Patient-Driven Protocols

Evidence-based, patient-driven protocols can improve health outcomes.5,6 Under medical direction and based on patient assessment, RTs use protocols to allocate and titrate respiratory care. Consistency and timeliness of implementation are keys to the effectiveness of protocols. Automation of protocols at the point of care can help RTs address these concerns. An automated protocol for discontinuation of the mechanical ventilation program on hand-held computers can decrease the time to the first spontaneous breathing trial and the length of stay in the intensive care unit (ICU) compared with a protocol without automation.⁷ At least once a shift, RTs enter information about each mechanically ventilated patient via a hand-held computer. When patients meet preset criteria, the computer program prompts the RTs to conduct a spontaneous breathing trial to help determine the patients’ readiness for ventilator discontinuation.

Clinical Decision Support

Information technology has the potential to assist clinicians actively with preventive measures, diagnosis, drug dosing, response to critical laboratory values, evidence-based care clinical practice guidelines, and chronic disease management. Clinical decision support systems match the characteristics of individual patients and their clinical interventions, drugs, and diagnostic tests to databases of scientific evidence and drug calculations and generate tailored recommendations, reminders, or even standing orders. These systems can optimally communicate these recommendations to clinicians via hospital information systems (HIS), e-mails, pagers, mobile phones, or printouts without the clinicians having to activate the system.

Clinical decision support systems are associated with improved clinician performance, decreased unnecessary care, and adherence to evidence-based clinical practice guidelines.8,9 These systems are particularly useful in preventive care. Computerized reminders increased the proportion of indicated influenza vaccinations, rates of screening, counseling, and adherence to medications. They have also resulted in decreased unnecessary hospital admissions for inappropriately diagnosed cardiac ischemia, appropriately decreased tidal volume and more consistent monitoring of plateau pressure in patients with acute respiratory distress syndrome, and decreased exacerbations in asthma patients.⁸ Clinical decision support is instrumental in improving clinical outcomes of patients by determining optimal drug dosages. Beneficial outcomes include the following:

Telemedicine

Telemedicine is the use of telecommunication and computer technology to promote access to diagnosis, monitoring, clinical decision support, and treatment for patients at medically underserved sites that are distant from health care providers. Telemedicine has been effectively implemented in various clinical settings, including home care, emergency departments, and ICUs, and is well accepted by patients.¹¹ Clinical outcomes have generally been similar to traditional health care delivery models; however, in the ICU setting, supplemental telemedicine has been associated with improved clinical outcomes, particularly among the most critically ill patients.^12,13 From a distance, on computers either within the hospital or at home, intensive care physicians can see the vital signs, ventilator data, medical record, and diagnostic images of the remote patients. Supplemental telemedicine helps to provide additional support that can potentially result in more rapid recognition of problems and timely, appropriate interventions.¹⁴

Treatment of Tobacco Use and Dependence

In the United States, tobacco use and dependence is the leading preventable cause of death and chronic diseases.¹⁵ Health care costs attributable to tobacco use are unsustainable. Effective evidence-based treatments are available, but their implementation by health care providers is lagging.¹⁶ RTs can play a vital role in the treatment of tobacco-related diseases and should aid in the pursuit of cost-effective ways to help tobacco users.

Emerging applications of computer technology, or eHealth applications, are exciting new components of treatment for tobacco use and dependence. With the extensive reach of the Internet and the demonstrated efficacy of some applications, the potential impact on health outcomes is immense. More than 10 million Internet users have searched for online information about how to quit smoking.¹⁷

Internet-based treatment programs can recruit tobacco users via search engines, or they can be an adjunct to telephone quitline counseling. Figure 7-2 is a screen shot from the smokefree.gov tobacco treatment website. When eHealth applications are tailored to individual tobacco users, with frequent automated contacts via e-mail or text messages, rates of long-term abstinence from tobacco use are similar to other evidenced-based interventions.^18–22

Consistent with the U.S. Public Health Service clinical practice guideline recommendation for a high-intensity, multicomponent approach, an Internet-based application has the capacity to provide both counseling that promotes tailored quit strategies and tobacco cessation medications that have been approved by the U.S. Food and Drug Administration (FDA).¹⁶ Internet-based applications can provide unlimited, sustained access to virtually limitless numbers of participants. These applications can be highly cost-effective. Table 7-1 lists some websites related to the treatment of tobacco use and dependence.

