Baptist Hospital Northeast

Proposed Emergency Room Respiratory Therapy Consult (RT Consult) Protocol Protocol Content: 1) Scope: A Licensed Registered Respiratory Therapist (RRT) or Certified Respiratory Therapist (CRT)
who has successfully completed and passed all competencies related to patient assessment and protocols. Although respiratory students may perform medicated aerosol therapy, they may not due so without direct supervision from a licensed therapist listed above using protocol and may not adjust therapy per protocol. 2) Assessment/Nursing Interventions/Evaluation/Documentation: a) Triage Nurse i) Identifies potential respiratory therapy consult (RT consult) patients at the triage level ii) Contacts appropriate respiratory therapist on-call for the emergency department and informs them of respiratory therapy consult with patients name and room number if known iii) Orders respiratory therapy consult (RT consult) in T-system iv) Notifies Attending ED physician of RT Consult

b) ED Nurse i) Supplies supplemental O2 (1) If patient is distressed and/or (2) O2 saturation is <90% and/or (3) Hypoxemia is suspected ii) Performs normal ED assessment/evaluation c) Respiratory Therapist i) Responds in a timely manner to ED when notified of RT consult ii) Performs RT Consult protocol as appropriate iii) Documents properly in patients electronic medical record iv) Communicates clearly with ED physician

3) Respiratory Therapy Consult (RT Consult) Protocol a) When a physician, physicians assistant, RN, or RT orders a respiratory therapy consult (RT consult) in the T-System the Respiratory Therapist (RT) will be called for a RT consult. The RT may initiate this protocol working within the following guidelines. b) Upon receiving the order, the respiratory therapist will assess the patient and select the appropriate therapy and medication. c) The following conditions are accepted indications for bronchodilator therapy: i) Bronchospasm/Wheezing ii) History of Asthma/Reactive Airway Disease (RAD) iii) Diminished lung sounds with associated shortness of air iv) COPD v) Prolonged expiratory phase vi) Impaired mucous clearance

d) The following medications are available for administering per protocol: i) Albuterol 0.083% 2.5mg unit dose ii) Duoneb unit dose

iii) Atrovent 0.5mg unit dose iv) Xopenex 1.25mg unit dose v) Ventolin 90mcg HFA MDI 4 puffs e) The following assessment and chart findings will be evaluated and documented as appropriate: i) Brief history including (verbal history is not to impede treatment when needed) (1) Previous hospitalizations for same/similar symptoms (2) Recent ED visits (3) Admissions requiring intubation (4) Co-morbid conditions (5) Current medications and last dose (6) Patients perception of symptoms (7) Known allergens (8) History of Glaucoma or increased ocular pressures ii) Vital signs (HR, RR, O2 sat, BP) iii) Current FIO2 iv) PEFR (if indicated) v) Patient assessment results (lung sounds, work-of-breathing, cough, secretions, ect.) Peak Expiratory Flow Rates (PEFR) will be done on asthmatics and other patients who report reversibility in symptoms with previous bronchodilator therapy. PEFR will be performed before and after initial treatment according to patients tolerance to perform the maneuver, or this will be performed as soon as patient is able. PEFR will also be performed after any subsequent treatments.

f)

g) Following an initial assessment, and initial treatment will be given to patients who meet the indications for therapy. If patient does not demonstrate improvement in PEFR, relief in dyspnea or reduction in expiratory rhonchi or wheezing, or improvement of other related symptoms, the treatment may be repeated. If necessary, a third treatment may also be given. h) If there is no improvement after (3) repeated treatments, the physician will be informed the patient is not responding to therapy. Further therapy will be given only with physician notification.

i) If the respiratory therapist determines the patient would benefit from a MDI bronchodilator for
home use or currently uses MDIs, and the patient meets the criteria for MDI use in the ED, an Albuterol MDI may be administered to patient. The patient will be instructed on correct use of the MDI, the difference between rescue and control MDIs, and the recommended frequency if needed. i) Criteria for MDI use: (1) Can physically perform the maneuver independently (2) Can follow directions (3) Is cooperative and alert (4) Can take a slow deep inspiration (5) Can hold breath for at least five seconds (6) Is able to perform a return demonstration (7) Has a respiratory rate less than or equal to 25 breaths per minute 4) Documentation/Communication a) Initial Assessment i) The respiratory therapist will document the order in the HEO portion of CAF under the patients electronic medical record including the RT consult, medication, dose, and frequency. ii) All therapies, assessments, and outcomes will be documented in the computerized charting system.

b) Re-assessments: i) All patients will be assessed with every treatment to determine the patients current pulmonary status and effectiveness of the aerosol therapy. ii) Adjustments of the patients therapy will be determined objectively by changes in the monitored parameters. c) Communication with physician i) RT will communicate initial and final assessment findings (1) After final aerosol therapy is given (2) At anytime if the patients progress deteriorates (3) If NPPV or invasive therapy (i.e. intubation) is necessary