RT consult or aerosolized medication protocol

I am presently working on writing the ideal RT Consult, otherwise known as an aerosolized medication protocol. Please help me out by adding any ideas or recommendations for the protocol below:

(For a printable copy of the protocol click here. For a printable copy of the forms, click here for side one and here for side two)

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RESPIRATORY THERAPY CONSULT (RT CONSULT)

Protocol Content:

1. Scope: A Licensed Registered Respiratory Therapist (RRT) or Certified Respiratory Therapist (CRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Although respiratory students and assistants may perform medicated aerosol therapy, they may not adjust therapy per protocol.
2. Policy:

A. The Respiratory Aerosolized Medication Protocol will be initiated on patients ordered on aerosolized medications, or when a physician orders “respiratory consult”, or RT Consult, or when the physician writes for “RT to assess and treat.”

B. The physician will be notified when:

• a. The respiratory therapist wishes to initiate the protocol on a patient who is not currently on therapy.
• b. An initial therapy of Q2 or greater is indicated.
• c. If the patient’s condition is deteriorating requiring more frequent therapy other than the occasional PRN treatment, or patient feels no relief after 24 hours.
• d. The patient refuses therapy that is indicated.
  e. The respiratory therapist wishes to adjust any non-protocol medications.
• f. The goal of therapy is not clear.
• g. The respiratory therapist is unable to determine appropriate therapy.

C. A respiratory therapist may initiate this protocol on any patient when asked for an assessment of respiratory distress. One treatment may be given, if deemed appropriate by the therapist, prior to a physician’s order for RT Consult. Once the treatment is given, the physician will be contacted with the results of the therapy, and to obtain an order for RT Consult.

D. The respiratory therapist will assess, order, monitor, adjust and terminate the patients medicated aerosol treatments according to the patient’s clinical needs and protocol boundaries.

E. The physician may write an order for “No Respiratory Aerosolized Medication Protocol” or “No RT Consult” if he or she does not want this protocol to be used. The order for no protocol should include an explanation in the progress notes and therapy monitoring criteria.

F. All changes regarding patient’s therapy are to be recorded on the RESPIRATORY THERAPY (RT) CONSULT FORM.

G. When treatment is not indicated, patient will be assessed at least every six hours for 24 hours for changes in respiratory status and indications for aerosol therapy.

H. If, after 24 hours, treatment is not indicated and is being discontinued, this will be recorded in the OTHER RECOMMENDATIONS/NOTES section of the RT CONSULT FORM, and a courtesy call to the physician may be made.

I. The RT CONSULT FORM will be placed in doctor’s orders section of patient’s chart.

3. Respiratory Aerosolized Medication Protocol:

A. The following conditions are accepted indications for aerosol therapy:

• a. Bronchospasm/ wheezing
• b. Asthma/ reactive airway disease
• c. Diminished lung sounds
• d. COPD
• e. Prolonged expiratory phase
• f. Obstructive defects of PFT
• g. Impaired mucous clearance
• h. History of Pulmonary disease

B. Medications available per protocol:

• a. Albuterol
• b. Duoneb
• c. Atrovent
• d. Xoponex

C. This protocol will be initiated anytime there is a request for aerosol therapy. Upon receiving the order, the respiratory therapist will establish the goals and indications for therapy and perform an assessment.

D. The following assessment and chart findings will be recorded on the RT CONSULT FORM as appropriate:

• a. Vital signs (HR, RR, BP)
• b. Current FiO2
• c. Pulse oximetry
• d. PEFR (if indicated)
• e. Most recent ABG results
• f. Other diagnostic evauation (Chest X-Ray, lab tests, etc.)
• g. Smoking history
• h. Patient assessment results (lung sounds, work-of-breathing, cough, secretions)

E. Appropriate treatment and frequency will be determined using the GUIDELINES FOR AEROSOL THERAPY AND FREQUENCY on the reverse side of the RT CONSULT FORM. Using these guidelines, and based on a patient and chart assessment, an assessment total will be assigned and used to determine a triage #, and this triage number will be used as a guideline to determining therapy and frequency as follows:

• a. Triage #1 patients will receive treatments Q2 & PRN 0.5cc Ventolin and Q4 0.5mg Atrovent.
• b. Triage #2 patients will receive treatments Q4 and PRN 0.5cc Ventolin and Q8 0.5mg Atrovent.
• c. Triage #3 patients will receive treatments QID & PRN 0.5cc Ventolin and/or 0.5mg Atrovent.
• d. Triage #4 patients will receive treatments Q6 PRN 2.5mg Ventolin or 2 puffs Ventolin Q6 PRN if MDI criteria are met (see MDI criteria below), or consider discontinuing aerosol therapy. Also consider 2 puffs Atrovent QID or 2 puffs Combivent QID.

F. Changes in frequency may be made without direct physician consultation. The patient will be assessed with each treatment and as needed to ensure tolerance of these changes.

G. All non-acute patients who are on home-aerosolized medications may have therapy initiated by the respiratory therapist under this protocol. The dosage and frequency of each medication should remain the same as taken at home, unless the patient’s physician specifies otherwise.

H. Peak Expiratory Flow Rates (PEFR) will be done on asthmatics before and after the initial treatment and then done twice a day, preferably in the morning and evening, and more frequently if necessary or as appropriate. The patient’s tolerance to perform this maneuver should be taken into account and documented.

