St. Dominic Jackson Memorial Hospital. Pulmonary Services. Therapist Driven Protocol. Assess and Treat Aerosol Therapy

Transcription

1 St. Dominic Jackson Memorial Hospital Pulmonary Services Therapist Driven Protocol Assess and Treat Aerosol Therapy Purpose The purpose of the Therapist Driven Protocol (TDP) aerosol therapy is to create a standardized protocol for the assessment and management of aerosol with a bronchodilator by the Respiratory Care Practitioner. Indications for Aerosol Therapy: non-ventilated and ventilated patients 1. Treatment of bronchospasms, wheezing, decreased or absence of breath sounds, and dyspnea. 2. Elevated airway resistance (Peak pressure plateau pressure) > 10 cm H2O. 3. Intrinsic PEEP Complications 1. Bronchospasms 2. Drug reaction 3. Systemic side effects (increased HR, increased BP, tremors) 4. RVR/A-fib 5. Hypertension 6. Urinary retention (due to use of dual anticholinergic Contraindications 1. ALI/ARDS Procedure When a physician orders aerosol therapy by HHN, EZPAP, IPV or any other modality used to give aerosol therapy, the aerosol protocol will be activated. Respiratory Care Practitioner (RCP) will: 1. Review the patient s chart for all pertinent information a. Physician s order b. Patient s history and physical examination c. Physician s progress notes d. Vital signs e. SpO2

2 f. Diagnostic reports (x-ray, PFT, sputum culture, etc. (if available) g. Arterial Blood Gas (if available) 2. Perform a Physical Assessment a. General observations: Patient s color, pattern and effort of breathing, chest expansion (symmetrical and bilateral), level of consciousness. b. Cough and sputum production: Observation of color and viscosity of sputum. If patient is unable to produce sputum, the Respiratory Care Practitioner should question the patient with regard to their sputum production, color consistency, frequency, and amount. c. Ability to take a deep breath and cough d. Auscultation of the lung fields 1) To evaluate airflow through the lung fields 2) To determine breath sounds Normal Crackles Rhonchi Wheezing or pleural rub 3. Hand Held Nebulizer with one unit dose Albuterol or one unit dose Ipratropium and Albuterol Sulfate if HR < 120. One unit dose of Ipratropium is optional if patient is in RVR/A-fib, HR > 100 or allergic to sulfur. 4. De-escalate aerosol therapy if a. Breath sounds are normal or clear b. Respiratory Rate within normal range (12-32 breaths per minute) c. No dyspnea 5. Frequency of treatments is to be de-escalated to prn only. All prn treatments are reassessed if RN, patient or family member request the need for bronchodilator aerosol therapy. 6. Frequency of treatment will be based on the bronchodilator assessment score found in cerner adhoc 7. Medication given is based on the assessment score 8. Patients will be reassessed by the Respiratory Care Practitioner with each treatment and therapy will be adjusted as needed. Any adjustments made in the frequency according to the assessment scorecard will be placed in orders by the Respiratory Care Practitioner. 9. A physician or nurse practitioner is to be contacted if the patient requires bronchodilator aerosol therapy more frequently than Q4 hours. 10. Any time the patient s clinical status deteriorates or an adverse event occurs; the physician or nurse practitioner will be contacted immediately. Exception

3 If a patient is taking home treatments, his/her treatment is not to be de-escalated beyond the home frequency.

4 References Journal of Aerosol Medicine and Pulmonary Drug Delivery, Volume 21, Number 1, 2008 Inhaled Bronchodilator Administration During Mechanical Ventilation: How To Optimize, and For Which Clinical Benefit Journal of Aerosol Medicine and Pulmonary Drug Delivery, Volume 25, Number 6, 2012 Inhalation Therapy in Patients Receiving Mechanical Ventilation: An Update Respiratory Care February, 2007 Vol 52 No 2 Bronchodilator Therapy in Mechanically Ventilated Patients: Patient Selection and Clinical Outcomes Respiratory Care, December 2008 Vol 53 No 12 Incorporating Tiotropium Into a Respiratory Therapist-Directed Bronchodilator Protocol for Managing In-Patients With COPD Exacerbations Decreases Bronchodilator Costs Journal of Critical Care Cost Savings with Interventions to Reduce Aerosolized Bronchodilator Use in Mechanically Ventilated Patients Respiratory Care, February 2007 Vol 52 No 2 Utilization of Bronchodilators in Ventilated Patients Without Obstructive Airway Disease Journal of Aerosol Medicine and Pulmonary Drug Delivery Vol 25, No6, 2012 Inhalation Therapy in Patients Receiving Mechanical Ventilator: An Update The protocol herein is developed collaboratively with the Medical Director of Pulmonary Services, Director of Pulmonary Services, Respiratory Therapists, and Pharmacy. It gives the Respiratory Therapists direction to proceed with aerosol therapy assessment and treatment within his/her scope of training upon initiation of its use by a Physician or Nurse Practitioner. The protocol is approved by the Medical Director and Director of Pulmonary Services and represents current standards of practice in pulmonary medicine. Approved by James S. Jones, MD Medical Director, Pulmonary Services Date/Time Approved Approved by John Campbell MA, MBA, RRT Director, Pulmonary Services Date/Time Approved

