Therapist Driven Approach to Respiratory Care Patients - Assignment Example

Review of Related Literature Studies and researches have been conducted on the topic at hand. These researches have tried establishing the benefitsand disadvantages of therapist driven approach to respiratory care patients. The studies which shall now follow shall assess and evaluate these studies, analyzing how they contribute to the wealth of material which shall be used in the conduct of this research. In a prospective study by Christman & Volsko (2006, pp. 1424-1430), they attempted to determine the effects of protocol-driven recommendations for oxygen therapy implemented by respiratory therapists in skilled nursing facilities. The researchers studied patients who had to undergo oxygen therapy in 17 Ohio-based skilled nursing facilities. In the course of the research, the respiratory therapists assessed the need of the patients for oxygen therapy. The assessment of recommendations for the oxygen use was made in accordance with an algorithm-based protocol and guidelines established by the Ohio Department of Health. Data gathering covered the time period January 1- March 31, 2005. The study was able to reveal that 261 out of the 346 were able to complete this study and complete the study sample. The mean standard deviation age was 83(+/-) 11.8 years, with 79% of respondents being male. 46% were under Medicaid, Medicaid Part A (36%), private pay at 11%, and Hospice care at 7%. Results were also able to reveal that 1175 billed days were saved and cost savings stood at $6,768 (Christman & Volsko, 2006, p. 1424). This study concluded that oxygen protocol therapy can indeed improve compliance with accreditation agency requirements by minimizing the number of missing and/or incomplete orders for oxygen therapy (Christman & Volsko, 2006, p. 1424). Financial costs were also reduced when oxygen therapy was discontinued during times when the patient had no need of the oxygen. Patient outcomes for the patient were also improved when the therapy was resumed when patient needed it the most (Christman & Volsko, 2006, p. 1424). In another study, Kollef, and colleagues (2000, p. 467) attempted to compare the clinical outcomes of patient who were receiving respiratory treatments managed by respiratory care practitioners (RCP)-directed protocols of physician-directed orders. This study was a single center and quasi-randomized, clinical study covering three internal medicine firms from an urban teaching hospital. It was able to cover 694 consecutive non-ICU patients admitted and ordered to receive respiratory treatments (Kollef, et.al., 2000, p. 467). The study measured outcomes for discordant respiratory care orders, respiratory care charges, hospital length of stay, and other patient-specific complications. It was able to establish that patients receiving RCP-directed treatment (239) had a lower rate of discordant respiratory care orders as compared to patients receiving physician-directed treatments. The study concluded that respiratory therapy which was managed by RCP-directed treatment protocols in non-ICU patients is a safe and effective choice in treatment (Kollef, et.al., p. 467). It also indicated greater agreement with institutional treatment algorithms with physician-directed respiratory care. Also, the overall utilization of respiratory treatments was significantly less among patients who were receiving RCP-directed respiratory care (Kollef, et.al., 2000, p. 267). Ely, et.al. (1999, pp. 439-446) sought to conduct a prospective investigation on the large-scale implementation of a respiratory-therapist-driven protocol covering 117 respiratory care practitioners while managing 1,067 patients with respiratory failure over 9,048 days of mechanical ventilation. In the course of a year, the researchers reintroduced a daily screen coupled with spontaneous breathing trials and physician prompt and a TDP without daily input from a physician or a ‘weaning team’ (Ely, et.al., 1999, p. 439). The study was able to establish that with staged educational interventions at 2 month intervals, patients under the RCPs had a 97% completion rate and a 95% correct interpretation rate for the daily screen. In the course of the implementation process, the frequency of patients who passed the daily screen and who underwent RCPs was increased. RCPs increased their spontaneous breathing trials once patients had passed daily screening and physician ordered more SBTs. The researchers then concluded that the implementation of a validated weaning strategy is feasible as a TDP without daily supervision from a