Initiation and Modification of Therapeutic Procedures

1. Initiation and Modification of Therapeutic Procedures Determine Appropriateness of the Prescribed Respiratory Care Plan and Recommend Modifications

2. Skills required for this part of the exam include: • Integration of the basics (indications and treatment options) with analysis and decision making • Be able to analyze the test item and provide a rationale as the basis for recommending modifications in therapy to the physician Success in the this portion of the exam is based on your ability to focus on: • Collection and assessment of patient data • Analysis of the data • Selection of the appropriate course of therapy for your patient

3. Analyzing Available Data to Determine Pathophysiological State Essential to be well informed on all the indications, contraindications, and modifications needed for common respiratory problems. A good respiratory care plan: • Begins with careful identification and assessment of the patient’s condition • Provide or recommend therapies appropriate to the patient’s problem

4. Reviewing Planned Therapy to Establish Therapeutic Plan Pay attention to the specifications in the order as well as the logical use of therapy given in response to the patient’s problems. A typical plan specifies: • Therapeutic objectives • Specifics of equipment type and settings • Drug names, dosages, and frequency of administration • Relevant cautions or protocols to follow

5. Determining Appropriateness of Prescribed Therapy and Goals for Identified Pathophysiological State You must be able to recall specific information about a pathophysiological state, and then analyze the data given to determine the appropriate course of action.

6. Recommending changes in therapeutic plan when indicated based on data When the data indicates the plan is not meeting the desired objectives you must be able to recommend appropriate changes.

7. Performing Respiratory Care Quality Assurance AARC standards indicate that the goals of a respiratory care quality improvement plan should include at least the following: • To provide ongoing monitoring of both the quality and appropriateness of respiratory care • To ensure that respiratory care methods and procedures are cost effective • To ensure that respiratory care methods and procedures are effective • To identify, rank, and resolve patient care-related problems Nine key steps for systematically implementing a quality improvement plan are: • Identification of problems • Determination of problem causes • Ranking of problems • Development of strategies for problem resolution • Development of appropriate measures • Implementation of problem resolution strategies • Compilation of results • Evaluation of outcomes • Reporting of results

8. Identifying Problems • Evaluate effectiveness of high-utilization or high-risk procedures within the context of therapeutic goals • Gather data from patient records • Determining Causes • Lack of skills, knowledge of procedure criteria • Failure to following procedure criteria • Failure to discontinue procedures when indicated • Resolving Identified Problems • Develop, implement, and monitor strategy to correct problems • Reporting and Ongoing Monitoring • Problem identification, resolution activities and success of intervention strategies must be documented and reported regularly • Continued monitoring to ensure that a problem does not reoccur

9. Developing, Monitoring, and Apply Respiratory Care Protocols NBRC expects you to: • Be proficient in applying treatment protocols. • Independently initiate and adjust therapy within protocol guidelines ACCP key elements required in a medically acceptable RC protocol include: • Clearly stated objectives • Outline of the protocol, including a decision tree or algorithm • Description of alternative choices at decision and action points • Description of potential complications and corrections • Description of end-points and decision-points where the physician must be contacted Review the AARC Model protocols available to AARC members for procedures in the following areas: • Adult acute acre • Adult ICU • Pediatric Acute Care • Pediatric ICU

10. Protocol Monitoring and Quality Assurance Ongoing quality monitoring to assess effectiveness of protocols must include: • Therapist competency • Medical and therapist compliance • Protocol outcomes • Participant feedback • Patient satisfaction Relevant protocol outcome measures may include: • Physician protocol orders (appropriateness and duration) • Comparison of protocol patients to those receiving care by standard order • Costs (direct costs, number of procedures, duration of treatment, missed treatments) • Clinical outcomes (changes in physiologic measures such as SpO2, FEV1%; adverse reactions; length of stay; readmissions) • Effect on staff (productivity, satisfaction) • Miscellaneous (percentage of protocol patients vs. percentage of physician-directed patients • Number of patients on protocols by DRG, case-mix index for severity score, assessment scoring system for severity of respiratory illness, patient satisfaction scores

11. Common Errors to Avoid on the Exam • Never assume that all wheezing is due to bronchospasm or asthma; congestive heart failure (CHF) can cause similar symptoms but requires different treatment (a fast-acting diuretic). • Never recommend mechanical ventilation for chronic ventilatory failure when the blood gas indicates compensated respiratory acidosis; instead, recommend conservative management (e.g., low-flow O2, bronchial hygiene therapy) and careful monitoring. • Never recommend raising the FiO2 above 0.60 in the presence of severe hypoxemia due to shunting; instead, recommend adding PEEP/CPAP. • Never proceed with a protocol beyond a defined end-point or when a notification criterion requires you to contact the physician.

12. Exam Sure Bets • Always differentiate atelectasis/consolidation from pleural effusion before recommending the appropriate treatment. • Always recommend oxygen, circulatory support, and NaHCO3 when metabolic acidosis is due to shock. • Always recommend CPAP/PEEP in the presence of severe hypoxemia due to shunting (PaO2<60 torr on FiO2>0.60). • Always assess the patient’s pathophysiological state before recommending any course of action.

13. More Exam Sure Bets • Whenever evaluation data indicate that a therapeutic plan is not meeting the desired objectives, always consider or recommend appropriate changes in respiratory care. • When formulating respiratory care plans, always consider family requirements for education, communication, and monitoring. • When participating in quality assurance efforts, always try to identify the cause(s) of problems before developing corrective strategies.

14. More Exam Sure Bets • Always conduct a comprehensive initial patient evaluation (e.g., chart review, physical assessment) before developing a respiratory care plan or implementing a protocol. • Always include multiple methods to asses the efficacy of therapy (patient outcomes) in your care plans. • Always document any adjustments in therapy (including reasons for change) in the patient record.

15. Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers