Implementation of a β-Agonist/Airway Clearance Protocol in a Pediatric ICU

Abstract

BACKGROUND: Respiratory therapist (RT)-driven protocols have been in use for over 30 years.Protocols have been reported to decrease unnecessary or harmful therapy, health-care costs, and hospital stay. This study represents the evaluation of an original respiratory care protocol in the pediatric ICU at Arkansas Children's Hospital for ␤-agonist and airway clearance interventions where one did not exist. METHODS: This project was composed of 2 parts: a survey administered to RTs and licensed independent practitioners and a retrospective review of outcome data comparing a therapist-driven ␤-agonist/airway clearance protocol with physician-directed respiratory care ordering in a patient population admitted for acute respiratory failure. RESULTS: Acceptance of the protocol was evident in the survey responses because overall perceptions surrounding the implementation of the ␤-agonist/airway clearance protocol were positive, and responders perceived that the protocol implementation elevated the status and increased the value of respiratory therapists. For the comparison of physician-directed orders with therapist-driven protocols, there were no significant differences between pre-and post-intervention groups for mean age, sex, mean daily acuity, or mean weighted daily acuity (P ‫؍‬ .33, .19, >.99, and .79, respectively). There were also no differences in pediatric index of mortality 2, pediatric index of mortality 2 rate of mortality, pediatric risk of mortality 3 probability of death, and pediatric risk of mortality 3 scores (P ‫؍‬ .63, .56, .19, and .44, respectively) between the 2 groups. When comparing physician-directed orders to therapist-driven protocols, all outcome measures (length of stay, ␤-agonist therapies, airway clearance therapies, and ventilator days) showed statistically and clinically important reductions, adjusting for subject characteristics (P < .001) for the therapist-driven protocol group. CONCLUSIONS: In this institution, implementation of a ␤-agonist/airway clearance protocol resulted in significant reductions of subject interventions and improved outcomes by decreasing length of stay and ventilator days as well as contributing information where clinical evidence is scant, specifically the pediatric ICU. Key words: respiratory care protocols; therapist-driven protocols; quality improvement; evidence-based medicine. [Respir Care 2017;62(3):259 -267.

The Handle of the Broom

“…The routine processes lie somewhere in the middle. Using the broom metaphor, and based upon the results of the study by Lowe and colleagues, 13 ␤-agonist and airway clearance treatments are clearly standards (ie, the handle of the broom).…”

“…[6][7][8][9][10] Reducing practice variation through standard care protocols and clinical pathways has been shown to reduce the costs associated with care, shorten the duration of mechanical ventilation, and reduce the stay in the PICU in a number of studies reported in this journal. 11,12 In this issue of RESPIRATORY CARE, Lowe et al 13 report the findings of a retrospective analysis of a quality improvement intervention in their PICU whose primary aim was to standardize the use of ␤-agonists and airway clearance for critically ill children with acute respiratory failure. 13 Physician-directed orders (pre-intervention group) were replaced by a standardized, respiratory therapistdriven protocol (post-intervention group).…”

“…11,12 In this issue of RESPIRATORY CARE, Lowe et al 13 report the findings of a retrospective analysis of a quality improvement intervention in their PICU whose primary aim was to standardize the use of ␤-agonists and airway clearance for critically ill children with acute respiratory failure. 13 Physician-directed orders (pre-intervention group) were replaced by a standardized, respiratory therapistdriven protocol (post-intervention group). There were no significant differences in any of the demographics or severity of illness between the pre-intervention (n ϭ 152 subjects) and post-intervention (n ϭ 171 subjects) groups.…”