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Wednesday, March 2, 2011

Treatment stacking and why RTs are so busy

Treatment stacking is something that I think all RTs do from time to time. And while this may not be ideal, it is often a necessity due to high patient loads and the uncertainty of when the RT will be needed at an emergency.

Treatment stacking, or more appropriately termed concurrent therapy, refers to giving more than one patient a breathing treatment at a time, and in many cases several patients at the same time. This is often viewed as bad because due to issues of patient safety and quality of patient care.

The American Association of Respiratory Care (AARC) Whitepaper on Concurrent Therapy notes that under the current health care system there are increasing demands on respiratory therapists on duty due to staff shortages. To get all their procedures completed, RTs feel pressured to stack treatments, "although it's against their better judgement."

Another interesting thing the AARC notes as a reason for the need to stack treatments is that many doctors and hospitals encourage superfluous ordering of bronchodilator breathing treatments. In fact, while I would estimate this figure to be at around 80%, the AARC figures that as many as 60% of all breathing treatments are not needed.

However, recently we had 20 patients on treatments, and my co-workers and I estimated about five needed the therapy, and this comes to a 75 percent unindicated rate.  Regrdless, the estimates for useless breathing treatments are somewhere between 60 and 80 percent, with the professionals taking the more conservative number.

There are many reasons for non indicated breathing treatments being ordered.
  1. Ignorance: The belief that all shortness of breath is caused by bronchospasm, the belief that all respiratory ailments will benefit from a bronchodilator, the belief that a bronchodilator will help a patient expectorate diseases, and the belief that nebulized bronchodilators work better than those given by MDI or DPI, and the beleif that nebulized Albuterol works similar to Tylenol to reduce a post operative fever.
  2. Intensity of Service: CMS will not reimburse for patient admission unless certain procedures are ordered to justify the patient needed to be admitted.
  3. Order sets: To meet intensity of service, many hospitals have incorporated these to make sure all patients diagnosed with certain illnesses (such as pneumonia) get breathing treatments.
  4. To create work: Some hospitals (Shoreline Medical included) want more treatments to justify budgeting RT staff.
  5. Pressure by bosses to get work done: RT Bosses believe a certain amount of pressure is justified because billings are dropped from our charting. After all, money is the bottom line.
So you can see, based on these five reasons for non indicated breathing treatments, many breathing treatments are ordered that simply are not needed.

To resolve the issue of treatment stacking, the AARC recommends that hospitals establish protocols. It notes that:
"The use of established protocols may help respiratory therapists deliver appropriate and efficient care under conditions of an increased workload. Protocols are based on scientific evidence and include guidelines and options at decision points. The use of protocols can help assure that all treatments have established indicators but also are highly effective in reducing the volume of unnecessary care. Evidence based literature exists supporting the use of protocols to minimize unnecessary treatments..."
Another option the AARC mentions to reduce the treatment load of RTs is to create a policy that allows the patient to administer his own breathing treatment, if the patient is stable and demonstrates that he is competent to do such a thing. I've actually done this, especially if I know the patient has treatments at home.

I would say that for larger hospitals protocols might work, yet at a smaller hospital that is trying to stay afloat, and often has only one RT on duty, it's difficult to go to protocols because the RT bosses are afraid this would result in too few breathing treatments, and an inability to justify budgeting the current level of RT staff.

Another reason administrators are afraid to go to protocols is because of the increased demand by CMS to order breathing treatments on account of their belief that certain procedures need to be ordered to meet criteria for reimbursement.

This is why our hospitals has developed order sets. Order sets work good in that they assure consistency in care based on best practice evidence, yet they also encourage unnecessary therapies just to be on the safe side.

So, ideally, an RT should never stack treatments. When I don't have ER, and don't have the stress that the ER pager might go off and I'll be needed down there for several hours, I am able to do one treatment at a time.

However, when I'm working alone at night, and I do have the ER pager, I find that I have no choice but to stack treatments just to make sure I get them done. However, I have certain rules that I follow when I do stack treatments.

The following are situations where treatment stacking is never justified:
  1. Any patient in respiratory distress
  2. Any patient with a compromised heart, or a heart you do not trust.
  3. Any child who needs constant observation (any child)
  4. Any unstable patient
  5. Any patient that just doesn't look right
  6. You do not know the patient
The following are situations where treatment stacking may be justified:
  1. The patient is stable
  2. The patient takes treatments at home and is stable
  3. The patient feels comfortable giving himself treatments
  4. The patient does not need the treatment to begin with (as many as 60% of treatments fit this category)
  5. The patient is on a telemetry (still you must follow the do not stack rules above)
(I also wrote about treatment stacking here.)

Treatment stacking is against CMS guidelines because the patient is not receiving the individual care needed to obtain optimal care. Yet again, CMS is not in the room and is not aware of the immediate needs of the patient in that room, and neither is the doctor, nor the RT bosses.  Besides, if the treatment isn't needed (which is the case a majority of the time) why is RT needed to do the procedure in the first place?

The Joint Commission on Accreditation of Health Care Organizations (JCAHO), notes that treatment stacking is a "problem" and should not be done. When treatments are stacked there must be a "clear indication for it and a policy and procedure that govern its application. It must be differentiated from treatments given individually."

Or we could simply use common sense.

That's why many JCAHO accredited hospitals have stacking policies, and some do not allow for stacking. Thankfully Shoreline is not accredited by JCAHO and is accredited by ISO instead, which allows each hospital to come up with it's own policies to follow.

Personally I don't see a problem with stacking so long as the rules outlined above are followed, even if it is for convenience purposes.



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kscottrichey said...

Thank you for you opinion on this subject. Yes, it is that time of year when any patient with a cough or upper respiratory infection gets prescribed aerosol medications. At institutions I work at I see this practice (prescribing non-indicated or prophylactic breathing TX’s).

I also agree with your opinion that “treatment stacking” may be justified or better yet triaged. We as practitioners know that it is hard to prioritize that PRN treatment on a patient diagnosed with congestive heart failure, when one is in CAT scan with a newly intubated ER patient.

Sadly, this is only one area of abused non-indicated orders our profession encounters.
ABG’s- the routine daily ABG.
Incentive Spirometry- on that ambulatory patient.
CPT- Vest Therapy on anybody with rhonchi & secretions.
EZPAP- every post open heart.

Thanks again,