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Authoritative Medical Direction Can Assure Cost-Beneficial Bronchial Hygiene Therapy
Authoritative Medical Direction Can Assure Cost-Beneficial Bronchial Hygiene Therapy Barry A Shapiro, M.D., EC.C.P.;* Roy D. Cane, M.D., EC.C.P.;t John Peterson, M.H.A, R.R.7:;+ and Donna Weber; R.N., M.S.N.§
A bronchial hygiene (BB) program for non-Intensive Care
Unit (ICU) patients in which regimens are determined by respiratory therapy evaluators is described. The medical director of Respiratory Care was given control of orders by the medical staff and assumed responsibility for the evaluators' decisions. Patterns of DB utilization were analyzed for 24 months and were compared with BB utilization patterns in a preceding similar program in which orders were controlled by primary care physicians. Extra-
I nappropriate utilization of intermittent positive
pressure breathing (IPPB), ultrasonic nebulization (USN)and chest physical therapy (CPT) was identified by the respiratory medicine community in 1974, at which time the lack of scientific justification for such bronchial hygiene therapy (BHT) was emphasized. 1 Despite this emphasis, from 1977 to 1980 more than a third of ordered BHT at Northwestern Memorial Hospital (NMH) could not be accomplished by a respiratory therapy staffof more than 120 therapists. In 1980, a program was initiated at NMH in which specifically trained respiratory therapists evaluated all non-Intensive Care Unit (ICU) patients for whom BHT was ordered.Y When this evaluation concluded that the patient would not benefit from the ordered BHl: the primary care physician was contacted in an attempt to alter the orders. Although this program was transiently successful in decreasing the volume of ordered therapy," many resident physicians became annoyed with "constantly being bothered" by the therapists and refused to alter the orders. The evaluation program continued to function well as a priority system to determine which patients should not be treated when the respiratory therapy staff could not deliver all ordered therapy, but failed consistently to minimize the volume of inappropriate orders for BHl: *Professor of Clinical Anesthesia, and Director, Division of Respiratory/Critical Care, Deparbnent of Anesthesia, Northwestern University Medical School, Chicago. tProfessor of Clinical Anesthesia, and Associate Director, Division of Respiratory/Critical Care, Department of Anesthesia, Northwestern University Medical School, Chicago. iAdministrative Director, Respiratory Care Services, Northwestern Memorial Hospital, Chicago. . 'Instructor, Deparbnent of Anesthesia, Northwestern University Medical School, Chicago. Manuscript received July 26; revision accepted November 6. ~nt requests: Dr. Shapiro, 250 East Superior Street, Wesley 678, Chicago 60611
1038
ICU DB therapy (BBT) decreased by 61 percent and neither morbidity nor mortality was undesirably affected. Cost savings exceeded $250,000 per year. Authoritative medical direction of such a program results in cost-beneficial utilization of BBT, provides an excellent guide for resident physicians to learn appropriate utilization of such therapy, provides for quality assurance and medical necessity documentation, and is well accepted by the medical
staR:
A revised Bronchial Hygiene Evaluation Program
was initiated in July 1985 that placed the authority for
determining non-ICU BHT orders with the medical director of Respiratory Care. The program was designed to allow specifically trained respiratory therapists to determine the non-ICU BHT orders while the medical director assumed the responsibility of assuring that the therapist's evaluations would consistently meet established criteria and provide appropriate patient care. The program was formally approved by the medical staff and the hospital administration. This unique and experimental program was deemed feasible at NMH for several reasons. First, a therapist evaluation system had been smoothly functioning for over five years'" and the NMH medical directors' criteria for administering BHT were published in a nationally recognized respiratory care text. 5 Second, it was well established that prevention of postoperative pulmonary complications in patients free of lung pathologic abnormalities can be effectively accomplished with simple stir-up regimens, such as encouraging cough, ambulation and the frequent use of incentive spirometry.P" Third, it was anticipated that the primary physician's prerogatives could be protected by that physician initiating the evaluation process when BHT was believed warranted, an effective means of communication be maintained and a reasonable appeal system established. An ongoing evaluation of the program was considered essential to assure appropriate patient care and to study the program's impact. This article describes the -evaluation system and reports a 24-month experience. METHODS
This study was conducted by prospectively reviewing and tabulating all bronchial hygiene (BH) evaluations performed from September 1,1985, through August 31, 1987. Comparisons were retrospecCost-Beneficial Bronchial Hygiene Therapy (Shapiro 8t 81)
18ble I-Protocol/or EaablUlaing the Bronchial HflgienB Problema
NORTHWESTERN MEMORiAl HOSPITAl RESPIRATORY CARE DEPARTJOT REQUEST FOR BROICHIAl HYGIDIE PROGRM
DATE:
TIME:
_
oUliiiiJ$IS: IlJltxfliMS flM
BRONCHIAL. HYGIENE PROGRAM:
o
Rltonchf and/or whHZIS - not clearing with cough and/or suction.
o
Atelectasfs and/or infiltrates on Chest X-Ray (specify location):
o o o o iidALS:
o o
o o
Decreastd breath sounds (specify location):
~~.ia ~ ~~taintd 1~~iOflS: I
_
I
11»:
_
flO,:
Per ~tions of "-'-..ry MI!cIicine/Atspil'ltory Other: _
ca... COMUltation.
FrequHt deep b....thi'" and coutIt1ng "'-»te expectorlUon by _iliz1"9 thick·ttNcious and/or dry·... tained secretions. Delher broftChodUator Other:
_
SU6GtsnO P[AN:
NO
Are bronchodilators contraindicated:
0
Are any "Uties undesil'lble:
0
JibtilfltiiAl UMiiS:
PHYSICIAN SIGNATURE:
YES
CCIIOTS
o o
PAGER ,:
_
FIGURE 1. Bronchial hygiene physician request form of Northwestern Memorial Hospital. Thisis completed at the time the order to "initiate bronchial hygiene program" is written by the patients physician. tively tabulated with records of BH orders, evaluations and therapy administered from September 1, 1983, through August 31, 1984. To evaluate the impact of this program on the pattern of physician requests for BH'I: comparisons were made between the 6rst and second 12-month periods of the new program. The BR Evaluation Program consists of the following components: (1) initiation of the evaluation process; (2) identification of BH problems; (3)establishment of the BH regimen; (4)establishment of the reevaluation cycle; (5) medical director supervision of the program; and (6) the physician appeal process.
