Am. J. Respir. Crit. Care Med.,
Volume 158, Number 4, October 1998, 1068-1075
Randomized Controlled Trial of Physician-directed
versus Respiratory Therapy Consult Service-directed
Respiratory Care to Adult Non-ICU Inpatients
JAMES K.
STOLLER,
EDWARD J.
MASCHA,
LUCY
KESTER,
and
DAVID
HANEY
Section of Respiratory Therapy, Department of Pulmonary and Critical Care Medicine, and Department of Epidemiology
and Biostatistics, Cleveland Clinic Foundation, Cleveland, Ohio
Although current evidence suggests that respiratory care protocols can enhance allocation of respiratory care services while conserving costs, a randomized trial is needed to address shortcomings of
available studies. We therefore conducted a randomized controlled trial comparing respiratory care
for adult non-ICU inpatients directed by a Respiratory Therapy Consult Service (RTCS) versus respiratory care by managing physicians. Eligible subjects were adult non-ICU inpatients whose physicians
had prescribed specific respiratory care services. Consecutive eligible patients were approached for
consent, after which a blocked randomization strategy was used to assign patients to (1) Physician-directed 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). Specifically, these patients
were evaluated by an RTCS therapist evaluator whose respiratory care plan was based on sign/symptom-based algorithms drafted to comply with the American Association for Respiratory Care (AARC)
Clinical Practice Guidelines. Appropriateness of respiratory care orders was assessed as agreement
between the prescribed respiratory care plan and an algorithm-based "standard care plan" generated by an expert therapist who was blind to the patient's actual orders. The compared groups were
similar at baseline regarding demographic features, admission diagnostic category, smoking status,
and Triage Score (mean, 3.8 ± 0.9 SD [RTCS] versus 3.7 ± 1.0). Similarly, no differences were observed between RTCS-directed and physician-directed respiratory care regarding hospital mortality
rate (5.7 versus 5.6%), hospital length of stay (7.9 ± 9.0 versus 7.7 ± 7.3 d), total number of respiratory 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). Notably, using both a stringent (S) and a liberal (L) criterion for agreement, RTCS-directed respiratory care demonstrated better agreement with the "standard care plan" (82 ± 17%
[S] and 86 ± 16% [L]) than did physician-directed respiratory care (64 ± 21% [S] and 72 ± 23% [L])
(p < 0.001). Finally, the true cost of respiratory care treatments was slightly lower with RTCS-directed
respiratory care (mean, $235.70 versus $255.70/pt, p = 0.61). We conclude that (1) compared with
physician-directed respiratory care, the RTCS prescribed a similar number and duration of respiratory
care services at a slight savings (that did not achieve statistical significance) and without any increased adverse events; and (2) compared with physician-directed respiratory care, RTCS-directed respiratory care showed greater agreement with Clinical Practice Guideline-based algorithms.
