Barnes-Jewish Hospital’s RT department prides itself on implementing therapist-driven protocols, research, and education.

photoDarnetta Clinkscale, MBA, RRT, is not content with just being the respiratory head of one of the nation’s top 10 hospitals. As patient care director of Respiratory, Rehabilitation (occupational, physical, and speech therapies), and Gastrointestinal Services of St Louis-based Barnes-Jewish Hospital, Clinkscale is determined to achieve a long-time goal—to transform her department’s therapists into true respiratory consultants.

“Our goal is to eventually have a situation where the physician writes the order and the respiratory therapist assesses, treats, and evaluates the patient,” Clinkscale says. She admits that this is happening a significant amount of the time at Barnes-Jewish and is confident that in the near future it will be common practice. How has Clinkscale been able to accomplish this goal for her respiratory therapists? Comprehensive therapist-driven clinical protocols and strong, supportive medical directors over the years have played a major role in expanding the clinical role therapists play at Barnes-Jewish Hospital. Marin Kollef, MD, medical director of the department, has contributed significantly to raising the recognition of respiratory therapists through published works and educational programs. In addition, respiratory care is included in physician in-services and orientations, so therapists are able to educate medical staff about their role and the use of therapist-driven protocols.

Nationally Recognized
Barnes-Jewish Hospital at Washington University Medical Center, the largest hospital in Missouri with 1,385 licensed beds and 156 intensive care unit (ICU) beds, was created through a 1996 merger between Barnes Hospital and The Jewish Hospital of St Louis. Rated by US News & World Report as the seventh best hospital in the country, Barnes-Jewish Hospital has a premier reputation in patient care, medical education, research, and community service.

photoJoe Fackelman, RRT, monitors a ventilated patient.

As an affiliated teaching hospital of the Washington University School of Medicine, Barnes-Jewish Hospital has a 1,572-member medical staff including full-time academic faculty of the school, as well as private physicians. The medical staff is supported by a house staff of more than 850 residents, interns, and fellows.

The hospital is comprised of two separate buildings: Barnes-Jewish Hospital North and Barnes-Jewish Hospital South. Respiratory staff are assigned to both facilities; however, Clinkscale is quick to point out that a “team” concept is used in assigning 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 (ED), cardiothoracic, or long-term acute care.

Within each of these departments, the staff is assigned to specific clinical service areas. For example, if a therapist is assigned to medicine, he or she will rotate through the various departments within medicine, such as the general medicine ICUs and floors. This is designed not only to give the therapists 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,” Clinkscale says. She notes that therapists are also allowed to rotate outside their teams periodically to gain additional exposure.

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. “The therapist stays on the assigned unit, their report is given on the unit, and they attend physician rounds as well,” Clinkscale says.

Clinical Protocols
Clinkscale stresses that therapist-driven protocols have probably had the largest impact on the expanding role of respiratory therapists at Barnes-Jewish Hospital. In fact, the respiratory staff has even worked with the pulmonary division of Washington University to publish studies on the effectiveness of these protocols. A 2000 study published in Chest1 (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.

photoDarnetta Clinkscale, MBA, RRT, is patient care director of Respiratory, Rehabilitation (occupational, physical, and speech therapies), and Gastrointestinal Services.

The study involved 694 consecutive hospitalized non-ICU patients ordered to receive respiratory treatments at Barnes-Jewish Hospital. The study found that the respiratory care managed by therapists through the use of protocols was safe and showed greater agreement with institutional treatment algorithms than physician-directed respiratory care. Furthermore, as the study indicates, “The overall rate of discordant respiratory care orders and the number of discordant orders per patient were significantly less among patients receiving RCP-directed treatments as compared with patients receiving physician-directed respiratory care.” The study went on to summarize, “…the use of RCP-directed treatment protocols decreased the overall use of respiratory care and decreased respiratory care charges without resulting in any detrimental clinical outcomes.”

Barnes-Jewish Hospital’s protocols were implemented in 1997 after being developed using a branched-chain logic format similar to that used at the Cleveland Clinic. The protocols followed the recommendations of the American Association for Respiratory Care Clinical Practice Guidelines and were developed by a working group of physicians and respiratory therapists at Barnes-Jewish Hospital.

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. Before they were accepted, each protocol underwent a trial period of utilization to determine its safety and effectiveness. Afterwards, the protocols were published as a hospital resource guide and made available to physicians with admitting privileges to Barnes-Jewish Hospital, hospital nursing units, and hospital administrative staff.

According to Clinkscale, another benefit of the protocols is that they serve as educational tools providing clinicians with information on the appropriateness of various medical practices for specific disease processes. “These protocols have helped physicians understand what the indications and contraindications are for different respiratory modalities,” Clinkscale says.

Research and Education
As the study on protocols indicates, therapists at Barnes-Jewish Hospital are involved in numerous research projects. Since Barnes-Jewish Hospital is one of the country’s premier medical research facilities, therapists are able to participate in many research projects that are considered experimental and state-of the-art. In addition to getting involved in clinical research with the pulmonary care division of Washington University, therapists working in each clinical service area have the opportunity to work on research projects specific to those areas. Another professional opportunity for Barnes-Jewish respiratory therapists is their exposure to new devices and equipment. Many manufacturers work closely with Barnes-Jewish Hospital to test new equipment, and therefore, its therapists are often among the first respiratory therapists in the country to conduct evaluations on cutting-edge devices. Two current investigations in the cardiothoracic ICU involve a CO2 and inhaled prostacyclin study.

