Walking out of the leadership meeting at Insley Medical Center the Pulmonary Services director, Barry Cones, was tasked with a simple directive: Decrease medication expenditure associated with his department. Barry was the director of a Pulmonary Services department that employed eighty-seven full-time Registered Respiratory Therapists, ten part-time Registered Respiratory Therapists, and three as-needed (PRN) Registered Respiratory Therapists. His immediate task was to put together a team of respiratory therapist and stakeholders to analyze, create, implement, and evaluate some program that would immediately address the medication expenditure initiative. Since leadership met quarterly, Barry understood there was a three-month window to demonstrate an effective program. With that, Barry returned to his office and started to identify a team of respiratory therapists and stakeholders.
Dramatis Personae
Barry Cones: Pulmonary Services director
Dr. Blasilda Bells: Pulmonologist and Medical Staff director
Scott Robins: Pulmonary Services manager
Ami Flackson: Pulmonary Services dayshift supervisor
Patrick Kerry: Pulmonary Services nightshift supervisor
Sarah Kanatsey, Lead electronic chart and instructional design officer
Dr. Hemant Pharma, Pharmacist
After initial onboarding phone calls to discuss the initiative, Barry called the team together. He explained that Insley Medical Center respiratory therapists had delivered approximately 375,000 nebulized aerosol treatments to approximately 35,000 patients throughout the 2019 fiscal year. For the Pharmacy department, this amounted to a 1.7-million-dollar annual cost associated with nebulized aerosol medications. As Barry distributed a list of medications associated with the high annual cost, one class of medications stuck out: Bronchodilators. Bronchodilators consisted of 92% of all nebulized aerosol treatments administered for fiscal year 2019.
For staff respiratory therapists, administration of bronchodilators such as Albuterol and Levalbuterol is a time invasive procedure intended to control symptoms of asthma and/or chronic obstructive pulmonary disease (COPD), such as wheezing and shortness of breath (Egan, 2017). In its simplest form, administration of a bronchodilator consists of squirting a medicated liquid into a cup and exposing the liquid to a high velocity of air and/or oxygen. This exposure “blasts” the medicated liquid into small inhalable sized particles, and the patient inhales the medicated liquid particles into their lungs via slow deep breathing. In total, a respiratory therapist will spend approximately twelve minutes at the patient’s bedside. At Insley Medical Center, the staff respiratory therapist will deliver approximately fifty aerosolized bronchodilators per twelve-hour shift.
“Good grief, that is a lot of Albuterol getting passed out daily throughout this hospital,” said Dr. Pharma, “there’s got to be a way to reduce the number of these we’re giving patients without doing harm.” “Well you know something,” Scott replied, “we’ve been giving Albuterol for years and years knowing after about a day the patient is no longer receiving any benefit from it. We’re just giving it because it’s an order on the chart prescribed by a provider and there’s nothing we can do to change that.” Dr. Bells commented, “Well you know, at the facility I completed my residency the respiratory therapists used a protocol for all patients receiving a bronchodilator. After a provider would send an order to administer a bronchodilator like Albuterol, it was on the respiratory therapist to assess the patient and recommend how often it is given. I’m not certain, but I think it really cut down on the number of unnecessary bronchodilator treatments given. Can you imagine being a patient and being woken up at 3:00 am just to get a medication you totally don’t need? I’d be so mad!” Sarah Kanatsey, the instructional designer, inquired, “What information would we need for this bronchodilator protocol? Like, current patient information or if they’ve ever taken this medication prior? Smoking history? I’m familiar with what a protocol is, but I need to know what information would need to be jammed into the electronic charting flowsheet for this.” With that, Barry selected Sarah, Patrick, and Ami to form a sub-task team and design a bronchodilator protocol template with determinants of patient information driving the clinical decision making.