weaning physician or team. The RCPs can actually perform and interpret daily screening data 95% of the time, however, there are barriers to SBTs that are often seen. Through a staged implementation process, and by using periodic reinforcement of all participants in ventilator management, it is possible to achieve better compliance with large–scale weaning protocol (Ely, et.al., 1999, p. 439). In a 2003 study, Krishnan and colleagues (2003, pp. 673-678), sought to compare the protocol-based weaning to usual physician-directed weaning in a closed medical intensive care unit with high physician staffing levels and structured, system-based rounds. In this study, the adult patients who had to be under mechanical ventilation for more than 24 hours were designated usual care of protocol weaning depending on their hospital ID number. The patients who were then assigned to usual care were treated based on their physician’s discretion; and the patients who were assigned to protocol were underwent daily screening and spontaneous breathing trial by respiratory and nursing staff without the physician’s assistance (Krishnan, et.al., 2003, p. 673). The study revealed that no baseline differences were present as far as patient characteristics in the two groups of patients were concerned. In terms of the proportion of patients successfully discontinuing mechanical ventilation, duration of mechanical ventilation, hospital mortality, ICU length of stay, rates of reinstating mechanical ventilation, the results in either group were similar. The study concluded that protocol-driven weaning may not be necessary in closed ICUs with sufficient physician staff and structured rounds (Krishnan, et.al., 2003, p. 673). The results of this study are slightly different from the results seen in other similar studies. It is important to note the pre-conditions and variables used in this study in order to seek repetition and reliability of results. Stoller, et.al., (1998, pp. 1068-1075) conducted a randomized controlled trial comparing respiratory care for adult non-ICU in-patients directed by a Respiratory Therapy Consult Service (RTCS) and comparing them with respiratory care delivered by physicians. They conducted the study because they noted that the existing evidence seems to suggest that respiratory care protocols seem to enhance allocation of respiratory care services and also conserve costs; and after considering this evidence, they considered a need to conduct a randomized trial in order to address shortcomings of available studies (Stoller, et.al., 1998, p. 1068). Eligible subjects who were included in this study were adult non-ICU patients who were indicated to undergo specific respiratory care services. There were consecutive eligible patients who were considered for consent, and these patients were then randomly assigned to either physician-directed respiratory care or assigned to respiratory care plans generated by the RTCS. These patients were assessed by an RTCS therapist evaluator who was guided by the standards and guidelines of the American Association for Respiratory Care. The variables considered in this study included demographic features, admission diagnostic category, smoking status and Triage Score (Stoller, et.al., 1998, p. 1068). There were no differences seen between RTCS-directed and physician-directed respiratory care in terms of hospital mortality, in terms of hospital length of stay, in total number of respiratory care treatments delivered, and in terms of number of days where respiratory care is required. The cost of care registered at lower costs in RTCS-directed respiratory care as compared to physician-directed care (Stoller, et.al., 1998, p. 1068). Based on the above results, the authors concluded that the RTCS-directed care as compared to the physician-directed respiratory care registers similar numbers and duration of respiratory care services with slight savings seen and without any increase in adverse events. They also concluded that the RTCS-directed respiratory care, as compared to the physician-directed respiratory care services reflected greater agreement with the Clinical Practice Guideline-based algorithms (Stoller, et.al., 1998, p. 1068). Hermeto, et.al., (2009, p. e907-e916) sought to assess the impact of implementing (on premature infants with birth weight < 1250 g) a ventilation protocol therapy which is driven by registered therapists. The researchers developed a ventilation protocol driven by a registered respiratory therapist developed by a multidisciplinary group and implemented in the NICU on July 2004. They reviewed 301 inborn