An expanded role for RCPs has proven beneficial for both them and their patients.
With a 66 percent HMO enrollment rate, Rochester, NY, began to experience changes in health care delivery long before most other US cities did, including metropolitan areas such as New York and Chicago. It was this environment that inspired Strong Memorial Hospital/University of Rochester, a 710-bed teaching hospital, to take steps to adapt to managed care.
During the past few years, the tertiary hospital’s respiratory care department has found innovative ways to cut costs and improve customer service. “Back in the eighties, respiratory care operated on a charge-base reimbursement system, which simply meant the more services you charged for, the more you made,” explains Jon Carlson, RRT, chief of respiratory care. “However, in today’s world of managed care, our department is viewed as a cost center, which means we constantly have to prove our worth.”
A Restructured Department
Demonstrating its value to the rest of the institution has required a lot of dedication and hard work on the part of Strong’s respiratory care department, which accomplished its goal through major reengineering efforts the past few years. When Carlson was promoted last year from a shift supervisor to the department chief, one of his first goals was to reduce the size of his management team.
“In the past we were too management heavy, and when downsizing took place, it was always the clinical FTEs [full-time employees] that were eliminated, not management,” Carlson says. Last year, he eliminated staff supervisor positions and created three new positions: the adult clinical coordinator, the pediatric/neonatal clinical coordinator, and the education/research clinical coordinator. In addition, each shift is now staffed by a rotating charge therapist. “I’m a strong believer in staff empowerment, and this new, leaner team gives everyone in the department more responsibility.”
There are 60 respiratory care employees on staff who are assigned to the surgical intensive care unit (ICU); medical ICU; cardiovascular care unit; trauma/burn unit; pediatric ICU; neonatal (Level III) ICU; or the bone marrow unit. Strong is unique, Carlson says, in that its RCPs work almost exclusively in the critical care area. In addition to the ICUs, there are two step-down units-the respiratory care unit and the cardiac thoracic unit-staffed by RCPs. The charge therapist covers the emergency room, anesthesia/recovery areas, and nuclear medicine, and responds to all codes.
An expanded role for RCPs has benefitted them as well as their patients. “When I started here 10 years ago, respiratory therapists were viewed as people who set up equipment and were sometimes called ‘tank technicians,’ ” explains Peter Popadakos, MD, attending anesthesiologist and professor of anesthesiology at Strong Memorial Hospital/University of Rochester. “Now they are viewed as vital members of the health care team whose input is valuable in the care of critically ill patients,” he says.
The majority of critical care physicians in the United States now recognize that RCPs are responsible for the moment-to-moment therapy and management of patients with acute respiratory failure, Popadakos says. As evidence, he points out that today many RCPs are members of critical care medical societies, such as the Society of Critical Care and the American Thoracic Society. Likewise, many critical care physicians have also become members of the American Association for Respiratory Care.
To prepare RCPs for this more involved role, most respiratory therapy schools have modified their curricula to emphasize the pathophysiology of respiratory problems and the mechanics of respiratory illness and treatment, Popadakos says. “Respiratory therapists today are being used in the community to teach people everything from the dangers of cigarette smoking to how to manage asthma,” Popadakos says. “Laypeople in the community are now starting to understand the role that respiratory therapists play in health care.”
Michael Apostolakos, MD, a pulmonologist and director of the medical ICU, concurs that with new modes of ventilation constantly emerging, the respiratory therapist’s expertise is particularly needed in treating critically ill patients. “Respiratory care is a vital part of patient care in a tertiary hospital such as ours,” he says.
RCPs as Educators
One of the newest and biggest roles for RCPs in today’s health care setting is that of educator, Popadakos says. At Strong Memorial, medical residents, fellows, staff physicians, and nurses all view RCPs as experts in the area of acute respiratory failure and asthma management. “At our hospital, the respiratory care practitioner is looked at as a resource by other health care professionals,” Popadakos says.
In restructuring the department, Carlson says his aim was to have his staff viewed as consultants by other members of the health care team. The department has accomplished this by proving to other professionals that not only are they experts in patient care, but they are appropriate teachers for physicians, nurses, physical therapists (PTs), occupational therapists (OTs), and speech therapists as well.
