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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: Patients with respiratory disorders constitute a major source of activity for Acute Medicine. We have examined the impact of Socio-Economic Status (SES) and weather factors on the outcomes (30-day in-hospital mortality) of emergency hospitalisations with a respiratory presentation., Methods: All emergency respiratory admissions to St. James Hospital, Dublin, from 2002 to 2014 were evaluated. Patients were categorized by quintile of Deprivation Index, and evaluated against hospital admission rate (/1000 population) and 30-day in-hospital mortality. Univariate and multivariable risk estimates (Odds Ratios (OR) or Incidence Rate Ratios (IRR)) were calculated, using logistic or zero truncated Poisson regression as appropriate., Results: There were 32,538 episodes in 14,093 patients, representing 39.5% of medical emergency episodes over the 13-yr period. Deprivation Quintile independently predicted the admission rate, with incidence rate ratios (IRR) of Q3 2.02 (95% CI: 1.27, 3.23), Q4 2.55 (95% CI: 1.35, 4.83) and Q5 5.68 (95% CI: 3.56, 9.06). The 30-day in-hospital mortality for the highest quintile was increased (p < 0.01), Q5 1.31 (95% CI: 1.07, 1.61). Particulate matter (PM 10 ) was predictive for the top two quintiles (>17.2 and 23.8 μg/m 3 respectively) with an OR for a worse outcome of Q4 1.22 (95% CI: 1.07, 1.40) and Q5 1.24 (95% CI: 1.08, 1.42). Weather (season) and the daily temperature did not affect the admission rate but were significantly associated with worse outcome., Conclusion: Socio-Economic Status influences the admission rate incidence and hospital mortality of respiratory emergency admissions; local environmental conditions (air pollution and temperature) appear only relevant to the mortality outcomes., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Few published data exist for adherence rates to spirometry acceptability and repeatability criteria in clinical respiratory laboratories. This study quantified adherence levels in this setting and observed changes in adherence levels as a result of feedback and ongoing training., Methods: Two tertiary hospital-based, lung function laboratories (L1 and L2) participated. Approximately 100 consecutive, FVC spirometry sessions were reviewed for each year from 2004 to 2008 at L1 and for years 2004 and 2008 at L2. Each spirometric effort and session was interrogated for adherence to the acceptability and repeatability criteria of international spirometry standards of the time. Feedback of audit results and refresher training were provided at L1 throughout the study; in addition, a quality rating scale was implemented in 2006. No formal feedback or follow-up training was provided at L2., Results: We reviewed 707 test sessions over the 5 years. There was no difference in adherence rates to acceptability and repeatability criteria between sites in 2004 (L1 61%, L2 59%, P = .89). There was, however, a significant difference between sites in 2008 (L1 92%, L2 65%, P < .001). No difference was seen at L2 between 2004 and 2008 (P = .26), while L1 experienced a significant increase in adherence levels between 2004 and 2008 (61% to 92% P < .001)., Conclusions: Clinical respiratory laboratories met published spirometry acceptability and repeatability criteria only 60% of the time in the first audit period. This improved with regular review, feedback, and implementation of a rating scale. Auditing of spirometry quality, feedback, and implementation of test rating scales need to be incorporated as an integral component of laboratory quality assurance programs to improve adherence to international acceptability and repeatability criteria.

Respiratory rehabilitation (RR) has been shown to be effective with a high level of evidence in terms of improving symptoms, exertion capacity and health-related quality of life (HRQL) in patients with COPD and in some patients with diseases other than COPD. According to international guidelines, RR is basically indicated in all patients with chronic respiratory symptoms, and the type of program offered depends on the symptoms themselves. As requested by the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), we have created this document with the aim to unify the criteria for quality care in RR. The document is organized into sections: indications for RR, evaluation of candidates, program components, characteristics of RR programs and the role of the administration in the implementation of RR. In each section, we have distinguished 5 large disease groups: COPD, chronic respiratory diseases other than COPD with limiting dyspnea, hypersecretory diseases, neuromuscular diseases with respiratory symptoms and patients who are candidates for thoracic surgery for lung resection., (Copyright © 2012 SEPAR. Published by Elsevier España, S.L. All rights reserved.)

