basically a systematically developed statement to assist practitioners when making decisions concerning patients,” says Jerry Greene, MPM, at Veterans Administration Medical Center, Castle Point, NY. “The guidelines are really a tool to assist in providing what the appropriate health care for those specific clinical circumstances is.”
But that broad definition also leads to confusion among those in the medical field as to what constitutes a proper clinical guideline. In many cases, while the AARC guidelines are used as a tool, they are not the deciding factor when determining the best care for the most advantageous cost. “People put a couple of triangles and boxes down on paper and say that’s a flow diagram and that’s what we do,” Greenway says. “If they want to call them guidelines, they ought to call them guidelines, and then they ought to list the evidence as it relates to whatever recommendation they’re trying to make. The National Institutes of Health (NIH) guidelines for asthma management do a good job of that. But there are not many rules basically. It’s really subjective as to what each of the decision nodes means, so you can decide if you want to follow what it recommends or not.”
Over the past 10 years, the Salt Lake Valley Hospitals, comprised of three hospitals in the state, have continuously developed and refined their protocols for respiratory care. Greenway explains that the hospital uses very few of the AARC guidelines because they are not specific enough to meet its needs. “We don’t use guidelines and algorithms the way most people do because they allow for too much independent practitioner judgment based on experience, not on data,” he says. Instead, the respiratory care department has established protocols that are rule-based and intensively reviewed by expert panels. “Our protocols require data and not necessarily experience. We call them implicit rules meaning that if a set of symptoms is noted, a specific care protocol is followed.”
Greenway, who has been with Salt Lake Valley Hospitals for 18 years, has observed that the guidelines established for the critical care pulmonary division have resulted in more standardization of care. “If a patient comes in today, they’re going to get treated basically in the same way as if they had come in a month from now. That may have not been the case previously, depending on who was taken care of them at the time,” he points out. “There wasn’t any consistency, but that’s pretty much changed now because of the guidelines. There are specific rules that everybody has agreed to follow and they’re explicit as they relate to the data required to make decisions in each of the rule steps.”
The standardization has naturally led to cost control. “With the standardization of care that is delivered, we have seen a substantial decrease in costs and an improvement in quality. And that’s because the rule-based process is grounded on evidence and data and it’s not subject to someone’s personal opinion.” He illustrates a protocol in action, using a patient on a ventilator as an example. “We manage the ventilator based on the physiology that the patient presents, not on our own subjective opinion of how things should go,” Greenway explains. “The guidelines, which are computerized, are specific to the disease entity and the process we’re trying to accomplish.”
Greenway admits that his hospital’s approach to guidelines is quite different from those of other facilities. Yet, he stresses that physicians, nurses, and therapists do have the option not to follow the guidelines if a situation calls for a different form of treatment. “The data are based on experience and input from clinicians and evidence-based literature. You take into account a person’s opinion and then their opinion has to agree with the literature. And if that’s the case and everybody agrees, then that’s the direction we move,” he explains. “But our guidelines are not set in stone. If someone has an objection and wants to opt out of protocol, they can opt out of it at any time they want to, but they have to document the reason why they opted out. It then becomes a point of discussion in the next protocol meeting.”
The protocol meetings, attended by physicians, give the guidelines accountability. It is what enables the hospital to achieve a more than 90%compliance rate. “It’s an excellent process,” Greenway says. “We discuss the physician’s logic to determine if it was appropriate. They can opt out based on their own clinical judgment, but they have to defend the reason. We assume that the logic is wrong and that the protocol clinical judgment is always right until proven otherwise.” Greenway points out that this subjectivity actually drives up cost. “For instance, I’m a doctor and I want this patient to have 15 lab tests done today because I want to know what everything is. And then you ask the question, ‘What decision did you make based on all that information that you gathered?’ If you didn’t make any decision, then why did you gather the information? So what we try to do is get specific pieces of data that we actually make decisions on and that’s the data that we use. You can order as many x-rays or lab results that you want, but in fact there aren’t many decisions based on those tests. We still do blood gases and routine lab tests, but we don’t do them nearly as often as we used to. And that’s what actually decreases health care costs. These costs decrease as you eliminate tests that are of questionable value. It’s not doing more things efficiently, it’s doing less things. And that’s what we’re striving to do.”
Greenway is currently spearheading a process to standardize respiratory care procedures in the area of small volume nebulization. “We’re going to try to develop a system to standardize how it’s done, on which patients it’s done, and then randomize patients into two specific groups to decide if it needs to be done at all. If it doesn’t need to be done, then we’re not going to do it anymore,” he explains. “Right now, there’s no evidence, so we’re going to establish evidence and meld it with the practice. If the practice is different from what the evidence supports, then we’re going to challenge that practice scientifically.”
