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* From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine (Drs. Kollef and Shapiro), and Department of Respiratory Care Services, Barnes-Jewish Hospital (Mss. Clinkscale, Cracchiolo, Clayton, and Hossin, and Mr. Wilner), St. Louis, MO. This investigation was supported by a grant provided by the American Association of Respiratory Care.
Correspondence to: Marin H. Kollef, MD, FCCP, Pulmonary and Critical Care Medicine, Washington University School of Medicine, Campus Box 8052, 660 South Euclid, St. Louis, MO 63110; e-mail: mkollef{at}pulmonary.wustl.edu
Context: Physicians frequently prescribe respiratory treatments to hospitalized patients, but the influence of such treatments on clinical outcomes is difficult to assess.
Objective: To compare the clinical outcomes of patients receiving respiratory treatments managed by respiratory care practitioner (RCP)–directed treatment protocols or physician-directed orders.
Design: A single center, quasi-randomized, clinical study.
Setting: Three internal medicine firms from an urban teaching hospital.
Patients: Six hundred ninety-four consecutive hospitalized non-ICU patients ordered to receive respiratory treatments.
Main outcome measures: Discordant respiratory care orders, respiratory care charges, hospital length of stay, and patient-specific complications. Discordant orders were defined as written orders for respiratory treatments that were not clinically indicated as well as orders omitting treatments that were clinically indicated according to protocol-based treatment algorithms.
Results: Firm A patients (n = 239) received RCP-directed treatments and had a statistically lower rate of discordant respiratory care orders (24.3%) as compared with patients receiving physician-directed treatments in firms B (n = 205; 58.5%) and C (n = 250; 56.8%; p < 0.001). No statistically significant differences in patient complications were observed. The average number of respiratory treatments and respiratory care charges were statistically less for firm A patients (10.7 ± 13.7 treatments; $868 ± 1,519) as compared with patients in firms B (12.4 ± 12.7 treatments, $1,124 ± 1,339) and C (12.3 ± 13.4 treatments, $1,054 ± 1,346; p = 0.009 [treatments] and p < 0.001 [respiratory care charges]).
Conclusions: Respiratory care managed by RCP-directed treatment protocols for non-ICU patients is safe and showed greater agreement with institutional treatment algorithms as compared with physician-directed respiratory care. Additionally, the overall utilization of respiratory treatments was significantly less among patients receiving RCP-directed respiratory care.
Key Words: asthma • chronic obstructive pulmonary disease • outcomes • protocols • respiratory care
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