Delegation Protocol Number: 70
Delegation Protocol Title:
Respiratory Therapy Treatment - Adult/Pediatric - Inpatient
Delegation Protocol Applies To:
UWHC Inpatients: (Specify) Adults and Pediatrics
Target Patient Population:
All inpatients with an order for “Respiratory Therapy per Protocol”
Delegation Protocol Champion:
Jon Ketzler, MD - Medical Director of Respiratory Care
Delegation Protocol Reviewers:
Director - Respiratory Care Services
This protocol delegates the authority from the ordering provider to the Respiratory Care Practitioner (RCP) or
Respiratory Therapist (RT) to initiate, modify, and discontinue respiratory therapy based on patient specific
conditions, objective assessments by following a structured set of treatment algorithms. All treatment algorithms
are reviewed and approved by the Respiratory Care Committee.
Who May Carry Out This Delegation Protocol:
Respiratory Care Practitioners (RCPs) or Respiratory Therapists (RTs) who are trained in the use of this
Guidelines for Implementation:
1. Order for “Respiratory Therapy per Protocol” is entered into Health Link by a provider.
2. Therapies/interventions that are implemented as part of the protocol will be communicated to other clinicians
in Health Link as an order. Examples include medication orders to pharmacists and oximetry monitoring
requirement to nursing.
3. The RCP or RT will assess the patient and will determine the appropriate treatment algorithm to use.
4. The patient will be reassessed with every treatment session and frequency and type of therapy will be
modified as indicated.
5. The therapy will be discontinued when patient condition no longer meets criteria for treatment.
1. AARC Clinical Practice Guidelines
2. The effectiveness of Respiratory Care Protocols. Stoller JK, Respir Care 2004 Jul; 49(7): 761-5.
3. Protocol-driven ventilator weaning: reviewing the evidence. Girard TD. Ely WE. Clin Chest Med. 2008 Jun
4. Use of Weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients:
Cochrane systematic review and meta-analysis. BMJ British Medical Journal 342 (211).
Collateral Documents/Tools: NA
UWHC Respiratory Care Committee: August 2012, August 2014 (expedited approval process)
UWHC Nurse Practice Council: August 2012, August 2014 (expedited approval process)
UWHC Pharmacy and Therapeutics Committee: August 2012, September 2014 (expedited approval process)
UWHC Medical Board: September 2012, September 2014 (expedited approval process)
Effective Date: September 2014
Scheduled for Review: September 2016
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: