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The Shelf in Every Comprehensive Hyperbaric Facility. Michael H BOOKS,SOFTWARE, AND OTHER MEDIA the shelf in every comprehensive hyperbaric new and to improve existing protocols. This test for readiness with rapid-shallow- facility. collection of protocols was developed by breathing index, exercise, evaluate progress, the University of California’s Respiratory and report information to clinicians) proto- Michael H Bennett MD FANZCA Care Services Department, and is published col with an addendum for synchronized Department of Diving and by Daedalus Enterprises. The CD-ROM intermittent mandatory ventilation with Hyperbaric Medicine contains the patient-driven-protocol manual pressure support (SIMV/PS); STEER for Prince of Wales Hospital in an Abode Acrobat PDF file, and 25 pa- cardiothoracic service postoperative (day 1) and tient-driven-protocol algorithms in Mi- open-heart surgery; and metered-dose- Faculty of Medicine crosoft Visio format, which allow the reader inhaler protocol for ventilated patients. The University of New South Wales to print high-quality color versions of the protocols in Part II follow the same format Sydney, Australia protocols. Macintosh users may have diffi- as those in Part I. Because of the depth of culty viewing the files; Visio is not avail- each protocol, there is considerably more The author has disclosed no conflicts of interest. able for Macintosh computers, so a third- explanation given in the overview sections. party program is needed to view them. On Part III contains 2 pediatric protocols: Respiratory Care Patient-Driven Proto- my computer I easily accessed and printed metered-dose-inhaler protocol, and a wean- cols, 3rd edition. University of California the PDF file. ing protocol. San Diego, Respiratory Services. Irving, The manual’s sections are: Acknowledg- This manual is intended as a reference Texas: Daedalus. 2008. PDF, illustrated, 184 ments; Overview of Patient-Driven Proto- tool for respiratory care departments devel- pages, $130. cols; Patient-Driven Protocols; Intensive- oping their own patient driven-protocols. All Care Patient-Driven Protocols; Pediatric the protocols are thorough, well explained, Therapist-driven and patient-driven pro- Patient-Driven Protocols; and Bibliography. easy to understand, and include bibliogra- tocols have been in use for over 20 years, The manual appears to be a reproduction phies sufficient to support the algorithms. and range from very simple oxygen-titra- of the University of California San Diego The algorithms are very readable and easy tion protocols to complex assess-and-treat (UCSD) Respiratory Care Services proce- to understand. The wide variety of proto- algorithms used when a physician orders an dure manual. cols included should meet the needs of nu- “RT consult.” Proponents of patient-driven This 3rd edition was clearly a collabora- merous facilities and patient populations. protocols argue that these clinical pathways tion by 35 different clinicians, including re- That said, I do have some difficulties with improve resource allocation and lower costs, spiratory therapists, physicians, and nurses. this manual. First off, the copyright was con- and there is evidence in the medical litera- The authors acknowledge that they used the fusing. The copyright states that UCSD Re- ture to support those assertions. It is likely American Association for Respiratory Care spiratory Care Services has proprietary that the clinicians who pioneered patient- (AARC) clinical practice guidelines in de- rights to the protocols and that they cannot driven protocols also advanced the respira- veloping the protocols, but there are differ- be used without permission. This would be tory care profession by elevating profes- ences to meet the unique needs of the pa- a disincentive to purchasing this manual if sional expectations. In today’s resource- tients at the UCSD medical center. one were not allowed to use the protocols as restricted health-care atmosphere, many The overview briefly describes opera- a basis for developing new protocols. I con- respiratory care departments use patient- tional structure, patient evaluation, initiation tacted UCSD Respiratory Care Services and driven protocols to efficiently manage re- of a patient-driven protocol, discontinuation asked them how hard it is to obtain permis- sources. Yet, surprisingly, many respiratory of therapy, and the history and an explana- sion to use their protocols. They indicated care departments still lack patient-driven tion of protocol use at UCSD medical cen- that they had no problem with departments protocols. ter. These give helpful insights into a highly using UCSD patient-driven protocols as long The development and implementation of functioning respiratory care department’s as they acknowledged UCSD Respiratory