Aims: In 2004, the NZ Branch of the TSANZ published "Standards for Adult Respiratory and Sleep Services" on the Ministry of Health's (MoH) website.1 The aim of this survey was to evaluate each of the 21 District Health Boards' (DHBs) performance against the published standards, concentrating particularly on staffing, infrastructure, clinical support services, implementation of guidelines, quality assurance activity, and basic services (sleep, lung function, and oxygen)., Methods: Postal questionnaire survey of all DHBs in late 2006., Results: All 21 DHBs responded. Only 10 of 21 DHBs were complying with the minimum standards of care. Main deficiencies in care related to: inadequate medical staffing rates, lack of quality assurance measures and insufficient laboratory testing (sleep and lung function). The lack of monitoring of such basic activities as outpatient clinic attendances, oxygen and sleep services, and the non implementation of treatment guidelines were of particular concern. Seven-fold variations in prescription of assisted ventilation equipment and oxygen therapy exist across the country., Conclusions: When evaluated against minimum standards of care published in 2004, major gaps in service provision exist in New Zealand. Access to services is variable. There is a lack of national leadership and insufficient regional organisation leading to large gaps in service provision of even basic respiratory services. Immediate changes to the current service provision structures are required.

The assessment of competency for respiratory care practitioners involves a thorough understanding of what defines competence, the development of a well-planned, continuous process that starts with new employee orientation, and a clearly communicated set of staff expectations. Career ladders are a tool that can be used to aid staff retention and recruitment, thereby reducing multiple costs associated with a high employee turnover rate, and to encourage professional development and accountability while achieving important departmental objectives.

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.

Despite publication of several management guidelines for COPD, relatively little is known about standards of care in clinical practice. Data were collected on the management of 1400 cases of acute admission with Chronic Obstructive Pulmonary Disease in 38 UK hospitals to compare clinical practice against the recommended British Thoracic Society standards. Variation in the process of care between the different centres was analysed and a comparison of the management by respiratory specialists and nonrespiratory specialists made. There were large variations between centres for many of the variables studied. A forced expiratory volume in one second measurement was found in only 53% of cases. Of the investigations recommended in the acute management arterial blood gases were performed in 79% (interhospital range 40-100%) of admissions and oxygen was formally prescribed in only 64% (range 9-94%). Of those cases with acidosis and hypercapnia 35% had no further blood gas analysis and only 13% received ventilatory support. Long-term management was also deficient with 246 cases known to be severely hypoxic on admission yet two-thirds had no confirmation that oxygen levels had returned to levels above the requirements for long-term oxygen therapy. Only 30% of current smokers had cessation advice documented. To conclude, the median standards of care observed fell below those recommended by the guidelines. The lowest levels of performance were for patients not under the respiratory specialists, but specialists also have room for improvement. The substantial variation in the process of care between hospitals is strong evidence that it is possible for other centres with poorer performance to improve their levels of care.

An outcomes management system was implemented to evaluate the effectiveness of an asthma education program and to test its feasibility as a quality improvement tool. The study demonstrated the value of continuous monitoring of health status and the advantages of a multidimensional approach to outcome assessment and program evaluation.

Patients with chronic obstructive pulmonary disease (COPD) consume many health care resources and require complex coordination of care among multiple caregivers. In this report, we share our experiences at Fletcher Allen Health Care, Burlington, Vermont, in developing and implementing a critical pathway for these patients. The COPD pathway has resulted in measurable improvements in the quality of care and has provided us with lessons that will enhance our use of critical pathway methods.

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.

Objective: To ascertain the standard of care for hospital management of acute severe asthma in adults., Design: Questionnaire based retrospective multicentre survey of case records., Setting: 36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland., Patients: All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management., Main Measures: Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians., Results: 766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan., Conclusions: The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians.

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)

Unlabelled: We developed a self-administered safety module (SM) to instruct respiratory care (RC) employees in their responsibilities during emergency situations. The SM has five phases--a pretest (PRE), statement of module objectives, presentation of information in outline form, a posttest (POST), and review of the POST. This training meets the specific requirements outlined by the Occupational Safety and Health Administration and the Joint Commission on Accreditation of Healthcare Organizations., Methods: To evaluate the effectiveness of the SM, we compared test scores among three groups of employees: those with no previous exposure to safety education in the hospital setting (G1), those with exposure at other institutions (G2), and those with exposure at this institution (G3). Our goal was to equalize the POST scores among the three groups. Using a 1-way analysis of variance, we tested to find whether the PRE scores were different from one another and repeated the test for the POST scores. We tested for within-group differences, PRE vs POST, using paired t tests., Results: Previous exposure to hospital safety management was associated with significantly higher PRE scores (p < 0.001). No previous exposure was associated with the greatest improvement (POST vs PRE), although all groups experienced significant improvement (p < 0.05). The POST scores for G1 were significantly lower than those of either G2 or G3 (p < 0.001). However, they were still adequate to pass (> or = 80%)., Conclusion: This self-administered SM is an effective and efficient method of educating RC personnel, regardless of entry-level knowledge, in safety issues and, although the POST scores were not statistically equalized, these scores were all sufficient to pass. Further evaluation of this process will include assessment of knowledge retention among employees.

