The Mayo Clinic gives RTs the opportunity to implement their skills through research and managing a multitude of cases.

photoThe prestigious Mayo Clinic may be headquartered in the small town of Rochester, Minn, but nothing about the 1,800-bed hospital is small. Mayo Clinic, Saint Mary’s Hospital, and Rochester Methodist Hospital together form what most Americans refer to as the renowned Mayo Clinic. The institution is more like a city in itself with approximately 18,000 employees, including more than 1,100 staff physicians and scientists. People come from all over the world to be treated by the Mayo Clinic’s team of specialists. Many celebrities and public figures—the most recent one being the Reverend Billy Graham—have been known to seek care here in what is considered one of the best-known private health care organizations in the world.

As one would imagine, there is also nothing small about the Mayo Clinic’s Respiratory Care Service. With 120 registered respiratory therapists assigned to 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, the respiratory department at the Mayo Clinic offers enormous opportunities for respiratory care professionals.

photoCurtis Buck, CRNA, RRT, director of respiratory care.

“At times it’s hard to convince some young, dynamic therapists to consider taking a job in a small town in the upper Midwest,” notes Curtis Buck, CRNA, RRT, director of respiratory care, “but if we get them to come here for an interview, they almost always take the job.”

One of the major reasons therapists are attracted to the Mayo Clinic is the wide range of professional opportunities that can be available only in an institution the world looks to as a leader in health care delivery and medical research. The Mayo Clinic’s Rochester campus consists of two acute care hospitals located about a mile apart: Saint Mary’s, which is made up of six buildings containing 1,157 licensed beds and offers heart and lung transplant, neurosurgery, and an emergency trauma unit; and Rochester Methodist Hospital, a 794-bed facility that offers transplant programs for the liver, kidney, pancreas, and bone marrow, among other services.

According to Buck, one of the most important developments in his department was when his predecessor, Bernie Gilles, CRNA, RRT, a nurse anesthetist and therapist, decided many years ago to concentrate the respiratory care department’s efforts in the intensive care unit. “This was a wonderful tactic because it has helped us to become a vital part of the critical care practice,” Buck says. 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. “Nursing management has even requested to administration that additional therapists be hired to help treat patients,” Buck says.

Internal Structure
The Respiratory Care Service at the Mayo Clinic is part of the Department of Anesthesiology with therapists working closely with both anesthesia and pulmonary critical care consultants and residents. Therapists also work closely with critical care fellows taking advanced medical training in that area. Four respiratory care supervisors provide management in different areas of the hospital and a lead therapist is on duty every shift, 24 hours a day, to make adjustments to staffing as needed.

photoRobyn Rozek, RRT, is monitoring cardiac output measurements in the medical ICU.

An additional supervisor oversees 11 CRTs and 22 assistants, who deliver and maintain equipment and make daily equipment rounds in the intensive care units and general care areas. “We make every effort to keep registered therapists at the bedside rather than making them locate equipment,” Buck says. As the CRTs retire, they will not be replaced but instead assistants will carry out their responsibilities.

The remaining four supervisors oversee therapists stationed in the two hospitals’ 10 intensive care units. The units include: neurology/neurosurgery, thoracic/vascular surgery, medical, trauma/general surgery, cardiovascular surgery, cardiovascular/transplant, coronary care unit, pediatrics, neonatal, and general/transplant. The Mayo Clinic’s ventilator census has grown steadily over the years and is one of the reasons the department has grown in size. Although the average number of patients requiring mechanical ventilatory support is 45 per day, this figure continues to grow. In 1998, the daily ventilator census was 36 and last February it was 48 and it has now surpassed that figure. “On our busiest day in 1998, we had 61 ventilators running and now we go a week at a time without dropping below 60, so we’re seeing huge growth in critical care,” Buck explains. The growth has been so strong that each time Buck has been given approval to add more staff on the general floors, these positions end up being consumed in the intensive care units. As this trend continues, Mayo’s therapists are finding they are not needed to do routine treatments in general care wards as much as being needed as consultants who provide in-services and advise in difficult cases. “Most therapists who choose to work here appreciate these professional opportunities,” Buck says.

