Parkview Hospital attains success through cost-efficiency and centralization of its respiratory department.

J0D00414.jpg (12332 bytes)In health care, being on the cutting edge of trends is not always a good thing. Take respiratory care departments. During the past decade, many respiratory care administrators completely overhauled their departments through decentralization in response to perceived pressure from managed care companies. Others placed a strong focus on patient-focused care. More conservative institutions, however, such as Parkview Hospital in Fort Wayne, Ind., chose to keep their respiratory departments centralized while expanding their scope of services. This may have been the best move yet. At least that is the opinion of Robert Chase, RRT, director of cardiopulmonary services.

“With continuing pressure to do more with less, there are a lot of trends and fads that come and go,” Chase says. “We’ve been fortunate to have the luxury of assessing how other hospitals have performed after making these changes—what we’ve found is that a lot of these trends did not turn out to be the panacea for improving respiratory care departments.”

Parkview Hospital is one of four hospitals in the Fort Wayne-based Parkview Health System. The other three are smaller community hospitals located in surrounding counties. As a regional referral center, Parkview Hospital treats patients from a 14-county region and some come from Ohio.

A Traditional Department
With approximately 60 full-time equivalents (FTEs), Parkview Hospital has the largest respiratory staff among all hospitals in the Fort Wayne area. It is a 503-bed charitable, nonprofit, community-owned acute care hospital. As one of the largest hospitals in western Indiana, Parkview has an intensive care unit (ICU), coronary care unit, pediatric ICU, and a level II nursery. Parkview Hospital provides state-of-the-art cardiac care and open-heart surgery, and participates in national heart research through its Stucky Research Center.

At Parkview, respiratory care is provided under the umbrella of cardiopulmonary services. The other portion of cardiopulmonary services is diagnostics, which includes electrocardiography (ECG), electroencephalography (EEG), pulmonary function testing, and the new sleep laboratory—scheduled to open by late spring. The department has one clinical manager, who oversees respiratory services provided in the newborn ICU, the pediatric ICU, and the children’s specialty clinic, and another clinical manager who oversees diagnostics (pulmonary function laboratory, ECG, EEG, sleep laboratory) and respiratory services in the emergency department, adult ICU, and coronary care unit. Both managers have about 50 employees reporting to them. Although there are no shift supervisors, the department has about 20 employees that rotate the shift leader duties.

J0D00413.jpg (11232 bytes)From left to right: Shelley Herber, RRT, Robert Chase, RRT, Dan Easley, RRT, and Ted Auguiano, RRT, discussing staffing issues.

Respiratory staff is assigned to various units based on work needs. The department’s computerized charting and order/entry system provides real-time information so that at the beginning of each shift, employees can be allocated to those areas that have the greatest workload. “The majority of our staff are generalists, and they rotate throughout the hospital based on need,” Chase says. “The only exceptions are our specialists who are permanently assigned to certain areas,” he adds. The specialists are nonmanagerial staff who provide clinical resources and expertise in a specific area. All of the specialists are registered respiratory therapists and have, depending on their area, extra credentials or certifications, such as ACLS, PALS or intubations.

The respiratory specialists include three neonatal professionals who work primarily in the newborn ICU and pediatric ICU; one children’s clinic specialist; one adult ICU specialist; one technical specialist who oversees equipment, and supplies and provides clinical backup; and one pulmonary function testing specialist who coordinates laboratory activities.

Therapist Involvement
Although Parkview has not been quick to follow any one particular trend, it did recognize the power of protocols about 10 years ago. In 1993, it teamed up with two other hospitals in town to develop its first therapist-driven protocols. The team used clinical practice guidelines and studied protocols from well-known institutions such as the Cleveland Clinic and Kettering Medical Center in Dayton, Ohio, in implementing their own protocols. “In our community, physicians have privileges at more than one hospital, so each of the hospitals wanted to make a consistent set of user-friendly protocols that the physicians would be comfortable with,” Chase says.

Parkview’s first protocol was linked to its Evaluate and Treat Program. Under this protocol, the respiratory therapist examines every adult patient with a respiratory order each day to determine what therapy is needed, how frequently it needs to be administered, and what adjustments need to be made.

