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Goal Directed Protocols Complete a Task or Achieve a Goal?

James R Dexter MD FACP FCCP

James R Dexter MD FACP FCCP jamesrdexter@gmail.com Medical Director Respiratory Care, Redlands Community Hospital Associate Professor of Medicine Loma Linda University 25 Years of Protocol Generation No Conflicts of Interest

Goal Directed Protocols: Topics

•  My History with Goal Directed Protocols •  Value of Goal Directed Protocols •  Prerequisites for a Successful Protocol •  Step by Step Review of a Relatively Complex Protocol •  Summary of Each of Our Protocols •  Contribution of Protocols to “Patient Centered Rounds”

Sherleen Bose sbose@csrc.org Redlands Community Hospital Office: 909-335-5616

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Goal Directed Protocols: My History

•  Pulmonary Fellowship completion 1980

•  Expectations: Write a specific order, check for task completion

•  Medical Director Respiratory Care Redlands Community Hospital •  1980: Write order, check for RRT task completion •  1985: CSRC was Encouraging Protocol Development for MDIs •  1990: Write simple RRT protocols, check for RRT task completion •  2000: Write complex protocols, check for RRT task completion •  2010: Write goal oriented protocols, RRT reports goal achievement

Goal Directed Protocols: Incentives

•  Save the hospital money • Prevent repeat of a sentinel event (or near miss) •  Solve interdepartmental turf conflict

Developing and Selling RRT Protocols: #1

• Culture Change is Painful, so Why Bother? •  Same Problem, Same Solution—Every Time! • Allows Consensus on “Best Practice”. • Allows Examination of “Best Practice” Results. • Allows Immediate Update if “Best Practice” changes. • Allows Selection of Least Expensive “Best Practice”.

Developing and Selling RRT Protocols: #2

•  Allows Medical/Hospital Staff to Share Expectations. •  Allows RRT to Shift from “Tasks” to “Goals”. •  Allows RRT to Develop Critical Thinking Skills. •  Allows Physicians to Concentrate on the 10% that Protocols don’t Cover. •  More Efficient as RRTs don’t have to Await Physician Call Backs.

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Developing and Selling RRT Protocols: #3

•  Convinced that Protocols Add Value? Getting there: •  Collaboration by RRT, Med Dir, Medical Staff, Hospital Administration. •  Helps to have a Med Dir that Values “Consistency” in Medical Care. •  Helps to have a Med Dir that is also Involved in Medical Staff Governance. •  Must have a Champion who Writes the Draft and Curates Revisions. •  Must have a Champion who Shepherds the Protocol Through Committees. •  Must have a Champion who Provides Liaison with Hospital Departments. •  Must have a Systematic Program for Med Dir to Assure RRT Competency.

Developing and Selling RRT Protocols: #4

•  Got It! Now What do I do with it? •  Evaluate Outcomes: Historical Comparisons; Benchmark Comparisons •  Validate Current Practice: “Is Ventilator LOS acceptable?” •  Identify Cheaper and Better Alternatives to Current Practice. •  Make Hospital Wide Changes in an Instant When Best Practice Changes. •  Standardize Medication Purchases for Less Waste and Discounted Price. •  Protect RRT Turf: “Could RN/PT/Med Student do a better job?” •  Physician Communication: “ARDSnet Failed; Now On PC 28/12 with I:E 2:1”. •  Become an Integral Part of the ICU Rounding Team.

Goal Directed Protocols: RRT Consult: #1

-Every Physician Orders RRT -Not Every Physician Knows Hospital

Medications and Resources -Wouldn’t it be Wonderful if:

Every Physician Order Had: Pulmonary Physician Filter Hospital Resource Filter Hospital Standard Filter Best Practice Filter

-Who Could Provide that Service? It Would Save Money It Would Decrease Risk It Would Assure Best Practice

Goal Directed Protocols: RRT Consult: #2

•  Under Auspices of the Protocol RRT can: •  Assess Patient Stability. •  Discontinue RRT services. •  Initiate SVN (Small Vol Neb) or LVN (Large Vol Neb) and add iBD and/or iCS. •  Initiate Bronchial Hygiene Measures. •  Initiate IS, EzPAP, CPAP, BiPAP. •  Initiate, Discontinue, Adjust Oxygen Therapy. •  Initiate ET Placement (in collaboration with a physician). •  Initiate NIV, CMV •  Request Pulmonary Physician Consultation

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Goal Directed Protocols: RRT Consult: #3

•  RRT Consultation Protocol: •  Any order for RRT service results in RRT consultation. •  RRT algorithm involves History, Physical Exam, and Test Results. •  RRT algorithm leads to the RRT modality that our Pulmonary Physicians

would order under the circumstances. •  RRT algorithm includes escalation criteria and stop criteria. •  Result: right treatment every time, always stopped on time.