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.

Aim: To audit the assessment and management of patients admitted to hospital with chronic obstructive pulmonary disease (COPD) during three months of the winter of 1992., Methods: Consensus management guidelines were developed as the basis for the audit. Consecutive cases were audited by review of the case notes. Half were admitted initially under a respiratory physician and half under a general physician. Ninety-five cases were audited., Results: The overall standard of medical assessment was adequate but a number of deficiencies were identified. The mean duration of stay in hospital was nine days. In the emergency department the use of pulse oximetry in preference to arterial blood gas analysis led to failure to diagnose significant ventilatory failure in five cases. Initial assessment by junior medical staff failed to include comment about level of consciousness in 50% of cases and chest hyperinflation in 40%. Oxygen therapy was given in 87% of cases, but was not prescribed in one third and was often not adequately monitored. Peak flow monitoring was performed on admission in 74% of cases and arterial blood gas measurement in 81%. Over 90% of patients were given nebulised bronchodilator therapy with both nebulised ipratropium bromide and salbutamol. Antibiotics were given in 77% of cases. Corticosteroids were given in 95% of cases, usually orally. Sedatives were prescribed inappropriately in six cases where there was acute ventilatory failure. Four patients died in hospital, none unexpectedly. Three patients were mechanically ventilated and all survived to leave hospital. There was no discharge summary in the case records in 29% of cases., Conclusions: Standards of assessment and treatment were adequate. Several areas were identified where improvements are required, particularly in the prescribing and monitoring of oxygen therapy. Hospital-wide guidelines for the management of COPD are to be developed.

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.

In the conclusion of a three-part series on patient-centered asthma care, the authors describe the program developed at National Jewish Center for Immunology and Respiratory Medicine. Beginning at the time of diagnosis, the interdisciplinary intervention team works in tandem with the patient and family to build confidence, skill, and motivation in self-management.

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.

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.

At present, the principal advantage of computer-assisted quality assurance is the acquisition of quality assurance date without resource-consuming chart reviews. A surveillance program like the medical director's alert may reduce morbidity and mortality. Previous research suggests that inadequate oxygen therapy or failures in airway management are important causes of preventable deaths in hospitals. Furthermore, preventable deaths tend to occur among patients who have lower severity-of-illness scores and who are not in ICUs. Thus, surveillance of the entire hospital, as performed by the HIS medical director's alert, may significantly impact hospital mortality related to respiratory care. Future research should critically examine the potential of such computerized systems to favorably change the morbidity and mortality of hospitalized patients. The departments of respiratory care and medical informatics at LDS Hospital have developed a computer-assisted approach to quality assurance monitoring of respiratory care services. This system provides frequent and consistent samples of a variety of respiratory care data. The immediate needs of patients are addressed through a daily surveillance system (medical director's alert). The departmental quality assurance program utilizes a separate program that monitors clinical indicators of staff performance in terms of stated departmental policies and procedures (rate-based clinical indicators). The availability of an integrated patient database allows these functions to be performed without labor-intensive chart audits.

Total quality management (TQM) is a unifying business strategy for achieving and sustaining growth. TQM proceeds, step by step, project by project, to transform the organization into one smoothly working, quality-focused team. For successful implementation of TQM, the small projects are every bit as important as the large ones. The simple, accessible successes validate the skills that employees are acquiring and encourage them to try more complex, long-term endeavors. This article discusses several TQM projects conducted at Baptist Medical Center in Columbia, SC: streamlining medical records processing (a large project that freed up millions of dollars in cash flow); improving the reliability of all hospital equipment; and ongoing small successes in the recovery room. Although the dollar value of the projects varied considerably, all were critical to creating a culture of total quality management at Baptist Medical Center.

Evolving from a traditional quality assurance to a continuous quality improvement mindset is both challenging and frustrating. How to phase out the old and embrace the new is not always clear. Approaching the shift as an evolutionary process by applying CQI techniques to issues identified through traditional QA methods can be effective. It helps to validate the significance of past efforts and provide tangible evidence of process improvement.

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.