Physician Support
Physicians have been very supportive of the expanding role for respiratory therapists at the Mayo Clinic. According to Buck, therapists are particularly respected by critical care physicians who rely on them to wean their patients from oxygen and provide hemodynamic monitoring. Teaching institutions like the Mayo Clinic also have hundreds of medical residents who depend on the therapists for information and technical assistance. “In our medical or trauma unit, many of the intensivists won’t even start rounds until the therapists are there,” Buck says. “The therapists are routinely asked for their opinions and are actively involved in the education of residents,” he adds. Some respiratory therapists have even pointed out that when problems arise in some of the units, the nurses frequently call the therapist before they call the resident. Mayo’s therapists may not be true physician extenders, since they are not therapist case managers, but doctors and nurses both clearly view them as integral members of the care team.

One factor that has helped therapists earn greater respect from physicians is the development of therapist-driven protocols. Since 1985, a pulmonary hygiene protocol has been in place where physicians can order either chest physical therapy 1 or chest physical therapy 2. If a therapy 1 is ordered, the nurse follows the treatment plan; if a therapy 2 is ordered, a respiratory therapist designs the treatment plan and provides the care.

Five years ago, a weaning protocol was implemented for routine postoperative patients. Originally designed for vascular surgery patients, the protocol is now used for liver transplant, cardiac surgery, and thoracic and vascular surgery, and a modification of the protocol is also used in the trauma unit. Although written by respiratory therapists, the protocol is designed to be used collaboratively by nurses and therapists. “When it’s time to start the weaning process, the nurse and the therapist are required to stand by the foot of the patient’s bed and ask each other if they are ready to start,” Buck says.

There are still some physicians who prefer to manage their patients’ care without the use of a protocol; however, currently 75% of all surgical patients that arrive back in the unit intubated are weaned by the protocol.

J0i00923.jpg (9171 bytes)Dave Hardy, RRT, a clinical specialist working in the chronic ventilator unit.

Following implementation of the weaning protocol, there was a 25% reduction in patients on ventilators and a 26% reduction in their ICU length-of-stay. The best example is in a 2-year-old thoracic surgery step-down intensive care unit, where therapists are assigned for 24 hours to monitor the patients’ arterial lines and pulmonary hygiene using the protocol. “This seamless approach to care actually came about when the thoracic surgeons recognized the value of having therapists and nurses collaborate by using the protocol,” Buck says. The step-down unit and use of the protocol have proven to be so successful that the hospital’s vascular surgery area just recently received approval to pattern their service after the thoracic surgery step-down unit.

Medical residents also appreciate the protocols since they promote consistency and streamline their treatment plans. “At a place like the Mayo Clinic with so many residents who are required to work an enormous number of hours, the protocols are well received by the residents since they understand immediately what steps are involved in weaning a routine postoperative patient,” Buck says. He adds that the protocols also serve as an educational tool for physicians in training since they are given the opportunity to see step by step what happens in the weaning process.

A strong relationship also exists between the Mayo Clinic’s nursing and respiratory staff. Buck explains that this was not always the case. “One major reason we’ve seen an improvement in this area is that we, as respiratory therapists, do everything possible to become part of the life of the different ICUs—we serve on unit councils, we are ad hoc members of practice committees, and we share in-services with nurses,” Buck says. The other major reason for the cohesive bond between nursing and respiratory therapy is that therapists spend most of their time in one or two “home” units, which gives them the opportunity to develop strong relationships.

Vanessa King, RRT, a staff therapist in one of the ICUs, believes that Mayo’s nurses are more accepting of respiratory therapists than the other hospitals she worked at in the past. “Many nurses that move to Rochester are surprised and sometimes struggle with how involved respiratory therapists are with patient care here, particularly in the ICU setting,” King says.

Research Activities
It is not surprising that the Mayo Clinic’s role as a major research institution has exposed respiratory therapists to a myriad of research projects that other hospitals could never provide. In addition to being a study center for the use of proportional assist ventilation, the Mayo Clinic also has active research protocols in nitric oxide, prone ventilation, and partial liquid ventilation. Therapists provide support and collect data for numerous critical care clinical studies. “The opportunity is available for every therapist to establish their own research projects,” Buck notes. “Therapists are involved intimately in recruiting patients and identifying those who would be appropriate for specific protocols.”

During the past few years, various Mayo Clinic therapists became recipients of the prestigious Respironics Fellowship for their work with noninvasive ventilation. One received it for an application of a 2-year-old tracheostomy case using noninvasive ventilation, one earned it for developing a registry of patients with chronic obstructive pulmonary disease (COPD) who had a trial of nocturnal noninvasive ventilation, and the last one earned it for coordinating the proportional assist ventilation study.