Initiation of the Evaluation Process For Incentive Spirometry (IS) only, the physician directly writes
that order and the floor nurse instructs the patient as to proper use
and frequency. When the physician desires more than IS for a nonICU patient, the order to "Initiate Bronchial Hygiene Program" is written in the physician order sheet. The physician also must complete and sign the bronchial hygiene request form (Fig 1). The respiratory therapists evaluation identifies the BH problems, establishes a BH regimen, and establishes a reevaluation cycle. The evaluation is completed within four hours. "STAr treatments are ordered directly and after indicated therapy is delivered the patient is placed in the evaluation system for additional indicated therapy.
Identifying the BH Problems The protocol for identifying the 8H problems is outlined in Table 1. The scientific and clinical rationales for this approach have been published previously. 5 This process results in identifying one or more of the following situations: (1) copious, thick or retained pulmonary secretions; (2) an inadequate cough mechanism; (3) wheezing; (4) absorptive atelectasis; (5) benefit of the doubt; and (6) no identifiable acute problem.
Therapeutic BHT Therapeutic BHT is defined as the application of techniques for
1. Establish bronchial hygiene-related diagnosis as best as possible ~ Review physician request fonn B. Chart review, especially last 48 h of physician's and nurses' notes 2. Obtain pertinent chart data A. Vital signs and temperature course B. Chest radiogram reports C. White blood cell and differential cell counts D. Blood gases E. Pulmonary function studies F: Recent pulmonary-related consultations 3. Interview patient A. Evaluate ability/willingness to cooperate B. Obtain sputum history C. Observe ventilatory pattern O. Evaluate cough 4. Chest examination A. Auscultation (befOre and after cough if possible) B. Observation (accessory muscles, expansion, etc) C. Percussion (especially areas of disparate breath sounds) 5. Obtain vital capacity and tidal volume A. Observe use of incentive spirometry where applicable the reoersal of sequelae attributable to inadequate BH mechanisms. These sequelae most commonly include retained secretions with or without absorption atelectasis. The need for therapy is primarily based on the patients ability or inability to mobilize secretions-not primarily on the severity of the pulmonary disease. Prophylactic BHT Prophylactic BHT is defined as the application of techniques for
Table 2-EattJbliah Bronchial Hygiene Regimen Findings Thick/tenacious secretions with or without wheezing Retained with adequate VC Retained with inadequate VC Able to mobilize Wheezing with thin secretions Wheezing without secretions Absorptive atelectasis Bene6t of doubt Postoperative fever Post-thoracotomy Chronic lung disease with questionable acute symptoms or findings No identi6able bronchial hygiene problem Postoperative Bedridden No increased risk of pulmonary disease Frequency of therapy Tachypnea, SOB or distressful . symptoms Patient not in distress
Therapy" USN/CPT + BO IPPBIUSN (± CFO + DO USN ± BO NEBBO ± CPT NEBBD USN/CPT (± BO) USN + IS USN/CPT + IS USN + BO
IS IS No therapy every 4 h (twice for every 8-h shift) QIO (twice on day &: evening shifts)
• Abbreviations: USN, ultrasonic nebulized 1/2 normal saline solution; Cn: chest percussion, vibration, postural drainage and cough assist; BO, bronchodilator; NEB BO, nebulized bronchodilator; IS, incentive spirometry. CHEST I 93 I 5 I MAY, 1988
1031
fIOR1ItW£ST£RII MOOtIAlHOSPITAl RESPIRATORY CAR£ D£PARTMDIT
NORTHWESTERN MDl)RIAl HOSPITAl
BROIICHIAl HYGIENE PROGRM EYALUATIOII
Fo... No. 501383
DEPARTMENT OF RESPIRATORY CARE BRONCHIAL HYGIENE MEDICATION ORDER
TIME:
DATE:
I
RESPIRATORY PROBLEM and
I
R£LEYMT PtII
I lit:
Ht:
IOn IOn
AIG's
CLINICAL DATA
PfT's P.r_ten
loa- Air:
IflO :
0 :
1FEY
I P: IDH: IDH:
IPCO.: Ipco.:
DATE:
IPO : IPO :
FEY 31:
11:
I RR:
I BPlMP:
I VT:
I Meas. YC/NIF:
I T:
11Il:
IIll:
TlME:
_
_
DURATION:
_
ORDER:
FYC:
_
FREQUENCY:
z.see of 0.61 METAPROTEREHOl
I k~=ble YC:
Bre.thing Pattern: Cough Ass.s. .nt (Effort/Ability): Spuw.
CD:
Airway Status:
Level of Conttciousness:
P!!Ys1cal 1. .1,..nt: BRONCHIAL HYGIENE EYAlUATION:,
Activity:
FIGURE 3. Bronchial hygiene medication order form of Northwestern Memorial Hospital. This is completed by the respiratory therapist evaluator and is valid for up to 60 h. Another bronchodilator medication may be substituted and the frequency and dosage prescribed according to the protocols. _
PLM:;
_
PAGER:
FIGURE 2. Bronchial hygiene evaluation and reevaluation form of Northwestern Memorial Hospital. This is completed by the respiratory therapist evaluator. The "therapeutic plan" section becomes the order of record. the prevention of sequelae attributable to inadequate BH mechanisms, This assumes that the lungs are relatively free of acute
disease.
