At Vanderbilt University Medical Center, skilled RTs and their department’s state-of-the-art ventilators have helped turn many life-saving measures into regular events.

 Vanderbilt University Medical Center, Nashville, Tenn.

One image that stands out in Don Adair’s mind is of a tiny hand reaching out of an abdominal incision to clutch the finger of the physician performing fetal surgery. Adair is director of the Department of Respiratory Care at Vanderbilt University Medical Center (VUMC) in Nashville, Tenn, which last year made the honor roll in US News & World Report’s 2002 edition of “America’s Best Hospitals.” Vanderbilt’s respiratory care program was among the services that brought it to the magazine’s attention. The department’s state-of-the-art ventilators and skilled respiratory therapists have helped make its fetal and neonatal surgery into regular, if not routine, occurrences.

The department also has played a vital role in research conducted by the hospital’s renowned pulmonary specialists, including a large clinical trial of mechanical ventilator use for intensive care patients with acute respiratory distress syndrome (ARDS), funded by the National Institutes of Health (NIH).

Anna Ambrose, manager of the Vanderbilt University Hospital’s Department of Respiratory Care, credits the hospital’s Department of Pulmonary Medicine, with which the RTs work closely, for some of the glory that has reflected onto her department. The important aspect about the ARDS clinical trial in terms of respiratory care, Ambrose says, is that the entire study was based on two protocols that the bedside RTs managed completely. “It was the therapist who drove the whole protocol.”

Vanderbilt’s respiratory therapists, as do RTs in other hospitals, take care of respiratory care needs all over the hospital, but about 75% of their work is in intensive care, Ambrose says. Their patients run the gamut from premature infants to adult burn patients. The RTs work in all the ICUs and in the pediatric outpatient clinic, conducting pulmonary function tests, pediatric bronchoscopy, and, recently, sweat chloride testing on cystic fibrosis patients. The trauma and surgical ICU patients probably account for the highest volume of patients.

Adair supervises a staff of about 110 and oversees a budget of about $65 million. Cheryl Burney-Jones manages respiratory care for Vanderbilt’s Children’s Hospital, which currently is located on the fourth, fifth, and sixth floors of the Vanderbilt University Hospital. It soon will move to the new Monroe Carell, Jr, Children’s Hospital, a 206-bed facility scheduled to open in December on the VUMC campus. The Vanderbilt University Hospital, part of the 127-year-old medical center, has 658 licensed beds.

Known as a top biomedical research facility, VUMC’s School of Medicine consistently ranks in the top 25 of 129 medical schools receiving NIH funding. It has two Nobel laureates to its credit and has made a name for itself for its level IV neonatal intensive care (NICU) unit, the first program of its kind in the country when it opened in 1961.

Capital Investment Rises
The department’s investment in personnel and new buildings is paralleled by its outlay in new ventilators and record-keeping technology. In the past year, the department has purchased 31 new ventilators at a cost of about $1 million, Adair says. Spurring this capital expenditure was the availability of new and better technology, including some very versatile models that “will ventilate a person from cradle to grave,” Burney-Jones says.

In addition to the new ventilators’ built-in, color graphics and their ability to be used on a wide range of patients, they also are transportable. Another ventilator used in the NICU has features that allow the RTs to measure accurately the tidal volume being delivered to tiny premature infants.

In all, the hospital has six different types of mechanical ventilators, compared to many medical centers that use only one. VUMC employs two full-time people just to train RT staff to use the machines. The primary reason for the diverse number and types of ventilators, Ambrose says, is because of the large variety of patients and the severity of their illnesses or injuries.

“We are the referral hospital for newborns, trauma cases, and surgical intensive care problems,” she says. “Patients are transferred here from all over the state.”

 (Left to right) Cheryl Burney-Jones, Don Adair, and Anna Ambrose.

The department has updated its patient documentation technology using a respiratory care information management system that also charts and bills. Adair offers an example of how the system might work for an asthma patient. The RT receives an order via wireless laptop from the doctor for some kind of bronchial dilator to relieve the patient’s wheezing. He or she then goes to the patient, makes an assessment, and starts treatment. The therapist pulls up a template on the computer that asks questions on breath sounds, sputum production, heart rate, and medication, among others. Once the final question is answered, the system triggers a bill, which goes to one file, while the documentation is dispatched electronically to another.