Management of Chronic Respiratory Diseases

Management of chronic diseases presents a grave challenge to the U.S. health care system. In the United States, 7 out of 10 deaths are due to chronic disease.²³ Chronic disease is present in 8 out of 10 Americans on Medicare, and chronic diseases account for three out of every four dollars of health care expenditures in the United States.^24,25 As baby boomers age in the coming decades, the proportion of the U.S. population 65 years old and older is expected to double. There is much interest in addressing the historically disjointed, misallocated processes of chronic disease management through advances in eHealth technologies, to improve health outcomes in a cost-effective manner. In the United States, 60% of households have access to computers, and the availability of broadband access to the Internet is expanding.¹⁷ In the United States, which has a population of 311 million people, there are more than 307 million wireless mobile phone connections.^26,27

Chronic Obstructive Pulmonary Disease

Increasingly, chronic obstructive pulmonary disease (COPD) is being managed in the home. Internet-based telemonitoring systems, smartphones, and mobile phones with computer applications extend the reach of health care providers into the home. eHealth applications for patients with COPD facilitates education, self-management, and timely feedback from health care providers (Figure 7-3). Patients generally have a positive attitude about the role of this technology, and the quality of the transmitted data is good.³⁵ Improved outcomes include earlier identification of deteriorating symptoms, better response to exacerbations, increased rate of sustained exercise after pulmonary rehabilitation, and decreased emergency department visits and hospitalizations.^35–37 Additionally, eHealth applications can help detect comorbidities, such as sleep apnea.³⁵

Blood Gas Laboratories

The accuracy and precision of blood gas data influence clinical decisions and patient safety. Computerized blood gas analyzers and computer-assisted quality assurance measures in a blood gas laboratory are crucial functions in a respiratory care department. Quality assurance data are necessary for accreditation of blood gas laboratories by the College of American Pathologists, the Clinical Laboratory Improvement Amendments, or The Joint Commission. Manual backup procedures must be in place in the event of computer system failure or downtime because of the critical nature of timely reporting of blood gas results and the need to be able to assess archived data at all times. Blood gas laboratories interface analyzers with HIS to make blood gas results immediately available at the point of care; additionally, this enables storage, retrieval, billing, and quality assurance.

Pulmonary Function Laboratories

Some hospitals interface their pulmonary function testing system with the HIS. Alternatively, other hospitals connect their desktop or notebook computer–based pulmonary function testing system to a local area network, which allows clinicians to access reports and graphics from multiple workstations. Most cardiopulmonary exercise and metabolic measurement systems use desktop or notebook computers.

World Wide Web

The World Wide Web is a far-reaching, rich source of information. RTs can “bookmark” helpful websites for clinical practice guidelines, evidence-based systematic reviews of clinical questions, accrediting agencies, or other relevant sites for rapid retrieval of important information (Table 7-2). For example, the Cochrane Collaboration (see www.cochrane.org), well respected for rigorously conducted systematic evidence-based reviews, provides free access to abstracts and summaries pertaining to relevant clinical questions, including questions related to “airways.”

Google Scholar

Google Scholar (see scholar.google.com) is a search engine for scholarly publications in a wide range of fields. It includes peer-reviewed manuscripts, abstracts, theses, and books from academic publishers, professional societies, and university libraries. Google Scholar uses a special algorithm to rank and determine the order of the search results. Variables in the algorithm include analyses of citations, authors, publications, and full texts.

Google Scholar is fast, yields wide-ranging search results, and provides citation data. Additionally, by virtue of agreements with certain publishers, search results sometimes include articles that are otherwise unavailable. The optimal application of Google Scholar may be for initial searches to find a relevant article quickly or when users know either an author or the title of a specific article that they are seeking.

PubMed and MEDLINE

PubMed (see www.pubmed.com) is the free search engine of the National Library of Medicine for health information. It searches several databases, including MEDLINE, the database of the National Library of Medicine of millions of references from thousands of journals related to medicine, nursing, the health care system, and science. The National Library of Science updates MEDLINE references in PubMed almost daily. Each MEDLINE citation in PubMed generally has the following information: title, authors, an abstract, journal, language, type of publication, and Medical Subject Headings (MeSH).

A unique feature of PubMed is that it maps users’ search terms to MeSH. PubMed uses Boolean logic, in which users can combine search words or phrases with connectors such as AND or OR to narrow or broaden searches. Box 7-1 provides examples to illustrate the use of Boolean connector terms.

