RT speaks with the people who put their respiratory departments into U.S. News and World Report’s top ten U.S. hospitals for 2003.

 One of the most distinguished honors a hospital can earn is to be recognized by US News & World Report in its annual listing of “America’s Best Hospitals.” For the past 13 years, the magazine has rated the nation’s top hospitals based on reputation, mortality rates, and survey data from the American Hospital Association. The hospitals are rated by specialties with respiratory disorders being one of the 17 categories. Respiratory care practitioners working at the top 10 hospitals for respiratory disorders are exposed to clinical cases and research projects that can be found only in world-class teaching institutions. The administrators, physicians, and nursing staffs at these top 10 respiratory hospitals—ranked here in descending order—share a common philosophy: They value respiratory care practitioners as vital decision-makers and contributors to patient care.

National Jewish Center, Denver
National Jewish Center not only has the distinction of being the number-one ranked hospital in the United States for respiratory disorders, it also is the only hospital in the world dedicated exclusively to respiratory, immune and allergic disorders. National Jewish was founded in 1899 as a tuberculosis hospital.

According to George Zeman, RRT, CPFT, director of pulmonary physiology services, respiratory care practitioners are attracted to National Jewish for its research and cutting-edge clinical practices. “We’re doing diagnostic procedures and research that therapists in typical hospitals have never heard about,” says Zeman.

During the past several years, one of the biggest changes at National Jewish has been the shift from being a predominantly inpatient acute care hospital to an outpatient facility. As a result, National Jewish therapists now work only 8- to 10-hour day shifts and there are no evening or weekend shifts.

National Jewish currently has 35 therapists. Of these, 20 are exclusively assigned to diagnostic procedures and 15 are responsible for clinical research areas. Therapists are actively involved in 34 research projects, covering topics such as interstitial lung disease, occupational medicine, nocturnal asthma, and childhood asthma.

Due to its focus on research, National Jewish prefers to hire therapists with a scientific background. “Most of our therapists have bachelor’s degrees and many also have master’s degrees,” says Zeman. “Several are even planning to attend medical school and believe that working in a research facility like National Jewish will benefit them professionally.”

Mayo Clinic, Rochester, Minn
The renowned Mayo Clinic, which includes Saint Marys Hospital and Rochester Methodist Hospital, has 18,000 employees, including more than 1,100 staff physicians and scientists. Saint Marys Hospital, a 1,157-bed facility, offers heart and lung transplants, neurosurgery, and an emergency trauma unit; and the 794-bed Rochester Methodist Hospital provides transplant programs for liver, kidney, pancreas, and bone marrow, among other services.

With 10 intensive care units, a busy pulmonary function laboratory, a research program with three full-time therapists who work exclusively on pulmonary and respiratory care research, and a variety of clinical specialties for therapists, Mayo’s respiratory department offers enormous opportunities for its 70+ respiratory care professionals. Respiratory care services is part of the Department of Anesthesiology with therapists working closely with both anesthesia and pulmonary critical care residents.

According to Curtis Buck, CRNA, RRT, RPFT, director of respiratory care, one of the most important developments in his department was when his predecessor, Bernie Gillis, CRNA, a nurse anesthetist, decided many years ago to concentrate the respiratory care department’s efforts in the ICU. “This was a wonderful tactic because it has helped us to become a vital part of the critical care practice,” says Buck. This expanded role for therapists has been particularly important in recent years since the Mayo Clinic’s acuity level has increased dramatically in the general care areas, causing an additional need for therapists. The Mayo Clinic’s ventilator census has grown steadily and is one of the reasons the department has increased in size. The average number of patients requiring mechanical ventilator support is 50 per day, and this number continues to grow.

Johns Hopkins Hospital, Baltimore
As the third-ranked hospital for respiratory disorders, the prestigious Johns Hopkins Hospital and Health System comprises three acute care hospitals: Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, and Howard County General Hospital. Although they share the same pulmonary faculty, each of the hospital’s respiratory departments is independent and has its own administrative staff.