infants with < 1250 g birth weight who were mechanically ventilated after birth. The study was able to reveal that the baseline characteristics of the population were similar in the groups studied. Significant differences registered in the three groups based on the time of the first extubation attempt (40%, on the duration of mechanical ventilation (26%), and on the rate of extubation failure (20%) (Hermeto, et.al., 2009, p. e907). No differences in the rate of air leaks, patent ductus arteriosus ligation, necrotizing enterocolitis, bronchopulmonary dysplasia, and death were seen in the patients included in this study. No significant decrease in the combined rates of intraventricular hemorrhage grades III to IV and or periventricular leukamalacia was also seen in the patients studied in this paper (Hermeto, et.al., 2009, p. e907). The researchers concluded that for the first time, they were able to demonstrate a significant improvement on the weaning time and duration of mechanical ventilation in the implementation of a ventilation protocol administered by a respiratory therapist in the premature newborn population. They recommend that other institutions can then customize their ventilation protocols in order to conform more with their local practice (Hermeto, et.al., 2009, p. e907). However, they pointed out that in order to confirm or establish more support for this study, they recommend that there is a need to conduct a prospective, randomized, and controlled study in order to evaluate long-term outcomes such as those related to BPD and neurodevelopment in the premature infant population who undergo mechanical ventilation. A study by Restrepo, et.al., (2004, pp. 274-284) sought to compare ventilator weaning time, time to spontaneous breathing and overall ventilator hours duration with the use of a ventilator management protocol against a standard nonprotocol-based care in a pediatric intensive care unit. In this study, a multidisciplinary task force came up with a comprehensive protocol for ventilator-management covering four specific phases: initial ventilator set-up and adjustment, weaning, minimal settings, and spontaneous mode before extubation (Restrepo, et.al., 2004, p. 274). A review of records of a total of 187 patients was undertaken for this study. The study revealed no significant differences between groups in PRISM scores, Murray scores, or oxygenation indices, however indices for patients under VMP settled at higher scores. The ventilator weaning times and time to spontaneous breathing modes registered at decreased levels in VMP patients as compared to nonprotocol patients. However, ventilator duration was not significantly different (Restrepo, et.al., 2004, p. 274). There were also no significant differences seen in extubation failure on the use of corticosteroids, or the use of racemic epinephrine between groups. The use of institution-specific VMP by multidisciplinary teams was also associated with reduced ventilator weaning time and time for spontaneous breathing. The authors recommend more studies on the subject matter in order to determine the veracity of the results revealed by this study (Restrepo, et.al., 2004, p. 274). Alex, et.al., (2001, pp. 36-39) sought to improve the quality and costs of care for ventilator dependent patients in adult ICUs. The primary objective of the project was to achieve a 20% reduction in the average number of days spent by a long-term care patient on a ventilator before transfer. The second phase objective of this project was to lessen the number of hours spent weaning from the ventilator at LUMC by 50% (Alex, et.al., 2001, p. 36). Through clinical and administrative leadership, an improvement project was supported by the Center for Clinical Effectiveness. This study convened a physician-led multidisciplinary team plus medical directors of three ICUs. The team was tasked to identify potential reasons for the high variability and costs of care for patients on long-term mechanical ventilation including lack of understanding of resources available to expedite discharge to long term care; lack of communication among units caring for ventilator dependent patients; inconsistent awareness and use of current evidence regarding ventilator management; and lack of materials to help standardize care (Alex, et.al., 2001, p. 37). The study resulted in improvement in quality and resource utilization. The key lessons include the following: senior leadership is important in improving project credibility in order to create urgency for change; data which demonstrate unacceptable variation in care actually helps to create