a new patient-driven protocol from incep- management of protocols. Care Services as the source material: “For tion to full functioning can be a daunting The first section contains 17 separate pro- department use there is no problem, and task. It can take several months and many tocols, on oxygen delivery and titration, permission will be readily granted… We man-hours to develop an algorithm or pro- oximetry, pulmonary hygiene, artificial- encourage others to utilize this resource to tocol, educate staff, conduct quality-assur- airway management, and inhaled-medica- develop their own program and edit the orig- ance audits, and fine-tune a protocol. Some tion delivery. The protocols all have a similar inal documents for their institutions.” (Rich- respiratory care departments have reduced format, which includes: overview, purpose, ard M Ford RRT FAARC, personal com- the protocol-development man-hours by scope, contraindications, related protocols, munication). starting with a protocol from another insti- documentation, assessment of outcome, I suggest that the next edition of this man- tution. The RC World Listserv (https:// justification of discontinuing, and re-evalu- ual include a chapter on protocol training. listserv.iupui.edu/cgi-bin/wa-iupui.exe?a0ϭ ation of therapies. The overviews provide What certification process do respiratory rc_world) and the American Association for thorough explanations; for example, the ox- therapists undergo to become qualified to Respiratory Care help site (http://www. ygen-device-selection protocol contains render a patient assessment? Protocol edu- aarc.org/help) often receive requests for pro- concise and useful descriptions of various cation and testing is often necessary for pa- tocols on various subjects and modalities. oxygen devices. tient-driven protocols to be successful. The 3rd edition of Respiratory Care Pa- Part II contains 4 intensive-care patient- My final criticism is about the manual’s tient-Driven Protocols is now available to driven protocols: extubation protocol; ven- lack of discipline in formatting terms. The help respiratory care departments to develop tilatorSTEER(screenforcontra-indications, term for fraction of inspired oxygen appears RESPIRATORY CARE • JULY 2009 VOL 54 NO 7 981 BOOKS,SOFTWARE, AND OTHER MEDIA bothasF and F . Likewise, the use of supportive care, and common pulmonary- dressed. Not all topic sections include ref- IO2 iO2 subscripts is not uniform; in some sentences specific procedures. Where there is data, the erences, and readers are expected to pursue the2inO2 was subscripted in one instance authors present it; where there is none, they the literature if they wish to learn about any and not in another. And some abbreviations clearly state that they provide their own ap- topic in more depth. are not defined (eg, STEER, and CT, which proaches based on clinical experience. There The section on supportive-care measures in this manual stands for cardiothoracic). may not be consensus on these suggestions, is particularly helpful. Other pediatric respi- This may seem like nitpicking, but with a but the reader is at least presented with 1 or ratory medicine texts tend to describe ther- price of $130 ($90 for AARC members), I 2 options used by these experienced clini- apies within a discussion of each disease. think attention to these details is warranted. cians. This text approaches these topics in a more This manual is an excellent resource for As the spelling of the book’s title im- general but practical way, contrasting hos- respiratory care department directors and plies, this is a British text, but the informa- pital and home oxygen delivery methods, medical directors looking to develop or im- tion provided is pertinent to patients in all criteria for weaning long-term oxygen ther- prove their own protocols. It is easy to read countries. A few of the medication names apy at home, and noninvasive positive pres- and the algorithms are easy to follow. It will need to be translated by United States sure therapy for children. Each topic section does not contain all the information needed readers (eg, salbutamol is albuterol), and provides clinical pearls and practical in- to develop patient-driven protocols, but it there are mentions of therapies used in the sights, without exhaustive details. does provide many useful examples of suc- United Kingdom but not the United States The section on common pulmonary pro- cessful protocols that could easily be mod- (eg, urokinase for fibrinolysis in children cedures will be of most use to trainees. It ified to suit the needs of other facilities. with empyema, and pithidine for sedation), provides practical points, such as chest-tube but this is not a serious drawback. The text insertion location, bronchoalveolar lavage is more specific
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