A major opportunity for therapists at Johns Hopkins is to participate in a variety of ongoing clinical trials. “Our therapists are on the front line when it comes to research,” says Steve Georas, MD, medical director of respiratory care, Johns Hopkins Bayview Medical Center. “Since we’re one of the participating centers for ARDSNET, our therapists are adjusting tidal volumes and plateau pressures well before the studies are published.” Johns Hopkins’ therapists also use cutting-edge modes of respiration such as high-frequency oscillators for adults. “Clinical trials are supporting high-frequency oscillation for adults with acute lung injury, and some therapists have been involved in this for more than a year.” Therapists also are responsible for airway management, and routinely change patients’ tracheostomies.

Georas credits therapist-driven protocols for ventilator weaning, chest physiotherapy, and bronchodilator usage for creating an environment that stresses teamwork and communication. “One of the tangible benefits is that we’re getting patients off vents more quickly,” says Georas.

Educational opportunities attract many therapists to Johns Hopkins. The department coordinates an annual conference; in addition, frequent in-services and an annual skills laboratory are offered to Johns Hopkins’ therapists.

Barnes-Jewish Hospital, St Louis
Comprehensive therapist-driven clinical protocols and strong supportive medical directors over the years are responsible for the expanded roles respiratory therapists play at Barnes-Jewish Hospital in St Louis. With 1,385 licensed beds and 156 ICU beds, Barnes-Jewish is the largest hospital in Missouri and boasts a premier reputation in patient care, medical education, and research.

The department’s 10 protocols cover patient assessment, chest physical therapy, bronchial hygiene, aerosolized medications, oxygen, sputum induction, biphasic pressure ventilation, pulse oximetry, and weaning from a ventilator on the long-term acute care unit. Therapists even have worked with the pulmonary division of Washington University to publish studies on the effectiveness of these protocols. A 2000 study published in Chest (which was supported by a grant from the American Association for Respiratory Care) has made some of the greatest strides in demonstrating the effectiveness of respiratory-driven protocols to physicians and other health care providers.

Darnetta Clinkscale, MBA, RRT, patient care director of respiratory, rehabilitation, and gastrointestinal services, says a “team” concept is used in assigning respiratory staff to specific areas. In general, the respiratory staff, which consists of approximately 110 staff therapists, four supervisors, and five shift coordinators, is assigned to broad clinical service areas—medicine, surgery, neurology, emergency department, cardiothoracic, or long-term acute care. In each of the service areas, the therapist works closely with the multidisciplinary team, which consists of physicians, nurses, physical therapists, occupational therapists, speech therapists, and social workers. “Therapists stay on the assigned unit, their reports are given on the unit, and they attend physician rounds as well,” says Clinkscale.

Therapists also rotate through departments within a service area. This is designed not only to give them variety in their job assignments, but also to enhance continuity of care for the patients and promote a multidisciplinary environment. “The advantage of this type of staffing is that the caregivers on the different floors get to know our therapists more closely,” says Clinkscale.

Massachusetts General Hospital, Boston
Massachusetts General Hospital (MGH) is the third-oldest general hospital in the United States and the largest in New England, with more than 42,000 annual inpatient visits. As the oldest and largest teaching hospital of Harvard Medical School, MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $300 million.

Respiratory therapists at MGH spend the majority of their time treating critically ill patients in the ICU as well as patients who are mechanically ventilated outside of the ICU. “Therapists have an integral role in the decision-making of patient care, and they are active participants during patient rounds,” says Bob Kacmarek, PhD, RRT, director of respiratory care and professor of anesthesiology at Harvard Medical School.

The ICU is divided into three clusters so that similarly trained therapists work in either neonatal/pediatric, surgical, or medical areas. “By having these permanent assignments, the therapists are familiar with the doctors and nurses in those areas,” says Kacmarek. “In each of these areas, designated therapists are involved in quality assurance and the overall discussion of running the unit. While many other respiratory departments have become more centralized, we have found it to be more effective to be decentralized—but at the same time we dedicate staff to different areas.”

Therapists are extensively involved in clinical and laboratory research, and at most times eight to 10 therapists are working on their own research projects. Structured conferences are also held every other week and the coursework is approved for CEUs.

