A Model for Conversion from Small Volume Nebulizer to Metered Dose Inhaler Aerosol Therapy* Michael F. Tenholder; M.D., F.C.C.f;t Martin] Bryson, R.R.L; and WafTrn L. Whitlock, MAl, MC, F.C.C.ft
Rationing of medical services will be necessary if we do not develop a more rational and efficient health care system. Respiratory care services are receiving emphasis as we try to curtail spiraling health care costs. In analysis of our respiratory care services, we found that small volume nebulizer (SVN) therapy was still a major portion of our workload. We instituted a protocol to convert to metered dose inhaler (MDI) therapy. All hospitalized patients, excluding those admitted to the spinal cord unit and intensive care units, with a physician's order for aerosol delivery by SVN, were evaluated by respiratory care practitioners for conversion to MDI therapy. A simple protocol for the therapist to use in this conversion was developed. All patients converted to MDI were trained in appropriate MOl use by the therapist. A three-day foUowup of each patient's compliance with proper MOl therapy was initiated. Even with a 72-h allowance for initial SVN
significant volume of literature in the last decade A has consistently failed to demonstrate a therapeu-
treatment, we realized a 9,350 procedure reduction from deleted treatments and an additiooal 7,650 conversions to MDI. Less than ! percent of our patients failed to make a completely successful conversion to MDI. Those patients who successfully converted to MDI resulted in reducecl hospital costs of $43,758 based on excess medication, supplies, and labor costs associated with SVN treatments. We also saved 5,000 h of technician time that was used to further instruct patients in appropriate MDI thera~ Aerosol therapy by MOl is cost-effective therapy. The institution of guidelines for MOl conversion has reducecl fear of failure for both clinicians and patients and illustrates the importance ofpatient education by quali&ed respiratory therapists. (Chat 1992; 101:634-37)
jet nebulization; SVN= small volume nebulizer
tic advantage to small volume nebulizer (SVN) over metered dose inhaler (MOl) for delivery, deposition, and efficacy of aerosol therapy in both asthma and chronic obstructive airway disease. 2-8 Despite the evidence for medical treatment equivalency a survey of five local hospitals showed no policy for affecting this conversion. Our respiratory therapists encountered concern from clinicians and even an occasional pulmonary or allergy specialist that this conversion would lead to an exacerbation of bronchospasm or respiratory failure. Staunch support for SVN therapy is evident from equipment manufacturers and those who sell solutions of aerosolized drugs. Some patients strenuously object to the withdrawal of their "jet nebulizer" at home. To alleviate these concerns, we implemented a model for conversion to MOl and aerosol therapy training.
A simple, well-defined protocol that would provide the practitioners with a way to screen patients consistently for conversion to the MOl after 72 h of conventional SVN treatment was developed. A SVN treatment consists of an aerosolized drug (usually a ~ adrenergic agonist with 0.5 ml of drug diluted in 2.5 ml of normal saline solution, delivered by an updraft nebulizer through connecting tubing to a mouthpiece of an aerosol mask at a flow rate of 6 Umin. The patient spends 15 min inhaling the drug and is encouraged to cough after the procedure. The MOl conversion consisted of four puffs of ~-agonist delivered at the same frequency as the SVN therapy or as modified by the physician (1able 1). Maximum dose to the thoracic airways is achieved by activating the MDI 4 cm from the open mouth, inbaling the released dose over 5 to 6 s (flow 1 Us) from functional residual capacity (FRC) and breath holding for 5 to 10 s at total lung capacity (TLC).- All patients who passed the MOl conversion protocol were instructed by this method of aerosol actuation.
Subjects Every patient with a physician·s order for a SVN in the medical center was eligible for the study Patients in the intensive care units or the spinal cord injury unit were excluded. This MOl conversion protocol was approved by the Clinical Executive Board.
Protocol ·From the Medical CoUege of Georgia (Dr. Tenholder); Pulmonary Disease Section, Veterans Affairs Medical Center, Augusta, Ga (Dr. Tenholder and Mr. Bryson); and the Pulmonary Disease Service, Letterman Army Medical Center, Presidio of San Francisco, Cal (Dr. Whitlock). t Associate Professor of Medicine. iChief, Pulmonary Disease Service. This work was supported by the Research Service of the Veterans Affairs Medical Center, Augusta, Ga. Manuscript received May 7; revision accepted July 12.
