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Capital equipment and technology administration, as outlined in this article, is one of many responsibilities for managers of respiratory care. Planning for 1, 5, and 10 years, strategic budgeting, and systematic evaluation of existing and future devices will assist in creating a successful equipment and technology program. A successful capital equipment and technology program will enable respiratory care practitioners to treat patients effectively with the proper tools for success.

Background: Retention of respiratory therapists (RTs) is a desired institutional goal that reflects department loyalty and RTs' satisfaction. When RTs leave a department, services are disrupted and new therapists must undergo orientation and training, which requires time and expense. Despite the widely shared goal of minimal turnover, neither the annual rate nor the associated expense of turnover for RTs has been described., Study Purpose: Determine the rate of RT turnover and the costs related to training new staff members., Methods: The Cleveland Clinic Health System is composed of 9 participating hospitals, which range from small, community-based institutions to large, tertiary care institutions. To elicit information about annual turnover among RTs throughout the system, we conducted a survey of key personnel in each of the hospitals' respiratory therapy departments. To calculate the costs of training, we reviewed the training schedule for an RT joining the Respiratory Therapy Section at the Cleveland Clinic Hospital. Cost estimates reflect the duration of training by various supervisory RTs, their respective wages (including benefit costs), and educational materials used in training and orientation., Results: Turnover rates ranged from 3% to 18% per year. Five of the 8 institutions from which rates were available reported rates greater than 8% per year. The rate of annual turnover correlated significantly with the ratio of hospital beds to RT staff (Pearson r = 0.784, r(2) = 0.61, p = 0.02). The cost of training an RT at the Cleveland Clinic Hospital totaled $3,447.11., Conclusions: Turnover among respiratory therapists poses a substantial problem because of its frequency and expense. Greater attention to issues affecting turnover and to enhancing retention of RTs is warranted.

Program budgeting and marginal analysis is a method of priority-setting in health care. This article describes how this method was applied to the management of a disease-specific group, chronic airflow limitation. A sub-program flow chart clarified the major cost drivers. After assessment of the technical efficiency of the sub-programs and careful and detailed analysis, incremental and decremental wish lists of activities were established. Program budgeting and marginal analysis provides a framework for rational resource allocation. The nurturing of a vigorous program management group, with members representing all participants in the process (including patients/consumers), is the key to a successful outcome.

Objectives: To evaluate a departmental computer system., Design: a. Direct comparison of the time taken to use a manual system with the time taken to use a computer system for lung function evaluation, loan of equipment and production of correspondence. b. Analysis of the accuracy of data capture before and after the introduction of the computer system. c. Analysis of the comparative running costs of the manual and computer systems., Setting: Within a department of respiratory medicine serving a hospital of 1323 beds., Main Outcome Measures: a. Time taken to perform functions with the assistance of computerised methods, in comparison to the manual method used alone. b. Accuracy of data capture. c. Relative running costs., Results: a. The computer system (CS) was significantly faster than the manual system (MS) for lung function evaluation (CS = 7.63 min/test, MS = 12.25 min/test), loan of equipment (CS = 0.40 min/loan, MS = 2.07 min/loan), and checking for overdue equipment (CS = 0.49 s/record, MS = 9 s/record). The production of correspondence was slightly slower with the computer (CS = 9.30 min/letter, MS = 8.54 min/letter). b. All outpatient episodes, but only 43 of 65 (66%) of in-patient episodes, were captured. Lung function and managerial report data were accurate using both manual and computerised methods. The manual system for equipment loans was inefficient, and use of the computer resulted in the recovery of 221 nebulisers. c. Development costs for 1988-1990 were high (72,178 pounds). Only 1200 pounds to 1845 pounds per year was recovered directly from staff time saved by the computer but larger savings resulted from changes in work practice (4049-4765 pounds). After 10 years the projected deficit is 10,000 pounds per annum in running costs., Conclusions: In comparison with the manual methods, the computer system has shown significant advantages which provide accurate information, with significant favourable effects on working practices. In evaluating computer systems used in clinical practice it is essential to ensure that the projected work practice benefits are achieved without unacceptable costs in staff time, inaccurate data and high financial outlay.