“This system has made us very efficient,” Adair says. “In the old days, we had to find the patient’s chart and write out what we did, then take pieces of paper and make charges to bill the patient. All that has changed now.”

Although the documentation system is expensive—Ambrose estimates its cost at about $500,000—she says it paid for itself within just a few months by recouping lost charges. “It’s a very smart investment.”

The department purchases its ventilation equipment and computerized documentation systems, but it leases blood gas and electrolyte analyzers on a monthly basis. “They generally go out of date, and newer and better technology comes along quicker than the life span of the equipment,” Ambrose explains.

A Few Years’ Difference
Over the past 10 to 20 years, Adair, Ambrose, and Burney-Jones have seen major changes in how RTs care for patients at Vanderbilt. In the neonatal respiratory care area, for example, the RT now has a much more hands-on role in patient care and high-risk deliveries than previously, Burney-Jones says. In addition to transporting the neonates to the hospital’s intensive care nursery, RTs take part in extra corporal oxygenation membrane (ECMO) heart-surgery bypass procedures for premature babies as young as 27 weeks, in which the blood is oxygenated outside the body, allowing the lungs to mature sufficiently to take over the job. “We actually have RTs who help run the machines, along with the nurses,” Burney-Jones says.

In general, protocols these days allow RTs more autonomy in terms of care. Ten years ago, a patient might stay hooked up to a mechanical ventilator until the doctor ordered removal. “Now, while the doctor’s in the operating room for 8 hours, we make a lot of changes, and when he comes out, the patient may be ready to come off the ventilator,” Adair says. “We use our independent judgment. It’s just a change in the whole environment of respiratory care.” She adds that such changes are driven not only by technology and medical advances, but also by financial considerations. “The idea is to get patients off the ventilator, because there is less risk of infection, and to get them out of the ICU, because sometimes we get only a [fixed reimbursement].”

Because Vanderbilt is a leading research institution and treatment facility for a pediatric-age population, the Children’s Hospital is often in demand for testing new equipment or procedures for infants or children, Burney-Jones says. One ongoing test is the use of nitric oxide to treat pulmonary hypertension. Approved by the FDA for use in term or near-term babies, it is also being tested in adult transplant and cardiovascular patients, Adair says.

Another change, Burney-Jones says, is that many more tests are being run using smaller amounts of blood and completed at the point of care rather than sent to a satellite laboratory. “We have the ability to run other blood parameters, such as electrolytes, metabolites, things that in the past only the main lab in the hospital would run. That makes it more efficient.”

From a single, small blood sample, almost a dozen laboratory results can be derived, according to Ambrose. The department runs four different blood-gas and electrolyte laboratories in the pediatric ICU, the adult trauma unit, the adult surgical unit, and the neonatal ICU. So these days, an RT’s job duties include not only respiratory care procedures but laboratory work as well, Ambrose says. The ability to do these tests at the patient’s bedside makes the RT a “frontline person,” Burney-Jones adds.

“When our patient is deteriorating and we can get a blood sample, we run it in our machine and can actually recommend treatment for this patient to the physician within a matter of minutes,” she says. In the past, the process was much more complex and time-consuming. Blood samples would be sent to the hospital laboratory and analyzed at a different site; their results would then be communicated to the physician, who would contact the RT, who would make necessary ventilator changes.

Family-centered Hospital
In the works for about 5 years, the new, freestanding Children’s Hospital has been purposely developed with the families of its young patients in mind. An advisory committee composed of families participated in making decisions about everything from the size of the rooms to the color of the carpeting. Families, some traveling from as far as 2 hours away, will be able to stay at the hospital in dorm-like rooms with beds, lockers, and showers. This will be the new location where some of the hospital’s most delicate surgeries take place, including the one on fetuses with spina bifida.

“It’s not something we do every day,” says Burney-Jones. “We’re called down [to surgery] in case the baby is born and we have to put it on a ventilator. But it’s definitely something we’re proud of because of the often-successful outcomes.”

Ruth Stroud is a contributing writer for RT.