willingness to change among physicians; sharing initial success helps gain physician acceptance for phase 2 – the ventilator weaning protocol; and diverse clinical expertise is important to project success (Alex, et.al., 2001, p. 36). Brochard, et.al., (1994, pp. 896-903) conducted a randomized trial in three intensive care units in mechanically ventilated patients who were able to meet standard weaning criteria. Those who were not able to accomplish 2 hours of spontaneous breathing were then randomly assigned to be weaned with T-piece trials with synchronized intermittent mandatory ventilation (SIMV) or with pressure support ventilation (PSV). The specific requirements for performing tracheal extubation were assigned for each mode of treatment. The number of patients who could not be separated from the ventilator at 21 days (failed to wean) was then compared between the groups (Brochard, et.al., 1994, p. 896). Those which required intubation in a 48 hour period after extubation were also classified as failures. In 456 mechanically ventilated patients who were able to meet the weaning criteria, 109 were included into this study. This study revealed that the three groups were comparable in terms of etiology of disease of characteristics at entry in the study (Brochard, et.al., 1994, p. 896). In considering all the causes for weaning, there were lesser failures seen with PSV as compared with the other two modes, with the difference just reaching the level of significance. When patients with weaning terminated for complications not related to the weaning process were excluded, the difference became highly significant (Brochard, et.al., 1994, p. 896). Chan, et.al., (2001, pp. 349-354) conducted a research in order to evaluate whether an evidence-based approach can actually be implemented safely and effectively through a multi-disciplinary team approach. In this study, the researchers designed an MDT-driven extubation protocol where several meetings were held to encourage constructive criticism of the design by attending physicians, nurses, and respiratory care practitioners in order to define protocol that was evidence-based and accepted by all clinical staff involved in the extubation process (Chan, et.al., 2001, p. 349). The outcomes that were measured included response of the MDT to the initiative, duration of the mechanical ventilation and length of stay in the ICU including reintubation rate. The study was able to establish that MDT patients responded well to the design and implementation of the MDT-extubation protocol because it was able to provide improved autonomy to the staff. The outcomes which were assessed in the literature and in the historical control group were compared with those in the protocol group and similar durations of MV and ICU stay were seen, as well as reintubation rates. There were no negative events documented (Chan, et.al., 2001, p. 349). The authors then concluded that an MDT approach to protocol-driven extubation can actually be implemented safely and effectively in a multidisciplinary ICU. Such efforts are viewed by the team as necessary in improving team building and cooperation (Chan, et.al., 2001, p. 349). Colice, et.al., (2005, pp. 29-34) conducted a prospective study in order to establish whether or not incorporating formoterol into a standardized respiratory therapist-directed protocol for administering bronchodilators to hospitalized patients with obstructive airway disease would reduce health care resource use and provide safety advantage. In this study, all the patients who were admitted to Washington Hospital Center with asthma and COPD were given bronchodilators under a standardized respiratory therapist-driven protocol (Colice, et.al., 2005, p. 29). Formoterol was used as the main bronchodilator for the intervention period from January through March, 2002. The results for the intervention period were then compared against two historical control periods. The health care resource used was determined through the number of bronchodilator treatments administered per admission. Costs were also calculated for the three time periods. Adverse events were also noted in a standardized manner for all three time periods (Colice, et.al., 2005, p. 29). This study was able to reveal that the bronchodilator treatments per admission, respiratory therapist visits for each admission, and the time which was spent for each admission, and even the cost of each bronchodilator treatment significantly decreased in 2002. There were also fewer adverse events seen in bronchodilator treatments in 2002 as compared to 2000. By adding