Staff RCPs are also active in the community, teaching classes in the PT program at nearby Ithaca College and three respiratory therapy schools, and lecturing at five area nursing schools. RCPs also offer weekly classes to Strong’s medical residents and fellows. “These classes are designed to teach physicians about the unique approaches in respiratory care that are used in each intensive care unit,” Carlson says. To ensure acceptance and credibility by other professionals, the respiratory therapist-led classes have always relied heavily on the latest research studies to support specific approaches to patient care, Carlson says.
Because RCPs as educators was a new concept to most physicians, it took a while before Strong’s medical staff recognized the importance of this new role, Carlson says. “Communication was instrumental during this period, and gradually the physicians began to see how they could benefit from attending our classes.”
Because multiskilling of the health care team has become more important in the managed care environment, Carlson also recognized the need to strengthen the relationship between nurses and RCPs. As a result, an RN/RCP task force, consisting of three nurses and three RCPs, was created for each ICU. “Not only do these groups help by exchanging knowledge about patient care, but they also address conflicts that may arise between the two departments,” he says.
Vital Team Members
As RCPs became recognized as a valuable resource at Strong Memorial and their professionalism reached new heights, it did not take long for each ICU’s interdisciplinary team to become stronger as well. One of the most important developments to come out of these teams was a weaning protocol created in a collaborative effort. According to Apostolakos’s research, which tracked more than 400 patients who received care under the protocol, it has already contributed greatly to decreased patient lengths of stay. “Because of the protocol, our therapists are able to get the patient off a ventilator half a day to one day sooner,” Carlson says. “What that means for many patients is that they are getting out of the ICU earlier, which not only makes the patient happier, but also decreases overall costs.” Carlson stresses that the weaning protocol might not have succeeded if RCPs had not been involved in its development or if the critical care physicians had not empowered therapists to take responsibility for carrying out the protocol.
Carlson points out that respiratory care’s clinical core teams, which were created to enhance staff development and improve customer service, have also been recognized hospitalwide by physicians and other health care practitioners as a way to educate different specialties and improve overall delivery of care. The core teams are voluntary committees comprising roughly 14 RCPs who develop and follow mutually agreed upon objectives that promote their own education as well as the education of other health care professionals at Strong. This is accomplished through in-services, printed handouts, and presentations of case studies.
Each member of the team has minimum performance goals that are monitored monthly by the team’s leader and two other team members. “What’s great about this is that three times a month, we get a snapshot of how an individual is doing,” Carlson says. In addition to addressing educational objectives, team members also interview patients and their families to learn about their level of satisfaction. Nurses are also interviewed to obtain information about how thoroughly the therapist interacted with the nurse regarding a patient’s assessment. Even though participation in a clinical core team is strictly voluntary, only a few therapists on staff have not taken part in one.
Apostolakos agrees that the clinical core teams have proven to be very effective. “Since the teams are made up of permanent [staff] members and they’re assigned together to a specific area, they get to know their patients better and are able to develop a deeper understanding of the needs of their specific ICU,” he says.
One of the biggest perks for Strong’s RCPs is the myriad research projects taking place at the hospital. An internationally recognized research center, Strong has always been on the cutting edge of developing and using new treatment modalities. “Several new modes of ventilation were pioneered here, such as inverse-ratio ventilation, pressure-regulated volume control, volume support, and tracheal gas insufflation,” Popadakos says. More recently, therapists have worked closely with University of Rochester researchers on major studies investigating nitric oxide as a treatment for acute respiratory distress syndrome. Strong Memorial’s respiratory care department has also been designated as a test site by major manufacturers evaluating mechanical ventilators and equipment.
“None of these research projects could have been conducted without help from our excellent respiratory care department,” Popadakos says. “In Rochester, physicians and other health care professionals have realized the importance of having respiratory therapists who are active thinkers and skilled practitioners. This is an exciting place to be if you’re a respiratory therapist.”
Carol Daus is a contributing writer for RT.