The best way to add value to aerosol therapy

So I'm reading this article in RT Magazine called "Adding Value to Aerosol Therapy" by Mark Grzeskowiak.  The article is about adding value to aerosol therapy without cutting on quality of care.

He writes:

When a respiratory care practitioner enters a hospital room, they bring with them their experiences, assessment skills, and the necessary equipment to the bedside in order to make a patient’s breathing a little easier. But in today’s healthcare environment, there is an increasing emphasis on becoming more productive. RCPs must be able to do more in less time and with fewer resources. This scenario can sometimes leave the RCP wondering which goal is more important: providing quality care, or completing more billable procedures.

In the case of aerosol therapy, value can be added to the treatment by increasing quality while decreasing costs. However, inexpensive products do not always provide a reasonable quality of care, and it is up to respiratory care departments to resist cost-cutting strategies that look good on paper but may compromise patient care. This article will focus on strategies that can allow RCPs to provide high-quality care and still keep budget offices happy.

He offers some viable solutions:

1. Adding value with equipment:  Here he explains that by preventing half the medicine from being wasted, the patient will get more of it. This can be done by adding a reservoir to the end of the nebulizer.  Another solution is breath actuated nebulizers.  The problem with these options is that the equipment costs more, with the breath actuated costly slightly less than the reservoir nebulizer.  Personally, I think it would be too hard for some patients with true bronchospasm to initiate the breath actuated nebulizer, and I think it would be less expensive just to give another breathing treatment when it is indicated. I emphasize "when indicated" because most patients would probably not need the second treatment anyway.  
2. Adding value by subtracting:  This would involve eliminating aerosol therapy for patients where there is no perceivable benefit.  The problem is that too many doctors and nurses thing aerosol therapy is the solution for all annoying lung sounds and all causes of dyspnea.  Personally, if a hospital would incorporate a system of RT driven aerosol therapy protocols, I think this is the way to go.  I think this would save the hospital money, save the insurance companies money, save the government money.  It would  even reduce RT burnout and apathy, and stop RTs from waking up patients in the middle of the night for no good reason.  It's a win-win for everyone. 
3. Adding value through change in practice:  Give a mouthpiece instead of a mask, because studies show 50% more medicine is lost when a mask is used. Placing the aerosol close to the patient in a ventilator or BiPAP circuit. The problem:  Most of the time masks are used by patient preference, or because the patient can't hold a mouthpiece.  Personally, if the patient needs more medicine to feel better, then we might as well be giving two breathing treatments.  If we went with option #2 above, giving an extra treatment once in a while when needed would not be a burden either financially or physically.   

I think another option that's missing here is to use metered dose inhaers (MDI) instead of aerosols.  Most studies show that aerosols are equally as effective at delivering medicine to the lungs as MDIs used properly with a spacer.  So, once a patient is breathing normal, MDIs should be used.

Albuterol MDIs cost about $40 a piece, and the instruction cost is about $140, which is way less than the cost of aerosol therapy, which is estimated at between $100 and $200 each treatment.

I think you can work to try to find better ways of delivering aerosolized medication to patients, but the best method of cutting costs, if that's the goal, is simply to make sure such therapy is only given to those who would truly benefit from them, and the only way to accomplish this is with RT driven protocols.

If, on the other hand, physicians are intent on giving aerosol therapy, then RTs should be allowed, per protocol, to give MDIs to those who can generate enough flow and otherwise coordinate the therapy.