Toble 3-Protocol for Initiating Inhalation Bronclaodilating AgentB Indications Physician request Wheezing on examination Added to USN* With history of airway reactivity When pulmonary inflammation is present or suspected Home regimen of inhalation bronchodilators Contraindications Specified by physician History of sensitivity or reaction, palpitations, 8ushing, tachycardia, headache Resting heart rate greater than 100 beats per minute Uncontrolled hypertension When both indications and contraindications coexist Physician must make decision and the communication must be noted in the evaluation narrative Standard inhalation bronchodilator Metaproterenol, 2.5 ml of 0.6 % solution Isoetharine, 4 ml of 0.l25 % soution when Requested by physician Metaproterenol not desirable for any reason Others only by physician request Every 4 h when respiratory distress due to bronchospasm Encourage physician to order self administered inhaler when reevaluation reveals bronchospasm is controlled *USN, ultrasonic nebulized VI normal saline solution. 1040
Distribution: 1 - PhaIWcy 2 - Nursing 3 - Respiratory Care
~:~~~~~t ~~~~~: Mr"t.b-.-,"IrMed~1c~a-1'W':Ib1~rec~to~r"""::o"P"f'"WRe=s"=":lp1r=ra~t~or~y~Ci~re='="
Analn1s:
Atelectasis .nd/or 1nfl1trates (specify location):
IlUSCUJUt1CMl: i8i0ftChi .....z.s. diCreasid bruth sGUllds - rIOt clearing w1tJt cough/Illbu .nd suctiCMl (specify type and locaUCMl):
I-IC
Ply Ply Ply Ply
Establishing the BH Regimen Based on previously published criteria," Table 2 outlines the way the identified problems are correlated to modes of therapy and frequency. The therapist completes the evaluation form (Fig 2) and enters the therapy and frequency. Thisbecomes the order of record. Table 3 outlines the criteria on which bronchodilating inhalation agents are prescribed. A bronchodilator medication fonn (Fig 3) is completed by the therapist in triplicate. Reevaluation Cycle
Patients assigned a frequency of every four hours or a "benefit of doubt" classificationare reevaluated in 24 h. All others are reevaluated in 48 to 60 h except for those on chronic home therapy regimens who are continued on the same home regimen until discharge. The reevaluation protocol is outlined in Table 4. Medical Superoision of Program
Each day the medical director or associate medical director reviews and signs the departmental copies of all evaluations and reevaluations. The evaluators review the medical directors comments and initiate order changes where appropriate. A log is kept of those circumstances in which the medical director disagrees with the therapists evaluation or therapeutic plan or both. Random patient examinations are accomplished by the medical director on a weekly basis. The medical director, associate medical director and evaluators attend a monthly meeting to discuss problems and create new policy where required. Physician Communication and Appeal System
A sticker is placed on the front of the chart upon completion ofan evaluation (or reevaluation) in addition to a statement in the progress notes stating that an evaluation (or reevaluation) has been completed. Resident physicians may page the evaluator, the medical director or associate medical director for discussion. However, only the attending physician of record can overrule the medical director followingjoint examination of the patient. The medical director utilizes all opportunities that allow for presentation of the indications for BHT and the criteria upon which the evaluation system is based to educate housestaff and attending
staff.
RESULTS
The medical staff department chairmen and hospital administration approved this BH Evaluation Program in November 1984 and implementation occurred in July 1985. The process was functioning smoothly by September 1, 1985. Cost-Beneficial BronchialHygieneTherapy (Shapiro et 81)
Table 4-Beevaluation Protocol· 1. Review evaluation and reevaluations 2. Review chart for all pertinent information since the last evaluation or reevaluation 3. Interview patient A. Evaluate abilitylwillingness to cooperate B. Obtain interim sputum history C. Observe ventilatory pattern D. Evaluate cough 4. Chest examination A. Auscultation (before and after cough if possible) B. Observation (accessory muscles, expansion, etc) C. Percussion (especially areas of disparate breath sounds) 5. Obtain vital capacity and tidal volume A. Observe use of IS 6. Evaluate efficacy of therapy & identify remaining DB problems A. No identifiable DB problem D/C therapy (not IS) continue therapy B. BB problem unchanged C. BB problem improved decrease frequency increase frequency; D. BB problem worse reevaluate modalities start appropriate modalities E. New BB problem and frequency F: Benefit of doubt evaluation D/C therapy except IS 1. No identifiable BB problem 2. Identifiable BB problem Continue appropriate regimen 7. Establish reevaluation cycle *IS, incentive spirometry; BB, bronchial hygiene; D/C, discontinue therapy.
From September 1, 1985 through August 31, 1986, 1,795 evaluations were performed representing monthly ranges of 112 to 192 with an average of ISO per month: 75 percent resulted in respiratory therapy treatments; 16 percent resulted in patient selfadministration of IS supervised by the nursing service; and 9 percent resulted in no therapy prescribed. It is not known what percentage of the "no therapy" patients were subsequently placed on IS. One thousand seven hundred ninety-one reevaluations were performed representing monthly ranges of 88 to 214 with an average of ISO per month: 61 percent were continued on treatments; 15 percent were placed on IS only; and 24 percent had no further therapy ordered. From September 1, 1986, to August 31, 1987, 1,605 evaluations were performed representing monthly ranges of 108 to 187 with an average of 147 per month: 90 percent resulted in respiratory therapy treatments; 9 percent resulted in patient self administration of IS supervised by the nursing service; and 1 percent resulted in no therapy prescribed. One thousand seven hundred forty-six reevaluations were performed representing monthly ranges of 89 to 222 with an average of 149 per month: 63 percent were continued on treatments; 14 percent placed on IS only; and 23 percent had no further therapy ordered. Over the two-year period, 97 percent of evaluations and 96 percent ofreevaluations were completed within the prescribed time limits. The primary reason fOr
Table S-EJJect ofBronclaitJl Hygiene Program Oft lloapittJl Stay and Treatmentl Total
Sept 1Aug 31
Patient Days
1983-1984 1985-1986 [Decrease] 1986-1987
202,323 [17%] 202,512
244,903
Average Length of Stay
Evaluations, reevaluations
Treatments
8.35 days 7.79 days [7%] 7.68 days
4,529 3,586 [21%] 3,351
60,713 23,394 [61%] 22,854
