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Background: Usual practice in community health-care settings indicates that arterial catheters are inserted by physicians. In the context of a respiratory therapist (RT)-managed arterial catheter placement protocol being implemented in our community hospital, the current study describes the implementation and outcomes of this RT-managed arterial catheter insertion and maintenance program., Methods: Tuality Healthcare is a 215-bed community health-care system (10-bed ICU) in Hillsboro, Oregon. With the goal of enhancing the quality of ICU care, an RT-managed multidisciplinary team was implemented to lead the delivery of protocolized ventilator liberation, arterial catheter insertion, and arterial blood gas utilization. Preparation for the program included didactic teaching, simulation-based training, and precepted procedural experience. A database was created for audit and quality improvement purposes. Outcomes and arterial blood gas utilization data were obtained from the audit database and from the hospital electronic health record., Results: During the 4-y period (March 1, 2012, to April 31, 2016), 256 arterial catheter insertion attempts were made by a team of 12 qualified RTs. The success rate for the initial placement attempt by RT was high (94.5% [242 of 256]). Sixty-three percent of arterial lines were placed in patients to help manage severe sepsis/septic shock. No ischemic or infectious complications were reported during the study period. Nearly 40% (96 of 242) of the successful placements by RTs on initial attempts were performed during the night shift, when intensivists were not physically present in the ICU., Conclusions: This experience establishes the feasibility of an RT-managed arterial catheter placement program in a community ICU. The RT-managed program was characterized by a high degree of success and safety and allowed arterial catheter placement at times when intensivists were not available in the ICU. This experience extends the sparse reported experience of RT-managed arterial catheter placement programs and underscores the value of RTs as members of the ICU team., (Copyright © 2017 by Daedalus Enterprises.)

Background: Nosocomial infections linked to the use of multi-dose bronchodilator nebulizer formulations have been reported in the literature., Objective: Survey American hospital respiratory therapy services to determine practice patterns, opinions, and awareness regarding unit-dose and multi-dose bronchodilator formulations., Methods: A quota sample targeted 4 hospital size categories (0-100 beds, 101-200 beds, 201-400 beds, and > 400 beds) using a listing of general medical/surgical hospitals from the American Hospital Association. Hospitals were contacted via telephone to identify the director of respiratory therapy services, who was invited to complete a 29-item Web-based survey of their hospital practices and their opinions about and knowledge of issues with multi-dose and unit-dose bronchodilator formulations., Results: One thousand forty-seven hospitals were recruited and 409 valid surveys were completed (completion rate 39%). The reported mean +/- SD percentage of unit-dose nebulizer treatments was 80.2 +/- 26.2%. Seventy-two percent (296) of respondents indicated having a policy and procedure manual that deals specifically with nebulized bronchodilator solutions, but only 107 reported having internal monitoring guidelines for compliance with those policies and procedures. Multi-dose bottles of bronchodilator concentrate were used with multiple patients in 77% of cases, and on average 9.7 +/- 8.5 patients were treated with the same multi-dose bottle. Eighty-one percent of respondents reported that treatments from multi-dose bottles are prepared at the bedside. The length of time a multi-dose bottle was kept (after being opened) ranged from 24 hours (8%) to 1 month (11%), and only 3% of respondents reported following manufacturers' recommendations. In the respondents' opinion the chief advantage of multi-dose was cost per dose (84%), and the chief advantage of unit-dose was less risk of contamination (92%). With other factors (therapist time, cost of saline diluent for multi-dose concentrate, dose-error, and contamination) considered, 73% thought that unit-dose vials were more cost-effective. Three hundred thirty-six respondents (82%) thought that a sterile, low-volume (0.5 mL) unit-dose vial of bronchodilator concentrate would be useful, and 249 (74%) of those 336 respondents indicated that such a formulation would replace multi-dose bottles. Only 56% of respondents knew about the evidence regarding the risk of contamination with multi-dose bottles., Conclusions: Multi-dose bottles of bronchodilator solution are used in approximately 20% of nebulizer treatments, and without strict adherence to infection control procedures they are a potential source of nosocomial infection. A sterile, low-volume unit-dose vial of bronchodilator concentrate would be a useful alternative to multi-dose concentrate for modifying doses or mixing drugs in nebulizer therapy.

