ACCP Position Paper on Respiratory Care Protocols

Physicians have traditionally written orders for respiratory therapy that were specific and allowed no variation by the respiratory care practitioner administering the treatment. If there was a change in patient condition, the physician would be called to have the orders adjusted. However, nationally referenced appropriateness indicators, such as the AARC Clinical Practice Guidelines, have now become widely accepted as practice standards and guides to rational respiratory care. Recently, protocols have been designed to allow assessment by properly trained and credentialed respiratory care practitioners, and for initiation and adjustment of treatment within guidelines previously decided by the physician. In a number of hospitals these protocols have proved highly efficient, safe, and cost-effective. They cover a variety of clinical circumstances including:

1. Perioperative respiratory care
2. Oxygen therapy and titration
3. Ventilator weaning and extubation
4. Bronchial hygiene therapy
5. Pulmonary volume expansion therapy
6. Pulmonary rehabilitation
7. Therapy assessment and prioritization

There are several clear advantages to using protocols (called “assess and treat” protocols in some institutions):

1. Therapy can be adjusted more frequently in response to changes in patient condition.
2. Physicians can still be contacted for major clinical changes, but not minor therapy adjustments, thus reducing nuisance calls.
3. Consistency of treatment can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be instituted.
4. Respiratory care practitioners become actively involved in achieving the goal of good patient outcome instead of performing rigid tasks. This enhancement of responsibility attracts and retains better educated and qualified practitioners.

Elements of successful Respiratory Care Protocols include:

1. Clearly stated objectives.
2. Outline of the protocol including a decision tree or algorithm.
3. Description of alternative choices at decision and action points.
4. Description of potential complications and corrections.
5. Description of end-points and decision-points where the physician must be contacted.

Implementation and maintenance of Respiratory Care Protocols requires:

1. Use of written protocols with sound scientific basis.
2. Strong medical director support.
3. Intensive education of respiratory care practitioners.
4. Medical staff approval and confidence in the protocol.
5. Frequent auditing of outcomes and continuing education.
6. Adjustment of protocol to meet needs and new scientific evidence.

Respiratory Care Protocols provide an opportunity to enhance the medical care of patients with timely, safe, and cost-effective therapy. Use of protocols meeting these criteria are encouraged by the American College of Chest Physicians.

*Accepted by the Respiratory Care Section Steering Committee. Chicago, Illinois, 10/27/92.