Randomized Controlled Trial of Physician-directed versus Respiratory Therapy Consult Service-directed Respiratory Care to Adult Non-ICU Inpatients

Abstract

Although current evidence suggests that respiratory care protocols can enhance allocation of respiratory care services while conserving costs, a randomized trial is needed to address shortcomings of available studies. We therefore conducted a randomized controlled trial comparing respiratory care for adult non-ICU inpatients directed by a Respiratory Therapy Consult Service (RTCS) versus respiratory care by managing physicians. Eligible subjects were adult non-ICU inpatients whose physicians had prescribed specific respiratory care services. Consecutive eligible patients were approached for consent, after which a blocked randomization strategy was used to assign patients to (1) Physician-directed respiratory care, in which the prescribed physician respiratory care orders were maintained (n = 74), or (2) RTCS-directed respiratory care, in which the physician's respiratory care orders were preempted by a respiratory care plan generated by the RTCS (n = 71). Specifically, these patients were evaluated by an RTCS therapist evaluator whose respiratory care plan was based on sign/symptom-based algorithms drafted to comply with the American Association for Respiratory Care (AARC) Clinical Practice Guidelines. Appropriateness of respiratory care orders was assessed as agreement between the prescribed respiratory care plan and an algorithm-based "standard care plan" generated by an expert therapist who was blind to the patient's actual orders. The compared groups were similar at baseline regarding demographic features, admission diagnostic category, smoking status, and Triage Score (mean, 3.8 +/- 0.9 SD [RTCS] versus 3.7 +/- 1.0). Similarly, no differences were observed between RTCS-directed and physician-directed respiratory care regarding hospital mortality rate (5.7 versus 5.6%), hospital length of stay (7.9 +/- 9.0 versus 7.7 +/- 7.3 d), total number of respiratory care treatments delivered (30.3 +/- 30 versus 31.6 +/- 30.5), or days requiring respiratory care (4.2 +/- 5.2 versus 4.1 +/- 3.6). Notably, using both a stringent (S) and a liberal (L) criterion for agreement, RTCS-directed respiratory care demonstrated better agreement with the "standard care plan" (82 +/- 17% [S] and 86 +/- 16% [L]) than did physician-directed respiratory care (64 +/- 21% [S] and 72 +/- 23% [L]) (p < 0.001). Finally, the true cost of respiratory care treatments was slightly lower with RTCS-directed respiratory care (mean, $235.70 versus $255.70/pt, p = 0.61). We conclude that (1) compared with physician-directed respiratory care, the RTCS prescribed a similar number and duration of respiratory care services at a slight savings (that did not achieve statistical significance) and without any increased adverse events; and (2) compared with physician-directed respiratory care, RTCS-directed respiratory care showed greater agreement with Clinical Practice Guideline-based algorithms.

Respiratory Therapist Job Perceptions: The Impact of Protocol Use

“…Specifically, by showing that respiratory care protocol use is associated with benefits regarding RT turnover and job satisfaction, these results extend our understanding of the benefits of respiratory care protocols. 9 In addition to their positive effect on allocation of respiratory care treatments, improved outcomes, and reduced costs, [10][11][12] this study suggests that respiratory care protocols can also be used to increase RT job satisfaction and reduce turnover intentions. In an environment of increasing demand and job shortages, RT job satisfaction and turnover intentions will be increasingly important to managers.…”

The Scientific Basis for Protocol-Directed Respiratory Care

“…Although physicians-in-training provided the intervention in this study, experience in other studies suggests that respiratory therapists can also be highly effective in this role. [30][31][32][33][34][35][36] Kallam et al 29 compared the prescribing patterns and associated costs with physician-directed care versus suggested RT-protocol-administered care. Protocols would have lessened the frequency of bronchodilator administration (eg, from 63.6% administered every 4 h to 11.3% administered every 4 h, P Ͻ .001) and the cost per patient ($10.3 Ϯ 9.4/patient vs $19.0 Ϯ 6.9/patient, P Ͻ .001).…”

“…Both trials compare the impact of in-patient respiratory care protocol services, versus usual physician-directed care, 35,36 and show that respiratorytherapist-directed care allows better allocation of respiratory care services than physician-directed care, with trends toward lower cost and no excess adverse events (Table).…”

“…In the first of these trials, Stoller et al 35 randomly allocated 145 non-ICU adult in-patients admitted to the Cleveland Clinic Hospital to receive respiratory care orders directed by the managing physicians, or to have their physicians' respiratory care orders pre-empted by those generated by a respiratory therapist using protocols. The protocols had a branching logic format, and were developed to operationalize American Association for Respiratory Care Clinical Practice Guidelines.…”

“…The study revealed that using respiratory-therapist-driven protocols (firm A) was associated with fewer RT treatments (10.7 for firm A vs 12.4 for firm B vs 12.3 for firm C, P ϭ .009), a greater percentage of bronchodilators administered via metered-dose inhaler (89% vs 77% vs 78%, P ϭ .01), fewer RT orders that were discordant with the protocol standard (24% vs 58% in firms B and C, risk 35 these benefits were achieved without any increase in adverse events. In summary, these 2 randomized controlled trials 35,36 (see Table 1) and the earlier observational studies [32][33][34] strongly satisfy both criteria to establish the scientific basis of respiratory care protocols. Specifically, respiratory therapists implementing protocol-based care benefit patients, and the use of such protocols enhances allocation and lowers cost, compared with traditional physiciandirected respiratory care.…”