The Mayo Clinic is also unique for having respiratory therapists who work full-time in research. Steve Holets, RRT, a study coordinator for the Anesthesia Clinical Research Unit, manages a wide range of research activities. Among his responsibilities are reviewing both internal and industry-

sponsored study protocols to determine feasibility and manpower requirements; assisting in protocol development; screening patients for study eligibility; explaining aspects of the study to patients and their families as part of the informed consent process; coordinating with pharmacy, laboratory services, nursing, and physicians to assure all tests and procedures are performed and data are recorded; and collecting and reviewing data.

“As respiratory therapists, we bring a unique perspective to the field of study coordination. Our understanding of respiratory physiology, oxygen and aerosol delivery systems, and ventilator management in conditions such as acute respiratory distress syndrome (ARDS) and COPD has proven extremely helpful in the development and conduction of several studies,” Holets explains.

Holets is currently participating in the following studies: industry-sponsored pharmacology studies testing new drugs for the treatment of sepsis and ARDS; studies testing new ventilators and ventilator modalities including proportional assist ventilation; and an internal-sponsored study testing the efficacy of borage seed oil as a nutritional supplement in the treatment of ARDS.

Life in the Unit
With nearly a half million patients treated annually, the Mayo Clinic gives therapists a chance to see a variety of diagnoses and therapies and to work with some of the world’s best physicians. “In addition to staying abreast of the latest respiratory therapy techniques, therapists see a huge variety of surgical procedures,” Buck says. It is not unusual to have a day in which three thoracic aneurysm repairs are performed, as well as nine craniometies.

Despite the advantages of working in a world-class hospital, King notes that there are also challenges in working in such an environment. Since patients and physicians come from all over the world to be treated and to work at the Mayo Clinic, conflicts can arise from language barriers and cultural misunderstandings. Another challenge is that therapists at the Mayo Clinic often treat some of the sickest types of patients, which makes it difficult to stay optimistic. “It is impossible not to get attached to some of these patients,” King stresses.

Each ICU at both hospitals has its own respiratory work room, where assigned group members report daily and obtain reports from previous shifts. Since the staff join only for the staff meetings and in-services, it had been difficult communicating with them. But now, thanks to the new respiratory care Internet page, it has become much easier to communicate directly in real time to therapists. Each supervisor has a section on the page where they can send memos to staff or vice versa. In addition, the page contains the department’s procedure manual, as well as a section where employees can make vacation requests or on-call assignments. “This has been one of the best tools for our staff and everyone admits that communication has improved since we’ve been online,” Buck says.

Training Tomorrow’s Therapists
The Mayo Clinic also offers a 24-month respiratory care program under its Health-Related Sciences Program. Although it currently offers an associate’s degree in respiratory care, the program will transition over the next 2 years to a 4-year baccalaureate degree program. The professional curriculum involves two academic years plus a 10-week summer session between the freshman and sophomore years. Students spend the first academic year at Rochester Community and Technical College completing general education and prerequisite science courses. During the final 12 months, Mayo provides both classroom and clinical instruction in the outpatient clinic and the two hospitals.

“It’s critical that we start offering a 4-year program,” Buck stresses. “You simply cannot give therapists all the skills they need for the long term in a 2-year program.” Most of the Mayo’s respiratory therapy graduates choose to work at the Mayo Clinic. However, since class sizes have been small in recent years, Buck has had to recruit from a number of other schools, preferring those with 4-year programs, such as the Universities of Virginia, Kansas, Iowa, and Central Florida, and North Dakota State University.

According to Buck, it is much more difficult recruiting appropriate students than in years past, primarily because they must possess a greater number of skills. “Today’s therapists need a thorough understanding of biostatistics along with evidence-based medicine and research,” he says. Buck adds that they also need more computer and leadership skills. “Therapists can no longer be the persons who perform the treatments and then disappear,” he says. “They need to be able to stand up at the bedside and have a discussion with the clinical nurse specialists and physicians about the patient’s care—and not just be limited to pulmonary issues since they need to integrate all aspects of the patient’s health.”

The Mayo Clinic is light years ahead of many other institutions. From the management of an enormous variety of clinical cases to coordination of research projects, the Mayo Clinic’s respiratory department offers therapists a wealth of professional opportunities. Buck concludes, “For the right type of therapist, a job at the Mayo Clinic brings numerous rewards.”

Carol Daus is a contributing writer for RT Magazine.