RANDOMIZED CONTROLLED TRIAL OF PHYSICIAN-DIRECTED VERSUS RESPIRATORY THERAPY CONSULT SERVICE-DIRECTED RESPIRATORY CARE TO ADULT NON-ICU INPATIENTS

Although current evidence suggests that respiratory care protocols can enhance allocation of respiratory care services while conserving cost s, a randomized trial is needed to address shortcomings of available s tudies. We therefore conducted a randomized controlled trial comparing respiratory care for adult non-ICU inpatients directed by a Respirato ry Therapy Consult Service (RTCS) versus respiratory care by managing physicians. Eligible subjects were adult non-ICU inpatients whose phys icians had prescribed specific respiratory care services. Consecutive eligible patients were approached for consent, after which a blocked r andomization strategy was used to assign patients to (1) Physician-dir ected respiratory care, in which the prescribed physician respiratory care orders were maintained (n = 74), or (2) RTCS-directed respiratory care, in which the physician's respiratory care orders were preempted by a respiratory care plan generated by the RTCS (n = 71). Specifical ly, these patients were evaluated by an RTCS therapist evaluator whose respiratory care plan was based on sign/symptom-based algorithms draf ted to comply with the American Association for Respiratory Care (AARC ) Clinical Practice Guidelines. Appropriateness of respiratory care or ders was assessed as agreement between the prescribed respiratory care plan and an algorithm-based ''standard care plan'' generated by an ex pert therapist who was blind to the patient's actual orders. The compa red groups were similar at baseline regarding demographic features, ad mission diagnostic category, smoking status, and Triage Score (mean, 3 .8 +/- 0.9 SD [RTCS] versus 3.7 +/- 1.0). Similarly, no differences we re observed between RTCS-directed and physician-directed respiratory c are regarding hospital mortality rate (5.7 versus 5.6%), hospital leng th of stay (7.9 +/- 9.0 versus 7.7 +/- 7.3 d), total number of respira tory care treatments delivered (30.3 +/- 30 versus 31.6 +/- 30.5), or days requiring respiratory care (4.2 +/- 5.2 versus 4.1 +/- 3.6). Nota bly, using both a stringent (S) and a liberal (L) criterion for agreem ent, RTCS-directed respiratory care demonstrated better agreement with the ''standard care plan'' (82 +/- 17% [S] and 86 +/- 16% [L]) than d id physician-directed respiratory care (64 +/- 21% [S] and 72 +/- 23% [L]) (p < 0.001). Finally, the true cost of respiratory care treatment s was slightly lower with RTCS-directed respiratory care (mean, $235.7 0 versus $255.70/pt, p = 0.61). We conclude that (1) compared with phy sician-directed respiratory care, the RTCS prescribed a similar number and duration of respiratory care services at a slight savings (that d id not achieve statistical significance) and without any increased adv erse events; and (2) compared with physician-directed respiratory care , RTCS-directed respiratory care showed greater agreement with Clinica l Practice Guideline-based algorithms.