Chase points out that one of the reasons the protocol has been successful is that it was incorporated into some of the early clinical pathways, such as the pneumonia and cardiovascular pathways. This gave early exposure to the protocol and physicians began to realize that it created efficiencies within the program. Last April, Parkview’s executive medical staff committee approved the implementation of the Evaluate and Treat protocol housewide.

“Most physicians at our hospital support protocols,” Chase says. “In the early years, it was just an issue of getting them to help design and buy into the development of protocols, but now most doctors can see how they have helped improve health care delivery.”

J0D00412.jpg (10744 bytes)Laura Baxter, RRT, assists a patient with an aerosol treatment.

Parkview also has a treatment protocol in place for patients in the newborn ICU and a new protocol was recently approved for implementation in the pediatric ICU. This new protocol is designed so that if a physician orders aerosol therapy for a patient, the respiratory therapist will evaluate the patient periodically and make changes if necessary. For the past 2 years, Parkview has also been using an asthma pathway in its emergency department. “This pathway has brought more consistency in how we treat asthma patients, and specifically how we make decisions concerning making an admission or discharge,” Chase says. “Not only does the pathway provide objective measurements and keeps the treatment plan flowing, it helps us refer asthma patients to our education program.” A weaning protocol has also been used for about a year for adult critical care patients.

A Change in Mind-set
According to Chase, the implementation of protocols has been a major reason the respiratory therapy profession has experienced a transformation during the past decade. Therapists are hired at Parkview for their critical thinking and assessment skills, not to mention their self-motivation. “When I started in respiratory care over 20 years ago, the physician would write the order and I would follow his directions,” Chase says. “You had your opinions, but for the most part you were task-oriented so you didn’t question most orders,” he adds. Today’s respiratory therapist, however, has taken on an expanding role and has become more of a physician extender.

Prudy Moore, RRT, senior respiratory therapist and a 17-year veteran of Parkview, can attest to the changing role. As a charge therapist assigned to different areas within the hospital, Moore works closely with physicians who place a great deal of trust in her decisions regarding respiratory care. “We’re fortunate that Parkview places a strong emphasis on the multidisciplinary team,” she says. “By being a part of this team, respiratory therapists play a vital role in patient care, so if you’re motivated, this is a great environment for therapists.”

Shelley Herber, RRT, education specialist, agrees that Parkview’s current focus on the multidisciplinary team is bringing about many positive changes within the hospital. According to Herber, the Joint Commission on Accreditation of Healthcare Organizations has urged hospitals to develop more multidisciplinary teams that address patient education, primarily because shortened hospital stays have increased the need for strong patient education programs. Last year, a multidisciplinary patient education team at Parkview was developed, composed of representatives from nursing, respiratory therapy, radiography, pharmacy, dietary, and physical rehabilitation (physical therapy, occupational therapy, and speech therapy). “This new committee has enhanced our ability to work together for the good of the patient,” Herber says.

In addition to the high level of teamwork within the organization, Herber stresses that respiratory therapists are attracted to Parkview for the wide array of clinical opportunities that exist within the hospital. With more than 64,000 admissions, Parkview’s regional trauma and emergency center is a stimulating environment for therapists. Staff is currently preparing it to become credentialed as a level II trauma center.

Parkview Hospital also maintains a helicopter dispatch system that transports patients from outlying areas. Included among the helicopter’s team members are respiratory therapists and neonatal nurses. Called Parkview Hospital’s Samaritan Flight Program, the service recently celebrated its 10th anniversary and over the past decade has transported more than 5,800 patients.

J0D00411.jpg (11919 bytes)Robert Chase, RRT, director of cardiopulmonary services.

A new area for Parkview respiratory therapists is the new sleep laboratory. The two-bed laboratory, which will be directed by a physician pulmonary group, will be located on the seventh floor of a renovated wing of the hospital, adjacent to the children’s clinic. Two therapists will be assigned to the sleep lab. “We’re excited about the launch of this new service,” Chase says. “There’s been a strong demand for sleep studies in our community, and we have the resources to turn this into a strong program.” Respiratory therapists also oversee the pulmonary function laboratory, which has one testing station and offers plethysmography and cardiopulmonary exercise tests.