5 St. Dominic-Jackson Memorial Hospital Title: Cancer Committee Authority Date Authenticated By Policy Management Committee: Document Type: Policy Owner/Author: Amy Evins, RN, MBA, OCN Applies To: St. Dominic Hospital Medical Staff Number: Approved By: Medical Executive Committee Date Approved: Inception Date: Category: Physicians-Related Date(s) Reviewed* or Revised: 03/2018 *Reviewed but not changed Purpose: To ensure the Cancer Committee has authority for goal setting, planning, initiating, implementing, evaluating and improving all cancer-related activities in the cancer program. Policy: The Cancer Committee is a multidisciplinary group responsible for leading the Cancer Program and ensuring compliance of the Commission on Cancer Standards. The members of the Cancer Committee include all required members as indicated in the current program standards of the Commission on Cancer as well as any additional members appointed by the Cancer Committee. The Cancer Committee has been delegated the authority to perform necessary cancer-program functions by the Medical Executive Committee. Guidelines: 1. The Cancer Committee reports to the Quality Coordinating Council who reports to the Medical Executive Committee then to the Board of Directors Performance of the Cancer Committee is assessed bi-annually through the Quality Coordinating Council. 2. The Cancer Committee is responsible for goal setting, planning, initiating, implementing, evaluating, and improving all cancer-related activities associated with St. Dominic Hospital. 3. All physicians involved in the evaluation and management of cancer patients and serving in a required physician position on the cancer committee must be board certified, or the equivalent, or in the process of becoming board certified. Cancer Committee Authority Page 1 of 2

6 Related Documents 1. Commission on Cancer, Cancer Program Standards 2016: Ensuring Patient- Centered Care. Cancer Committee Authority Page 2 of 2

7 St. Dominic-Jackson Memorial Hospital Title: Pronouncement of Death by Hospital Staff Applies To: St. Dominic Hospital Category: Clinical Owner/Author: Suzie Allen, RN, Director of Document Type: Guideline Nursing Professional Development & Quality Approved By: Michael Sanders, MD, St. Dominic Hospital Medical Director Date Approved: 07/22/2013 Date Authenticated By Policy Management Committee: 08/08/2013 Inception Date: 04/1999 Date(s) Reviewed* or Revised: 01/2000, 07/2002, 12/2005*, 01/2009*, 01/2010, 06/2012, 08/2013, 03/2018 *Reviewed but not changed Purpose: To define the criteria and circumstances in which hospital staff may pronounce the death of a patient Guidelines: 1. At St. Dominic Hospital, a registered nurse (RN) may pronounce the death of a patient when: 1.1. The RN has documented training on pronouncement procedures The patient status is DNR A ventilated patient has a code status of DNR and expires while still ventilated, and with a physician s order to extubate the patient, then a qualified RN may pronounce the death of the patient. 2. A certified licensed nurse practitioner or a physician assistant may pronounce the death of a patient without further documented training He/she may choose to obtain training offered to registered nurses. 3. The nursing supervisors and selected nurse managers are trained to perform pronouncements. 4. An RN will not pronounce in the following circumstances: 4.1. A patient is connected to or dependent on life saving devices 4.2. A patient is a coroner s case 4.3. A patient is a known organ donor 4.4. There is question about the patient's resuscitation status 4.5. The family requests the physician pronounce the patient s death. Template Date: 12/2012 Page 1 of 2

8 5. Regardless of who pronounces the patient s death, the physician s responsibilities include: 5.1. Prior to the patient s death Following the guidelines for documenting resuscitation status Explaining to the family the impending possibility of death and documenting the discussion in the Progress Notes Responding if there is a question from the RN regarding the patient's DNR status or if the family requests to speak to the physician After the patient s death Giving an order, at his/her discretion, that a qualified nurse pronounce the patient Certifying the death by completing and signing the death certificate Only a medical doctor can certify the death. 6. The following steps should be followed: 6.1. The RN should contact the physician when a patient expires or death is imminent The qualified RN should document the following in the physician Progress Notes: No respiratory movement X 2 minutes Heart tones inaudible X 2 minutes Pupils fixed and/or dilated Blood pressure inaudible Write an order to release patient's body to funeral home after the patient is pronounced. Related Documents: 1. Autopsy, St. Dominic Hospital guideline 2. Brain Death, St. Dominic Hospital guideline 3. Coroner s Cases, St. Dominic Hospital guideline 4. Death of a Patient, St. Dominic Hospital guideline 5. Death of a Radioactive Patient, St. Dominic Hospital guideline 6. Do Not Resuscitate (DNR) Orders, St. Dominic Hospital guideline 7. Donation of Body to Medical Science, St. Dominic Hospital guideline 8. Fetal and Infant Death, St. Dominic Hospital guideline 9. Morgue, St. Dominic Hospital guideline 10. Organ and Tissue Donation, St. Dominic Hospital guideline References: 1. Mississippi State Board of Nursing Template Date: 12/2012 Page 2 of 2