NCB / WFUBMC has made quite a reputation for itself by featuring five departments dedicated to respiratory and pulmonary care.

North Carolina Baptist Hospital/Wake Forest University Baptist Medical Center in Winston-Salem has made quite a reputation for itself across the board, garnering a raft of kudos for the care it provides. Last year, the facility was ranked as one of “America’s Best Hospitals” by U.S. News & World Report, and the it received commendations for its cancer, geriatrics, urology, ENT, heart, and orthopedics departments. U.S. News & World Report also ranked Wake Forest University Baptist School of Medicine eighth among the nation’s 125 medical schools for its geriatrics curriculum, 43rd in research, and 47th for primary care. Baptist Medical Center was one of the first 14 hospitals in the nation to receive Magnet Recognition for Excellence in Nursing Services from the American Nurses Credentialing Center. Finally, the Pulmonary Center was recently designated by the National Institutes of Health as one of 12 Preventive Pulmonary Academic Award Programs in the United States.

f03a.jpg (11478 bytes)Garland George (left), Matt Brinck, and Timmy Snow transfer a ventilator from an ambulance to the facility.

Not only does NCBH/WFUBMC receive praise, this not-for-profit member of the University Health System Consortium likewise makes its services available far and wide. The facility offers 1,291 acute care, rehabilitation, and long-term care beds at its 4,000,000-square-foot main location, and has subsidiary or affiliate hospitals as well as 87 satellite clinics scattered throughout the state’s Piedmont region. Four new patient care buildings have opened since 1996, another new building housing the children’s hospital and some adult services will open in 2002, and a comprehensive cancer center is currently under construction. Together, these components provide a continuum of care that includes primary care centers, outpatient rehabilitation, dialysis centers, home health care, and long-term nursing centers.

The fully integrated facility also features five impressive departments dedicated to respiratory and pulmonary care. The respiratory care department, pulmonary laboratory, pulmonary rehabilitation unit, extracorporeal membrane oxygenation (ECMO) section, and the Oak Summit Nursing Facility all work together to address a vast array of respiratory diseases, and to assist in patient management within other areas of the medical center.

Respiratory Care
“Respiratory care procedures are available in nearly every area of the hospital, including medical/surgery, adult and pediatric intensive care units (ICUs), the burn unit, the bone marrow transplant unit, and neonatal intensive care,” says Rick Sells, RRT, director of the NCBH/WFUBMC.

Other value-added programs are the neonatal transport program, which consists of a therapist and nurse transport team operating primarily by ground ambulance but occasionally utilizing the AirCare flight program. In addition, the therapists are responsible for running the ECMO program, with assistance from nursing personnel.

In order to keep the department running smoothly, a series of specific patient satisfaction questionnaires are mailed to more than 400 patients each quarter.

“Satisfaction surveys are then returned to a quality improvement coordinator who tabulates the information and reports back to supervisors and staff on an ongoing basis,” Sells says. “For the last few years, the surveys have averaged 95% of the scores being in the ‘good’ and ‘very good’ categories.”

That measure of appreciation comes in part from the use of the best technology on the market. Any equipment acquisitions are decided on by a combination of departmental staff, medical directors, and biomedical equipment technologists utilizing demonstrations and clinical trials.

The hospital is cognizant of the need to maintain a full inventory of respiratory care technology and does not normally go outside for its equipment, except for short-term leases during peak workload periods.

“We primarily use in-house services for maintenance as well,” Sells says. “Our respiratory care biomedical department employs two full-time technicians who work for the Department of Clinical Engineering but are assigned permanently to respiratory care. They take care of all of our equipment maintenance, both routine scheduled and emergent, equipment evaluations, and preventative maintenance.

“We do lease capital equipment on an as-needed basis for short-term use,” Sells continues. “But we usually buy new equipment only and seldom, if ever, buy reconditioned.”

The Pulmonary Center
The Pulmonary Center is comprised of the pulmonary ward and a 66-bed ICU, both of which are contained in the main hospital. The pulmonary section maintains an active inpatient ward service with about 10 to 15 patients at a time, and has sole responsibility for care in the medical ICU, which has roughly eight to 16 patients at any one time. The section sees 400 to 500 inpatient consults each year, with another 5,000 outpatients coming into the pulmonary clinic annually.

Elizabeth Owen, RRT, monitors a ventilated patient.

Clinical cases seen in the Pulmonary Center include pulmonary allergy and bronchial hyperreactivity, chronic obstructive pulmonary disease (COPD) and pulmonary rehabilitation, pulmonary complications of thermal injury and trauma, sleep-related breathing disorders, diagnosis of nosocomial pneumonia, and lung cancer, which can be diagnosed and staged using transbronchial needle aspiration and positron emission tomography scanning. The pulmonary section also performs more than 600 fiber-optic bronchoscopies per year, and the laboratory provides its pulmonary technologists to the cystic fibrosis clinic every week.

Clinical Trials
Over the past 6 years, new faculty has been added to the pulmonary, critical care medicine, and allergy components of the center in order to expand the areas of clinical interest and expertise. That has included work on clinical trials.

Currently, there are nine clinical faculty members who are board-certified in pulmonary medicine and certified in critical care medicine. Three faculty members who are board-certified in allergy and immunology provide clinical expertise over the spectrum of allergic and immunologic disease, and strengthen the research programs in lipid biology and asthma. There are six fellows in the pulmonary program, which has a primary goal of training physicians for careers in academic medicine.