We should embrace respiratory care protocols. We have had a system in our hospital for more than two years; it has been very successful. We have approximately 60-70% of all of our therapy now ordered by a true protocol process. Some people have been dragged kicking and screaming through this process, including a number of respiratory care practitioners. It is more work. It is harder. Yes, it takes more time and more work to be a professional, but a professional is what you want to be. Anybody can go around and stick those nebulizers in people's mouths, but not everyone has the skill to determine which patients do not need that nebulizer or which may need a different drug or a different therapy. We must demonstrate through projects our ability to have an impact on the delivery of unnecessary and inappropriate care, and we must have physician support for what we are doing. These elements are essential to our survival. When we embrace appropriate and effective technology, we demonstrate value. If we show--through improved weaning technology--that we can decrease length of stay by decreasing the time that people are on ventilators, we demonstrate value. If we function as effective bronchoscopy assistants who help to treat people and get them out of the hospital or avoid hospitalization entirely, we demonstrate value. So, we must embrace technology. We need to function across the entire continuum of care to demonstrate value. We need to start managing health instead of managing illness.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Background: During the months of July, August, and September 1993, we implemented a respiratory care assessment-treatment pilot study on the orthopedic surgery floor in our hospital. The purpose of the study was to determine feasibility and establish cost-effective treatment plans with quality patient outcomes, while maintaining appropriate communications with physicians and nursing staff., Study Development & Implementation: The study's Task Force developed protocols for oxygen therapy, aerosolized medication therapy, volume expansion therapy, and bronchial hygiene therapy using the American Association for Respiratory Care's Clinical Practice Guidelines as supporting documents. Meetings were held with the orthopedic surgeons and nursing staff to inform them of the key components of the pilot program. Ten patient evaluators were trained to assess patients and implement treatment plans., Evaluation Methods: A reference book was established that contained the protocols and support material. Patient outcomes were evaluated using previously established quality assurance plans. The length of stay, procedural volume, and cost data were collected., Evaluation Results: More than 50% of the orders received during the pilot program were for "Respiratory Care Protocol." This allowed the patient care evaluator the flexibility to initiate one of the approved protocols if indicated. No changes in patient outcomes were noted and average length of stay remained unchanged during the pilot study compared to the base period. Treatment volumes decreased, resulting in identified cost savings of $5,318 during the study. Nurses and physicians supported protocol implementation, and increased communication among caregivers was documented. We believe that professionalism of the RCPs was enhanced without compromising the ultimate decision-making responsibilities of the physician., Conclusions: The use of respiratory care protocols is an acceptable method of developing clinically effective and fiscally responsible care plans. RCPs at our hospital were able to implement care plans that resulted in cost savings without a measured change in patient outcomes. Approval has been extended from the Executive Committee of the medical staff to expand hospital-wide.

Unlabelled: The management staff of the Respiratory Care Department at the suggestion of the Department of Anesthesiology determined that there was a need for respiratory care practitioners (RCPs) to be trained to perform endotracheal intubation. This need was demonstrated by the frequency with which anesthesia personnel were called away from the operating room (OR) to perform endotracheal intubations in other hospital areas., Methods: The training program included didactic instruction followed by written examination, simulations, and intubation experience in the OR under the direct supervision of a staff anesthesiologist., Results: Initially 15 therapists, from all shifts were trained. Currently, there are 20 fully-trained RCPs on staff. These therapists have successfully intubated 160 patients in 178 attempts over a 49 month period. All attempts followed failed attempts by other professionals. No major complications were observed in the patients intubated by RCPs., Discussion: This training program has successfully provided support for endotracheal intubation procedures, sparing the anesthesiology staff and expanding the role of RCPs in our hospital.