formoterol to a respiratory therapist directed protocol in administering bronchodilators, it was possible to minimize health care resource use and adverse events in patients with asthma and COPD. Randolph, et.al., (2002, pp. 2561-2568) sought to assess whether or not weaning protocols are superior to standard care for infants and children with acute illnesses requiring mechanical ventilator support and whether a volume support weaning protocol using continuous automated adjustment of pressure support by ventilator is superior to manual adjustment of pressure support by clinicians. This study was conducted as a randomized controlled trial conducted in the pediatric intensive care units of 10 children’s hospitals across North America admitted from November 1999 to April 2001. Data that was gathered unearthed 182 spontaneously breathing children receiving ventilator support for more than 24 hours and who later failed the test for extubation readiness on minimal pressure support (Randolph, et.al., 2002, p. 2561). In this study, patients were randomly assigned to a PSV protocol, to a VSV protocol, or to a no protocol. It measured the duration of weaning time and extubation failure. This study revealed no significant difference in extubation failure rates for the three groups in this study. In terms of weaning success, there was also no significant difference in the median weaning time for the three groups in this study. The study however revealed that male children more frequently failed extubation (Randolph, et.al., 2002, p. 2561). In instances when sedative use was increased in the first 24 hours of weaning, the likelihood for extubation failure and in instances of extubation successes, the duration of weaning was also increased. The researchers concluded that majority of the children, as compared to adults were successfully weaned from the mechanical ventilator within the first 48 hours or less. The application of weaning protocols also did not affect the duration of weaning (Randolph, et.al., 2002, p. 2561). Scheinhorn, et.al., (2001, pp. 236-242), through a prospective cohort study with historical control sought to establish the outcomes in post-ICU mechanical ventilation through a therapist-implemented weaning protocol. They conducted the study through a weaning protocol which incorporated the procedures and pace of LTAC using available scientific evidence and expert consensus. After staff was trained; pilot data was collected and analyzed; protocol was revised and refined, the TIPS protocol was then implemented in the hospital. The protocol was assessed for outcome, variance, for respiratory care practitioner and physician compliance (Scheinhorn, et.al., 2001, p. 236). The study revealed that 46 RCPs worked with 8 pulmonologists and they treated 271 consecutive patients who were admitted for weaning from PMV during the 18 month period. 252 patients were then compared with 238 patients treated by physicians in the 2 years before protocol weaning was instituted. The study was also able to establish that median time to wean was reduced significantly from 29 days to 17 days in historical control subjects for TIPS patients (Scheinhorn, et.al., 2001, p. 236). Overall, the study concluded that the patients using therapist-implemented protocol at BRH registered shorter time to wean as compared to historical control subjects with comparable outcomes. The weaning outcome information collected after the TIPS protocol was established can be attributed to its use because a high degree of compliance to the protocol was established. Schultz, et.al., (2001, pp. 772-782) attempted to compare the outcomes between physician-directed and protocol-directed weaning from mechanical ventilation in pediatric patients. This study was conducted as a prospective randomized study covering pediatric and cardiac intensive care units in a 307 bed tertiary referral hospital for children. In this research, the control group was weaned according to individual physician order for reduction in minute ventilation, positive end-expiratory pressure, and oxygen saturation parameters for reduction in fraction of inspired oxygen. On the other hand, the study group was weaned according to a predetermined algorithm through a program developed for this study. The study was able to include 223 patients with 116 assigned to physician-directed therapy and 107 protocol-directed. The patients were assessed for hemodynamics, ventilator parameters, arterial blood gas values, oxygen saturation, weaning time, pre-weaning time, and extubation time (Schultz, et.al., 2001, p. 772). They also monitored the