Protocols  and teamwork  reduce lengths of stay and improve outcomes at this LTAC

Relationships and healing have one thing in common: they both require time. Long term acute care (LTAC) hospitals, by their very definition, have time on their side. Although the luxury of time has some benefits, working at an LTAC is not without its unique challenges. Many of these hurdles appear very early on when the medical staff has to work to gain not only the patients’ trust but the families’ as well. These families who have loved ones entering long-term care are likely to have experienced letdowns in the past at traditional intensive care units. This history often leaves them leery of medical professionals.

Most patients entering LTACs did not recover as planned. Others were not discharged from the hospital in the expected amount of time, and those results have a direct impact on a family. To make caring for this population even more complicated, the patients who end up at LTACs are very high acuity patients who require intense, hands-on care. In addition to traditional ICU patients, some are complex trauma patients or patients with surgical complications, head injuries, or neuromuscular disease. Their families have often been on an emotional roller-coaster ride, and the new institution offers new possibilities and a glimmer of hope.

At Regional Hospital for Respiratory and Complex Care in Tukwila, Wash, the staff sees the patient’s family as an important factor in healing, according to Donavan Knight, RRT-NPS. “These families have had a lot of frustration sometimes before they came to us. Establishing trust is critical for us and so is good rapport and communication, so they feel comfortable leaving their family members in our hands. We do it well—establishing that trust,” says Knight, respiratory care manager at Regional. “We don’t just take care of the patients, we take care of the families.”

Patients are referred to Regional from hospitals throughout the Pacific Northwest, but only those with a reasonable chance at recovery are accepted. Regional was the first designated LTAC in a five-state area; although patients have come from as far away as Hawaii and Alaska, most are from the Seattle-Tacoma area. Average patient stays at the 27-bed hospital range from 30 to 50 days, but visits have been as short as a few days, and some have extended for more than a year. Most patients who are discharged go to skilled nursing facilities or rehabilitation programs; few are released to their homes. More than 90% of all patients admitted to Regional are there because of the facility’s ventilator weaning programs.

Respiratory therapists have a lot of autonomy in the ventilator weaning process. The medical director of respiratory care oversees all work, and the weaning follows a therapist-driven protocol. Teamwork is paramount at Regional, according to Knight. “A lot of hospitals talk teamwork and talk interdisciplinary care and are successful on some level, but here at Regional Hospital it really works. It’s the standard of care. It’s the way we operate. And that team-oriented approach, professionally and socially, [results in] a family environment among the team members here. It’s a very close team,” says Knight, who has run RT departments, pulmonary service departments, and a cardiac catheterization laboratory.

The culture of collaboration was in place when Knight arrived almost 4 years ago after 2 decades in the Air Force. He believes that the support for respiratory is as strong as he has ever seen. Respiratory therapists are also involved in family conferences: meetings between families, physicians, registered nurses, social workers, and a chaplain to discuss subjects such as end-of-life issues, resuscitation options, and patient goals.

Regional is also well staffed, and this is one of the reasons that Knight believes the hospital is a great place to work. Its administrators believe in staffing well so they can commit an ideal amount of time to each patient. In the short term, that approach requires more employees and more money spent on salaries, but that is offset by reduced lengths of stay and improved outcomes.

Field Trips Raise Spirits
Getting patients out of the hospital is one approach Regional uses to improve patient care. The staff loads up the ventilators and take the patients to shopping malls, museums, the aquarium, or the movies. Of course, not all are ready for this and patients have to be carefully screened before leaving the hospital. The positive effects can be seen almost immediately. The patients’ spirits are lifted for weeks, and Knight thinks this contributes to their recovery.

On the higher technology front, Regional also performs bedside percutaneous tracheostomies. The staff started performing these procedures at the end of 2002. Before that, the minor surgery was a big undertaking for the patient and the staff because the patient had to be transported. The help of a surgeon and an anesthesiologist was required to insert the tracheotomy tubes in the patient’s neck. The transport increased the stress level for the patient and therefore increased the recovery time.

Doing the procedure at the bedside has multiple benefits. The first is for the patient, who does not have to leave the LTAC. Instead, one physician, one registered nurse, and two RTs, with whom the patient is familiar, perform the 10-minute procedure. There is less interruption in the workflow for the staff, and the patient undergoes less stress and can begin to focus on recovery immediately. The hospital has looked at data on complications since the inception of the program, and the rates are well below those  they have seen in the medical journals, says Knight. Regional has completed more than 70 of these procedures, and at the end of last year, it received a best practice award from the National Association of Long Term Hospitals for their work.

A Driving Force
Whether talking about cutting-edge care at Regional or its commitment to collaboration, it is difficult to talk to any of the hospital’s employees without hearing the name Robert Clark, MD, the medical director at Regional Hospital, who is largely responsible for the success of the enterprise.