delay was patient unavailability. There was a 1.9 percent incidence (68 of 3,586) of the medical director not agreeing with the therapists decision the first year and 3.3 percent (110 of 3,351) the second year, These were jointly reevaluated and corrected within 24 h. The first year there were seven official appeals, each by a different attending physician. Six were amicably resolved while one physician accepted the medical director's decision but officially protested in writing to the hospitals patient care committee. The second year there were two official appeals that were amicably resolved. The 12-month periods (September through August) 1983 to 1984 and 1985 to 1986 allow for valid comparisons between a system in which the respiratory therapist evaluator suggested the therapeutic program (1983 to 1984) and a system in which the respiratory therapist evaluator determined the therapeutic program (1985 to 1986). Since DRGs were introduced in 1984 to 1985, a 10 percent decrease in bed capacity and a 7 percent decrease in average length of stay resulted in a 17 percent decrease in total patient days in 1985 to 1986 compared with 1983 to 1984 (Table 5) while a 61 percent decrease in BH treatments occurred. There was no significant change in hospital mortality statistics during this period. Additionally, no valid instance of increased patient morbidity attributable to deficiencies in BHT was brought to the attention of the medical director by the medical staff Review ofrepeat requests for BHT made within 48 h of cessation or denial of therapy revealed no instances of increased morbidity attributable to inadequate BHl: As listed in Table 6, this program resulted in a minimum yearly savings of $250,000. The 61 percent decrease in volume of therapy directly resulted in a reduction of ten adult care therapist positions representing a $218,000 savings while nonsalary expenses were reduced by $60,000. Similar savings occurred in the second yean Table 7 compares fiscal years 1985 to 1986and 1986to 1987 as to the proportion of evaluation requests that resulted in no therapy or IS only being ordered by the evaluator There was no significant change in patient days or average length of stay between these two years while an II percent reduction in evaluation requests occurred. There was a 53 percent decrease in evaluaCHEST I 93 I 5 I MAY. 1988
1041
Table 6-Stminga Baulting From Bronchitll Hygiene Program
Category Adult care Salary Nonsalary
rrs-
1983-1984
1985-1986
38.1 $1,306,977 $408,020
28.i $1,089,078 $347,098
Net Decrease (If,)
10 (26) $217,899 (17) $60,922 (15)
·FrE, full time equivalent
tion requests resulting in IS only and a 92 percent decrease ih requests resulting in no therapy. Chisquare analysis applied to these differences in BHl: IS only and no BHT fur the two years was found to be highly sigirlfieatlt (xl = 161.16, two degrees of freedom and p
Our seven-year history of documented attempts to limit administration ofextra-ICU BHT to patients who may potentially benefit from such therapy reveals that only transient improvements can be accomplished without authoritative medical direction. This means that the hospital medical staff must be willing to delegate authority fur determining the extra-ICU BHT orders to the medical director of respiratory care. This has been well accepted at NMH over the past two years by the vast majority of attending and resident physicians. . Formore than two years the present Bronchial Hygiene Evaluation Program has resulted in all indicated therapy being delivered at significant cost savings while avoiding the administration of unnecessary therapy. We are riot aware of any instance of increased patient morbidity as a consequence of this program, an observation consistent with a recently published report by Zihrak et ale 11 This program appears to have improved the ability of the primary care physician to appropriately evaluate the need fur BHl: Compared with the first year of the program, the second year showed a 92 percent decrease in the incidence of physicians requesting therapy for patients deemed to require no therapy by the evaluation system. Further; those patients requiring IS only were more often placed directly on the therapy by the primary care physician as reflected in a second year 52 percent decrease in evaluation requests resulting in IS only. These data suggest that the primary care
Table 7-~omptJriaora ofFiacal Years1985-1986 and 1986-1987 tDida Regard to Eooluation &quata*
1985-1986 1986-1987 [Decrease]
Evaluations
IS Only %
NoBHT (%)
1,795 1,605 [11%]
287 (16) 151 (9) [53%]
161 (9) 13 (1) [92%]
*IS, incentive spirometry; BIn: bronchial hygiene therapy.
1042
physicians have learned to better evaluate which patients are candidates for IS only and not request more expensive prophylactic therapy. Quality assurance programs are becoming a high priority with entities such as lCAH, Medicare, Blue Cross and others. Our program fully satisfies standard quality assurance criteria as well as most medical necessity criteria. In conchision, we have demonstrated that with authoritative medical direction and medical staff cooperation, an evaluation program utilizing suitably trained respiratory therapists can ensure delivery of high quality extra-ICU bronchial hygiene therapy at minimal costs. Although our program may not be applicable to all institutions, we believe that appropriate adaptations should improve BHT utilization, reduce costs and meet quality assurance and medical necessity criteria. Most importantly, this is aecomplished while protecting the appropriate prerogatives of the primary care physician through acceptable guidelines and educational processes. The key elements are a competent respiratory therapy department and a qualified medical director given proper authority by the medical staff ACKNOWLEDGMENTS: The authors wish to acknowledge the performance and dedication of Priscilla Goodwill, R. R.T., Rozlyn Caruso, R.R.L, Louise Keane, R.R.T., John Parson, R.R.T. and the respiratory therapist evaluators. The cooperation. and confidence of the medical staff and administration of Northwestern Memorial Hospital are appreciated. REFERENCES
1 Proceedings of the Conference on the Scientific Basis of InHospital Respiratory Therapy, Atlanta, November 14-16, 1979. Am Rev Resp Dis 1980; 122(5:pt2):1-161 2 Sandrick KM. The Executive Utilization Review Committee at Northwestern Memorial Hospital. QRB 1981; 22 3 Walton JR, Shapiro BA. Appropriate utilization of bronchial hygiene therapy. QRB 1981; 21-25 4 Walton JR, Shapiro BA, Harrison CH. Review of a bronchial hygiene evaluation program. Resp Care 1983; 28:174-79 5 Section II: Bronchial hygiene therapy. In: Shapiro BA, Harrison RA, Kacmarek RM, Cane RD. Clinical application of respiratory care, 3rd ed. Chicago: Year Book Medical Publishers, 1985: chap 5-10 6 Craven JL, Evans GA, Davenport PJ, Williams RHE The evaluation of the incentive spirometer in the management of postoperative pulmonary complications. Dr J Surg 1974; 61:793-97 7 Dohi S, Gold MI. Comparisons of two methods of postoperative respiratory care. Chest 1978; 73:592-95 8 Jung R, Wight J, Nusser R, Rosoff L. Comparison of three methods of respiratory care following upper abdominal surgery. Chest 1980; 78:31-35 9 Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Resp Dis 1984; 130:12-15 10 Ford G'I: Guenter CA. Toward prevention of postoperative pulmonary complications. Am Rev Resp Dis 1984; 130:4-5 11 Zibrak JD, Rossetti ~ Wood E. Effect of reductions in respiratory therapy on patient outcome. N Engl J Med 1986; 315:292-95 Cost-Beneficial Bronchial Hygiene Therapy (Shapiro8t aI)
