After almost closing its doors, UCSD’s respiratory care department thrives through implementing a new therapist-driven patient protocol program.

At the University of California, San Diego (UCSD) Medical Center–Hillcrest, respiratory care department staff members can boast of several recent successes. Within the past 8 years, the department has successfully implemented a therapist-driven patient protocol program, devised an information system that instantaneously tracks data acquisition and outcomes inputted by each of the department’s 90 full-time RCPs, finessed the joining of its administration and patient care services with those of a sister department 20 miles away, and still managed to keep ahead of the curve on new technological advances.

Like many respiratory care departments nationwide, the successful changes at UCSD have stemmed largely from a single adversity: The need to control cost. “[UCSD] is in the most competitive managed care environment in all of California, and there was no question that in order to survive in this environment, the hospital, and the department, had to find different ways of doing things that would radically reduce our costs,” says Rick Ford, RRT, RCP, director of the respiratory care department. By 1993, Ford says, goals of trimming budgets by 3 percent or 5 percent at the 440-bed hospital and its 120-bed sister facility, Thornton Hospital in nearby La Jolla, had vanished. “Our budget targets were 25 percent and 30 percent of prior operating expenses. There was no question about the need to reduce cost. If we didn’t do it, we simply wouldn’t be here today.”

Role Playing
Although the hospital briefly considered elimination of its respiratory care department, it chose instead the route of dramatic change. “There have been several departments across the country that have been eliminated or decentralized,” Ford notes. “But it made more sense to keep the respiratory care department here and put the therapists in a position where they could evaluate the necessity of treatment, and be experts in the application of technology and patient-family education.” The result? A new role for RCPs as evaluators and assessors.

The change came about through UCSD’s patient protocol program, first implemented in 1993. Today, the department’s protocol program has grown from two to more than 25 patient protocols, with no signs that the growth will stop any time soon. “Protocols were such a success for us. Before it was about survival, but now we’re so far ahead of the game, 99 percent of our patients are in the protocol program,” says Jan Phillips-Clar, BS, RRT, RCP, the department’s assistant director. Emergency department and pediatric patients remain exempt from protocols, although Phillips–Clar expects to see a pediatric protocol in place by mid-1999.

Care planning and patient needs assessment rank among the most essential, and useful, of RCP skills, according to Ford. Allowing UCSD’s respiratory staff to emphasize that aspect of their capabilities via its protocol program, the department found that it could “ensure that what the physician wants to happen, happens, that necessary care is provided, that unnecessary care is not given,” he explains.

“The reality is, respiratory care is one of those ancillary services that is available at the bedside 24 hours a day, 7 days a week,” Ford says. “RCPs are the ones who technically administer the therapy, so logistically, who better to make decisions regarding the treatment plan than the individual who is actually there at the bedside, administering therapy and observing the patient’s response?”

In keeping with that philosophy, when designing its patient protocol program, the department elected to make every staff therapist an evaluator. “Many places that implement these protocols rely on expert evaluators, people they hire just to perform this task,” Ford notes. “We wanted to make sure that all of our RCPs were experts in evaluations and that every one of them made care planning decisions–that we didn’t simply turn to an expert who came in once a shift to do the evaluation.”

Under the protocol program, Phillips-Clar says, the department not only rescued itself from elimination but created a valuable new role for its therapists. “At the same time, we identified some things the RCPs did in the past that held no value–some other practitioner could perform them more effectively,” she says. From a cost standpoint, the results are impressive: in its first year, the UCSD respiratory patient protocol program reduced departmental costs by $700,000, to $2.8 million over the next 4 years.

“The reason we achieved those savings is precisely because every therapist acts as an evaluator, so the patient isn’t looked at every 24 hours by an expert; every time we see a patient, that patient is treated by an expert,” Ford points out. Every patient-therapist interaction becomes an opportunity for treatment assessment, which allows for more accurate, efficient patient care. “Quite simply, you don’t have to wait until the next day to get care plans changed,” Phillips-Clar says.

Step One: Phasing in the Protocols
UCSD’s respiratory department encountered only minor physician resistance to the implementation of the patient protocol program. “Overall, we received good physician support,” Ford says. “It was important that the approach to implementing our protocol program involved our faculty every step of the way.” The department took care to ensure that its protocols did not simply mirror national guidelines but rather emphasized what UCSD’s own physician staff wanted for its patients.

In contrast to the physician reaction, it took more convincing to win over the department’s own RCP staff to the benefits of a patient protocol program. “Initially, when we implemented the protocol program, the nurses and physicians were on board, but our own therapists were not,” Phillips-Clar admits. “It’s easy to just go along with the program, and before protocols, our staff never got involved with what the chart stated–they just carried out the orders.” After exposure to the program’s goals and an exhaustive training program that provided RCPs with the tools to succeed as evaluators, however, Phillips-Clar says the staff welcomed the patient protocol approach.

“The training was intense,” Ford emphasizes. While the protocol program officially got under way in January 1993, “it took us a year to do the preparation and staff training work.” Even now, in 1999, many of the department’s weekly in-service education programs still involve assessment-oriented topics, he says.

Focusing on Technology
UCSD does not limit its education and training to implementation of new programs, such as the patient protocols. The entire department stresses the key role that knowledge plays in a well-run respiratory care environment. According to Ford, “we’re a very technology-driven field, so we expect our therapists to thoroughly understand all the devices we’re dealing with. A physician may order 40 percent oxygen and, at least at UCSD, it’s up to the therapist to understand all the available technology as well as the appropriate solution in a given situation. The physician really isn’t concerned with which device we use, the physician simply wants the patient to receive 40 percent oxygen.”