PubMed Clinical Queries Filter

The Clinical Queries search filter in PubMed is easy to use and very effective in retrieving valid research studies. To access it, on the PubMed home page, in the center column, under “PubMed Tools,” click “Clinical Queries” (Figure 7-4). On the Clinical Queries page, select one of the “Clinical Studies Categories,” such as “Therapy” or “Diagnosis.” Then select the scope of the search, as either “Broad” or “Narrow.” A “Broad” search is more sensitive, providing more search results; a “Narrow” search is more specific, providing fewer search results. Selection of “Broad” versus “Narrow” depends on the reason for the search. Search results include clinical research studies in the left column and systematic reviews in the center column, or the user can elect to include only systematic reviews in the search results (Figure 7-5). When the user selects “Therapy” from the “Clinical Study Categories” with a “Narrow” scope, the Clinical Queries filter automatically searches for randomized controlled trials and systematic reviews.

 Rule of Thumb

When developing evidence-based patient-driven protocols, the user might elect to start with a “Broad,” sensitive search that is more comprehensive.

When time efficiency is a high priority, such as when retrieving information to assist in the care of an individual patient, the user might select a “Narrow,” specific search strategy.

The Clinical Queries search filter is very sensitive (true positives/true positives + false negatives) and specific (true positives/true positives + false positives) in the retrieval of the best available scientific evidence. A validation study of this search filter yielded 93% sensitivity and 97% specificity.⁴⁰ The Clinical Queries search filter effectively retrieves valid research studies, while eliminating nonrelevant information and poorly designed studies. Compared with Google Scholar, which lacks any way to filter a large volume of information, PubMed Clinical Queries filter is equally sensitive but considerably more specific, reducing the time it takes to find the best available evidence.⁴¹

Ovid

Ovid is an extensive collection of Web-based information resources, including databases, journals, books, and searching software. Many medical libraries and large hospitals in the United States purchase and use Ovid in some form. An institution can customize Ovid content and resources to meet its particular needs. Among hundreds of available databases in Ovid, medical databases include Medline, Evidence-Based Medicine Reviews, and CINAHL. The Evidence-Based Reviews databases include the Cochrane Database of Systematic Reviews and the ACP Journal Club by the American College of Physicians. The ACP Journal Club features reviews of clinically relevant research studies that were conducted in a rigorous manner. The CINHAL (Cumulative Index to Nursing and Allied Health Literature) database features literature from nursing and 17 allied health professions, including respiratory care.

Information Retrieval by Patients

With the advent of extensive available information on the Web, patients increasingly seek knowledge about diseases and treatments on their own. Eight in 10 Internet users have searched the Web for health information.¹⁷ However, many Web users neglect to scrutinize the quality or source of the information, which is largely unregulated.⁴² RTs should be able to offer guidance to patients about appropriate information sources. Table 7-3 presents the Health on the Net criteria for evaluating the quality of medical and health websites. Selected resources for patients include the AARC site for patients (see www.yourlunghealth.org), the website of the National Lung Health Program (see www.nlhep.org) dedicated to COPD patients, and MedlinePlus.gov of the National Library of Medicine. MedlinePlus features online interactive tutorials, practical instructional handouts for patients, a medical encyclopedia, and videos of surgical procedures.

Respiratory Care Management Information Systems

Many respiratory care departments use respiratory care management information systems. In addition to charting and billing, respiratory care management information systems provide a means to organize and assign respiratory care orders, measure staff productivity, report clinical results, and execute respiratory care protocols, along with generating data to show their effectiveness via outcomes research (Figure 7-6).

Respiratory care management information systems, such as CliniVision MPC and MediLinks, provide point-of-care, mobile, charting capabilities via hand-held computers, with wireless transmission of data to HIS. These hand-held computers integrate the AARC Uniform Reporting Manual, which includes time standards for respiratory care procedures, billing codes, and clinical practice guidelines. Additionally, they function as pagers and telephones, provide access to the Internet, and interface with mechanical ventilators and blood gas analyzers.

Hand-held computers offer several advantages compared with paper charts. Hand-held computers facilitate the organization and assignment of workload, facilitate the fulfillment of physicians’ orders, and improve documentation.43,44 Documentation of patient assessment becomes immediately available to other members of the health care team in the HIS. Incomplete or lack of patient information, which is more likely to occur with paper charts, is associated with numerous medical errors that cause adverse events, including prolonged hospitalization and death.⁴⁵

Benchmarking

Benchmarking is valuable for each of the primary functions of respiratory care managers, including planning, organizing, directing, and evaluating. The AARC provides an online benchmarking system (Figure 7-7) in which managers can compare the performance of their department with other similar departments. Managers can compare the ratio of ventilator days with the number of patients or the number of missed treatments in a given time frame. Benchmarking helps to show the productivity of the department and establish best practices.