A bronchial hygiene (BB) program for non-Intensive Care
Unit (ICU) patients in which regimens are determined by respiratory therapy evaluators is described. The medical director of Respiratory Care was given control of orders by the medical staff and assumed responsibility for the evaluators' decisions. Patterns of DB utilization were analyzed for 24 months and were compared with BB utilization patterns in a preceding similar program in which orders were controlled by primary care physicians. Extra-
I nappropriate utilization of intermittent positive
pressure breathing (IPPB), ultrasonic nebulization (USN)and chest physical therapy (CPT) was identified by the respiratory medicine community in 1974, at which time the lack of scientific justification for such bronchial hygiene therapy (BHT) was emphasized. 1 Despite this emphasis, from 1977 to 1980 more than a third of ordered BHT at Northwestern Memorial Hospital (NMH) could not be accomplished by a respiratory therapy staffof more than 120 therapists. In 1980, a program was initiated at NMH in which specifically trained respiratory therapists evaluated all non-Intensive Care Unit (ICU) patients for whom BHT was ordered.Y When this evaluation concluded that the patient would not benefit from the ordered BHl: the primary care physician was contacted in an attempt to alter the orders. Although this program was transiently successful in decreasing the volume of ordered therapy," many resident physicians became annoyed with "constantly being bothered" by the therapists and refused to alter the orders. The evaluation program continued to function well as a priority system to determine which patients should not be treated when the respiratory therapy staff could not deliver all ordered therapy, but failed consistently to minimize the volume of inappropriate orders for BHl: *Professor of Clinical Anesthesia, and Director, Division of Respiratory/Critical Care, Deparbnent of Anesthesia, Northwestern University Medical School, Chicago. tProfessor of Clinical Anesthesia, and Associate Director, Division of Respiratory/Critical Care, Department of Anesthesia, Northwestern University Medical School, Chicago. iAdministrative Director, Respiratory Care Services, Northwestern Memorial Hospital, Chicago. . 'Instructor, Deparbnent of Anesthesia, Northwestern University Medical School, Chicago. Manuscript received July 26; revision accepted November 6. ~nt requests: Dr. Shapiro, 250 East Superior Street, Wesley 678, Chicago 60611
1038
ICU DB therapy (BBT) decreased by 61 percent and neither morbidity nor mortality was undesirably affected. Cost savings exceeded $250,000 per year. Authoritative medical direction of such a program results in cost-beneficial utilization of BBT, provides an excellent guide for resident physicians to learn appropriate utilization of such therapy, provides for quality assurance and medical necessity documentation, and is well accepted by the medical
staR:
A revised Bronchial Hygiene Evaluation Program
was initiated in July 1985 that placed the authority for
determining non-ICU BHT orders with the medical director of Respiratory Care. The program was designed to allow specifically trained respiratory therapists to determine the non-ICU BHT orders while the medical director assumed the responsibility of assuring that the therapist's evaluations would consistently meet established criteria and provide appropriate patient care. The program was formally approved by the medical staff and the hospital administration. This unique and experimental program was deemed feasible at NMH for several reasons. First, a therapist evaluation system had been smoothly functioning for over five years'" and the NMH medical directors' criteria for administering BHT were published in a nationally recognized respiratory care text. 5 Second, it was well established that prevention of postoperative pulmonary complications in patients free of lung pathologic abnormalities can be effectively accomplished with simple stir-up regimens, such as encouraging cough, ambulation and the frequent use of incentive spirometry.P" Third, it was anticipated that the primary physician's prerogatives could be protected by that physician initiating the evaluation process when BHT was believed warranted, an effective means of communication be maintained and a reasonable appeal system established. An ongoing evaluation of the program was considered essential to assure appropriate patient care and to study the program's impact. This article describes the -evaluation system and reports a 24-month experience. METHODS
This study was conducted by prospectively reviewing and tabulating all bronchial hygiene (BH) evaluations performed from September 1,1985, through August 31, 1987. Comparisons were retrospecCost-Beneficial Bronchial Hygiene Therapy (Shapiro 8t 81)
18ble I-Protocol/or EaablUlaing the Bronchial HflgienB Problema
NORTHWESTERN MEMORiAl HOSPITAl RESPIRATORY CARE DEPARTJOT REQUEST FOR BROICHIAl HYGIDIE PROGRM
DATE:
TIME:
_
oUliiiiJ$IS: IlJltxfliMS flM
BRONCHIAL. HYGIENE PROGRAM:
o
Rltonchf and/or whHZIS - not clearing with cough and/or suction.
o
Atelectasfs and/or infiltrates on Chest X-Ray (specify location):
o o o o iidALS:
o o
o o
Decreastd breath sounds (specify location):
~~.ia ~ ~~taintd 1~~iOflS: I
_
I
11»:
_
flO,:
Per ~tions of "-'-..ry MI!cIicine/Atspil'ltory Other: _
ca... COMUltation.
FrequHt deep b....thi'" and coutIt1ng "'-»te expectorlUon by _iliz1"9 thick·ttNcious and/or dry·... tained secretions. Delher broftChodUator Other:
_
SU6GtsnO P[AN:
NO
Are bronchodilators contraindicated:
0
Are any "Uties undesil'lble:
0
JibtilfltiiAl UMiiS:
PHYSICIAN SIGNATURE:
YES
CCIIOTS
o o
PAGER ,:
_
FIGURE 1. Bronchial hygiene physician request form of Northwestern Memorial Hospital. Thisis completed at the time the order to "initiate bronchial hygiene program" is written by the patients physician. tively tabulated with records of BH orders, evaluations and therapy administered from September 1, 1983, through August 31, 1984. To evaluate the impact of this program on the pattern of physician requests for BH'I: comparisons were made between the 6rst and second 12-month periods of the new program. The BR Evaluation Program consists of the following components: (1) initiation of the evaluation process; (2) identification of BH problems; (3)establishment of the BH regimen; (4)establishment of the reevaluation cycle; (5) medical director supervision of the program; and (6) the physician appeal process.