incidence of reintubation, subglottic stenosis, tracheitis, and pneumonia in the patients. The study revealed no significant difference in 12-hour and 24-hour pediatric risk of mortality scores between groups. The protocol-directed group registered at shorter total ventilation time, weaning time, pre-weaning time, and time to extubation. There was also no significant difference seen in the incidence of reintubation, new onset tracheitis, subglottic stenosis or pneumonia (Schultz, et.al., 2001, p. 772). Based on the above results, the researchers then concluded that protocol-directed weaning led to shorter weaning time as compared to physician-directed weaning in pediatric patients (Schultz, et.al., 2001, p. 772). Researchers Vitacca, et.al., (2001, pp. 225-230) sought to assess the application of a prospective multicenter randomized controlled study in 3 long-term weaning units. They aimed to evaluate whether or not the protocol, inspiratory pressure support ventilation or spontaneous breathing trials are more effective in weaning patients with COPD requiring mechanical ventilation for 15 days. About 52 of 75 patients who failed an initial T-piece trial at admission were randomly assigned to PSV or SB groups. The study revealed no significant difference in weaning success rate, mortality rate, duration of ventilator assistance, or total hospital stay between the two groups (Vitacca, et.al., 2001, p. 225). These results were then compared with the uncontrolled clinical practice of weaning historical control patients. Their comparison revealed that the overall 30 day weaning success rate was greater and the time spent under mechanical ventilation by survived and weaned patients was actually shorter in the patients in the study as compared to those in historical control patients (Vitacca, et.al., 2001, p. 225). Hospital stay was also shorter; spontaneous breathing trials and decreasing levels of PSV were also effective in difficult to wean patients who had COPD. Considering the above circumstances, the researchers concluded that in the application of a well-defined protocol which is beyond the coverage of the mode used may actually result to improved outcomes as compared to uncontrolled clinical practice (Vitacca, et.al., 2001, p. 225). Results Restated, the question being assessed by this study is as follows: Does the therapist driven protocol increase the efficiency of work (patient outcomes) and reduce hospital costs? After considering the above studies evaluated and analyzed for this research, this study was able to reveal that the therapist-driven protocol increased the efficiency of work and improved patient outcomes. In the process, this therapist-driven approach was able to reduce hospital costs since the patients recovered faster from their maladies and the chances of weaning them from the mechanical ventilator was improved. Most of the studies also revealed that the patient’s prospects for spontaneous breathing were also improved. Consequently, their chances for survival and for gaining improved patient outcomes were increased. Recommendations The studies cited in this literature review recommended that more prospective studies or applications for this study be undertaken in order to achieve more accurate results. These recommendations came from studies which did not show any significant difference in their results. This indicates that they are not sure of the prospective and clinical applications and reliability of their results. Based on the results of this literature review, this student recommends that more prospective studies be undertaken on this topic and these prospective studies must take into consideration the limitations which were seen in the previous studies. These limitations must be evaluated and avoided in future studies in order to avoid similar problems encountered in the conduct of new research. This student also recommends that the studies which compare adult and pediatric responses be undertaken in order to adequately assess a well-rounded application of the therapist-driven protocol for patients under mechanical ventilation. This student also recommends that studies which compare the duration of weaning in long-term care and short-term care patients should be conducted in order to determine the applicability of therapist-driven protocols and physician-driven protocols in patients. Long-term care patients may have longer weaning time as compared to short-term care patients and would therefore benefit from the therapist-driven protocols. The cost would be lower and the patient outcomes might prove to be better. However, limited