The pulmonologist was running a similar hospital in Detroit when he was recruited to turn a four-bed unit at the then-named Highline Hospital in Tukwila into a full-blown LTAC. Before Clark came, the unit was a specialty care center that the hospital wanted to upgrade. It began the upgrade by putting some respiratory-intense patients into those four beds. When Clark arrived, he went to work on getting the necessary licenses and conducting public hearings. When those went favorably, he started hiring everyone he needed, from the marketing professionals to the doctors and nurses. He also traveled throughout the area telling people about the regional weaning center. Many individuals initially heard the term LTAC and did not know if it was a burn unit or a nursing home. The word got out and the beds began to fill.

When they did, the physical and occupational therapy departments did not know how hard a ventilated patient could work, but Clark got them to try new things. Trying new things became an integral part of the institution, and the patients benefited.

“If we used the same techniques as everyone else used, we’d get the same results as everyone else,” says Clark.

One of the first things he tried was getting the patients outside—uncommon at the time. Clark would often make sure that the families of the patients joined them. With a crash cart, nurse, and RT, they would leave the hospital in a van. The results were impressive. It was like turning the patients on again, Clark says. They were different human beings after 1 hour outside the hospital.

Clark hired a clinical psychologist to study patients that had taken field trips. Before the trip, many suffered from anxiety or depression. After the field trip, those conditions were undetectable. The results of this study were published as an abstract a few years ago, according to Clark. The staff was regularly amazed at how different the patients were when they came back, and the staff that went on these outings benefited as well. Outside of the hospital, the staff members saw the patients interact with their families, which reinforced the staff’s realization that these people had a life outside the hospital that they had to get back to. This increased the motivation to help them take steps away from being a patient.

Even in an interview conducted over a cell phone, Clark’s enthusiasm is contagious, going right into the listener’s head. This may not be accidental, since getting into a patient’s mind and staying there is one of his goals. “In terms of prognostic factors, if I lose their head, I’m going to lose the patient,” Clark says.

In addition to setting up shop in a patient’s brain, Clark is also concerned with the patient’s stomach. In the past, staff members would follow formulas like the Harrison-Benedict formula that dictated caloric requirements. Still, they would find that some patients were not getting their necessary calories. So they started conducting weekly metabolic studies.

“This subset of patients does not fit the standard profile of what one would predict. We study all patients every week and adjust their nutritional inputs based on that metabolic cart study. That gives us an edge. We see some people who are just ravaged nutritionally in spite of them being adequately fed, based on what the best formulas are,” Clark says.

An extreme example of this problem was a patient with hemorrhagic pancreatitis and an open abdomen. Her predicted normal daily requirement was 2,500 calories. The staff studied her and found out that she needed 4,500 calories. After her daily caloric intake was increased, she began to recover. Clark now talks about the importance of finding the appropriate caloric needs when he speaks and lectures to other professionals.

Families Are Important, Too
Emotional well-being is constantly considered, and, for this reason, there are unlimited visiting hours at Regional. Families of patients in the ICU are often very angry, according to Clark “They get in [to visit] for 5 minutes, and they’re angry because they want to be part of making something happen for their loved one,” says Clark. He asked himself if there was a way to take this energy that was available in the waiting room and bring it into the ICU and use it constructively.

He answered his own question by including loved ones in patient care. If there is a quadriplegic patient that requires suctioning, staff members will bring in the family early and show them how to do it. They become a part of the care-giving team. They are also taught how to roll the patient over. “They feel like they’re doing something constructive and that it’s you and them standing at the bedside caring for their loved one. It’s not you against them, caring for their loved one. But they’re all on the same page, and they’re all on the same team,” Clark says.

Although Clark laid much of the groundwork, he relies on the work of RTs and the rest of the staff to help him make an educated decision about patients. Sure, physicians can get a snapshot of how patients are doing during rounds, but those at Regional rely on the observations and suggestions of the RTs who are around the patients for hours at a time. The experience of many of Regional’s employees is also impressive: some staff members have 20 years of experience, and there are three ex-managers on staff. Clark insists that they use their experience and offer suggestions for care.

“It’s unique working in a place like this,” says Shannon Taisey, CRT. “It’s a lot different here. As far as RTs [go], we have a lot of autonomy with Dr Clark. He really lets us be involved every step of the way with our patients. He takes to heart everything we have to say when it comes to weaning the patients off the ventilators. The autonomy and the trust he has in us are just amazing.”

The hospital has a close affiliation with Highline Community College, and it hosts clinical students every semester. This tie helps with recruiting and keeps a steady stream of fresh faces coming through. Having extra help also benefits the patients, because the RTs can spend as much time as necessary to get the patients off the ventilators. Each weaning strategy is individualized and a collaborative effort. “It takes a lot of time, but it’s really nice because everyone puts their two cents in,” Taisey says. “Everybody has a say in patient care, and Dr Clark respects [our opinions] and takes [them] to heart.”

Taisey had been out of school for a year and appreciates being around the experienced staff and developing a relationship with patients. “It can be hard at times, but we become a part of their lives and see a big difference. It’s great to see them when they come back and they’re doing well. It’s very satisfying,” Taisey says.

Stephen Krcmar is a contributing writer for RT Magazine.