Initiation of the Evaluation Process For Incentive Spirometry (IS) only, the physician directly writes
that order and the floor nurse instructs the patient as to proper use
and frequency. When the physician desires more than IS for a nonICU patient, the order to "Initiate Bronchial Hygiene Program" is written in the physician order sheet. The physician also must complete and sign the bronchial hygiene request form (Fig 1). The respiratory therapists evaluation identifies the BH problems, establishes a BH regimen, and establishes a reevaluation cycle. The evaluation is completed within four hours. "STAr treatments are ordered directly and after indicated therapy is delivered the patient is placed in the evaluation system for additional indicated therapy.
Identifying the BH Problems The protocol for identifying the 8H problems is outlined in Table 1. The scientific and clinical rationales for this approach have been published previously. 5 This process results in identifying one or more of the following situations: (1) copious, thick or retained pulmonary secretions; (2) an inadequate cough mechanism; (3) wheezing; (4) absorptive atelectasis; (5) benefit of the doubt; and (6) no identifiable acute problem.
Therapeutic BHT Therapeutic BHT is defined as the application of techniques for
1. Establish bronchial hygiene-related diagnosis as best as possible ~ Review physician request fonn B. Chart review, especially last 48 h of physician's and nurses' notes 2. Obtain pertinent chart data A. Vital signs and temperature course B. Chest radiogram reports C. White blood cell and differential cell counts D. Blood gases E. Pulmonary function studies F: Recent pulmonary-related consultations 3. Interview patient A. Evaluate ability/willingness to cooperate B. Obtain sputum history C. Observe ventilatory pattern O. Evaluate cough 4. Chest examination A. Auscultation (befOre and after cough if possible) B. Observation (accessory muscles, expansion, etc) C. Percussion (especially areas of disparate breath sounds) 5. Obtain vital capacity and tidal volume A. Observe use of incentive spirometry where applicable the reoersal of sequelae attributable to inadequate BH mechanisms. These sequelae most commonly include retained secretions with or without absorption atelectasis. The need for therapy is primarily based on the patients ability or inability to mobilize secretions-not primarily on the severity of the pulmonary disease. Prophylactic BHT Prophylactic BHT is defined as the application of techniques for
Table 2-EattJbliah Bronchial Hygiene Regimen Findings Thick/tenacious secretions with or without wheezing Retained with adequate VC Retained with inadequate VC Able to mobilize Wheezing with thin secretions Wheezing without secretions Absorptive atelectasis Bene6t of doubt Postoperative fever Post-thoracotomy Chronic lung disease with questionable acute symptoms or findings No identi6able bronchial hygiene problem Postoperative Bedridden No increased risk of pulmonary disease Frequency of therapy Tachypnea, SOB or distressful . symptoms Patient not in distress
Therapy" USN/CPT + BO IPPBIUSN (± CFO + DO USN ± BO NEBBO ± CPT NEBBD USN/CPT (± BO) USN + IS USN/CPT + IS USN + BO
IS IS No therapy every 4 h (twice for every 8-h shift) QIO (twice on day &: evening shifts)
• Abbreviations: USN, ultrasonic nebulized 1/2 normal saline solution; Cn: chest percussion, vibration, postural drainage and cough assist; BO, bronchodilator; NEB BO, nebulized bronchodilator; IS, incentive spirometry. CHEST I 93 I 5 I MAY, 1988
1031
fIOR1ItW£ST£RII MOOtIAlHOSPITAl RESPIRATORY CAR£ D£PARTMDIT
NORTHWESTERN MDl)RIAl HOSPITAl
BROIICHIAl HYGIENE PROGRM EYALUATIOII
Fo... No. 501383
DEPARTMENT OF RESPIRATORY CARE BRONCHIAL HYGIENE MEDICATION ORDER
TIME:
DATE:
I
RESPIRATORY PROBLEM and
I
R£LEYMT PtII
I lit:
Ht:
IOn IOn
AIG's
CLINICAL DATA
PfT's P.r_ten
loa- Air:
IflO :
0 :
1FEY
I P: IDH: IDH:
IPCO.: Ipco.:
DATE:
IPO : IPO :
FEY 31:
11:
I RR:
I BPlMP:
I VT:
I Meas. YC/NIF:
I T:
11Il:
IIll:
TlME:
_
_
DURATION:
_
ORDER:
FYC:
_
FREQUENCY:
z.see of 0.61 METAPROTEREHOl
I k~=ble YC:
Bre.thing Pattern: Cough Ass.s. .nt (Effort/Ability): Spuw.
CD:
Airway Status:
Level of Conttciousness:
P!!Ys1cal 1. .1,..nt: BRONCHIAL HYGIENE EYAlUATION:,
Activity:
FIGURE 3. Bronchial hygiene medication order form of Northwestern Memorial Hospital. This is completed by the respiratory therapist evaluator and is valid for up to 60 h. Another bronchodilator medication may be substituted and the frequency and dosage prescribed according to the protocols. _
PLM:;
_
PAGER:
FIGURE 2. Bronchial hygiene evaluation and reevaluation form of Northwestern Memorial Hospital. This is completed by the respiratory therapist evaluator. The "therapeutic plan" section becomes the order of record. the prevention of sequelae attributable to inadequate BH mechanisms, This assumes that the lungs are relatively free of acute
disease.