Objective: To assess whether the management of asthma has improved from three consecutive surveys., Design: Retrospective case note survey of acute asthma admissions in 1983 and 1989; case notes selected from 1985-6 survey of prospectively identified patients to include only patients with a final discharge code of asthma., Setting: A large city teaching hospital. Patients--101 patients with acute asthma as the primary diagnosis in 1983; 85 in 1985-6; and 133 in 1989, 14 of whom were subsequently transferred elsewhere., Main Measures: Conformity with a checklist of important aspects of the process of asthma management including initial assessment, treatment, supervision, and discharge and review arrangements., Results: All patient groups were similar in age, smoking habit, and stay in hospital and, as an objective guide to severity of asthma, had similar initial pulse rates. Major improvements occurred in management: by 1989, 119(90%) patients were treated with oral corticosteroids (69(68%), 67(79%) in 1983, 1985-6 respectively) and 109(82%) with oxygen (62(61%), 51(60%)) (both p < 0.001). 114(86%) had regular recording of peak flow measurements (53(52%), 54(64%); p < 0.001), and 103/119(86%) were discharged taking oral corticosteroids (66(65%), 63(74%); p < 0.01). Significantly fewer patients, however, had their regular inhaled corticosteroid treatment increased on discharge (38/119(32%) v 53(52%), 39(46%); p < 0.01), but more were receiving high dose inhaled treatment on admission., Conclusions: The management of asthma improved significantly, and the normal practice of doctors has changed in an area of practice with longstanding problems.

The difficulty of delivering respiratory therapy according to currently accepted standards is an important problem in many hospitals. As a result of this problem in our hospital, we developed a new therapy delivery system--the Respiratory Care Protocol. In response to an order for Respiratory Care Protocol from an attending physician, a senior respiratory therapist evaluates the patient, prescribes specific respiratory therapy according to a protocol, and then daily re-evaluates the patient and makes appropriate therapeutic changes, including discontinuing respiratory therapy when appropriate. The Respiratory Care Protocol has been well-accepted by patients, physicians, and respiratory therapists, and by Joint Commission on Accreditation of Hospitals evaluation teams. We believe that our use of the Respiratory Care Protocol has led to improved quality and to the reduced cost of our in-hospital respiratory care.

Although our operational audit involved evaluating the cost effectiveness and efficiency with which procedures or functions are performed, our focus remained on the actual operational problem as defined in our criteria. The pre-determined standards, on which our criteria statements were based, provided the yardstick for measurement. Our assessment and Treatment Plan for patient care was audited, followed by a review of our policy and procedure compliance and the application of managerial systems and controls. Although the total impact of this audit tool on astute clinical care, management, judgement, and educational needs is yet to be addressed, we believe we have taken an important step in the direction of quality control through the initiation of an evaluation system in the Respiratory Department.

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.

Unlabelled: Because our Respiratory Care Department resources were overburdened and many orders for medicated aerosol therapy (MAT) and lung hyperinflation therapy (LHT) seemed inappropriate, we developed ordering guidelines for MAT and LHT. We then studied the effects on numbers of inappropriate treatments when therapist-evaluators discussed questionable orders with physicians., Methods: For 6 weeks, the physicians were divided into two groups, one interactive with therapists, the other serving as controls. The physicians then switched groups for a second 6-week period. Therapist-evaluators examined all orders for MAT and LHT and suggested therapy changes to interactive-group physicians who wrote questionable orders; they did not discuss inappropriate orders with control-group physicians. The percentages of inappropriate treatments ordered by both physician groups were recorded, and the costs of inappropriate therapy were calculated. After the 12-week study, the program continued, with evaluators interacting with all physicians when treatment was inappropriate., Results: Of treatments ordered by control-group physicians, 48% were inappropriate. Of treatments ordered by physicians in the interactive groups, 35% were inappropriate. Inappropriate treatments cost $15,960 in labor and supplies and required 3.6 full-time technicians. The cost of evaluation was $1,193. By 6 months following the study, therapist-physician interaction had reduced inappropriate treatments to 11% of treatments given., Conclusions: The use of ordering guidelines and therapist-evaluators who interact with physicians can significantly reduce the number of inappropriate respiratory care treatments and reduce costs.

The quality of services provided by respiratory therapists must be measured as part of a hospital's overall evaluation of patient care, as mandated by the Joint Commission on the Accreditation of Hospitals. An internal audit helps both the respiratory therapists and the attending physicians to know what kind of specific documentation is needed in the medical records to meet the desired standards. It also serves as a useful tool in identifying staff educational needs.

The equipment used in respiratory therapy can be the source of serious nosocomial infections unless close attention is given to appropriate sterilization, disinfection, and general measures that come under the heading of good housekeeping. And even the best of these measures will fail if therapists do not observe the cardinal rule of regular hand washing.