Goal Directed Protocols: RRT Consult: #4

Triggers for an RRT Consultation:

Goal Directed Protocols: RRT Consult: #5 Goal Directed Protocols: RRT Consult: #6

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Goal Directed Protocols: RRT Consult: #7

Prerequisites to Choosing an RRT Intervention (Stable):

Goal Directed Protocols: RRT Consult: #8

Prerequisites to Choosing an RRT Intervention (Unstable):

Goal Directed Protocols: RRT Consult: #9

RRT Consult Follow-Up:

#10

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#11 #12

#13 Goal Directed Protocols: RRT Consult: #14

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Goal Directed Protocols: MDI/SVN

•  MDI and SVN Protocols •  Written because of Cost of Multiple Medications and MDI •  MDI Protocol has been discarded as cost of MDI > cost of RRT/SVN •  SVN Protocol is integrated with the RRT Consultation Protocol •  Continuous Neb Protocol is integrated with the RRT Consultation Protocol •  Education and stop criteria are part of the protocol •  Results: all patients needing treatments are supported and treatments are

stopped as soon as they are not longer needed. Least expensive/most effective medications are selected.

Goal Directed Protocols: Oxygen

•  Oxygen Protocol: •  Written Because of Inappropriate Oxygen Use and Excessive Cost •  Integrated with the RRT Consultation Protocol •  Every Oxygen Check includes titration to SaO2 of 90%

•  Post MI and Neuro patients are excluded •  Oxygen is discontinued when SaO2 is >90% on RA •  Result: adequate oxygenation with no wasted oxygen •  Result: FIO2 trend defines patient progress

Goal Directed Protocols: Intubation #1

•  Intubation Protocol: •  Integrated with the RRT Consultation Protocol. •  Training begins with mannequin, then close Pulmonary Physician

supervision, then Anesthesiologist supervision, then RRT supervisor supervision.

•  Competency of every RRT is certified every year. •  Predicted ET difficulty and RRT success is documented for each ET attempt. •  Sites of RRT Intubation include ICU, ED, Wards, OR. •  Results: RRTs are Facile as they do the Majority in ET Placements. •  Results: RRTs are at the Bedside so Procedures are not Delayed.

Goal Directed Protocols: Intubation #2

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Goal Directed Protocols: Intubation #3 Goal Directed Protocols: Ventilator Care

•  Ventilator Protocol: •  2 Options: ARDSnet Protocol and Asthma Crisis Protocol •  Integrated with:

•  APRV Protocol •  Inverse IE/Pressure Control Protocol •  Prone Ventilation Protocol •  Ventilator Weaning Protocol •  Tracheostomy Protocol •  Extubation Protocol

•  Results: Pulmonary Physician and RRT share expectations which facilitates communication over the spectrum of respiratory failure management

•  1. Indications: •  A) PaO2/FIO2 < 150 •  B) FIO2 > 0.6 •  C) PEEP > 5 •  D) On ventilator < 36 hours

•  2. Contraindications: •  A) Recent surgery/trauma/recent stroke •  B) Hemoptysis/untreated DVT •  C) Pregnancy •  D) MAP < 65

Goal Directed Protocols: Prone Positioning #1 Goal Directed Protocols: Prone Positioning #2

•  3. Staff Required •  A) RRT at head of bed to manage ETT/OG •  B) RN to manage all other lines and tubes •  C) 2 RN or lift team members to roll patient

•  4. Training Required •  A) All members must watch video "Roche, Quarterly Review, 2011.

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•  5. Procedure •  A) Adhesive pads to forehead, chest, iliac crests, knees for protection. •  B) Turn patient prone at 07:00, return to supine at 24:00 for total 17 hours. •  C) Place cardiac electrodes on patient's back •  D) Turn head to opposite side every 2 hours •  E) Keep head of bed elevated 30°.