The pulmonary function laboratory is home to a number of ongoing clinical trials in asthma, critical care, and lung cancer staging. The center has research programs that are nationally recognized and extramurally funded, and the laboratory now has five PhDs or MD/PhDs in the section who direct cutting-edge bench and clinical research along with the clinical faculty.

The most recent trial undertaken is on “Dietary Supplementation with PLT3514 in Asthmatics,” which examines the effect of dietary supplementation with fish oil and borage oils in decreasing the production of leukotrienes in the blood cells of asthmatic patients. The respiratory department also is involved in a number of research protocols related to the administration of nitric oxide, acute respiratory distress syndrome, and ventilator weaning.

f03c.jpg (9901 bytes)NCBH / WFUBMC was ranked as one of “America’s Best Hospitals” by U.S. News & World Report.

Pulmonary Rehab Program
The Breathing Plus Pulmonary Rehab Program was created to promote lifestyle changes to enhance quality of life in patients with pulmonary diseases. It encompasses several elements designed to enable individuals diagnosed with chronic lung disease to enhance their quality of life through physical conditioning, understanding of the disease process, and enhancement of treatment.

Participants in the program can attend lectures on topics specifically designed for COPD patients including traveling preparations, disease management, exercise programs, stress management, and nutrition. They also undergo monitored exercise conditioning, and each program is developed to meet individual needs. Finally, patients have access to stress management sessions with a certified counselor and dietary intervention from a registered dietician.

• WFUBMC was ranked eighth among the nation’s 125 medical schools for its geriatric curriculum and 43rd in research by U.S News & World Report.
• The facility offers 1,291 acute care, rehabilitation, and long-term care beds.
• The 4,000,000 sq ft location has 87 satellite clinics scattered throughout the state’s Piedmont region.
• Four new patient care buildings have opened since 1996 and another new building housing the children’s hospital and some adult services will open in 2002.

The ECMO program at Wake Forest University Baptist Medical Center began clinical operations in January 1996 and now is the fifth busiest ECMO program in the world, with approximately 36 cases per year. The program can accommodate three ECMO patients at one time.

The program falls under the department of respiratory care services, with medical direction supplied by the department of cardio-thoracic surgery. ECMO allows extracorporeal support for neonatal, pediatric, and adult patients in cardiac or respiratory failure. Patient care is supported by faculty and staff from pediatrics, neonatology, cardiology, radiology, nursing, pediatric surgery, and respiratory care. In addition, all pediatric ECMO patients are supported in the pediatric intensive care unit (PICU) at nearby Brenner Children’s Hospital.

Patients who typically require ECMO suffer from severe pulmonary hypertension, pneumonia, respiratory failure from trauma or severe infections, and heart failure. The average number of patients is one to two per month, and ECMO’s typical patient mix is 40% neonatal pulmonary failure, 30% cardiac failure, 15% pediatric pulmonary failure, and 14% adult pulmonary failure.

Patients must previously have been unresponsive to maximal medical therapy, including surfactant therapy and nitric oxide, before they will be admitted to ECMO. Once the patient is placed on ECMO, the ventilator settings are decreased, as are the dosages of drugs supporting cardiac function. When the heart or lungs have healed and can work on their own, the patient can stop ECMO and be transferred to another department for further support.

Oak Summit
The Nursing Center at Oak Summit is one of only a few long-term care nursing facilities in North Carolina providing care for ventilator-dependent patients. Respiratory therapists are available to meet the needs of patients requiring airway maintenance and resuscitation. Residents also have access to the expertise provided by the medical center’s specialists in geriatric medicine, geriatric psychiatry, and general internal medicine. Medical direction of the center is provided by the faculty of the Wake Forest University School of Medicine.

The 170-bed facility was designed for comfort and features decorated and furnished rooms, including a family-style dining room. All accommodations are located on one level for easy access. The 24-hour center consists of 100 skilled-nursing beds, 60 intermediate care beds, and a 10-bed unit for ventilator-dependent patients.

A Rapid Recovery Program within the center is designed for patients who are discharged from the hospital, but need more medical attention and personal support than they can get at home. The Nursing Center also runs a program of respite care for patients who are being cared for at home.

Patient Mix
Within all realms of the hospital, Medicare/Medicaid patients make up 39% of the patients seen at the center, while managed care and other commercial payors make up 49%. Self-pay patients make up 8%, and other sources, including workers’ compensation cases, account for the remaining 4%, according to Sells.

“Referrals come primarily from a 26-county area in northwest North Carolina and southwest Virginia, although patients also come from all over the state, as well as from more than 35 other states and several foreign countries,” he says. About 44% of the patients are inpatient, and 56% are outpatient.

Although NCBH/WFUBMC is a massive construction, both literally and figuratively, Sells stresses that the respiratory and pulmonary elements are not islands. Each is instead a key component of the whole.

“We are still a centralized department with individuals receiving daily assignments made by the supervisors at the beginning of each shift,” Sells says. “We do staff critical care environments with full-time therapists around the clock, and many therapists are dedicated to these units, ie, PICU, ICN, and some adult ICUs, on an ongoing basis. Other therapists rotate in and out of general med/surgery and critical care environments. Basically, everyone is required to understand how to work with a full range of patients and technologies throughout the medical center environment.”

Liz Finch is a contributing writer for RT Magazine.