1.53 Respiratory Therapy Protocols
Category: UWHC Patient Care Policy
Effective Date: June 29, 2016
Manual: Respiratory Care Services
I. PURPOSE Respiratory Therapy (RT) protocols allow the Respiratory Care Practitioner (RCP) to initiate,
modify, and discontinue therapy based on patient specific conditions and objective assessments. A structured
set of algorithms/treatment plans approved by the Respiratory Care Committee are utilized.
A. RT Protocol will be initiated when ordered by an approved provider.
B. Patients in respiratory distress should be seen immediately. Patients that are not in distress will be
assessed within a pre-determined time frame.
1. Adult patients within two hours.
2. Pediatric patients within one hour.
C. The type of therapy provided will be determined based upon algorithms and treatment plans. For specific
algorithms, access the related link.
D. The frequency of therapy will be determined and changed per the triage score obtained during the
E. The implementation, modification, or discontinuation of therapy must be accompanied by an order and
1. A progress note for adults
2. A comment on the doc flow sheet for pediatric patients.
F. The covering provider will be contacted when the patient’s condition requires therapy beyond the scope
of RT protocol.
G. Appropriate Health Facts for You (HFFY) will be given to the patient when therapy is administered.
Review and acknowledge the provider’s order.
B. Assess the patient and review their medical record to determine:
1. The presence of contraindications or hazards to proceeding with therapy.
2. The presence of the appropriate indications for a specific therapy
3. Past Medical History
4. Current problems
5. Current medications
6. Interpretations of recent CXR
C. Using the triage score and treatment algorithms/treatment plans, determine the indicated therapy and
frequency of that therapy.
D. Enter orders in Health Link for the prescribed therapy using Protocol / Policy without cosign as the Order
E. Patient reassessments will occur at scheduled intervals or when a change in the patient’s condition
F. For detailed steps on how to complete a protocol, please see related link titled “Steps for Completing an
Adult Initial Protocol Assessment.”
A. AARC Clinical Practice Guidelines
B. All related therapy P&P’s
C. All related HFFY
Approved by Director and Medical Director of Respiratory Care:
A copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].