Chest
Volume 110, Issue 2, August 1996, Pages 422-429
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Clinical Investigations: Respiratory Care
Physician-Ordered Respiratory Care vs Physician-Ordered Use of a Respiratory Therapy Consult Service: Results of a Prospective Observational Study

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Objective

To assess the impact of a respiratory therapy consult service (RTCS) on practices and appropriateness of ordering respiratory care services

Design

Nonrandomized prospective observational cohort study with concurrent controls.

Setting

Adult non-ICU inpatient wards of an academic medical center.

Patients

A convenience sample of 98 adult non-ICU inpatients at the Cleveland Clinic Hospital, representing 20 inpatient clinical services. Patients whose respiratory care plans were determined by respiratory care practitioners using sign and symptom-based algorithms to specify treatment comprised the treatment group (n=51, respiratory therapy consult group). The nonconsult group (n=47) were patients whose respiratory care plans were specified by their own physicians.

Intervention

Specification of the respiratory care plan by the RTCS vs by the physicians themselves. Use of the RTCS was at the discretion of the managing physician.

Outcome measures

Types and number of respiratory care treatments, length of hospital stay, costs of the respiratory therapy provided, appropriateness of respiratory care orders (based on comparison of the actual respiratory care orders with a reference respiratory care plan generated by a study investigator who was kept blind to the actual respiratory care plan), and adverse respiratory events.

Results

Patients for whom the RTCS was requested by their physicians had a greater severity of respiratory illness based on having a lower triage score, but were otherwise similar at baseline. Fewer initial orders for respiratory care were discordant with the reference algorithms in RTCS patients (15%±26% [SD]) than in nonconsult patients (43%±36%; p<0.001), and a smaller fraction of RTCS patients received at least one discordant initial respiratory care order (37% vs 72%; p<0.001). Though provided to sicker patients with longer lengths of hospital stay, RTCS-directed care incurred similar respiratory care costs per patient ($335.63±$272.69 [RTCS] vs $349.06±$273.27; p=0.72).

Conclusions

These results suggest that the RTCS can be an effective strategy to allocate respiratory care strategies appropriately while conserving the costs of providing respiratory care.

Section snippets

MATERIALS AND METHODS

The design of the RTCS and the structure of the triage score have been described previously.12, 13 Briefly, major elements of RTCS include the following: (1) a team of therapist evaluators, who see consult patients in a timely fashion and generate respiratory care plans based on algorithms that have been published previously and that comply with available clinical practice guidelines of the American Association for Respiratory Care (AARC);14, 15, 16, 17 (2) a team of implementing therapists,

RESULTS

Ninety-eight patients were studied as a convenience sample. Over the 19-month study period, approximately 23,209 non-ICU adult inpatients were ordered to receive respiratory therapy at the Cleveland Clinic Foundation. Table 1 compares the demographic and clinical features of the two patient groups: those ordered by the physicians to receive respiratory care prescribed by the RTCS (n=51) vs those receiving respiratory care prescribed by the physicians themselves (nonconsult) (n=47). For

DISCUSSION

There are several main findings in this study.

  • (1)

    Use of a physician-ordered RTCS was associated with fewer misallocated initial respiratory care orders than when physicians prescribed respiratory care treatment themselves. By design, orders were considered misallocated or discordant when they deviated significantly from a standardized reference respiratory care plan that was based on AARC clinical practice guidelines for respiratory care treatment. Furthermore, in a multivariate analysis,

ACKNOWLEDGMENT

In appreciation for collaboration in completing this study, the authors wish to thank Larry Fergus, RN, MBA, RRT, Rebecca Meredith, RRT, Doug Orens, MBA, RRT, Beth Dobish, and the Section of Respiratory Therapy, Cleveland Clinic Foundation.

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  • Cited by (0)

    Supported in part by an educational grant from Nellcor Puritan-Bennett Corporation, Carlsbad, Calif.

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