Additionally, many respiratory care managers benchmark the incidence of ventilator-associated pneumonia in their hospital to that reported to the National Nosocomial Infections Surveillance system. This type of benchmarking can lead to increased efforts to implement evidence-based interventions to reduce the rate of ventilator-associated pneumonia, improving patients’ outcomes.

Hospital Information System

An HIS is a comprehensive system for communication and information processing. It encompasses networks, computer hardware and software, and computerized patient records. The HIS supports both the administrative and the clinical missions of hospitals. For administrative purposes, it facilitates patient billing, reimbursement, and communication. For clinical purposes, key functions of an HIS are to serve as a data repository and a means to report results.

The HIS can permit chart review of clinical data at both central and remote locations. Ideally, patient data are accessible across the continuum of care, from outpatient clinics, emergency departments, and hospitals to rehabilitation centers. Patient data may include chest x-rays, bronchoscopy videos or images, sputum culture results, blood gases, and PFT results. Because hospitals consist of many different clinical units and allied health departments, being able to share data between different devices and computer systems is an important characteristic of an HIS.

Electronic Health Records

Electronic health records can improve access to patients’ updated health information for both clinicians and patients and assist clinicians with clinical decision support. Many investigators have begun to focus attention on the development of a seamless network of transferable, widely accessible, longitudinal electronic health records. A comprehensive national health information infrastructure would result in interconnectivity among health information systems in the United States.⁴⁶ Core functions are shown in Box 7-2.

The electronic health record would become the central component of health care information systems, satisfying the information needs of health care providers, public health officials, and individuals, and potentially reduce medical errors and elimination of redundant diagnostic tests (Figure 7-8). It would support health systems planning and development of policies. Major barriers and challenges for the development and implementation of electronic health records are costs, the lack of uniformity of data, the inability to establish an interface among different health information systems, and accounting for the needs of various health professional disciplines.

Clinical Simulation

Computerized clinical simulation is a powerful learning aid. Computer-based simulation is a long-standing principal educational method for hazardous occupations that have shown remarkably low rates of failure (e.g., airline pilots, members of the military, astronauts, and nuclear power plant operators). Health care education has progressed to include the use of computer-based, full-body manikins and high-fidelity clinical simulators. These devices feature software to program clinical scenarios and simulated vital signs and physical examination findings that either improve or deteriorate in response to the actions of the learners. The simulators can reproduce situations requiring complex airway management or advanced life support. In virtual surgical simulators, haptic devices allow learners to exert force against simulated tissue that offers realistic resistance, and in virtual bronchoscopy simulators, vocal cord movements are exhibited that are synchronous with the phases of breathing and cough.

Learners are able to suspend disbelief, immersing themselves in carefully planned case scenarios and performing in a manner similar to that of real clinical situations (Figure 7-9). They develop psychomotor, critical thinking, decision-making, and team-building skills. In contrast, traditional methods of didactic education in combination with clinical apprenticeships can result in increased knowledge, but limited, inconsistent experiential learning opportunities, without the benefit of remediation and extensive practice based on feedback. Clinical simulators, to a certain extent, allow for in-depth evaluation of learners’ competencies, rather than evaluation based on the length of time for clinical rotations or the number of performed procedures. They are an excellent tool to help respiratory care departments meet The Joint Commission requirement of demonstrating the competencies of respiratory care staff in an ongoing manner.^47,48 Recommended steps in clinical simulation education are diagrammed in Figure 7-10.

Clinical simulators are particularly valuable for learning how to function in rare but high-risk clinical situations. Training via simulators has resulted in improved performance of health care providers in emergency airway management, advanced life support, bronchoscopy, and surgery.49–53 Clinical simulators have the potential to reduce medical errors and improve patient safety. Simulations promote relatively comprehensive learning (Box 7-3). Performances in clinical settings become more refined and automatic.

DataARC

DataARC (see www.dataarc.ws) is a secured, password-protected, Web-based database management system for documenting and reporting clinical educational activities for nursing and allied health professions, including respiratory care. The records help both students and faculty members identify underaddressed clinical activities and competencies (Figure 7-11). Functions include the following:

Students and faculty can use hand-held computers or personal digital assistants to access it. DataARC archives data daily.

National Board for Respiratory Care Credentialing

The National Board for Respiratory Care (NBRC) uses computerized credentialing examinations. NBRC credentialing for the registry for advanced RTs consists of two distinct examinations—the written examination and the clinical simulation (Figure 7-12).