In large part due to the foregoing issues, Medicare program officials have focused on respiratory therapy as an area with great potential for abuse, and may well introduce significant reforms in the near future. Accordingly, any contractual arrangements for respiratory therapy programs of the type discussed above should be carefully reviewed for compliance with Medicare requirements and for a realistic assessment of the parties' potential exposure to liability under the anti-kickback statute. At a minimum, these agreements should provide for short "without cause" termination provisions, or include a so-called "jeopardy" provision that permits the parties to renegotiate or terminate their contract if significant changes occur in, or if the current arrangement is found or threatened to be found to violate, applicable law.

A prescribing protocol for infective exacerbations of chronic obstructive airways disease (COAD), specifying the use of oral amoxycillin 500 mg tid (or erythromycin 500 mg qid if allergic) as first line therapy, and oral ciprofloxacin 500 mg bd as second line treatment, was introduced in 1991. Every third sequential admission was screened for the year preceding (1990) and the year after (1991) the protocol was implemented. Only those patients with a discharge diagnosis of infective exacerbation of COAD, but without pneumonia, were included in the analysis. The two groups (1990 and 1991) were matched in terms of age, sex and pre-treatment given by their General Practitioner (GP), but differed with respect to severity score, with 1991 being more severe. The outcome measures showed that duration of hospital stay was comparable as was duration of treatment. Response to first line therapy was 68% and 67% for 1990 and 1991, respectively. Of those who had received antibiotics from their GP, 67% responded to first line therapy, while of those who had not received antibiotics from their GP 75% responded. Duration of therapy was shorter in first line responders (mean and 95% CI: 7.3 (6.3-8.3) days vs 12.7 (10.1-15.3) days). The mean cost per day antibiotic treatment was reduced by 54.6% (95% CI 52.3-56.9%) from 3.77 pounds to 1.71 pounds. In conclusion, the introduction of antibiotic prescribing guidelines for treatment of infective exacerbations of COAD showed no detrimental effect on outcome measures, but was associated with a significant reduction in the cost of antibiotic therapy.

Background: Although many hospital departments that were revenue producers have become cost centers and revenues above expenditures have shrunk, some departments continue to contribute., Methods: I analyzed the financial statements of our 240-bed, not-for-profit hospital to determine the Respiratory Care Department's actual contribution to the hospital's 'bottom line' (ie, revenue above expenditures). The Respiratory Care Department's financial statement, the Hospital's profit and loss statement, and the financial statements for all 54 hospital departments were reviewed., Results: Analysis revealed that the Respiratory Care Department's revenue dollar contributed $0.095 to the hospital bottom line for each revenue dollar generated. Analysis also demonstrated that the break-even contribution margin for revenue departments was 76.77%. Departments with contribution margins greater than 76.77% were revenue contributors and those departments with less than 76.77% were cost centers., Conclusions: The Respiratory Care Department was the hospital's largest revenue contributor, generating 42.8% of the hospital's revenue above expenditures. In today's health-care environment, it is sound fiscal reasoning to control cost and to strengthen those departments and services that are responsible for the financial viability of the institution. The results of this study show that our Respiratory Care Department has assumed the leadership role in the economic viability of our hospital and is its most cost-efficient contributor to health care.

In summary, the field of respiratory care has witnessed a continuum of accelerating change in its first half century of existence as a health care profession. These changes were effected by internal change agents as well as external forces in the health care arena. Based upon a health care system undergoing a near cataclysmic pace of change in a time of multifocal and critical inspection, it is anticipated that the field will undergo an even more dramatic change in its scope and direction in the next 50 years. With the guidance and assistance of administrators, medical staff, and partner departments, the respiratory care department should continue to function as an integral part of the hospital organization.

Unlabelled: Our Respiratory Care Services Department provides an endotracheal intubation service that responds to all intubation requests. Intubation is performed by registered respiratory therapists who complete an 8-hour training program, advanced cardiac life support (ACLS) training and certification, and clinical performance of intubation with supervision. The goals of this service are (1) to provide competent persons for performing this service, (2) to assure a rapid response time, and (3) to be cost-effective., Evaluation Methods: A retrospective analysis of our service was conducted over a 1-year period (7/90 to 6/91), and calculations were made of the intubation success rate and complication rate., Results: Of the 833 total intubations, 791 were successfully performed by respiratory care practitioners; 730 of those successful intubations (92.3%) were accomplished in fewer than 3 attempts. Recognized complications occurred in 96 intubations (12.1%) and included oral bleeding, vomiting, and short periods of oxygen desaturation. In the 5.1% (42) of the patients not intubated by our service, 22 required heavy sedation, and an anesthesiologist was consulted; 17 patients were intubated by other physicians; and 3 tracheotomies were performed. Multiple intubation attempts were a result of secretions, induced bradycardia, blade-light malfunction, damaged cuff, and esophageal intubations., Conclusion: Respiratory Care Services can provide an effective intubation service. Cost savings were realized by centralizing equipment.