Background: Accumulative evidence suggests that respiratory care is frequently misallocated. We report the results of a pilot study of a delivery system aimed at correcting such misallocation., Methods: The delivery system (Respiratory Therapy Consult Service, or RTCS) allows respiratory therapists (when requested by the case-managing physician) to determine respiratory care, with decisions guided by algorithm (ie, Consult patients). In the pilot study, Therapist Evaluators responded to requests for Consults on two study wards. All staff therapists participated in implementing Evaluator-determined treatment., Study Design: We evaluated 38 patients (20 of whom were Consult patients) randomly selected from a total of 82 patients undergoing abdominal surgery during the study period., Results: Consult patients were significantly older than non-Consult patients, more likely to be heavy smokers (67 vs 43%), and sicker as suggested by a higher Triage Score. Consult patients received more types and more total respiratory care services, demonstrated a trend toward longer stay, and had significantly higher respiratory therapy charges., Conclusion: Our experience shows that a consult program can be successfully implemented in a large, tertiary care institution with widespread physician and nursing support. Whether the RTCS fulfills its goal of ameliorating misallocation of respiratory care has yet to be proven and awaits the completion of other studies currently under way.

Respiratory care as an organized discipline is only about 45 years old, and the management of this dynamic allied health profession has usually been characterized by a demand-for-service mentality. As pressure continues to control costs, those departments that maximize quality patient care cost-effectively with thoroughly documented outcomes are in a better position to compete for future resources. The practice of respiratory care is changing as is the practice of medical care in general. Accountability for resource consumption and the quality of the product delivered are essential elements in the delivery of respiratory modalities. We have developed and implemented a comprehensive patient-data-based approach to the management of respiratory care. The essential elements of this approach are (1) relative-value-unit procedure base; (2) individual, shift, and department productivity that is attached to the annual performance review process; (3) management reporting on a 24-hour basis, with biweekly review at the management level; (4) development and implementation of a comprehensive patient-data-documentation system that permits automatic patient billing and 100% data review for quality-assurance documentation; (5) the development of a medical alerting system that alerts the Medical Director and Respiratory Care staff to potentially harmful events that, if untreated, may result in increased morbidity or mortality; and (6) the development of concurrent and retrospective tools for patient-outcomes research. These functions are supported by an active Medical Informatics Department that is nationally recognized in medical computing and logic application.

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.

We investigated the effects of establishing a blood gas analysis service controlled by respiratory care practitioners (RCPs) on the appropriateness of arterial blood gas (ABG) sampling. An ABG analyzer was placed outside the surgical intensive care unit (SICU) and only RCPs were permitted to process samples on it. In 1-month and 1-year follow-up audits of appropriateness of ABG analysis, the nursing staff improved from 42% appropriate to 73% appropriate in both follow-up periods. RCPs maintained a high degree of appropriateness in all periods (90%, 87%, and 91%), although the percentage of the total ABGs performed by RCPs increased. Additional benefits included a better mutual understanding of each caregiver's role and work load, more collaboration among caregiver groups, and caregiver's perception of improved patient care.