Toble 3-Protocol for Initiating Inhalation Bronclaodilating AgentB Indications Physician request Wheezing on examination Added to USN* With history of airway reactivity When pulmonary inflammation is present or suspected Home regimen of inhalation bronchodilators Contraindications Specified by physician History of sensitivity or reaction, palpitations, 8ushing, tachycardia, headache Resting heart rate greater than 100 beats per minute Uncontrolled hypertension When both indications and contraindications coexist Physician must make decision and the communication must be noted in the evaluation narrative Standard inhalation bronchodilator Metaproterenol, 2.5 ml of 0.6 % solution Isoetharine, 4 ml of 0.l25 % soution when Requested by physician Metaproterenol not desirable for any reason Others only by physician request Every 4 h when respiratory distress due to bronchospasm Encourage physician to order self administered inhaler when reevaluation reveals bronchospasm is controlled *USN, ultrasonic nebulized VI normal saline solution. 1040
Distribution: 1 - PhaIWcy 2 - Nursing 3 - Respiratory Care
~:~~~~~t ~~~~~: Mr"t.b-.-,"IrMed~1c~a-1'W':Ib1~rec~to~r"""::o"P"f'"WRe=s"=":lp1r=ra~t~or~y~Ci~re='="
Analn1s:
Atelectasis .nd/or 1nfl1trates (specify location):
IlUSCUJUt1CMl: i8i0ftChi .....z.s. diCreasid bruth sGUllds - rIOt clearing w1tJt cough/Illbu .nd suctiCMl (specify type and locaUCMl):
I-IC
Ply Ply Ply Ply
Establishing the BH Regimen Based on previously published criteria," Table 2 outlines the way the identified problems are correlated to modes of therapy and frequency. The therapist completes the evaluation form (Fig 2) and enters the therapy and frequency. Thisbecomes the order of record. Table 3 outlines the criteria on which bronchodilating inhalation agents are prescribed. A bronchodilator medication fonn (Fig 3) is completed by the therapist in triplicate. Reevaluation Cycle
Patients assigned a frequency of every four hours or a "benefit of doubt" classificationare reevaluated in 24 h. All others are reevaluated in 48 to 60 h except for those on chronic home therapy regimens who are continued on the same home regimen until discharge. The reevaluation protocol is outlined in Table 4. Medical Superoision of Program
Each day the medical director or associate medical director reviews and signs the departmental copies of all evaluations and reevaluations. The evaluators review the medical directors comments and initiate order changes where appropriate. A log is kept of those circumstances in which the medical director disagrees with the therapists evaluation or therapeutic plan or both. Random patient examinations are accomplished by the medical director on a weekly basis. The medical director, associate medical director and evaluators attend a monthly meeting to discuss problems and create new policy where required. Physician Communication and Appeal System
A sticker is placed on the front of the chart upon completion ofan evaluation (or reevaluation) in addition to a statement in the progress notes stating that an evaluation (or reevaluation) has been completed. Resident physicians may page the evaluator, the medical director or associate medical director for discussion. However, only the attending physician of record can overrule the medical director followingjoint examination of the patient. The medical director utilizes all opportunities that allow for presentation of the indications for BHT and the criteria upon which the evaluation system is based to educate housestaff and attending
staff.
RESULTS
The medical staff department chairmen and hospital administration approved this BH Evaluation Program in November 1984 and implementation occurred in July 1985. The process was functioning smoothly by September 1, 1985. Cost-Beneficial BronchialHygieneTherapy (Shapiro et 81)
Table 4-Beevaluation Protocol· 1. Review evaluation and reevaluations 2. Review chart for all pertinent information since the last evaluation or reevaluation 3. Interview patient A. Evaluate abilitylwillingness to cooperate B. Obtain interim sputum history C. Observe ventilatory pattern D. Evaluate cough 4. Chest examination A. Auscultation (before and after cough if possible) B. Observation (accessory muscles, expansion, etc) C. Percussion (especially areas of disparate breath sounds) 5. Obtain vital capacity and tidal volume A. Observe use of IS 6. Evaluate efficacy of therapy & identify remaining DB problems A. No identifiable DB problem D/C therapy (not IS) continue therapy B. BB problem unchanged C. BB problem improved decrease frequency increase frequency; D. BB problem worse reevaluate modalities start appropriate modalities E. New BB problem and frequency F: Benefit of doubt evaluation D/C therapy except IS 1. No identifiable BB problem 2. Identifiable BB problem Continue appropriate regimen 7. Establish reevaluation cycle *IS, incentive spirometry; BB, bronchial hygiene; D/C, discontinue therapy.
From September 1, 1985 through August 31, 1986, 1,795 evaluations were performed representing monthly ranges of 112 to 192 with an average of ISO per month: 75 percent resulted in respiratory therapy treatments; 16 percent resulted in patient selfadministration of IS supervised by the nursing service; and 9 percent resulted in no therapy prescribed. It is not known what percentage of the "no therapy" patients were subsequently placed on IS. One thousand seven hundred ninety-one reevaluations were performed representing monthly ranges of 88 to 214 with an average of ISO per month: 61 percent were continued on treatments; 15 percent were placed on IS only; and 24 percent had no further therapy ordered. From September 1, 1986, to August 31, 1987, 1,605 evaluations were performed representing monthly ranges of 108 to 187 with an average of 147 per month: 90 percent resulted in respiratory therapy treatments; 9 percent resulted in patient self administration of IS supervised by the nursing service; and 1 percent resulted in no therapy prescribed. One thousand seven hundred forty-six reevaluations were performed representing monthly ranges of 89 to 222 with an average of 149 per month: 63 percent were continued on treatments; 14 percent placed on IS only; and 23 percent had no further therapy ordered. Over the two-year period, 97 percent of evaluations and 96 percent ofreevaluations were completed within the prescribed time limits. The primary reason fOr
Table S-EJJect ofBronclaitJl Hygiene Program Oft lloapittJl Stay and Treatmentl Total
Sept 1Aug 31
Patient Days
1983-1984 1985-1986 [Decrease] 1986-1987
202,323 [17%] 202,512
244,903
Average Length of Stay
Evaluations, reevaluations
Treatments
8.35 days 7.79 days [7%] 7.68 days
4,529 3,586 [21%] 3,351
60,713 23,394 [61%] 22,854
