Goal Directed Protocols
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1 James R Dexter MD FACP FCCP Goal Directed Protocols Complete a Task or Achieve a Goal? 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:
2 Goal Directed Protocols: My History Goal Directed Protocols: Incentives 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 Save the hospital money Prevent repeat of a sentinel event (or near miss) Solve interdepartmental turf conflict Developing and Selling RRT Protocols: #1 Developing and Selling RRT Protocols: #2 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. 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. 2
3 Developing and Selling RRT Protocols: #3 Developing and Selling RRT Protocols: #4 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. 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 Goal Directed Protocols: RRT Consult: #2 -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 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 3
4 7/5/16 Goal Directed Protocols: RRT Consult: #3 RRT Consultation Protocol: Goal Directed Protocols: RRT Consult: #4 Triggers for an RRT Consultation: 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: #5 Goal Directed Protocols: RRT Consult: #6 4
5 7/5/16 Goal Directed Protocols: RRT Consult: #7 Goal Directed Protocols: RRT Consult: #8 Prerequisites to Choosing an RRT Intervention (Stable): Prerequisites to Choosing an RRT Intervention (Unstable): Goal Directed Protocols: RRT Consult: #9 #10 RRT Consult Follow-Up: 5
6 7/5/16 #11 #13 #12 Goal Directed Protocols: RRT Consult: #14 6
7 Goal Directed Protocols: MDI/SVN Goal Directed Protocols: Oxygen 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. 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 Goal Directed Protocols: Intubation #2 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. 7
8 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 Goal Directed Protocols: Prone Positioning #1 Goal Directed Protocols: Prone Positioning #2 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 < 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,
9 Goal Directed Protocols: Prone Positioning #3 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 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 < 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: 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 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 Goal Directed Protocols: A-Line Protocol Begins with Creating Expectations Prior to ET Placement Literature shows less VAP and shorter LOS with < 7 days Tracheostomy Placement Assistant Physician does bronchoscopy and positions ET. RRT then manages bronchoscope while tracheostomy is placed RRT removes ET 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 9
10 Goal Directed Protocols: Nitric Oxide Goal Directed Protocols: EBUS 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. 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 Goal Directed Protocols: Ebola Procedural Sedation: Written but not yet instituted I m gowned to enter the room of a patient with possible Ebola. I did this once/day RRTs did it 24/7 10
11 7/5/16 RRT in ICU: Multidisciplinary Patient Rounds Patient Centered Multi-disciplinary ICU Rounds: Intensivist Patient Family (HIPPA) Bedside CCRN RRT Pharmacist Dietitian Physical Therapist MSW Case Manager Chaplain Nurse Manager Structure: Rounds are from 10 to 11:30 every day including weekends and holidays ICU Rounds usually include 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 RRT in ICU: Multidisciplinary Patient Rounds Advantages of Multidisciplinary Patient Rounds RRT Standardized ICU Rounds Report (30-60 seconds). 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. Days on Ventilator Ventilator Mode/PEEP/FIO2 Wean Status/Trend Sputum Production Anomolies 11
12 7/5/16 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? 12
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