Many of the therapists attracted to MGH have strong scientific backgrounds, and about 60% have baccalaureate or master’s degrees. Given the opportunities that exist for therapists at MGH, staff turnover is usually not a problem. The turnover rate is about 5% and the department is currently fully staffed. “Many of our therapists come to us because of our research programs, and once they get here, they tend to stay,” says Kacmarek.

University of California, San Francisco Medical Center
The sixth best hospital in the United States for respiratory disorders, UCSF Medical Center is recognized throughout the world as a leader in health care, known for innovative medicine, research, and advanced technology. Within UCSF Medical Center is a hospital within a hospital, the UCSF Children’s Hospital.

Respiratory Care Services (RCS) operates under the medical direction of Linda Liu, MD, an anesthesiologist and critical care attending physician. Of the more than 80 employees in RCS, 73 are licensed as respiratory care practitioners and 60 are registered respiratory therapists. “The quality and credibility of our staff and the importance of their role in patient care are well recognized by all disciplines,” explains Julio Barba, RRT, manager of RCS and clinical engineering. “As a result, respiratory care practitioners have been added as permanent team members to four specialty clinics, and our staff is constantly in demand to participate in educational activities for physicians, nurses, and other medical professionals.” UCSF Medical Center is one of the few ARDSNet sites in which the clinical coordinators are respiratory care practitioners.

After staff meet competency requirements in adult, pediatric, and neonatal clinical services, they are assigned to one of these areas; however, they rotate out to other areas as needed and to maintain annual competency. “Not only does this provide much more efficient manpower utilization, it also gives a continuous cross-fertilization of ideas and techniques that benefits both the adult and pediatric services,” says Barba.

Like most of the respiratory departments in top hospitals, RCS has focused protocol development efforts in critical care. Effective ventilator management and weaning protocols have been implemented in all adult critical care units. ARDS patients are managed according to the protocol based on ARDSNet research. “In addition to improving outcomes, reducing the duration of mechanical ventilation, and decreasing length of stay and cost, the protocols have increased the stature of respiratory care practitioners and have increased their job satisfaction,” says Barba.

University Hospital, Denver
The 350-bed University of Colorado Hospital is the Rocky Mountain region’s only tertiary, specialty care, and referral center and is a teaching hospital for the University of Colorado Health Sciences Center.

After a major restructuring 5 years ago, University of Colorado Hospital’s respiratory department merged with nursing. E.J. Amrhein, RN, director of patient services, has a nursing background but serves as director of respiratory care. The department’s 37 therapists are assigned to either the adult or neonatal ICUs. A regular group of therapists is permanently assigned to the neonatal ICU, and the remaining therapists are cross-trained to work in the different adult ICUs.

Many respiratory care practitioners are drawn to the University of Colorado Hospital because it is a major training center for pulmonologists and pulmonary fellows. Edward Abraham, MD, chairman of the division of pulmonary services and critical care, is one of the nation’s leading researchers on ARDS, and a number of therapists work on ventilator studies with him. The department relies heavily on therapist-driven protocols, such as the ARDSNet protocol, weaning protocols, respiratory protocols, and extubation protocols.

“Given the type of research conducted here, we try to hire more scientific-based respiratory therapists,” says Fran Piedalue, RRT, clinical coordinator. “Ideally, we look for therapists with 3 years of critical care experience and the ability to understand the use of different types of ventilators, but it’s not always easy finding these individuals in today’s job market.”

Cleveland Clinic
For the past eight years, US News & World Report has named the Cleveland Clinic the leader in cardiac care in the United States. The 954-bed hospital is also a world-class academic medical center and designated national referral center.

StollerGiven the large surgical volume and prolific research projects at the Cleveland Clinic, the hospital’s 100-plus, full-time respiratory care practitioners have many professional opportunities to enhance their careers. The Cleveland Clinic was also on the forefront of developing therapist-driven protocols that use branched chain logic diagrams in creating respiratory plans. These protocols, developed in the early 1990s, have been used by many hospitals throughout the United States. “Our protocol concept has been an outgrowth of our desire to come up with a better paradigm for developing the practice of respiratory care,” says James Stoller, MD, medical director of respiratory therapy.

