Unit 2: Quality and Evidence-Based Respiratory Care

(6 hours)

Introduction
Quality is defined as a characteristic reflecting a high degree of excellence, fineness, or grade.
Ruskin, a nineteenth-century British author, stated, “Quality is never an accident. It is always the
result of intelligent effort.” Because the components of quality are always changing, the
conclusions formed from the assessment of quality are only transitory. Quality in the practice of
respiratory treatment, in particular, includes numerous dimensions. It includes the people who
offer respiratory care, the equipment that is utilized, and how the care is delivered.

Learning Outcomes
At the end of this unit, you are expected to:
1. describe the elements for delivering high-quality respiratory care;
2. explain how respiratory care protocols improve the quality of respiratory care services;
and
3. describe evidence-based medicine.

Presentation of Contents

Determining the quality of a respiratory care department's services necessitates thoughtful efforts
to set rules for providing high-quality care and a means for monitoring that care. In today's cost-
conscious health-care environment, quality can be harmed by pressures to cut costs, making quality
measurement and monitoring even more critical.

We look at the components of a hospital-based respiratory care program in detail, with an emphasis
on medical direction, practitioners, and technological direction. We next examine respiratory care
protocols as an essential approach to offer high-quality respiratory care, with the objective of high
quality being competent delivery of appropriate treatment. Finally, we go through the idea of
evidence-based medicine as it applies to the practice of respiratory care.

I. ELEMENTS OF A HOSPITAL BASED RESPIRATORY CARE

PROGRAM: ROLES SUPPORTING QUALITY CARE

Medical Direction
The medical director of respiratory care is in charge of the department's clinical function and
oversees the clinical treatment provided. The job is a full-time obligation; the medical director
must be available 24 hours a day, 7 days a week for consultation and assistance to other physicians
and respiratory care employees. Hence, administrative, leadership, and medical abilities are all
required of a medical director.

Fundamentals of Respiratory Therapy 1 | 1

 Box 2.1 Responsibilities of a Medical Director of Respiratory Care
• Medical supervision of respiratory therapist in the following areas:
o General medical, surgical, and respiratory nursing wards
o Intensive care units
o Ambulatory care (including rehabilitation)
o Pulmonary function laboratory
• Development and approval of department clinical policies and
procedures
• Supervision of ongoing quality assurance activities
• Medical direction for respiratory care in-service and training
programs
• Education of medical and nursing staff regarding respiratory therapy
• Participation in the selection and promotion of technical staff
• Participation in preparing the department budget

The ability to give appropriate (i.e., clinically indicated) and skilled respiratory care is perhaps the
most important part of providing high-quality respiratory care. The physician has traditionally
examined patients for respiratory care and given specific respiratory therapy instructions for the
respiratory therapist (RT) to follow. Traditional techniques, on the other hand, have been linked to
what has been dubbed "misallocation of respiratory care." These studies show that misallocation
of respiratory treatment is a common occurrence. As a result of this misallocation, respiratory care
protocols (as implemented by RTs) are now used.

Respiratory Therapists
The training, education, experience, and professionalism of RTs are the most important factors in
determining their quality. To create qualified RTs for assessing patients and implementing
respiratory care regimens, adequate training and clinical education are essential.

Designations and Credentials of Respiratory Therapists

The two levels of general practice credentialing in respiratory care are
(1) certified respiratory therapists (CRTs); and
(2) registered respiratory therapists (RRTs).

A CRT might be able to take the registry exams to become a credentialed RRT. Students who
finish a two-year program earn an associate degree, while those who complete a four-year program
earn a bachelor's degree. Some respiratory therapists go on to earn a graduate degree (master's or
doctorate) and pursue further studies in respiratory care, education, management, or health
sciences.

The American Association for Respiratory Care (AARC) has advocated the expansion of graduate
education in respiratory care, and several masters-level respiratory therapy programs are now
available. The Committee on Accreditation for Respiratory Care (CoARC) evaluates respiratory
care education programs.