At Southside Hospital in Bay State, NY, Stephen Smith, assistant director of respiratory care, conducted a similar process. While protocols had been in place at the hospital for about 5 years, they were not being followed consistently by physicians. His pilot program, which coincided with a respiratory care assessment in accordance with the Joint Commissioners Standards of Patient Assessment, determined that guidelines are effective in providing optimum care to patients. “When they are used, guidelines give therapists the opportunity to use their skills and to help manage the patient,” Smith explains.
As a result of the pilot program, Smith received funding approval for a full-time assessment coordinator. The new coordinator will serve as a liaison between respiratory care, the physician and the patient. “It will be a unique process for our area and different in terms of our staff treatment of patients,” Smith says. “Right now, there’s no time to get back to doctors. So the assessment person will determine if a patient’s therapy needs to be increased or decreased and contact the doctor immediately. Then the chart will be flagged and the follow-up conducted at the next physician’s visit. We’re not here to take over for the physician, but rather to serve as an extension of the physician.”
Research indicates that the new protocols, with the addition of a dedicated person for assessment, will reduce hospital and patient costs in the long run. “The use of protocols can eliminate a patient remaining on therapy longer than needed,” he explains. “Decreasing the length of stay or our service will impact the hospital and the patient. The assessment position is doing more than meeting standards. It’s addressing good care.”
For John Welker, director of respiratory services at Chapman Medical Center in Orange, Calif, respiratory care guidelines enable the staff to provide a much higher level of patient care. “We set standards of care, all of which are discussed at monthly meetings,” Welker explains. “We’re given autonomous orders at this facility. No patients are the same, so to have the autonomy to change treatment under certain guidelines enables everyone to work smarter.”
When Welker first came to Chapman in 1997, there were limited protocols in place. Those that were in place were seldom, if ever, used by physicians. So through interactions with physicians, nurses and surgeons, educational guidelines were established through a team approach. “Each person accepts their responsibility level and no one views patient care as a mere job. They love what they’re doing because they’re part of a team,” Welker says. “Physicians respect the needs of respiratory therapists, and medical directors are very active in the department.”
While health care costs are forcing many departments to streamline their services, Welker notes that his department’s guidelines have allowed him to enhance its services. “Our respiratory care department is expanding to include such services as ultra-sensory testing and nerve stimulation. By working more effectively and productively, the guidelines have enabled us to enhance our department and our budget.”
The Veterans Administration Medical Center presents its own set of unusual problems. “In the VA, there’s so much pressure for us to ensure that we’re doing all we can to promote high-quality care,” Greene explains. “We have to be able to demonstrate consistency, quality, and patient satisfaction and by following the guidelines, we’re going to get those.”
“I think the most important issue is that when you take a look at how guidelines improve care, the first thing that they really do is give you a handle on the right amount of care. It gives you a guideline to what should be there. And most patients don’t get what should be there, so guidelines show that we’re undercutting services or shorting the patient in terms of the proper amount of care,” Greene points out. “It allows a chance to decrease–or give you greater potential to decrease–medical error, either an error of commission or an error of omission. It gives you an idea of what the evidence-based standardized treatment approach is. These are the things that help the practitioner do the right thing in the right way.”
The VA Medical Center in New York, and those throughout the entire network, utilize the AARC guidelines, but allow for flexibility as needs warrant. “Most of them are the AARC’s consensus statements and guidelines,” Greene notes. “I think the most important issue when we talk about guidelines is that they ensure consistency and predictability. When we have so many people turning to teams and interdisciplinary forms of care, this allows the different inputs to be homogenized. And when we go to update a guideline, we now have multiple input and it becomes a consensus statement, so that if we want to change any guideline, it has to be with the consensus of all the practitioners. We get consistency of care, we get consistency of quality all across the network, so what is done at one place is done in another. And that really is important.”
Equally important, Greene says, is the accountability that comes through the use of guidelines. “If we’re saying that we’re going to give the right amount of care, we’re going to prevent errors, and we’re going to make care consistent, at the same time we’re also going to be saying that if you deviate from a guideline, there has to be a reason why. So that has to be documented,” he emphasizes. “And when we get a lot of these documentations on several patients’ charts, then we have to go back and take a look to see if the guideline is too strict or if there’s something else wrong with it, that perhaps it needs to be changed.”
For both physician and patient, guidelines also foster education. “When new employees come, it helps show them how things are done. Guidelines give people an opportunity to understand where others are coming from in terms of knowing why a particular guideline is recommended,” Greene explains. “For patients, you can educate them on what they can expect in terms of their treatment. It’s an educational format for them too. So patients should be reassured in the long run that they’re getting the best care and they understand what’s going to happen to them so there’s no surprises.”
Greene reports that for the past 3 years, the VA has been developing cost accounting systems to help the network determine what it really costs to provide optimum care. “If you say that you are going to improve quality through the use of guidelines, in the long run that’s going to cut some costs. We’re pretty sure when you start talking practice guidelines, you’re talking about improved quality, improved consistency, and decreased errors. And all of those things automatically decrease costs.”
Maryellen Cicione is a contributing writer for RT. r
