Physician-Ordered Respiratory Care vs Physician-Ordered Use of a Respiratory Therapy Consult Service

Results of a Prospective Observational Study

¹ From the Section of Respiratory Therapy, Cleveland Clinic Foundation
² From the Department of Pulmonary and Critical Care Medicine, and Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation

Objective: To assess the impact of a respiratory therapy consult service (RTCS) on practices and appropriateness of ordering respiratory care services

Design: Nonrandomized prospective observational cohort study with concurrent controls.

Setting: Adult non-ICU inpatient wards of an academic medical center.

Patients: A convenience sample of 98 adult non-ICU inpatients at the Cleveland Clinic Hospital, representing 20 inpatient clinical services. Patients whose respiratory care plans were determined by respiratory care practitioners using sign and symptom-based algorithms to specify treatment comprised the treatment group (n=51, respiratory therapy consult group). The nonconsult group (n=47) were patients whose respiratory care plans were specified by their own physicians.

Intervention: Specification of the respiratory care plan by the RTCS vs by the physicians themselves. Use of the RTCS was at the discretion of the managing physician.

Outcome measures: Types and number of respiratory care treatments, length of hospital stay, costs of the respiratory therapy provided, appropriateness of respiratory care orders (based on comparison of the actual respiratory care orders with a reference respiratory care plan generated by a study investigator who was kept blind to the actual respiratory care plan), and adverse respiratory events.

Results: Patients for whom the RTCS was requested by their physicians had a greater severity of respiratory illness based on having a lower triage score, but were otherwise similar at baseline. Fewer initial orders for respiratory care were discordant with the reference algorithms in RTCS patients (15%±26% [SD]) than in nonconsult patients (43%±36%; p<0.001), and a smaller fraction of RTCS patients received at least one discordant initial respiratory care order (37% vs 72%; p<0.001). Though provided to sicker patients with longer lengths of hospital stay, RTCS-directed care incurred similar respiratory care costs per patient ($335.63±$272.69 [RTCS] vs $349.06±$273.27; p=0.72).

Conclusions: These results suggest that the RTCS can be an effective strategy to allocate respiratory care strategies appropriately while conserving the costs of providing respiratory care.

Key Words: misallocation • respiratory therapy • respiratory therapy consult service • therapist-driven protocols

Submitted on January 1, 1995
Accepted on February 7, 1996

This article has been cited by other articles:

				E. W. Ely, M. O. Meade, E. F. Haponik, M. H. Kollef, D. J. Cook, G. H. Guyatt, and J. K. Stoller Mechanical Ventilator Weaning Protocols Driven by Nonphysician Health-Care Professionals : Evidence-Based Clinical Practice Guidelines Chest, December 1, 2001; 120(6_suppl): 454S - 463S. [Abstract] [Full Text] [PDF]

				M. H. Kollef, S. D. Shapiro, D. Clinkscale, L. Cracchiolo, D. Clayton, R. Wilner, and L. Hossin The Effect of Respiratory Therapist-Initiated Treatment Protocols on Patient Outcomes and Resource Utilization Chest, February 1, 2000; 117(2): 467 - 475. [Abstract] [Full Text] [PDF]

				C. Wong, F. Visram, D. Cook, L. Griffith, J. Randall, B. O'Brien, and D. Higgins Development, dissemination, implementation and evaluation of a clinical pathway for oxygen therapy Can. Med. Assoc. J., January 1, 2000; 162(1): 29 - 33. [Abstract] [Full Text] [PDF]

				J. K. STOLLER, E. J. MASCHA, L. KESTER, and D. HANEY Randomized Controlled Trial of Physician-directed versus Respiratory Therapy Consult Service-directed Respiratory Care to Adult Non-ICU Inpatients Am. J. Respir. Crit. Care Med., October 1, 1998; 158(4): 1068 - 1075. [Abstract] [Full Text] [PDF]