Random assessments of SaO2 were performed via pulse oximetry in 274 hospitalized non-ICU patients prescribed supplemental O2 in a large tertiary care university hospital. In 507 assessments performed in patients inspiring the prescribed O2, 426 were receiving excessive amounts of O2 to maintain a SaO2 > or = 92 percent. In 233 of these assessments, SaO2 was > or = 92 percent while breathing ambient air. In an additional 193 assessments, the concentration of inspired supplemental O2 was excessive to maintain a SaO2 > or = 92 percent. However, in 81 assessments performed in patients inspiring O2, the prescribed amount was insufficient to maintain SaO2 > or = 92 percent. These results indicate that O2 prescription in hospitalized non-ICU patients is excessive or not required in the majority of cases. Furthermore, routine use of pulse oximetry in hospitalized patients prescribed O2 may be useful in determining the continued need for supplemental O2 and adjusting the proper concentration needed to avoid hypoxemia.

Flexible fiberoptic bronchoscopy is a commonly performed procedure for which the indications, technical aspects, and potential patient complications have been well described. However, limited information is available regarding damage to the instrument itself. In order to better describe the types and causes of bronchoscope damage, repair costs, and time out of service, we performed a postal survey of hospital bronchoscopy laboratories in Alabama, Mississippi, and Louisiana. We received 43 completed surveys from laboratories that perform an average of 233 bronchoscopies per year. The respondents reported 103 episodes of bronchoscope damage, the majority of which consisted of damage to the bronchoscope cover, broken fiber bundles, malfunction of the bending apparatus, and suction channel damage. The respondents attributed 62% of all the damage to one of the three following categories: unknown, improper handling, and damage caused by biopsy forceps, brushes, or needles. Of the 103 episodes of bronchoscope damage, 66 (64%) were judged to be preventable, 13.6% not preventable, and 17.5% to be indeterminant. The average time out of service (mean, SD) for each damaged bronchoscope was 3.5 (3.9) weeks, and the average repair cost per episode of bronchoscope damage was $2,726.13 ($1,391.21). At least 19 episodes of bronchoscope damage occurred during cleaning and disinfecting procedures. We conclude that the majority of bronchoscope damage and repair costs should be potentially preventable and suggest that a program to familiarize all personnel handling bronchoscopes with proper maintenance and handling procedures should decrease the risk of bronchoscope damage.

More hospitals are being forced to restructure in a bid to cope with financial constraints. One effective option is the transfer of clinical programs between facilities. The procedure is complicated and commands good leadership, negotiating skills, trust and a comprehensive understanding of the program being transferred. This article deals with the knowledge gained from the recent successful transfer of the Adult Cystic Fibrosis Program and its associated operating funds from one Toronto hospital to another.

Home oxygen therapy for chronic lung disease is a prominent example of an increasing tendency for the provision of adaptive medical technologies by tertiary-level hospital outreach. Flinders Medical Centre has carefully monitored its home oxygen service using cost-centre management. Despite strict prescription criteria and cost-saving technological advance, this budget remains under continued pressure. Demand from eligible patients is increasing, and their enhanced survival means that numbers accumulate over the years. Unfortunately, long-term community support does not fit easily into conventional hospital budgetting. Hospitals at present do not explicitly record the benefits nor bring to account the cost savings from maintaining patients in the community. Several intermediate improvements are suggested.

To assess the cost impact of using metered dose inhalers (MDIs) versus small volume nebulizers (SVNs) for hospitalized adult patients not being managed in ICUs, we analyzed the labor, equipment, and medication costs associated with using MDIs at The Cleveland Clinic Foundation. Over the study interval (January 1988-December 1989), a policy was implemented to enhance MDI use, resulting in increased use of MDIs (18% of all bronchodilator treatments in 1989 vs 5% in 1988). Based on a volume of approximately 70,000 bronchodilator treatments/year in our hospital, increased MDI use with this policy reduced direct costs by $26,510, with associated savings in respiratory-therapist time. To extend this analysis of costs to other institutional settings, we present an analysis of projected changes in institutional costs when the volume of bronchodilator therapies and the percentage administered by MDI varies.

