At Springhill Medical Center’s Respiratory Therapy Department, patient satisfaction comes first.

 Joe Woulard, RRT, RPFT, at Springhill Medical Center.

They do things differently at Springhill Medical Center. At least they do in the Respiratory Therapy Department, according to department director Joe Woulard, RRT, RPFT, who has been at the Mobile, Ala-based facility for 22 years.

By most accounts, Springhill is similar to many fast-growing medical facilities. The 252-bed medical-surgical health care facility has experienced steady growth since it opened in 1975, most recently opening a five-story cardiac center in October 2001. The campus includes three medical practice office buildings, an auditorium, nursing facility, and athletic club, and preparations are under way for construction of a new orthopedic outpatient surgery center in the fall of 2003.

This facility caters to a community of 300,000, serves a range of patients from all types of insurance, and competes with two other larger community hospitals as well as a large university medical system in meeting the local population’s needs. While its offerings are comparable to many systems, Woulard says the way the respiratory department operates makes the difference.

“We do things here that are not usually undertaken by departments in facilities of our size, and most of those hinge on our therapist-driven protocols (TDP), which were installed about 8 years ago,” Woulard says.

The system replaced care that was “task-oriented” with care that is “patient-oriented,” according to Woulard. Since adopting this approach, Woulard has found that the best solutions to quality and utilization issues involve therapists’ clinical decision-making.

“The TDP delivery model empowers respiratory therapists to do this routinely,” he says. “My job becomes easier, which includes keeping the protocols up to date with current best practice guidelines and keeping staff up to date in their clinical skills. We are strong believers that this system is the best way for us to make sure that care is appropriate, cost-effective, and individualized.”

A Growing Facility
Prior to the advent of diagnosis-related groups and Medicare reimbursement, the primary focus at Springhill had been to grow by adding services and increasing revenue. After managed care became popular, the staff was faced with making sure that what they were doing was necessary, beneficial to the patient, and cost-effective. The best way to ensure that, Woulard reasons, was to take a hard look at best practices, and so he attended a 1-day program in New Orleans led by Judy Tietsort, RN, RRT, FAARC, who started the first TDPs in the country in Lutheran Hospital in Colorado.

“I heard her rationale and learned how Lutheran Hospital developed their TDP program, and that sounded like the best path for us to undertake to empower the respiratory therapists with more decision-making capabilities,” he says. “We wanted to make sure we were delivering the right care at the right time.”

For instance, Woulard describes a common situation of a patient admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD), and showing symptoms of nocturnal dyspnea, wheezing, and airway clearance problems.

“In some cases, after the patient begins responding to therapy, the dyspnea will no longer keep him up at night,” he says. “However, the original physician’s order is often for treatment to continue for the duration of the patient’s stay. What we have seen is that as patients progress, we can safely diminish the frequency of their therapy, and, therefore, not wake them if they don’t require treatment.”

 Michelle Richard, RRT, clinical coordinator, reviews a patient’s diagnostic and physical assessment chart.

TDPs also are helpful in cases of perioperative respiratory care as well, particularly in patients who are not responding to the therapy and who are developing atelectasis. “Today we had a patient on incentive spirometry after cardiac surgery,” Woulard says. “The patient’s atelectasis was worsening, so we started expiratory positive airway pressure therapy, which helps recruit collapsed alveoli and solves the problem. This way, the therapists can institute another therapy as outlined in their protocol.”

Though Springhill has saved money over time with the TDPs, that was not the prime reason for developing them. “In fact, if we wanted cost savings, we could embark on other projects, but this is a quality issue. We want to maintain that quality while keeping costs appropriate,” he says. “The big thing that TDPs did was correct a practice problem, as far as I am concerned. Prior to this, we were very task-oriented. When the therapists came to work, it was not ‘who am I taking care of?’, but ‘how many aerosol procedures do I have?’ That’s not the case. We talk about a patient’s condition and our assessment is better because it has become part of the job routine.”

Patient Care
That, in turn, has an impact on overall patient care at Springhill. If patients are not responding to the respiratory therapists’ protocols, the physician is informed, and a pulmonary consultation may be in order. The whole idea is to look at the patients, not just at what task is ordered for RCPs to complete, Woulard says. He adds, “We could not have been successful without the support of our physician staff, especially our pulmonologists.” The department works closely with Randy Dotson, MD, and William Schulte, MD, both of Pulmonology Associates P.C.

The TDPs within the respiratory department apply to the full range of interventions, including aerosol drug administration, oxygen therapy, ventilator management, intubation, secretion management, bronchial hygiene, hyperinflation therapy, and postoperative ventilator weaning and medical intensive care unit (MICU) ventilator weaning. In the case of the latter, Woulard and Michelle Richard, RRT, clinical coordinator, are at work implementing new protocols.

“Most every hospital has postoperative ventilator weaning orders,” Woulard says. “But more and more, we are developing management and weaning protocols for the MICU, and we are in the process of setting up a committee to look at best practices for that area. In doing so, we are referring to a supplement by Neil R. MacIntyre, MD, on weaning patients from mechanical ventilatory support.”1

 Michael Doyle, RRT, and Marcy Anderton, RRT, prepare a patient for a diagnostic bronchoscopy procedure.