Distance Education

Respiratory care educators use interactive video networks and the Internet to deliver distance education courses. This technology improves access to a respiratory care education for students in rural areas. Asynchronous Web courses enable practicing RTs to advance their education to the baccalaureate or master level, by allowing for flexibility in coordinating completion of coursework with their work schedule. Wimba Classroom is an adjunct to the Blackboard learning system, in which Web-based classes are live and interactive. Students can talk to their instructor and classmates via live audio or chat or asynchronously access archived classes via streamed video or mp3 or mp4 files downloaded to their computers or smartphones.

Continuing Education

Continuing education is vital and often a requirement for state licensure. Computer-based and Web-based continuing education is accessible, efficient, and cost-effective. These qualities are especially pertinent to the respiratory care profession. Most RTs care for patients across various shifts and schedules in hospitals, where assembling the staff to attend face-to-face delivery of continuing education proceedings is often challenging at best.

American Association for Respiratory Care

The AARC provides plentiful continuing education opportunities on the Web (see www.aarc.org). Web casts and text-based courses are available in both a live and an asynchronous manner. RTs may earn continuing respiratory care education (CRCE) credit by completing these courses (Figure 7-13). The AARC also provides Web-based CRCE credits through the Respiratory Care journal. Therapists can read the journal, use a copy of the test that appears in the journal to draft answers, and then complete the Web-based test on the journal website (www.rcjournal.com/online_resources/crce). The AARC maintains a database of members’ CRCE credits, which RTs can access on the AARC website.

Additionally, to facilitate electronic networking among RTs, the AARC offers Specialty Sections and Roundtables. Each Specialty Section features an e-mail listserv for discussions, e-newsletters, e-bulletins, and a website. Roundtables feature e-mail listserv for discussion.

Pulmonary Artery Catheter Education Project

The Pulmonary Artery Catheter Education Project (see www.pacep.org) provides excellent online training in hemodynamic monitoring. It includes Web casts with audio and slides and pretesting and posttesting for each module and case studies for many of the modules.

Data Sources

Clinical databases are rich data sources for outcomes research. In a tobacco cessation program, clinicians can compare rates of tobacco consumption and abstinence from intake and follow-up patient interviews.

Additionally, public data sources are available on the Web to support descriptive and analytic research. The National Center for Health Statistics (see www.cdc.gov/nchs), the principal health statistics agency in the United States, oversees birth and mortality data, the National Maternal and Infant Health Survey, the Longitudinal Studies on Aging, the National Asthma Survey, and the NHANES. The NHANES is a comprehensive survey and examination of a nationally representative sample and includes data concerning demographics, tobacco use and other behaviors, pulmonary diseases, laboratory data, physical examination, and spirometry. State public health agencies are sources of public data available to researchers from instruments such as the Youth Behavioral Risk Survey.

Data Collection

Computers facilitate data collection via either hand-held computers or Web-based survey software. Compared with traditional paper methods of data collection, hand-held computers improve adherence to instructions, are faster, are preferred by research subjects, and may improve data accuracy.⁵⁴

Web-based survey software, such as Survey Monkey (see www.surveymonkey.com) and Questionmark Perception (see www.questionmark.com/us/perception/index.htm), is a cost-effective approach for data collection. These tools enable researchers to create secured, Web-based, questionnaires with the capacity for adaptive branching of questions, tracking respondents, and downloading data into spreadsheets or statistical software.

Statistical Software

Statistical software programs, such as SPSS, SAS, and Statistica, are instrumental in research. In the hands of RTs with knowledge of statistics, these powerful programs can perform laborious and complex statistical tests for descriptive, analytic, and inferential analyses and reporting.

Citations and Bibliographies

Web-based software (see www.EndNote.com; www.RefWorks.com) automates the otherwise unwieldy and sometimes exhausting task of generating and formatting citations and bibliographies in research manuscripts. With relative ease, researchers can search for, import, organize, manage, and share databases of references.

Protection of Human Research Subjects

Research that features human subjects must have the ongoing approval of an institutional review board, which is responsible for protection of human subjects in research. Institutional review boards use information technology systems to help regulate the researchers’ compliance with regulatory requirements for submission and monitoring of human and animal research.

Confidentiality

Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations concerning confidentiality are pertinent to electronic medical records and research data that contain personal health information (see Chapter 5). To emphasize two important points concerning electronic personal health information, users of hospital and respiratory care information management systems and researchers must (1) refrain from sharing passwords and (2) access personal health information only on a need-to-know basis. Some respiratory care information management systems now feature thumbprint protected security.