studies have been conducted on this subject, hence; it would serve a variety of benefits for more researches to be conducted on this subject matter. This student also recommends that more researches reviewing other hospitals or critical care centers be assessed in order to determine the wider or the more general application of this practice. It is important to determine if this research would apply to a wider population because its application may then be used to introduce innovations into the respiratory therapy practice especially considering long-term care patients under mechanical ventilation. The concessions or adjustments to the practice that may be introduced can only be those which are based on evidence and research. This will help ensure evidence-based and patient-centered practice in the present and in the future. This student also recommends that the therapist-driven approach be used because it is comparatively the better approach to the physician-directed approach. There are some gaps in the physician-driven approach which can adequately be filled by the therapist-driven approach. This student also recommends that the standardization of protocol may help in improving patient outcomes. The therapist-driven approach can serve as a jumping off point in ensuring that the patient under respiratory therapy would eventually recover spontaneous breathing. Respiratory therapy should also be considered in some countries that do not have respiratory therapists because there is a greater assurance that the patient will be properly cared for under the hands of the health professional specializing in respiratory therapy. The respiratory therapist has the necessary specialized skills and training to care for the patient under respiratory therapy. The respiratory care patient would have a better chance at recovery, spontaneous breathing, and being eventually weaned off the mechanical ventilator. Respiratory therapy cannot adequately be delivered to the patient by the doctor because the doctor also has other responsibilities which would not allow him to focus on providing the best respiratory care for the patient. The nurse also has other responsibilities which would not allow her to provide optimum respiratory therapy to the patient. Therefore, different countries should make an eventual effort towards providing respiratory therapy-driven care to patients in order to ensure better patient outcomes. The inclusion of multidisciplinary teams in the therapist-driven protocol is an important addition in caring for the patient under respiratory therapy because it helps ensure that the expertise of each member of the team is brought into the care of the patient. Each member of the team has a skill and expertise, which, when combined with other members of the health care team allows for a comprehensive and coordinated health care delivery for the patient. Multidisciplinary health care teams can help ensure that each system and each aspect of the patient’s health is expertly and adequately handled. Not included in this research Butler, R., Keenan, S., Inman, K, Sibbald, W., Block, G., 1999, Is there a preferred technique for weaning the difficult to wean patient? A systematic review of literature, Critical Care Medicine, volume 27, pp. 2331-2336 Chia, J. &Clay, A., June 2008, Effects of Respiratory-Therapist Driven Protocols on House-staff Knowledge and Education of Mechanical Ventilation, Clinics in Chest Medicine, volume 29, number 2, pp. 313-321 Bottom of Form Cullen, D., Van Scoder, L., Podgorski, K., Elmerick, D., April 2003, Reliability of and Correlation Between the Respiratory Therapist Written Registry and Clinical Simulation Self-Assessment Examination, Chest Journal, volume 123, number 4, pp. 1284-1288 Des Jardins, T. & Burton, G., 2006, Clinical manifestations and assessment of respiratory disease, Missouri: Mosby Elsevier Fujiwara, M., Smith, P., Rosenberg, J., Rogando, R., Maffia, B., & Bergman, M., 2008, Respiratory Therapist-driven rapid extubation protocol, Chest Journal Guyatt, G., McKim, D., Weaver, B., Austin, P., Bryan, R., Walter, S., 2001, Development and testing of formal protocols for oxygen prescribing, American Journal Respiratory Care Medicine, volume 163, number 4, pp. 942-946 Ibrahim, E., & Kollef, M. 2001, Using protocols to improve the outcomes of mechanically ventilated patients, Critical Care Clinics, volume 17, pp. 989-1001 Kavathia, D. & Betensley, A., 2005, Successful Weaning from Mechanical Ventilation after Failing a Respiratory Therapist Driven Protocol, Chest Journal, volume 128, number 4 Koch, R., Therapist Driven Protocols: