Growing RTs in a Tight Market

In Marion, Ohio, the Marion General Hospital RT department uses protocols and a tiered organizational system to retain and provide growth opportunities for RTs.

 Marion General Hospital is in a small town between Cleveland and Columbus.

The 215-bed Marion General Hospital in Marion, Ohio, sits in the midst of seven north central Ohio counties that are steeped in agriculture and industry. The largest hospital in the area, Marion serves a region populated mostly by blue-collar workers—and that means the hospital sees a higher-than-average occurrence of respiratory diseases such as chronic obstructive lung disease (COPD).1 While therapists certainly thrive on having responsibility for patient care, their dependence upon physicians to make treatment decisions can undermine that responsibility. Add to that the fact that trends in health care have made RTs something of a dwindling breed, and Marion Hospital becomes a microcosm of the factors that threaten to greatly debilitate the respiratory care field as a whole.

“Within the next 10 to 20 years, there will be a great chasm between the number of RTs available and the number of patients needing respiratory care,” says Travis Grasley, RT, manager of the respiratory care department. “At Marion, we knew we needed to come up with innovative ideas about how to meet patient demands with a smaller number of RTs, and at the same time retain good-quality therapists on our staff.”

In November 2001, Grasley instigated a system of therapist-driven protocols in the respiratory department, and a tiered system of employment is under development. The hospital hopes the latter will allow RTs to progress in their careers while remaining committed to Marion Hospital, while the former has already proven to be a great success in patient outcomes, length of stay, and staff efficiency.

Lorelei Heineman, RT, director of the in-patient and outpatient respiratory therapy departments, says the protocol system “allows us to do whatever we feel is necessary for the patients.

“About 3 years ago, we merged a medical center and the original hospital facility, which meant merging two respiratory therapy departments as well,” says Heineman, who is also director of the intensive care unit, the sleep disorders center, and the infusion clinic. “One of those departments was very traditional and decentralized, and the other was very centralized and protocol-based, so we had to make those two types of departments work as one.”

The shift to an entirely protocol-based system involved using the latest standard guidelines set by key medical associations to standardize care for each type of respiratory or pulmonary problem that comes in the door.

“Research into treatment protocols is ongoing, and specifically nothing has changed within the past few years,” Grasley says. “The standard of care has been pretty consistent. While we can adapt our pathways when research comes out, we haven’t had to do that.”

Treatment protocols are in place within the emergency department for COPD, trauma, and cardiac alerts, as well as within the inpatient areas of the hospital. Those cases seen on an outpatient basis are not exempt from the high standards of care either.

“If we follow the asthma protocol in the emergency department in our main facility, and discharge the patient to the medical center, we automatically set up an appointment for them as an outpatient with pulmonary rehabilitation,” says Eric Alexander, RRT, CPFT, EMTB, and lead therapist.

 Travis Grasley, BBA, RRT, Lorelei Heineman, MS, RRT, CPFT, BJ Vest, CRT, Mary Anderson, CRT, and Eric Alexander, RRT, CPFT

Coordinator Kathy Gruber, RRT, who is also a polysomnography technician, notes that protocols are used within the sleep laboratory, primarily in titration for CPAP and bilevel therapy.

In every case, RTs assess the patient and consult specific guidelines to come up with a mode and frequency of therapy that assures each patient gets top-notch treatment.

“We see the patient every day, 24 hours a day, and although the physician isn’t always there, we can catch changes in patients’ conditions and head anything off immediately,” Grasley says. “We aren’t constantly calling physicians because we can follow the set pathways.”

That freedom has been a hit with the therapists, who are happy to manage care without waiting for a physician to tell them what to do, and who are pleased that they are viewed as highly skilled professionals.

“My favorite thing here is our ventilator protocols,” Alexander says. “We intubate patients on the floor, at the setting we think is necessary, and we also extubate and wean them when necessary. We know that we can do it and we have a good rapport with the physicians because they know our abilities as well. Our staff is well trained so we can keep that respect.”

“Now the physicians at Marion see our education and what we can offer, and they trust us more with assessing their patients,” Grasley says.