As the scope of services has expanded at Parkview, Chase admits that his department has been fortunate to recruit talented respiratory therapists. Indiana Vocational Technical College in Fort Wayne offers a 2-year respiratory therapy program, which helps in locating new graduates. “Since these students rotate through our hospital, we have a chance to learn about their capabilities,” he says. One noticeable trend, however, has been the gradual decrease in the size of the respiratory class during the past few years, which could indicate a possible therapist shortage in the future.

The changing role of respiratory therapy has also made it difficult at times to attract therapists who have the right clinical background and attitude toward working as an integral member of the multidisciplinary team. “When we were in the early stages of developing protocols and discussing how the responsibilities of therapists would change, I was told by a highly regarded professional in the field of respiratory therapy that it would be easier to get my medical director and physicians to buy into our proposed changes than my respiratory staff,” Chase explains. “Many respiratory therapists were scared 10 years ago about where our profession was going.”

To help convince staff that these changes were necessary, Parkview was quick to address their fears by educating them about the value of this shift in job function. “It didn’t take therapists long to realize that by working differently, they could ultimately improve patient care by making it more efficient and cost-effective,” Chase says.

Staying Equipped
Parkview has an enviable inventory of equipment with 35 adult ventilators, three oscillators, and six infant ventilators. Currently, the department plans to replace many of its ventilators. According to Chase, it is an exciting time to acquire new equipment since so many improvements have been added to ventilators. “Computer-based technology has really changed the way ventilators work and are used,” he says. “Their capabilities are far beyond what people would have envisioned 20 years ago.” Chase notes that one of the most remarkable changes with today’s equipment is its smaller size, despite the fact that it is still able to meet patient demand more completely than older, more bulky ventilators. Although improvements have been made to ventilators, Chase adds that the hefty price tags affixed to some of the more sophisticated equipment make it difficult for many smaller community hospitals to afford them.

Herber, who is responsible for training staff on the new equipment, admits that respiratory therapists can quickly learn how to use the latest state-of-the-art ventilators. “Once they have the foundation for how a ventilator works, they can—with a little practice—begin to feel comfortable with these new models,” Herber says.

Even though Parkview is not a teaching hospital, from time to time therapists have opportunities to become involved in research activities. Established in 1993, Parkview’s Stucky Research Center is a research institute designed to study advanced treatments in the community. Studies are typically sponsored by pharmaceutical companies, which have new drugs in clinical trials, or by national organizations, such as the National Institutes of Health, which are testing new therapies, devices, or treatments.

Managed Care Issues
While managed care companies have forced many hospitals throughout the country to take drastic steps to achieve cost containment, Parkview has been relatively lucky since managed care penetration is still fairly low in Indiana. In addition, the HMO market in Indiana is very fragmented with no single major player. “We aren’t forced to bend in order to meet a plan’s needs,” Chase says. “We have even refused to participate with some plans because we objected to their requirements.”

This does not meant that Indiana hospitals have been immune from the changes taking place in health care. Just as respiratory therapists in different parts of the country have had to adjust their work styles, Parkview therapists have had to work smarter and more efficiently with a constant focus on cost containment.

Despite the challenges facing the health care delivery system, respiratory therapists at Parkview are now readily accepting the changes taking place within their profession. Today’s Parkview therapists are carving out new territory for future graduates in the field of respiratory therapy. As the field continues to evolve, Chase stresses that respiratory schools will have to do a better job of preparing students, particularly with their assessment skills and knowledge of ventilatory equipment. As a stopgap measure, Parkview offers ongoing inservices to ensure adequate training of new therapists.

In an environment that continues to focus on cost containment and cost efficiency, Chase is confident that respiratory therapists will play a larger role in the years ahead. No other health professionals have the type of training that therapists receive on respiratory assessment and equipment, he notes. Furthermore, as protocols prove their value in helping patients get off ventilators and oxygen sooner, the connection between successful implementation of protocols and earlier hospital discharges will become more apparent. “In today’s world where reimbursement is declining, a respiratory therapy department’s ability to ensure faster discharges means the difference between whether the hospital loses or makes money,” Chase says. “Hospital administrators, as well as physicians, have started to recognize that this is just one of many contributions that respiratory therapists make in today’s health care environment.”

Carol Daus is a contributing writer for RT Magazine.