Credentialing is a general term that refers to recognizing individuals in particular occupations or

professions.

The two major forms:

(1) state licensure, and
(2) voluntary certification

Licensure is the process in which a government agency gives an individual permission to practice
an occupation.

Fundamentals of Respiratory Therapy 1 | 2

 • A license is granted only after verifying that the applicant has demonstrated the minimum
competency necessary to protect the public health, safety, or welfare.
• Licensure laws are normally made by state legislatures and enforced by specific state
agencies, such as medical, nursing, and respiratory care boards.

Certification is a voluntary, non-government process whereby a private agency grants recognition

to an individual who has met certain qualifications.
• As a voluntary process, certification involves standards that are often higher than the
minimum standards specified for entry-level competency.
• Certification generally does not prevent others from working in that occupation, as do most
forms of licensure. Both types of credentialing apply in respiratory care.

National Board for Respiratory Care (NBRC)

• The primary method of ensuring quality in respiratory care is voluntary certification or
registration
• The NBRC is an independent national credentialing agency for individuals who work in
respiratory care and related services.
• The NBRC provides the credentialing process for both the entry-level CRT and the
advanced-practitioner RRT.
• As established in January 2006, to be eligible for either the CRT or the RRT examination,
all candidates must have an associate degree or higher.

To keep his or her license, most states require the RT to complete a certain amount of continuing
education credits. The Joint Commission (TJC) mandates that many institutions undertake annual
skill checks or competency reviews. Respiratory care protocols point to the necessity for RTs to
learn and monitor additional abilities.

Box 2.2 Additional Respiratory Therapist Skills Required for

Implementing Protocols
• Assess and evaluate patients regarding indications for therapy and for the
most appropriate delivery method
• Be cognizant of age-related issues and how they affect the patient’s ability
to understand and use various treatments
• Adapt hospital policies and procedures to alternative care sites
• Conduct and participate in research activities to ensure a scientific basis
for advances in respiratory care technology
• Communicate effectively with all members of the health care team, and
advance knowledge in the field of respiratory care.

Professionalism by definition, professionalism is a key attribute to which all RTs should aspire
and that must guide respiratory care practice.

• Webster’s New Collegiate Dictionary defines a profession as “a calling that requires

specialized knowledge and often long and intensive academic preparation.”
• A professional is characterized as an individual conforming to the technical and ethical
standards of a profession.
• RTs demonstrate their professionalism by maintaining the highest practice standards,
engaging in ongoing learning, conducting research to advance the quality of respiratory
care, and participating in organized activities through professional societies such as the
AARC and associated state societies.

Fundamentals of Respiratory Therapy 1 | 3

 Box 2.3 Professional Characteristics of a Respiratory Therapist
• Completes an accredited respiratory therapy program
• Obtains professional credentials
• Participates in continuing education activities
• Adheres to the code of ethics put forth by the institution or state
licensing board or both
• Joins professional organizations

Technical Direction is often the responsibility of the manager of a respiratory care department,
who must ensure the equipment and the associated protocols and procedures have sufficient quality
to ensure the safety, health, and welfare of the patient using the equipment.

• The FDA also regulates the drugs that are delivered by RTs. The purpose of this is to
establish safety and effectiveness standards and to ensure that these standards are met by
equipment and pharmaceutical manufacturers.
• Procedures and protocols related to the use of equipment and medications must be written
to provide a guide for the respiratory care staff. In addition, equipment must be safety
checked and specific maintenance procedures must be performed on a regular basis.
• New medications and delivery devices for the treatment of asthma and newer strategies for
treating other respiratory diseases (e.g., low-stretch ventilatory approaches for ARDS)
continue to evolve.
• Individuals responsible for technical direction must ensure that these new devices,
methods, and strategies not only are effective but also have value.

Respiratory Care Protocols

Respiratory care protocols are a set of rules for providing effective respiratory care treatments and
services. Because well-trained RTs have significant knowledge of respiratory therapy modalities
and the assessment and communication skills required to apply the protocols effectively, using
respiratory care protocols by qualified RTs is a sensible practice.