delay was patient unavailability. There was a 1.9 percent incidence (68 of 3,586) of the medical director not agreeing with the therapists decision the first year and 3.3 percent (110 of 3,351) the second year, These were jointly reevaluated and corrected within 24 h. The first year there were seven official appeals, each by a different attending physician. Six were amicably resolved while one physician accepted the medical director's decision but officially protested in writing to the hospitals patient care committee. The second year there were two official appeals that were amicably resolved. The 12-month periods (September through August) 1983 to 1984 and 1985 to 1986 allow for valid comparisons between a system in which the respiratory therapist evaluator suggested the therapeutic program (1983 to 1984) and a system in which the respiratory therapist evaluator determined the therapeutic program (1985 to 1986). Since DRGs were introduced in 1984 to 1985, a 10 percent decrease in bed capacity and a 7 percent decrease in average length of stay resulted in a 17 percent decrease in total patient days in 1985 to 1986 compared with 1983 to 1984 (Table 5) while a 61 percent decrease in BH treatments occurred. There was no significant change in hospital mortality statistics during this period. Additionally, no valid instance of increased patient morbidity attributable to deficiencies in BHT was brought to the attention of the medical director by the medical staff Review ofrepeat requests for BHT made within 48 h of cessation or denial of therapy revealed no instances of increased morbidity attributable to inadequate BHl: As listed in Table 6, this program resulted in a minimum yearly savings of $250,000. The 61 percent decrease in volume of therapy directly resulted in a reduction of ten adult care therapist positions representing a $218,000 savings while nonsalary expenses were reduced by $60,000. Similar savings occurred in the second yean Table 7 compares fiscal years 1985 to 1986and 1986to 1987 as to the proportion of evaluation requests that resulted in no therapy or IS only being ordered by the evaluator There was no significant change in patient days or average length of stay between these two years while an II percent reduction in evaluation requests occurred. There was a 53 percent decrease in evaluaCHEST I 93 I 5 I MAY. 1988
1041
Table 6-Stminga Baulting From Bronchitll Hygiene Program
Category Adult care Salary Nonsalary
rrs-
1983-1984
1985-1986
38.1 $1,306,977 $408,020
28.i $1,089,078 $347,098
Net Decrease (If,)
10 (26) $217,899 (17) $60,922 (15)
·FrE, full time equivalent
tion requests resulting in IS only and a 92 percent decrease ih requests resulting in no therapy. Chisquare analysis applied to these differences in BHl: IS only and no BHT fur the two years was found to be highly sigirlfieatlt (xl = 161.16, two degrees of freedom and p
Our seven-year history of documented attempts to limit administration ofextra-ICU BHT to patients who may potentially benefit from such therapy reveals that only transient improvements can be accomplished without authoritative medical direction. This means that the hospital medical staff must be willing to delegate authority fur determining the extra-ICU BHT orders to the medical director of respiratory care. This has been well accepted at NMH over the past two years by the vast majority of attending and resident physicians. . Formore than two years the present Bronchial Hygiene Evaluation Program has resulted in all indicated therapy being delivered at significant cost savings while avoiding the administration of unnecessary therapy. We are riot aware of any instance of increased patient morbidity as a consequence of this program, an observation consistent with a recently published report by Zihrak et ale 11 This program appears to have improved the ability of the primary care physician to appropriately evaluate the need fur BHl: Compared with the first year of the program, the second year showed a 92 percent decrease in the incidence of physicians requesting therapy for patients deemed to require no therapy by the evaluation system. Further; those patients requiring IS only were more often placed directly on the therapy by the primary care physician as reflected in a second year 52 percent decrease in evaluation requests resulting in IS only. These data suggest that the primary care
Table 7-~omptJriaora ofFiacal Years1985-1986 and 1986-1987 tDida Regard to Eooluation &quata*
1985-1986 1986-1987 [Decrease]
Evaluations
IS Only %
NoBHT (%)
1,795 1,605 [11%]
287 (16) 151 (9) [53%]
161 (9) 13 (1) [92%]
*IS, incentive spirometry; BIn: bronchial hygiene therapy.
1042
physicians have learned to better evaluate which patients are candidates for IS only and not request more expensive prophylactic therapy. Quality assurance programs are becoming a high priority with entities such as lCAH, Medicare, Blue Cross and others. Our program fully satisfies standard quality assurance criteria as well as most medical necessity criteria. In conchision, we have demonstrated that with authoritative medical direction and medical staff cooperation, an evaluation program utilizing suitably trained respiratory therapists can ensure delivery of high quality extra-ICU bronchial hygiene therapy at minimal costs. Although our program may not be applicable to all institutions, we believe that appropriate adaptations should improve BHT utilization, reduce costs and meet quality assurance and medical necessity criteria. Most importantly, this is aecomplished while protecting the appropriate prerogatives of the primary care physician through acceptable guidelines and educational processes. The key elements are a competent respiratory therapy department and a qualified medical director given proper authority by the medical staff ACKNOWLEDGMENTS: The authors wish to acknowledge the performance and dedication of Priscilla Goodwill, R. R.T., Rozlyn Caruso, R.R.L, Louise Keane, R.R.T., John Parson, R.R.T. and the respiratory therapist evaluators. The cooperation. and confidence of the medical staff and administration of Northwestern Memorial Hospital are appreciated. REFERENCES
1 Proceedings of the Conference on the Scientific Basis of InHospital Respiratory Therapy, Atlanta, November 14-16, 1979. Am Rev Resp Dis 1980; 122(5:pt2):1-161 2 Sandrick KM. The Executive Utilization Review Committee at Northwestern Memorial Hospital. QRB 1981; 22 3 Walton JR, Shapiro BA. Appropriate utilization of bronchial hygiene therapy. QRB 1981; 21-25 4 Walton JR, Shapiro BA, Harrison CH. Review of a bronchial hygiene evaluation program. Resp Care 1983; 28:174-79 5 Section II: Bronchial hygiene therapy. In: Shapiro BA, Harrison RA, Kacmarek RM, Cane RD. Clinical application of respiratory care, 3rd ed. Chicago: Year Book Medical Publishers, 1985: chap 5-10 6 Craven JL, Evans GA, Davenport PJ, Williams RHE The evaluation of the incentive spirometer in the management of postoperative pulmonary complications. Dr J Surg 1974; 61:793-97 7 Dohi S, Gold MI. Comparisons of two methods of postoperative respiratory care. Chest 1978; 73:592-95 8 Jung R, Wight J, Nusser R, Rosoff L. Comparison of three methods of respiratory care following upper abdominal surgery. Chest 1980; 78:31-35 9 Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Resp Dis 1984; 130:12-15 10 Ford G'I: Guenter CA. Toward prevention of postoperative pulmonary complications. Am Rev Resp Dis 1984; 130:4-5 11 Zibrak JD, Rossetti ~ Wood E. Effect of reductions in respiratory therapy on patient outcome. N Engl J Med 1986; 315:292-95 Cost-Beneficial Bronchial Hygiene Therapy (Shapiro8t aI)