When a SVN was ordered, the patient was evaluated by the respiratory care practitioner during the first 48 h of therapy by the following conversion criteria: (1) The patient must have a vital capacity of 900 ml or greater and be able to hold this volume for a minimum of 5 s. (2) The patient must have a respiratory rate less than 25 breaths/min. (3) The patient must be oriented and be able to respond appropriately to the following questions: What is your name? What year is it? (4) The patient must demonstrate fun use of Corwer8ion from Small VolumeNebulzer to MOl (Tenholder, Bryson, Whitlock)
Table 1- Metered Dose Inhaler (MID) Conversion Form Dear Physician: 1. Your patient has met the criteria for the metered dose inhaler protocol that was applied with your order for a jet nebuliMDI and inzer. A practitioner will issue a struct your patient in its use for three days at a frequency of 2. If you wish to change the type of drug or the frequency you ordered, please do so at this time. Drug: Frequency:
Puffs: 3. If you have any questions about this conversion, please call Respiratory Therapy at _ Physician signature: _
the arm and hand used to dispense medication from a MDI and must be able to sit up without assistance. In addition, the patient must demonstrate adequate hand actuation of the MDI at the appropriate portion of the respiratory cycle (early inspiration). (5) The respiratory care practitioners also evaluated patients who failed in MDI actuationlbreathing coordination to determine whether a spacer device (Aerochamber) could be used to help with delivery. If the patient met these criteria, a conversion sheet informing the physician that the patient had passed the protocol was amended to the medical record (Table 1). After 72 h of SVN, the clinician had a choice of three options. They may discontinue the therapy, convert to MDI, or obtain a pulmonary consult to continue SVN therapy. Following the decision to convert to M D I use, the respiratory therapist was responsible for patient teaching. The equipment needed for teaching included a placebo, the medication ordered by the physician, and a spacer device (Aerochamber) when indicated. The therapist also was responsible for three-day follow-up training in appropriate technique to assure continued patient understanding and compliance. RESULTS
In 1987, 53,000 SVN treatments/annum were delivered at our institution. Following the initial protocol evaluation for 1988 and 1989, we reduced SVN treatments by 17,000 per annum (Fig I). The patients continued to receive SVN therapy for the initial 72 h
Small Volume Nebulizers I Annum
of their hospital stay during these two calendar years. Small volume nebulization reduction occurred for two reasons. Interaction between the practitioner and the physician was all that was needed to discontinue aerosol p-adrenergic agonist therapy in 55 percent of the cases (9,350 procedures), while the other 45 percent converted to MDI (7,650 reduction in SVN treatments). We computed representative hospital costs by surveying and averaging costs at five local hospitals (Table 2). If aerosol therapy is ordered every 4 h for one week, the savings per patient week is $122.14 by conversion to MDI. For the initial set-up, the savings is only $0.72; however, additional savings occur if the patient does not need a spacer (Table 2). Less than 10 percent of our patients required a spacer. The conversion to MDI translated into hospital cost savings of $43,7581annum (45 percent X 17,000 procedures X $5.721procedure without spacer device [Aerochamber]). Formal pulmonary consultation was required in only 5 percent of the cases. Subsequent failure to pass protocol or return to SVN therapy occurred in less than 2 percent of the patients. No cases of respiratory failure occurred related to MDI conversion. Based on a conservative estimate of 20 to 30 min for a SVN procedure, conversion to MDI treatments saved 5,000 h of respiratory therapists' time. We compared our volume ofSVN treatments/annum with those in four other hospitals (Fig 1). Hospital A is a private religious organization of 300 beds, hospital B is a county nonprofit hospital of 750 beds, and hospital C is a state institution of 500 beds. As a point of reference, hospital C (52,629 SVN treatments per year) is of comparable size to the Veterans Affairs Hospital in Augusta, Ga, but they have twice the number of respiratory care staff (60/30). Hospital D is a 3OO-bed military hospital on the West Coast. Hospitals A, B, and C had no MDI conversion policy at this time. Hospital D concurrently instituted a protocol similar to ours except they did not use the initial Table 2-Hospital Cost· Small volume nebulizer (SVN)
FIGURE 1. Small volume nebulizer (SVN) treatments per annum at five hospitals. Solid bar shows the reduction in SVN treatments with protocol at VA Hospital and hospital D.