Box 2.4 Key Elements of a Respiratory Care Protocol Program

• Strong and committed medical direction
• Capable respiratory therapists (RTs)
• Active quality monitoring
• Collaborative environment among RTs, physicians, and nurses
• Responsiveness of all participants to address and correct problems

Box 2.5 Elements of an Accepatble Respiratory Care Protocol as

Described by the American College of Chest Physicianss
• Clearly stated objectives
• Outline that includes an algorithm
• Description of alternative choices at decision and action points
• Description of potential complications and corrections
• Description of end points and decision points at which the physician
must be contacted
• Protocol program

The acceptance of many stakeholders in the hospital, including hospital administrators, physicians,
nurses, and RTs, is required for successful protocol implementation. RTs' willingness to change
and abandon outdated task-driven practices in respiratory care necessitates a desire to be
progressive.

Fundamentals of Respiratory Therapy 1 | 4

 Box 2.6 Tactics for Implementing Respiratory Care Protocols
1. Select a planning team with diverse membership.
2. Conduct an audit to assess the occurrence of misallocation of therapy to
justify departure from usual care.
3. Identify sources of resistance (e.g., physicians, nurses, administrators,
respiratory therapists [RTs])
4. Design a protocol program that fits the individual hospital.
5. Develop a training program for RTs.
6. Develop an evaluation and quality monitoring system.

With the use of a respiratory therapy consult service, the sequence of events for a respiratory
therapy consult may occur as shown in Box 2.7.

Box 2.7 Sequence of Events for a Respiratory Care Consult

1. A physician writes an order for a respiratory care protocol or consult.
2. A physician order entry system or the nursing unit secretary notifies a
respiratory therapist (RT) evaluator.
3. The evaluator assesses the patient using specific guidelines.
4. The evaluator writes a care plan using designated indications and
algorithms and documents the care plan in the patient’s chart for review
by the physician
5. The RT covering the nursing unit delivers the care.
6. The patient is assessed on a shift-by-shift basis for changes in status and
indicated modifications for the care plan, which are also documented.
7. The physician is notified of any deterioration in the patient’s status.
8. When indications for respiratory care no longer exist, respiratory care
treatment is discontinued, and notification is placed in the patient’s chart.

Respiratory care protocols include better allocation of respiratory care services without increasing
the frequency of respiratory treatments, as well as cost savings. As part of a quality control
program, establishing the respiratory therapist's competency to administer the care and checking
the correctness of audits are other important aspects of a protocol service.

II. EVIDENCE-BASED MEDICINE

Another crucial notion in terms of high-quality care. Evidence-based medicine is a method of
selecting the best therapeutic therapy based on a variety of practices, as follows:

(1) a rigorous and systematic review of available evidence,

(2) a critical analysis of available evidence to determine which conclusions are most sound
and applicable, and
(3) a disciplined approach to incorporating the literature with personal practice and
experience.

Data-based medicine, in a larger sense, can be defined as the knowledge and application of the
highest quality evidence available (i.e., the best-designed, most rigorous clinical trials) to support
the most suitable and correct therapeutic decisions feasible.
Recognize the many designs and types of study designs from which scientific evidence is derived
when judging the quality of scientific evidence.
• A single case report is the simplest and least rigorous approach, in which a new clinical
issue or problem is documented in a single patient. A single case report is a discussion of
the positive outcome of utilizing a new mode of mechanical breathing in one patient with
refractory hypoxemia.

Fundamentals of Respiratory Therapy 1 | 5

 • A case series is a collection of patients with similar clinical features that may have a bigger
impact than a single case report since it implies that the problem is more widespread than
in a single patient. Because no comparison or control group is included, a case series, like
a single case report, cannot prove the efficacy of a treatment or the causality of a risk factor.