Working together in such a way has always been the approach at Springhill, though Woulard says that, as the facility grows, the departments are becoming more centralized. “When we were a small hospital, we wore a lot of hats,” says Woulard, whose department has 29 full-time respiratory therapy and cardiopulmonary diagnostics personnel, including assistant director James Botts, RRT. “Anything that would come up we’d offer to do. Well, as we have grown, the hospital has provided more services with higher volume so it has become necessary to centralize. The transition has been that, as we got bigger, there has been more concentration on providing care for pulmonary patients.”

Respiratory therapists are still called on to work in all areas of the facility, and most are cross-trained in diagnostics as well as therapeutic procedures; however, there have been some recent changes. Echocardiography used to be provided in the respiratory department, but when the new cardiology center was built in 2001, that equipment was moved with the noninvasive cardiology department. Likewise, the hyperbaric chamber previously located in the respiratory department was transferred to the wound management center in order to be used more often for chronic wound care.

Today, the respiratory therapy department offers 24-hour-a-day, 7-day-a-week service. Outpatient diagnostic services are routinely offered on weekdays, and RTs are on call to perform those procedures after hours as needed. The Department of Respiratory Therapy also serves as a clinical teaching site for students from the School of Cardiopulmonary Sciences at the University of South Alabama. Respiratory therapists have a hand in discharge planning, which may include looking at whether patients need smoking cessation referrals, or whether they are candidates for pulmonary rehabilitation.

“We cannot do those things without a physician’s order, but we can communicate with them and talk about the benefits,” Woulard says. “And if home care is ordered, we begin the teaching process on that before they leave the hospital.” For example, if patients need to use a nebulizer, the therapists’ responsibility is to give them a smooth transition from the hospital to their home, when the home care company can step in. If a patient going home is ventilator-dependent, therapists coordinate with the company and provide the equipment and monthly assessment.

“We begin teaching patients and their families how to provide care at home,” Woulard says. “In the case of asthmatics, we start very early in their treatment, discuss how to take medications, stress the importance of preventative measures on a regular basis, and enhance their ability to judge whether they feel bad.

“We offer educational sessions for patients with COPD or asthma that the physician can order, and these are provided over several days but are not designed to take the place of a true pulmonary rehabilitation program,” he continues. “We do, however, want to start them on that road while they are inpatients. And we will provide instructions for any treatment modality we provide that the physician may want them to continue. That is part of discharge planning.”

The department is able to serve patients in such a comprehensive, thoughtful way because it also benefits from excellent staff relationships. While he has not done an employee satisfaction survey in a number of years, Woulard notes that the staff’s longevity speaks for itself. More than half of the respiratory staff has been at the hospital for 10 years or more, with the median stay being 8 years. “We have a good working relationship,” Woulard says. “I try to treat them as professionals and let them make decisions. I am here to support them and provide resources for them.”

New Technology
Those resources include new technologies, and Woulard is responsible for some acquisitions with input from staff members, physicians, and other departments within the facilities. Acquisitions are evaluated on their ability to improve patient care and meet the strategic goals set by the facility. In the past 5 years, the hospital has invested approximately $4 million in new information systems, including a new billing, clinical documentation system, scheduling, archiving, and an email communications program.

The Respiratory Therapy Department utilizes all of these systems and shares the laboratory information systems for blood gas analyses. This summer, the department will broaden its information system capabilities with the addition of a ventilator documentation interface. Most recently, the department acquired new-generation ventilators to meet the demand of the hospital’s expanding heart program, and Woulard is in the process of evaluating new point-of-care blood gas analyzer systems.

“My basic philosophy in directing the services of the Respiratory Therapy Department is to start with a vision, choose the right things to do, choose the right way to do them, and select the right people to carry them out,” Woulard says. “For us, the vision has always been to make a difference in the lives of our patients, their families, and our coworkers. We do this by making sure that the care we provide is proven, reliable, efficient, and individualized to meet patients’ physical and emotional needs. Helping patients’ healing processes and making their journey to wellness as good as it can be is the reward.”

Springhill constantly monitors how patients feel about their care in the hospital by utilizing patient satisfaction surveys, which are mailed to all inpatients on an ongoing basis. “We have a general hospital survey, but the Respiratory Therapy Department follows its own informal surveys,” Woulard says. “We go around and ask patients what they do and don’t like.

“At Springhill, patient satisfaction is recognized as the key to success, competitively speaking,” he continues. “No matter what our technical capabilities are, if patients are not satisfied with their care, they won’t come back, they won’t tell their relatives to come here, and we will not be successful.”

Liz Finch is a contributing writer for RT Magazine.

1. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. A Collective Task Force Facilitated by the American College of Chest Physicians, the American Association for Respiratory Care, and the American College of Critical Care Medicine. Available at: vol120/6_suppl/. Accessed on July 24, 2002.