Optimizing Respiratory Therapy Resources by De-Implementing Low-Value Care

Abstract

Background: Our institution was experiencing a respiratory therapy staffing crisis during the COVID-19 pandemic, in part due to excessive workload. We identified an opportunity to reduce burden by limiting use of 3% hypertonic saline and/or N-acetylcysteine nebulizer therapies (3%HTS/NAC).

Methods: Leveraging the science of de-implementation, we established a policy empowering respiratory therapists to discontinue 3%HTS/NAC not meeting the American Association for Respiratory Care (AARC) Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients. After a 3-month period of educating physicians and advanced practice practitioners the policy went to into effect. Outcomes measured included monthly number of treatments, orders, and full-time employees associated with administering nebulized 3%HTS/NAC.

Results: Post policy activation, the monthly mean 3%HTS/NAC treatments were significantly reduced to 547.5 ± 284.3 from 3,565.2 ± 596.4 (P < .001) as were the associated monthly mean of full-time employees, 0.8 ± 0.41 from 5.1 ± 0.86 (P < .001). The monthly mean 3%HTS/NAC orders also fell to 93.8 ± 31.5 from 370.0 ± 46.9 (P < .001). Monthly mean non-3%HTS/NAC treatments remained stable; post policy was 3,089.4 ± 611.4 and baseline 3,279.6 ± 695.0 (P = 1.0).

Conclusions: Implementing a policy that empowers respiratory therapists to promote adherence to AARC Clinical Guidelines reduced low-value therapies, costs, and staffing needs.

Keywords: De-implemention; N-acetylcysteine; health workforce; hypertonic saline; nebulizer.

Fig. 1.

Box plots (median, 25th percentile, 75th percentile, minimum value that is not an outlier, maximum value that is not an outlier) for A: 3% hypertonic saline solution and/or N-acetylcysteine (3%HTS/NAC) treatments, B: non–3%HTS/NAC treatments, C: 3%HTS/NAC orders entered, and D: full-time employees required for 3%HTS/NAC treatments. Asterisk indicate extreme outlier and circles are mild outliers (all in the first month post-policy activation).

Fig. 2.

Control charts: A: Monthly mean 3%HTS/NAC treatments, B: monthly mean non-3%HTS/NAC treatments, C: monthly mean 3%HTS/NAC orders entered, and D: monthly mean full-time employees required for 3%HTS/NAC treatments. Time periods depicted are baseline, education, and post policy.