• Cohort studies, which compare the clinical outcomes of two groups (or cohorts), are more
scientifically rigorous than case studies or case series, and are divided into two types:
observational cohort studies and randomized controlled trials.

o In observational cohort study examines the results of two groups of patients when
the treatment is given to one but not the other in order to determine if a treatment
works (i.e., has efficacy).

o A randomized controlled trial is a study design that is sometimes regarded as the

most methodologically rigorous (when well conducted). A randomized controlled
treatment trial, when properly designed and carried out, eliminates all forms of bias
that would preclude attributing variations in outcomes between the compared
groups to anything other than the treatment under investigation.

• Evidence-based medicine is the practice of systematically reviewing the available

literature, or what is called meta-analysis of the literature. In other instances (called
narrative analyses), the quality of the data from each available trial (based on methodologic
criteria) is evaluated to offer a conclusion about the clinical issue.

Although it is hoped that issuing such evidence-based guidelines will improve the care that such
individuals receive by allowing clinicians to quickly access the most up-to-date information,
experience suggests that clinicians may be slow to adopt the most up-to-date evidence when caring
for their patients.

Several studies in Respiratory Care examined the effectiveness of RTs and various respiratory care
treatment modalities using an evidence-based approach as a measure of the value of evidence-
based medicine in respiratory care.

The AARC's Clinical Practice Guidelines are undergoing a thorough revision in order to reflect
the rigorous approaches of evidence-based medicine.

Fundamentals of Respiratory Therapy 1 | 6

 Feedback
1. Explain how respiratory care protocols improve the quality of respiratory care services. Support
your answer with the evidence from the text.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Providing quality care to the patient involves many dimensions. List three elements that are part
of quality respiratory care and discuss each.
A. __________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

B. __________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

C. __________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. Quality must be monitored to ensure it is being obtained. Give an example of each main
monitoring strategy.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Fundamentals of Respiratory Therapy 1 | 7

______________________________________________________________________________
______________________________________________________________________________

4. Explain the importance of evidence-based medicine.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5. Protocol-based therapy and quality assurance efforts do not always work. Discuss some of the
reasons you think these two strategies might fail.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6. Evidence-based medicine (EBM) uses meta-analysis. What does this term mean? Why is
meta-analysis different from standard reviews of literature? Is it better?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Fundamentals of Respiratory Therapy 1 | 8

Summary of the Unit
In this unit, you learned about the quality of evidence – based respiratory care. It should be
noted that:

• High-quality respiratory care can be defined as the competent delivery of indicated

respiratory care services.

• Delivery of high-quality respiratory care requires the combined activities of a qualified

and committed medical director and capable RTs and can be enhanced by well-constructed
respiratory care protocols.

• Respiratory care protocols are guidelines for delivering appropriate respiratory care
services and are widely used in current respiratory care practice.

• Available evidence suggests that use of respiratory care protocols can improve allocation
of respiratory care services. In doing so, the use of respiratory care protocols lessens
misallocation of respiratory care.

• Misallocation of respiratory care services, which hinders the delivery of high-quality

respiratory care, can be defined as overordering or underordering of respiratory care
services and is common in current practice.

• Maintaining and improving quality requires ongoing monitoring, as may be accomplished

by quality audits and repeated competence testing of RTs.

• Evidence-based medicine is an approach to determining the best possible patient

management based on critically assessing the available evidence. It is recommended that
RTs use this approach as they assess the information that is available regarding respiratory
care management strategies.

Reflection

Now that you have reached this far, it is time to reflect and make a move by answering the
following questions
• What is the most important thing you learned from this unit? Why do you think so?
• How did you gain learning?
• What can/should you do with what you know?

References:
Kackmareck, R. M. et. al. (2017). Egan’s Fundamentals of Respiratory Care. Eleventh Edition.
Canada: Elsevier

Eubanks, D. and Bone R. (1990), Comprehensive Respiratory Care. Second Edition. USA:
Curvelwell Publisher

Fundamentals of Respiratory Therapy 1 | 9