Background: Increased stress, burnout, and lack of job satisfaction may contribute to a decline in work performance, absenteeism, and intent to leave one's job or field. We undertook to determine organizational, job-specific, and personal predictors of level of burnout among respiratory care practitioners (RCPs). We also examined the relationships among burnout, job satisfaction (JS), absenteeism, and RCPs' intent to leave their job or the field., Methods: A pilot-tested assessment instrument was mailed to all active NBRC-credentialed RCPs in Georgia (n = 788). There were 458 usable returns (58% response rate). A random sample of 10% of the nonrespondents (n = 33) was then surveyed by telephone, and the results were compared to those of the mail respondents. Variables were compared to burnout and JS scores by correlational analysis, which was followed by stepwise multiple regression analyses to determine the ability of the independent variables to predict burnout and JS scores when used in combination., Results: There were no significant differences between respondents and sampled nonrespondents in burnout scores (p = 0.56) or JS (p = 0.24). Prediction of burnout: The coefficient of multiple correlation, R2, indicated that in combination the independent variables accounted for 61% of the variance in burnout scores. The strongest predictor of burnout was job stress. Other job-related predictors of burnout were size of department, satisfaction with work, satisfaction with co-workers and co-worker support, job independence and job control, recognition by nursing, and role clarity. Personal-variable predictors were age, number of previous jobs held, social support, and intent to leave the field of respiratory care. Prediction of job satisfaction: R2 indicated that, in combination, the independent variables accounted for 63% of the variance observed in satisfaction with work, 36% of the variance observed in satisfaction with pay, 36% of the variance in satisfaction with promotions, 62% of the variance in satisfaction with supervision, and 48% of the variance in satisfaction with co-workers. Predictors of work-satisfaction level were recognition by physicians and nursing, age, burn-out level, absenteeism, and intent to leave the field. Predictors of level of satisfaction with pay were actual salary, job independence, organizational climate, ease of obtaining time off, job stress, absenteeism, intent to leave the field, and number of dependent children. Predictors of level of satisfaction with promotions were recognition by nursing, participation in decision making, job stress, intent to leave the field, past turnover rates, and absenteeism. Predictors of level of satisfaction with supervision included supervisor support, role clarity, independence, and ease of obtaining time off. The strongest predictor of level of satisfaction with co-workers was co-worker support. As overall level of JS increased, level of burnout decreased significantly (r = -0.59, p less than 0.001). As burnout level increased, increases occurred in absenteeism (r = 0.22, p less than 0.001), intent to leave the job (r = 0.48, p less than 0.001), and intent to leave the field (r = 0.51, p less than 0.001)., Conclusions: Reduced job stress, increased job independence and job control, improved role clarity, and higher levels of JS were all associated with lower levels of burnout. Managerial attention to these factors may improve patient care and reduce absenteeism and turnover among RCPs.

Increases in the utilization of respiratory therapy and the need to avoid its misuse have placed increasing management responsibilities on medical and technical supervisors of respiratory care services. To improve our managerial capabilities we designed a computerized respiratory care record system. Respiratory therapists use specially designed forms to record initial respiratory assessments and subsequent progress notes. A computer program allows secretaries to enter information from the forms into a data base. Another program tabulates information from the data base. As an example of the usefulness of this system we present a study of the utilization of intermittent positive-pressure breathing (IPPB) therapy in patients undergoing intrathoracic or upper abdominal surgery. Although all such patients were routinely educated preoperatively in the use of IPPB, chest physiotherapy, and incentive spirometry, the study revealed that only 14% of the patients received IPPB postoperatively, whereas more than 90% received chest physiotherapy and incentive spirometry. As a result of our findings we are saving time and money by discontinuing routine IPPB education for this population.

Unlabelled: We prospectively investigated strategies for assuring that oxygen was provided to patients hospitalized in our institution, according to standard indications (Blue Cross/Blue Shield Medical Necessity Guidelines)., Method: After a baseline observation period (Phase I) during which no specific interventions were made, therapists were informed that appropriate oxygen utilization was an administrative goal and a department priority, and intensive instruction and case review were provided by the Technical and Medical Directors (Phase II). In Phase III, therapists were encouraged to continue to assure that guidelines were met, but instruction, discussion, and review ceased, and the Technical Director assumed responsibility for all oxygen therapy decisions. Finally, all concerted policing activity by the Technical Director ceased (Phase IV)., Results: The total number of patients and percentage of patients with no indications for therapy fell progressively through Phases II and III and returned almost to baseline after policing activities were discontinued in Phase IV., Conclusions: We believe that it is unlikely that any department can sustain the educational and supervisory input necessary to assure optimal conformance to published standards for oxygen therapy when all members are involved. Therefore, assigning one qualified person to manage oxygen therapy may be more successful than other approaches. Requiring all therapists to monitor conformance to standards for low-flow oxygen therapy is time consuming and less effective and limits the time that can be spent caring for patients with problems that respond favorably to other forms of respiratory therapy.