•  6. Criteria for stopping successful prone positioning include the following 4 hours after returning to supine position: •  A) PaO2/FIO2 > 150 •  B) PEEP <10 •  C) FIO2 < 0.6

•  7.Criteria for discontinuing unsuccessful prone positioning •  A) Failure of prone positioning including decrease PaO2/FIO2 by 20% for more than

5 minutes. •  B) Movement complications such as mainstem bronchus intubation, extubation,

etc.

Goal Directed Protocols: Prone Positioning #3 Goal Directed Protocols: Extubation

•  Preparation •  RN to Stop all Sedation at 03:00 •  Weaning Criteria Evaluated at 05:00 and “T Piece” wean started If:

•  Improving Medical Condition •  VC > 10 ml/kg •  Peak Neg Pressure < -20 •  PaO2 < 60 mmHg on FiO2 < 45%; pH 7.35-7.45 •  PaCO2 stable at Patient baseline •  VS Stable (RR<35; CR <20%; BP<20% •  Airleak heard around deflated ET cuff

•  Plan Extubation for 07:00 if weaning is successful •  Call MD prior to extubation if any of above are not met

Goal Directed Protocols: Trach Assist

•  Protocol Begins with Creating Expectations Prior to ET Placement •  Literature shows less VAP and shorter LOS with Trach @ < 7 days

•  Tracheostomy Placement Assistant •  Physician does bronchoscopy and positions ET. •  RRT then manages bronchoscope while tracheostomy is placed •  RRT removes ET

Goal Directed Protocols: A-Line

•  Arterial Line: •  RRTs are Trained by the Pulmonary Physicians, then First 10 Procedures are

Supervised by the Lead RRT •  Each Procedure is Evaluated and RRT Competence is Certified Every Year •  Limited Number of RRT are A-Line Certified so Volume Remains High •  Result: RRT are Facile with the Procedure •  Result: Pulmonary Physicians are Allowed to Concentrate upon Care

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Goal Directed Protocols: Nitric Oxide

•  INO Protocol in Conjunction with Right Heart Catheterization •  We do not use it in the ICU because cost and complexity do not

justify the marginal benefit.

Goal Directed Protocols: EBUS

•  Prior to starting EBUS Pulmonary Physicians, Sedation Team, RRT Reached Consensus on the Protocol •  RRT can now Predict:

•  Location •  Medications •  Equipment •  Biopsy Containers

Goal Directed Protocols: Sedation

•  Procedural Sedation: •  Written but not yet instituted

Goal Directed Protocols: Ebola

I’m gowned to enter the room of a patient with possible Ebola. I did this once/day RRTs did it 24/7

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Patient Centered Multi-disciplinary ICU Rounds: Intensivist Patient Family (HIPPA) Bedside CCRN RRT Pharmacist Dietitian Physical Therapist MSW Case Manager Chaplain Nurse Manager

RRT in ICU: Multidisciplinary Patient Rounds

•  Structure: •  Rounds are from 10 to 11:30 every day including weekends and holidays •  ICU Rounds usually include 10-15 patients (5-10 minutes/patient) •  Bedside RN uses standardized format to report patient condition & progress •  RRT uses standardized format to report patient condition & progress •  Each of the team members follow suit •  Pulmonary physician summarizes the patient condition and prognosis •  Patient family is encouraged to ask questions of the team •  EMR orders are written during rounds

RRT in ICU: Multidisciplinary Patient Rounds

•  Advantages of Multidisciplinary Patient Rounds •  Care Team and Patient Family Share Expectations. •  Care Team Activities are Coordinated. •  Everyone on the Team Knows what the Physician Thinks About Each Case. •  Medication Choice and Dosage Double Checked by Pharmacy. •  Discharge Planning Begins on the Day of Admission. •  RRT and Phy RX no longer argue about “Walk vs Wean”. •  No More Conflicting Status Reports to Family from Different Departments. •  All physician orders are completed by 11:30.

RRT in ICU: Multidisciplinary Patient Rounds

•  RRT Standardized ICU Rounds Report (30-60 seconds). •  Days on Ventilator •  Ventilator Mode/PEEP/FIO2 •  Wean Status/Trend •  Sputum Production •  Anomolies

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Multidisciplinary Patient Rounds: RRT Multidisciplinary Patient Rounds: CCRN

•  Standardized CCRN Rounds Report (60-90 seconds): •  Name; Age; ICU day; Transferred from; Reason in ICU •  Problems That Need to be Addressed •  Orders to be Considered

Questions?