Health care is faring better than most professions hard-hit by the recession, but the impacts are starting to filter into hospitals. New legislation aimed at reducing the cost of ancillary services threatens to hinder respiratory therapy expansion efforts and may force directors to cut personnel.

This notice establishes schedules of salary equivalency guidelines for Medicare program reimbursement for the reasonable costs of respiratory therapy services furnished under an arrangement with a hospital or other institution. These schedules update the schedule of guidelines that was published in the Federal Register on October 6, 1978 (43 FR 46378) with respect to registered therapists and certified therapists. These schedules also include, for the first time, salary equivalency amounts calculated for respiratory therapists who are neither registered nor certified. These schedules are to be used by the Medicare program's fiscal intermediaries to determine the maximum hourly amount that the Medicare program will pay to a hospital or other institution for covered respiratory therapy services furnished under an arrangement. In addition, these guidelines would also apply, where appropriate, to reimbursement under the Medicaid program as specified in 42 CFR 447.250 et seq. of the regulations.

Maintenance records during 12 months for 16 MA-1 ventilators, 7 BEAR-1 ventilators more than one year old, and 6 new BEAR-1 ventilators were compared. The MA-1 ventilators had the best record in every important category except cost for accessory parts and ventilator cost per patient hour with retrofit and preventive maintenance. The MA-1 ventilators needed repair once every 8,329 hours of use, compared with once every 2,500 hours for older BEAR-1 ventilators and once every 4,277 hours for newer BEAR-1 ventilators. Total costs of repairs were $430.84 for 16 MA-1 ventilators, and $3,064.44 for 7 BEAR-1 ventilators out of warranty. Costs of replacement parts were $3,097.01 for the MA-1 ventilators, $986.21 for the older BEAR-1 ventilators, and $845.32 for the newer BEAR-1 ventilators. The total cost per patient hour of use was 11 for the MA-1 ventilators and 13 and 3 respectively for the two BEAR-1 groups. Adding costs for retrofit for the MA-1 ventilators and projected costs for preventive maintenance of the BEAR-1 ventilators tripled the cost per hour of use for all three groups. The frequency of breakdowns for both brands of ventilators underlines the need for preventive maintenance, but substantial cost increases will result from those programs.

In the 1970s the demand in our hospital for bronchial hygiene therapy (aerosols, IPPB, incentive spirometry, chest physical therapy) had increased to such a level that 20-30% of the ordered therapy was not being administered. Because the respiratory therapists and medical directors were convinced that much of the ordered therapy was unnecessary, the Respiratory Therapy Department began a program in 1978 in which specially trained respiratory therapists were authorized to evaluate all non-intensive-care patients for whom bronchial hygiene therapy had been ordered. The program protocol consists of a medical record review, a physical assessment of the patient, the development of a patient-care plan, and a re-evaluation every 2-3 days of the patient's continued need for therapy. We found that initiation of the program has led to improved documentation of the need for bronchial hygiene therapy and a significant decrease in total procedures performed, not merely a substitution of therapies. After being adjusted to the 1981 Consumer Price Index (CPI), total charges for bronchial hygiene therapy were markedly decreased even though hospital charges increased 77.4% above the CPI inflation rate. Since the program was begun, the respiratory therapy staff has been able to administer all ordered respiratory care services to patients in a critical care setting and not less than 90% of ordered bronchial hygiene therapy to patients outside the intensive care unit. House staff, attending physicians, and patients and their families appear to be satisfied with the therapist-evaluators, and the morale of respiratory therapists seems to have improved as a result of their being able to take a more role in the treatment of their patients and to apply their skills to the patients most in need of them.

This document makes certain corrections in the schedules of guidelines for Medicare program reimbursement for respiratory therapy services published in the Federal Register on June 3, 1980 (45 FR 37527).

A respiratory therapy department determined that it could achieve substantial savings by producing rather than purchasing its own sterile water.

A computer-aided methodology for integrating the budgeting, staffing, and labor productivity systems of Ancillary Services using Respiratory Therapy as an example is presented. The data needed, staffing computations and schedules, and productivity analysis are presented and discussed. A summary of the predicted savings and other benefits for the application hospital are presented with comparisons to present productivity systems.