In addition to optimizing the care it provides, the department encourages therapists to take a scholarly approach in practicing respiratory care, and the majority attend national meetings and write abstracts. “We attract very high-caliber therapists who enjoy using their assessment skills,” says Stoller.

Therapists are generally assigned permanently to one of the nine ICUs, although they are given the option to move periodically. “We recognize that broad-based experience is important and our staffing bias is to encourage therapists to work in many venues over time,” says Stoller.

Because therapists have demonstrated their scientific background and assessment skills to other departments, the department is frequently invited to participate in new areas within the hospital. For example, when the subacute and heart failure units were opened, medical staff in those areas sought help from respiratory care practitioners. “Unlike many respiratory departments in other hospitals, our group has actually grown over time because, as the scope of services at the Cleveland Clinic has expanded, respiratory therapists continue to be assigned to these new areas.”

University of California, San Diego Medical Center
Respiratory Services at UC, San Diego Medical Center has been recognized nationally during the past decade for its effective utilization of clinical protocols and its respiratory care information system that provides a real-time measurement of workload. The center was implementing therapist-driven protocols in 1993, when many institutions’ respiratory departments had barely heard of the term. “About 95% of our care is provided through protocols, and during the past 10 years this has resulted in a significant reduction in operational cost,” says Rick Ford, RRT, RCP, director of respiratory services.

StollerUC, San Diego Medical Center; inset, Rick Ford, RRT, RCP.

The department values therapists who have strong patient assessment skills and extensive knowledge about technology. Even newly hired staff who demonstrate this background must participate in 3 months of orientation prior to being permanently assigned to their jobs.

Staffing is handled very efficiently at UCSD Medical Center due to its computerized information system, in which staff are deployed to work areas based on need. At midshift, an assessment is made to determine whether staff should be redeployed. “This automated tool sets us apart from other institutions because we are able to manage workload distribution in real time, can ensure that staff have enough time to accomplish tasks, and can assign staff to areas where they’re needed the most,” says Ford.

The department also places a high priority on staff education. Funding, ranging from $10,000 to $12,000 a year, is available for every therapist seeking additional training. Respiratory Care Services still has a full-time educator and educational in-services are offered every week for CEUs. “The payoff for offering such educational and professional opportunities is that the turnover among full-time staff is only 2%,” says Ford.

University of Michigan Health System, Ann Arbor, Mich
With more than 75 respiratory therapists working in the adult and pediatric ICUs of University of Michigan Health System (UMHS), Respiratory Care Services is a bustling place. Many of the respiratory care practitioners have more than 20 years of experience working at UMHS, including Ken Bandy, RRT, director of the department. “The working environment for respiratory therapists is very good because they get regular exposure to all levels of critical care,” Bandy says. Therapists are primarily assigned to core ICUs; however, they do float to other areas depending on patient census.

StollerUniversity of Michigan Health System.

“One of the reasons we have done so well in both providing excellent care and retaining the best therapists is that we have always had incredibly strong medical directors supporting our department,” explains Bandy. “Many physicians who are primary investigators on research projects seek us out for our co-participation.” With such a strong focus on research, Bandy notes that he has a number of therapists who are highly skilled in research and statistics. “In many instances, after partnering with physicians or nurses on a particular research project, our therapists will become involved in offshoots of these projects.”

Bandy credits his hospital’s use of protocols for maximizing the skills of the respiratory therapists. This not only has made the therapist an integrated member of the care team, it also has given them an ownership stake in the care of the patient. He stresses that even though many hospitals have protocols, the medical staff and other professionals do not always support them. “The physicians and nurses have to have confidence in the respiratory therapist’s decision,” he says. “The successful implementation of protocols says a lot about the medical staff and nursing staff of a hospital.” Given the success of therapist-driven protocols at UMHS, it is clear that physicians and other caregivers respect the role of the respiratory care practitioner.

Carol Daus is a contributing writer for RT.