Ongoing training allows therapists at UCSD to apply their critical thinking and assessment skills in this type of situation, to communicate with physicians and nurses about how to solve the patient’s needs. For example, a full-time educator works with department staff to ensure continued competency both with complex respiratory devices as well as with high-risk treatment protocols, such as arterial blood gas, nitric oxide therapy, heliox (helium-oxygen mixture) therapy, and pediatric transport. A yearly skills fair also emphasizes the importance of keeping up-to-date with respiratory technology.

John Newhart, RCP, the department’s clinical research specialist, says that the constant technological flux inherent at any research and teaching hospital makes preparation all the more important. “We have a fairly sophisticated department; if anybody is doing it, we’re doing it here,” he says. “So we constantly hold staff workshops to keep everyone informed about new technologies and techniques.”

Although the department prides itself on its cutting edge status, Newhart also emphasizes the need for caution. “We do a lot of new things here, especially when it comes to ventilators and other devices, so we’re always on the lookout for new technologies. Still, we evaluate everything thoroughly.” Rather than adopt new devices just for the sake of innovation, UCSD keeps an eye out for technologies that will make the therapeutic process simpler by enhancing the patient protocols or by superseding devices that require excess staff time.

Streamlining Present and Future
Not long after UCSD’s patient protocol program began in 1993, the department took another big step when it introduced a department-wide information system, complete with handheld computers for the entire staff.

In addition to featuring a current version of the protocols so the computer can serve as a protocol coach every time an RCP works with a patient, the system allows for tracking of data and outcomes. In effect, Ford explains, it helps the department keep track of compliance simply by prompting each therapist to input not only the key patient data, but also the visit’s outcome: What did the therapist do based on the patient data he or she encountered?

“I’ve got therapists making critical patient care decisions out there. If they make a wrong decision, it may result not only in the patient being compromised, but also in physicians not trusting our program because we don’t have staff that make good decisions.” The information system offers a means of tracking therapist care plans remotely without the need to rely on supervisors in every area of the hospital. “The person with the data is in a better position to make decisions,” Ford insists.

Originally designed as a billing and documentation system, UCSD’s current information system resulted from a reconfiguration that emphasized bedside function and protocols. And while Ford is pleased with the system’s present capabilities, he notes that it has yet to reach its limits. “I still think we’re at the tip of the iceberg,” he says. Today, while the system interfaces with the hospital’s information system to eliminate some duplicate documentation, it remains essentially a respiratory care-specific system. “What I see happening down the road is that our information system will be better integrated with the hospital system and will facilitate an electronic medical record.”

New Freedoms for Staff
Patient protocols, a comprehensive information system, and other departmental changes have resulted in at least one obvious benefit for staff: “They don’t have supervisors looking over their shoulders every minute,” Ford says. However, the staff benefits far beyond cosmetic workplace independence. According to Newhart, “Our data acquisition system, combined with the patient protocols, has eliminated unnecessary treatments, which significantly freed up staff time to explore other areas.” Staff have welcomed the opportunity to expand their role both beyond the department’s doors–into skilled nursing facilities, for example–as well as into new treatment areas such as bronchoscopy, intubations, nitric oxide administration, and metabolics. Newhart also predicts a greater role in the hospital’s research efforts, and more opportunities to test emerging technologies.

The lack of supervisory input also made way for greater staff involvement in the department’s administrative processes. “We provide opportunities for our staff to participate in work groups, in which I totally empower them to make whatever decision is needed,” Ford explains. At any given time, four or five active staff work groups tackle key departmental concerns. The ongoing intensive care unit cost-containment work group, for instance, meets regularly to decide how to redesign a flow sheet, apply technology, or alter department policy. An education planning committee works to revise competency checklists and new employee orientation.

The Next Step:
Patient-Family Education
With its patient protocols and department-wide information system firmly in place, UCSD’s respiratory care department has broadened its focus during the past 12 months to encompass the role of staff as educators. “We’ve invested a great deal of time in ensuring that we move toward programs that give patients a better understanding of their disease,” Ford says. In addition to helping patients better understand their disease process so they can improve their self-care techniques, improve quality of life, and decrease their need for hospital visits, patient-family education allows the department to improve its overall customer relations. “The therapist is interacting with the customer at a level that demonstrates real concern and compassion, and we’ve found that patients really need that,” he says.

Following a recent continuous quality improvement (CQI) program that emphasized patient-family education, Phillips-Clar says that staff have increased their involvement in this crucial aspect of patient care. “Staff helped to develop take-home pamphlets, arranged to have manufacturer videos played on the hospital learning channel, and identified staff behavior that enhances patient teaching,” she says. After completion of the CQI, staff feedback regarding the quality of patient-family education improved 80 percent, according to Phillips-Clar.

“We recognize that RCPs, with their background skills and knowledge, and the fact that they’re in the patient’s room several times daily, are the best persons in this hospital to teach patients about respiratory interventions,” Ford adds.

Over the next few years, the UCSD respiratory care department plans to increase its emphasis on patient education. Ford hopes that in doing so, the department can take better advantage of its role within the community. “We are in a box here in the hospital,” he says. “We haven’t broken out of that box yet, but I’d like to see our therapists involved in outreach programs, smoking prevention programs, clinics, even asthma education in schools.”

Kathryn Olson is a contributing writer for RT.

UCSD’s Respiratory Care Department

  • Offers a patient protocol program which has grown from two to more than 25 patient protocols.
  • Holds staff workshops to keep everyone informed about new technologies and techniques.
  • Predicts a greater role in the hospital’s research efforts, and more opportunities to test emerging technologies.
  • Plans to increase its emphasis on patient education.