Cost of circuits Cost of medication Technician time/cost (14 h) Total cost Metered dose inhaler (MDI) Cost of spacer device (Aerochamber) Cost of medication Technician time/cost (4.2 h) Total cost
Initial Setup Cost/Week
$2.90 $ .40 $3.33
$ 8.70 $ 16.80 $140.00 $165.50
$ 5.00 $ 3.36
$ .83 $5.91
*The following reflects the cost of each therapy delivery six times! day for seven days. These figures project savings of $0.72 for the initial setup and $122.14 per patient for the week by conversion to MDJ therapy. CHEST I 101 I 3 I MARCH. 1992
72-h SVN allowance. Hospital D reduced SVN treatments by 60 percent through MDI conversion (Fig 1) and saved 3,500 h of technician time. This compares with the 5,000 h we saved at our institution with a larger volume of SVN work. DISCUSSION
In 1981 to 1982, a Massachusetts hospital association and a Massachusetts Blue Cross-Blue Shield task force reviewed respiratory care services at New England Deaconess Hospital. Zibrak and colleagues'? from that hospital then showed that consistent application of prescribed guidelines for respiratory therapy resulted in marked decreases in its use and that such decreases do not reduce quality of care. They realized a 92 percent decrease in intermittent positive pressure breathing (IPPB) and a 57 percent reduction in ultrasonic nebulization. We had a 32 percent reduction of SVN therapy during our study period. An important aspect of their program was the professional discussion between respiratory therapists and all clinicians to ensure proper implementation and follow-up of their modifications to requested respiratory care services. In our model, patients were trained, observed, and followed up by respiratory therapists when converted to MDI. This allowed us to ensure that the patients were thoroughly trained in the proper technique and that they continued to use their inhalers as prescribed. The protocol allowed our respiratory care practitioners to teach in a consistent manner. The educational aspect of our model and the salutary results of the organized protocol have allowed respiratory care and our clinical colleagues to feel comfortable with elimination of the initial 72-h SVN allowance. Since we instituted immediate assessment for MDI conversion for all patients, including those with spinal cord injuries and in intensive care units, we further reduced our SVN treatments to 8,000 treatments/annum. We have been surprised by the continued strong support for SVN or jet nebulization ON) for aerosol delivery in hospitalized patients. Many well-designed scientific protocols investigating deposition and/or therapeutic response have documented MDI efficacy in acute and chronic airflow obstruction. 11.12 This work has extended from the home l3-15 to the emergency department," to the hospital ward,17-23 and even to the intubated patient in the intensive care unit. 24-. This investigative action has resulted in a better understanding of this mode of aerosol therapy and the fiscal implications that result from MDI use instead of the conventional jet nebulizer. 18,19.21 Although the MOl is widely used in the home, it has been a slower process to accept MOl as standard therapy in emergency departments and hospital ward care. We admit to a bias in that these studies have convinced us that MOl therapy is the aerosol delivery 838
procedure of choice for all but a few hospitalized patients. Since medicine is a science in which skepticism is healthy and an active lobby supporting costly SVN therapy has fortified itself in clinical practice, we found ourselves in a defensive position in suggesting conversion to MOl. The burden of proof is on respiratory care providers to show conversion to MDI is effective, saves money for the patient and the institution, and does not result in a decrement in quality of care or an increase in respiratory failure. There are many articles devoted to the efficacy of MOl, so why has it been a slow process to convert to this mode of therapy in the hospital setting? One reason could be the reluctance of some patients to change established patterns of treatment. The uninformed patient may feel that the MOl, which takes a fraction of the time to accomplish, could not possibly be as effective as SVN. With individualized training, this "placebo effect" can be overcome. Another reason could be the debate over the delivery of an effective dose by MOl. Fuller and colleagues.'" using four puffs from an MOl, showed better deposition by MOl than SVN. Our standard treatment regimen was four puffs for each MDI use. One more factor that may contribute to MDI conversion failure may be the tendency for some hospitals to delegate MOl distribution and! or training to the pharmacy or nursing staff, both already overloaded with responsibilities and time management constraints. Since the respiratory care department saved a significant amount of time (5,000 h at our institution) by eliminating the SVN, we assumed these responsibilities. The respiratory care practitioners were the most practical resource for this bedside aerosol distribution and training and a valuable resource to assess patient response for the physician. There has been an appropriate amount of concern that MOl therapy success depends on our diligence in education and training of patients.r" There is no question that supervision of patients by trained personnel has the best potential for a "practice makes perfect" result. 7 It is our contention that any hospital can realize similar savings of resources if it uses a simple welldefined protocol for screening and requires its respiratory care department to follow through with consistent patient training and monitoring of compliance until hospital discharge. The message was clear in the special article by Zibrak et al l O five years ago. A critical analysis of IPPB through the last two decades defined a very narrow arena for its appropriate use. Thus, requests for IPPB treatments from respiratory care have been replaced by less costly, more effective strategies such as incentive spirometry. Just as l3-adrenergic agonist aerosol delivery by IPPB was replaced by SVN delivery, the role of SVN delivery is likewise being criticized. It is now time to relegate ConYeraion from SmaH Volume Nebulzer to MOl(Tenholdel; Bryson, Whitlock)
the bulk of our SVN s to the closet in the respiratory care department next to the IPPB machines. There, they will still be available to a relatively small number of patients who may require this form of respiratory care assistance (inhaled pentamidine treatments, patients with spinal cord injury, or those with tracheostomies). The MOl prococol supported by consistent screening and teaching procedures is an effective tool for accomplishing this objective. ACKNOWLEDGMENTS: The proper application of successful respiratory care protocols reflects the integrity and work ethic of our 28 respiratory therapists.
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