A Look Back and Moving into the Future, Critical Care Clinics, Volume 23, number 2, pp. 149-159 Konschak, M., Binder, A., Binder, R., 1999, Oxygen therapy utilization in a community hospital: use of a protocol to improve oxygen administration and preserve resources, Respiratory Care, volume 44, number 5, pp. 506-511 MacIntyre, N., Cook, D., Ely, W., 2001, Evidence-based guidelines for weaning and discontinuing ventilator support: A collective task force facilitated by the American College of Chest Physicians, Chest Journal, volume 120, number 6 suppl, pp. 375S-395S Meade, M., Guyatt, G., Cook, D., 2001, Predicting success in weaning from mechanical ventilation, Chest Journal, volume 1, number 120, pp. 400S-424S Schmidt, B., Roberts, R., Millar, D., Kirpalani, H., 2008, Evidence-based neonatal drug therapy for prevention of bronchopulmonary dysplasia in very low birth weight infants, Neonatology, volume 93, number 4, pp. 284-287 Works Cited Alex, C., Smith, K., Vanderwarf, R., Bleffer-Riding, Reed, L., Letarte, P., Davis, K., Barron, W., 2001, Management of Ventilator Dependent Patients: Improving Setting and Processes of Care, Academy of Healthcare Improvement, viewed 23 September 2009 from http://a4hi.org/symposium/2001/Barron2001.pdf Brochard, L., Rauss, A., Benito, S., Conti, G., Mancebo, J., Gasparetto, A., Lemaire, F., 1994, Comparison of three methods of gradual withdrawal from ventilator support during weaning from mechanical ventilation, American Journal of Respiratory Care, volume 150, pp. 896-903 Chan, P., Fischer, S., Stewart, T., Hallet, D., Hynes-Gray, P., Lapinsky, S., MacDonald, R., Mehta, S., 2001, Practising evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol, Critical Care, volume 5, number 6, pp. 349-354 Bottom of Form Christman, S. & Volsko, T., 2006, Evaluation of an Oxygen Protocol in Long-Term Care, Respiratory Care, volume 51, number 12, pp. 1424-1431 Colice, G., Carnathan, B., Sung, J., & Clark, P., 2005, A Respiratory Therapist-Directed Protocol for Managing Inpatients with Asthma and COPD Incorporating a Long-Acting Bronchodilator, Journal of Asthma, volume 42, number 1, pp. 29-34 Ely, E., Bennett, P., Bowton, D., Murphy, S., Florance, A., Haponik, E., 1999, Large Scale Implementation of a Respiratory Therapist–driven Protocol for Ventilator Weaning, American Journal of Respiratory Critical Care Medicine, volume 159, pp. 439-446 Hermeto, F., Bottino, M., Vaillancourt, K., Sant’Anna, G., Implementation of a Respiratory Therapist-driven protocol for neonatal ventilation: Impact on the Premature Population, Pediatrics Journal, volume 123, number 5, pp. e907-e916 Kollef, M., Shapiro, S., Clinkscale, D., Cracchiolo, L., 2000, The Effect of Respiratory Therapist-Initiated Treatment Protocols on Patient Outcomes and Resource Utilization, Chest Journal, volume 117, pp. 467-475 Krishnan, J., Moore, D., Robeson, C., Rand, C., Fessler, H., January 2003, A Prospective, controlled trial of a protocol-based study to discontinue mechanical ventilation, American Journal of Respiratory and Critical Care Medicine, volume 169, pp. 673-678 Randolph, A., Wypij, D., Ventakataraman, S., 2002, Effect of Mechanical ventilator protocols on respiratory outcomes in infants and children: a randomized controlled trial, JAMA, volume 288, number 20, pp. 2561-2568 Restrepo, R., Fortenberry, J., Spainhour, C., Stockwell, J., & Goodfellow, L., 2004, Protocol-Driven Ventilator Management in Children: Comparison to Nonprotocol Care, Journal of Intensive Care Medicine, volume 19, number 5, pp. 274-284. Scheinhorn, D., Chao, D., Stearn-Hassenpflug, M., Wallace, W., 2001, Outcomes in post-ICU mechanical ventilation. A therapist implemented weaning protocol. Chest Journal, volume 119, pp. 236–242. Schultz, T., Lin, J., Watzman, H., 2001, Weaning children from mechanical ventilation: A prospective randomized trial of protocol-directed versus physician-directed weaning, Respiratory care, volume 46, number 8, pp. 772-782 Stoller, J., Mascha, E., Kester, L., & Haney, D., 1998, Randomized Controlled Trial of Physician-directed versus Respiratory Therapy Consult Service-directed Respiratory Care to Adult Non-ICU Inpatients, American Journal of Respiratory Care and Critical Care Medicine, volume 158, pp. 1068-1075 Vitacca, M., Vianelo, A., Colombo, D., Clini, E., Porta, R., Bianchi, L., Arcaro, G., Vitale, G., Guffanti, E., Lo Coco, A., Ambrosino, N., 2001, Comparison of two methods for weaning COPD patients requiring mechanical ventilation for more than 15 days, American Journal of Respiratory Care and Critical Care Medicine, volume 164, pp. 225-230 Read More