“It is working out wonderfully also because we are not bothering the doctors, and they trust our decisions,” says Mary Anderson, CRT. “We have a lot of freedom to write our own orders as well as a good rapport with doctors. I have heard a lot of positive responses from patients as well.”

That trust is solidified by the impressive outcomes already coming out of the treatment protocols. While the disparities in treatment planning at other facilities lead to varying results and lengths of stay, such is not the case with protocols in place. Grasley says the hospital’s volume of procedures went from 12,418 in January 2001 to 8,809 in December of that same year. “By using the protocols, we were able to knock out some unnecessary or redundant treatments,” he says. “That in turn gives us time to focus on those patients who are more in need, and to give them the level of care they require.”

Before the department implemented its ventilator management protocol in 2001, the average length of stay for ventilator patients was 6.89 days. According to Grasley, that dropped to 1.38 days in 2002, once the protocols were in place. Similarly, the average length of stay for COPD was 4.32 days in 2001 and in 2002 it was 3.93 days; and the average length of stay for pneumonia was 4.73 days in 2001, 4.67 days after the protocols were in place. “That is not a dramatic drop, but in a year, it’s significant,” Grasley says.

Marion had only one case of ventilator-associated pneumonia among such patients from 2001 to 2003. “Pneumonia used to occur in 10% of our ventilator patients,” Gruber says. “It has been proven that our therapist-driven protocols get patients off the ventilators more quickly.”

The protocols also have shown success in terms of RT productivity, and Grasley notes a 40% improvement in the efficiency of the department from 2001 to 2002. Such success occurs even in face of technology that “isn’t the newest,” according to Alexander.

“ We are replacing our ventilators in a few years with a whole new fleet,” he says. “We do have Heliox available, and nocturnal pulse oximetry, but it is all pretty standard equipment .”

Employee Structure
Without the lure of the latest and greatest equipment, Marion’s respiratory department sought other ways to keep its staff of 27 full-time, part-time, and contingent RTs interested. The answer is a tier system, which is designed to give staff members more growth opportunities. The system is modeled on one at the Cleveland Clinic, though it was adapted to fit Marion’s facility and medical culture.

“It is a tight job market, and everyone is pressing for RTs,” Grasley says. “RTs tend to get good offers and jump around. We were concerned that our staff members be able to grow within their profession.”

The tiers are structured to offer more responsibility as well as more employee satisfaction, and provide therapists with a way to climb within the department.

“Some people want to do more, such as insert arterial lines or become more involved with neonatal care, and the tiers are there to offer them that chance,” Alexander says. “Some therapists don’t want to be stuck in one position year after year.”

“The opportunities that the tier system provides to therapists are huge in Ohio, because there is only one other hospital that offers it in the state,” Heineman says. “In return, we hope to retain good-quality therapists on staff.”

The Future for RTs
Planning for the future goes beyond Marion; a statewide group of respiratory care managers meets bimonthly to discuss how to promote the profession within the state. “We are also working with the licensure board to build our professional practice and attract more students,” Gruber says. “And locally, we have begun some very preliminary discussions with technical schools.

“There is a waiting list for nursing students, so it makes sense to offer them an allied health professional program as an alternative,” Gruber says. “We don’t want to lose people in the health care field.”

Building the kind of culture that can meet the high demands for health care services and still appeal to respiratory therapists is something that Grasley says should be on the agenda of every facility with a stake in the field.

“I think the entire respiratory therapy practice will evolve more into that standard of patient assessment, and RTs will be able to delegate more responsibilities along the lines of set protocols,” Grasley says. “We are starting to get a head start on that at Marion, and hopefully, we can be a model in the future for other departments.”

“At the same time, by elevating our practice here at Marion, we can attract higher professional level therapists,” Gruber says. “Ultimately, we want to become an employer of choice. Marion is on its way to becoming a magnate hospital for nursing, and there is no reason we shouldn’t make that crossover into respiratory therapy as well.”

Elizabeth Finch is a contributing writer for RT.

1. New leads for lung-disease prevention offered in NIOSH study that charts areas of high prevalence. Available at: lungdisprev.html. Accessed April 30, 2003.