Because of the constant need to stay current with rapidly changing technology and procedures, a wide array of in-services and educational programs are offered to therapists both through the department and outside of the department. “Any of the educational opportunities that are available to house staff are also available to our staff,” Clinkscale says. The respiratory department also offers several formal in-services monthly in addition to CEU offerings. Last year, the department featured two full-day programs in which therapists were able to obtain 12 CEUs. “Even during Respiratory Care Week last year, staff could earn CEUs available at our picnic,” Clinkscale remarks.

Professional Opportunities
As one of the country’s top 10 hospitals, Barnes-Jewish Hospital exposes therapists to clinical situations that are not available in most other hospitals. One example of this is the hospital’s lung transplant program, to which six respiratory therapists are assigned. Founded in 1988, the program enabled Barnes-Jewish Hospital to become one of the first facilities in the United States with a service fully dedicated to lung transplantation. In 2001, 57 lung transplant operations were performed, making Barnes-Jewish one of the most active adult lung transplant centers in the world.

Dottie Biggar, RN, MSN, CS-ANP, supervisor of the Lung Transplant Program, notes that a special type of respiratory therapist is attracted to lung transplant programs. “They obviously have very advanced skills in pulmonary rehabilitation and have strong expertise in treating patients with end-stage lung disease, but they also have to have a strong nurturing side since many of our patients have been waiting a long time for an operation,” Biggar says. The therapists assigned to this program assess the patients while they are candidates, prepare them for the transplant, and treat them immediately following the surgery.

Another area that attracts respiratory therapists is Barnes-Jewish Hospital’s new 62-bed emergency and trauma center, which opened in February. The facility is as big as a football field and is divided into five patient care pods, so specialized care can be provided in separate areas. Barnes-Jewish Hospital’s trauma program has earned the distinction of Level I verification from the American College of Surgeons and is the only hospital in the St Louis area to earn this honor. Like other areas within the hospital, therapists are assigned specifically to the ED but are also able to rotate into this area periodically.

Retention and Recruitment
Barnes-Jewish Hospital’s respiratory department currently has a very low attrition rate, which Clinkscale attributes to the working environment. “Most of our therapists tend to stay here, given all the professional opportunities,” she stresses. “Occasionally, someone leaves to pursue other interests, but most therapists stay here for a large portion of their careers,” says Clinkscale, who has spent 24 years with the institution.

However, as with any hospital in the country, Barnes-Jewish Hospital does experience problems with recruitment as new programs are created and the demand for therapists increases. One innovative long-term plan for recruitment assists individuals who either are at the juncture of making a decision about their career or are making career changes. “Once these people are identified, we will assist them financially by paying full tuition for classes and books,” Clinkscale says. The program, which is a partnership between a local community junior college and Barnes-Jewish Hospital, appears to be working as students have already enrolled in the respiratory care program. “This is a win-win situation because not only do we provide financial support for the students, but we also support them by offering jobs within our hospital—both entry-level, nonrespiratory jobs in the beginning and respiratory positions once they are officially enrolled in the respiratory care program,” Clinkscale says.

An Expanding Role
Identifying appropriate students and grooming them for respiratory positions at Barnes-Jewish Hospital is particularly important as the need for therapists with advanced thinking and assessment skills increases. To maintain a climate where respiratory therapists are true consultants, Clinkscale stresses that therapists need to not only possess advanced clinical skills, but also strong communication skills and the power of persuasion in order to work effectively with physicians and other members of the multidisciplinary team.

One step that has helped advance the level of professionalism has been to insist that therapists be credentialed. “For the past several years, we have not had any therapists who are uncredentialed,” Clinkscale says. Staff is also encouraged to obtain their bachelor’s degrees, and tuition reimbursement programs are available to assist them financially. As therapists have become more advanced in respiratory and pulmonary assessment, physicians have begun to rely on them much more. “In the past, the physicians didn’t have a strong need for respiratory therapists to be present at rounds,” Clinkscale says. “Now, because of what we bring to the table, they insist that a therapist be available every day during rounds, and if a therapist can’t make it due to demands in their areas, we send a shift coordinator or supervisor.”

One reason therapists now have to possess advanced respiratory skills is that the type of patient they treat is much different than in the past. According to Clinkscale, due to changes brought by managed care, the field has evolved more into caring for patients in critical care areas than on the general floors. “Advanced levels of expertise are needed because we’re treating patients who are more critically ill than years before,” she says. “As a result, our therapists need to feel comfortable functioning in a critical care environment most of the time.”

As these changes have taken place in the field, Clinkscale stresses that it only makes sense that therapists become true respiratory care consultants. “The people attracted to this profession are much different than in the past—they are willing to take on greater challenges and want to get involved with treating the whole patient,” she says. “By becoming consultants, therapists will be even more actively involved in patient care plan and will be relied upon more heavily by physicians for making comprehensive patient assessments.”

Carol Daus is a contributing writer for RT Magazine.

1. Kollef MH, Shapiro SD, Clinksdale D, et al. The effect of respiratory therapist-initiated treatment protocols on patient outcomes and resource utilization. Chest. 2000;117:467-475.