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Health care organizations are complex adaptive systems, a set of connected or interdependent parts or agents that include caregivers, patients, and processes. Consequently, health care organizations are prone to problems and are not always predictable environments. Fundamental changes are needed in the organization and in the delivery of health care in the United States. This article presents a proven method of instituting and tracking the changes that can ensure a respiratory care department is delivering the appropriate level of care.

Respiratory care (RC) protocols are widely regarded as the most appropriate method for properly allocating and delivering most forms of respiratory therapy. The use of protocols has increased steadily over the past 15 years, but, despite the successes and modest implementation of RC protocols across the country, there is room for improvement in adopting RC protocols for the effective use of respiratory care services. It also seems that many physicians have yet to be won over, and RC managers need to take the first step toward protocol development and implementation. This article addresses some of the issues surrounding the development of respiratory care protocols and the impact that their implementation may have based on experience gained to date.

The development of the AHA Guidelines for CPR and ECC and the AARC RACH Clinical Practice Guideline should both be instrumental in improving the performance of RCPs on in-hospital resuscitation teams. The AARC and AHA are assuming important leadership roles in this movement by publishing CPGs for CPR and ECC. RCPs with ACLS training are in a prime position to assume more responsibility on resuscitation teams within acute care facilities. They should be prominent members of the resuscitation team--committed to the entire team's performance--and be actively involved in ACLS training. The first step in that process is to study the current levels of RCP competence in ACLS. Further, RCPs and health-care providers should define the goals of resuscitation in terms of long-term survival, quality of life, and years of useful life after CPR. The cost of inadequate attention to which patients should have DNR orders is a drain on the entire health-care system. Research on the impact of disease categories on CPR outcome should be used to educate physicians, nurses, and RCPs so they can help patients better understand their chances of regaining their pre-CPR quality of life. Successful CPR outcome should be carefully defined using the patient's disease category. Each patient should be individually evaluated for DNR orders. As suggested by Schwenzer, "Patients' perception of their quality of life before and after CPR should guide their and our decisions." However, we must all accept the responsibility for defining the limitations of medical technology and try to determine when CPR is futile.

Pneumonia is the second most common nosocomial infection in the United States and is associated with substantial morbidity and mortality. Most patients with nosocomial pneumonia are those with extremes of age, severe underlying disease, immunosuppression, depressed sensorium, and cardiopulmonary disease, and those who have had thoracoabdominal surgery. Although patients with mechanically assisted ventilation do not comprise a major proportion of patients with nosocomial pneumonia, they have the highest risk of developing the infection. Most bacterial nosocomial pneumonias occur by aspiration of bacteria colonizing the oropharynx or upper gastrointestinal tract of the patient. Intubation and mechanical ventilation greatly increase the risk of nosocomial bacterial pneumonia because they alter first-line patient defenses. Pneumonias due to Legionella spp., Aspergillus spp., and influenza virus are often caused by inhalation of contaminated aerosols. Respiratory syncytial virus (RSV) infection usually follows viral inoculation of the conjunctivae or nasal mucosa by contaminated hands. Traditional preventive measures for nosocomial pneumonia include decreasing aspiration by the patient, preventing cross-contamination or colonization via hands of personnel, appropriate disinfection or sterilization or respiratory therapy devices, use of available vaccines to protect against particular infections, and education of hospital staff and patients. New measures under investigation involve reducing oropharyngeal and gastric colonization by pathogenic microorganisms.

Background: An early study demonstrated that standard cleaning techniques did not adequately disinfect reusable pulse oximetry sensors that had been intentionally contaminated with high titers of pathogenic microorganisms. This current study evaluated patient-ready sensors being used in hospitals, by testing them for bacterial contamination., Methods: Reusable pulse oximetry sensors from 15 hospitals throughout the United States were tested. Each sensor was deemed by the hospital to be ready for patient use, and it had been prepared for use according to hospital procedures. Patient-contact areas of each sensor were swabbed, and the swabs were analyzed for bacterial contamination using standard testing procedures. This study had two stages, and different sensors were tested in each stage. In the "bacterial-growth stage," swabs were evaluated for bacterial contamination but organisms were not identified; in the "identification stage," bacterial species were identified., Results: Forty-four sensors were evaluated, 16 in the bacterial-growth stage and 28 in the identification stage. Bacteria were cultured from 29 of the 44 sensors (66%), including 20 that had been cleaned with alcohol or an antibacterial/antiviral agent. Among the isolated organisms were Staphylococcus aureus, Staphylococcus haemolyticus, Enterococcus faecalis, and Klebsiella oxytoca. Bacterial contamination was found on sensors from 12 of the 15 participating hospitals., Conclusions: These data demonstrate the need to define effective cleaning methods for reusable sensors, and we are currently conducting such studies. The data also suggest that disposable patient-dedicated sensors may be the most appropriate choice when infection control is of particular concern.

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.

Acquired immunodeficiency syndrome (AIDS) has recently received considerable media attention. Health care workers, including respiratory care practitioners, are concerned about the many medical and psychosocial implications of the disease. This article reviews the epidemiology and clinical features of AIDS. Health care workers do not have a demonstrably higher incidence of AIDS infection than does the general population; risks to the respiratory care practitioner may be minimized by adherence to the suggested guidelines for infection control. Respiratory care practitioners are ethically bound to treat all patients, regardless of the nature of their disease; the guidelines given in this article will help practitioners do this.

Measurement of the effect of therapy is a principle in the provision of all care, including respiratory therapy of newborns. Crucial to such measurement are guidelines of respiratory therapy services. The author offers a method for establishment of these guidelines, as well as a literature review of the outcomes of infants who required respiratory care.

Half the task of setting up a quality assurance program is selling the idea to departments and enlisting committee members with positive attitudes to seek out and help solve problems.