I. Once the level of care is determined, the respiratory therapist will initiate the program by documenting on the RT CONSULT FORM the drug, dose and frequency. The RCP will then sign his or her name followed by credentials. The physician’s name does not have to be included once he or she has initiated the protocol.

J. With any changes to therapy the RT CONSULT FORM must be completed.

K. The respiratory therapist will decrease frequency of treatments when the goals of therapy have been met in accordance with the GUIDELINES FOR DETERMINING AEROSOL THERAPY AND FREQUENCY.

L. Criteria for MDI use:

• a. Can physically perform the maneuver.
• b. Can follow directions.
• c. Is cooperative and alert.
• d. Can take a slow deep inspiration.
• e. Can hold breath for at least five seconds.
• f. Is able to perform a return demonstration.
• g. Respiratory rate <= 25

M. If a patient has MDI for medications approved per this protocol ordered for home use, and a breathing treatment is not currently indicated, and/or the patient wishes to continue this home routine, this MDI may be ordered for in hospital patient use if the patient meets the criteria for MDI use listed above. The order must be for the same med as the patient uses at home (or the generic equivalent as determined by pharmacy), and the same dose and frequency.

N. After the initial instruct on proper MDI use, and the patient demonstrates effective technique, the MDI may be turned over to nursing.

5. Bronchopulmonary Hygiene Protocol:

A. Indications: Productive cough, pneumonia, rhonchi on auscultation, history of mucous producing disease, patient unable to deep breathe and cough spontaneously, post-op, difficulty with secretion clearance with increased sputum production.

B. If these indications are met, Chest Physical Therapy (CPT) may be performed as tolerated by patient. The recommended frequency is QID and prn.

C. Re-evaluate patient every 24 hours.

D. Assess outcomes to determine if goals have been achieved:

• a. Optimal hydration with improved sputum production.
• b. Lung sounds from diminished to adventitious with rhonchi cleared by cough.
• c. Patient subjective impression of less retention and improved clearance.
• d. Resolution/ improvement in chest x-ray.
• e. Improvement in vital signs and measures of gas exchange.
• f. Post-op patient shows no signs of distress and demonstrates good cough and/or is able to move around in bed or room with or without assistance.

E. Discontinue therapy if improvement is observed and sustained over a 24-hour period, and record this in the OTHER RECOMMENDATIONS/NOTES section of the RT CONSULT FORM. F. Patients with chronic pulmonary disease who maintain secretion clearance in their own home environment should remain on treatment no less than their home Frequency.

6. Hyperinflation Therapy Protocol:

A. Indications: Atelectasis, decreased lung sounds; the goal is to prevent Atelectasis; the patient had thoracic or abdominal surgery; prolonged bed rest, restrictive lung defect.

B. If these indications are met, the patient may be provided with an Incentive Spirometer (IS) and educated on its proper use.

C. Once the initial instruct is provided to the patient, the IS treatment may be turned over to the care of the patient and/or RN to be performed by patient Q1-2 W/A.

7. Documentation: A. Initial Assessment:

1. A Respiratory Care Assessment will be completed for all patients ordered on RT Consult.

2. The respiratory therapist will document this assessment on the RT CONSULT FORM. On this form, the RCP will mark all indications for therapy, and circle all recommended medications indicated for patient, the recommended doses for each medication, and the recommended frequency for each medication.

3. If a physician did not initiate the protocol, the physician must be notified and an initial order received and documented in the patient’s chart or, if the physician is available, he or she may sign the initial RESPIRATORY THERAPY CONSULT FORM and no further order need be written.

4. All therapy will be documented in Meditech.

B. Re-assessments:

1. All patients will be assessed with every treatment to determine the patient’s current pulmonary status and effectiveness of the aerosol therapy.

2. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters, and by using the GUIDELINES FOR DETERMINING BRONCHODILATOR THERAPY.

3. The respiratory therapist will fill out a new RESPIRATORY THERAPY CONSULT FORM for all patients whose frequency or therapy is adjusted.

8. REFERENCES:

1. Spectum Health (2005) Aerosolized Medication Protocol, Grand Rapids: Spectrum Health.

2. Northern Michigan Hospital (2004) Bronchodilator Protocol, Petosky, MI: Northern Michigan Hospital.

3. Covenant Health Care (2005) Respiratory Therapy Consult, Saginaw, MI: Covenant Health Care.

4. “Guidelines for Preparing a Respiratory Therapy Protocol.” Retrieved August 23, 2007, from

http://www.aarc.org/members_area/resources/protocol_guidelines.html

5. “Respiratory Therapy Protocols.” Retrieved August 4, 2007, from http://www.st.alexius.org/about_stas/services/Resp_Care/protocols.asp?printable=1

6. Phillips, Jan, “Bronchopulmonary Hygiene Protocol,” May 5, 2003. Retrieved from http://www.aarc.org/resources/protocol_resources/documents/broncho_hygiene_algorithm.pdf
7. “Hyperinflation Protocol.” Retrieved from http://www.aarc.org/resources/protocol_resources/documents/AARCpedHyp.pdf
8. Phillips, Jan, “Hyperinflation Protocol,” May, 5, 2003. Retrieved fromhttp://www.aarc.org/resources/protocol_resources/documents/hyperinflation_algorithm.pdf

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