After undergoing a care role redesign, Texas Children’s Hospital recognizes RCPs’ value by assigning new roles.

As we approach the beginning of a new millennium, the roles of respiratory care practitioners (RCPs) in many areas of the United States have dramatically changed. Managed care and other structural alterations within the US health care system over the past decade have been the driving force behind many of these changes.

Texas Children’s Hospital is a 456-bed, acute care hospital that is part of a larger integrated health care delivery system. Located in the Texas Medical Center in Houston, it is the largest pediatric hospital in the United States and is in the process of expanding by 1.2 million square feet. US News & World Report ranked Texas Children’s Hospital among the nation’s top hospitals for pediatrics in 1999.1 Like many health care organizations adapting to the changing health care environment, Texas Children’s Hospital undertook a redesign of both health care provider roles and care delivery processes.

Guiding the organization through these changes was the administration at the hospital, physicians from the affiliated Baylor College of Medicine, and private attending physicians. Early in the redesign process, these groups made a commitment to the continued delivery of the highest quality of care to the patients. Cost reduction was among the strategic goals listed for redesign, but it was not the overriding concern; instead, maintaining and improving the quality of care delivered to neonatal/pediatric patients was the foundation on which care role redesign was engineered.

Redesign Presents Opportunity
RCPs were identified early in the care role redesign process as members of the health care team who could contribute a unique skill set. And, as licensed professionals, they would be able to function independently in several of these nontraditional roles.

The assumption of nontraditional roles was possible because of strong support from our medical director, strong overall physician and nursing support flexibility, coupled with a positive, collaborative attitude on the part of RCPs. Dan Seilheimer, MD, chief of Pulmonary Medicine Service and medical director of Respiratory Care Services, believed that the most important factor allowing RCPs to assume nontraditional roles was the “can do” attitude exhibited by the department.

Many of the opportunities that would allow RCPs to develop and grow into non-traditional roles existed in other departments and entities within the integrated system. Therefore, department management recognized there was a probability that the Respiratory Care Services Department would lose talented individuals seeking positions elsewhere within the system. Again, the decision was made to support those individuals pursuing professional growth that could positively contribute to the development of the entire integrated health care delivery system.

A New Model and New Roles
Redesign sought to emphasize development of functional, multidisciplinary care teams throughout the hospital incorporating a Family-Centered Health Care2 delivery model. The Family-Centered Health Care delivery model encourages the family to participate in the care of the sick child, to the extent practical, while the health care team assists both the child and family in treating and coping with the illness. Each of the care team members views parents as partners that assist in caring for their sick children.

The process of care role redesign allowed critical reexamination of care roles throughout the integrated health care delivery system and analysis of how care role redesign could contribute to improved service. Prior to redesign, members of the centralized respiratory care department were assigned as primary RCPs in different clinical settings throughout the hospital. As care role redesign and reorganization under the new model evolved, a number of new or modified roles, which could be assumed by RCPs, were identified and included:
• administrator for transport services and transport specialist;
• administration—assistant vice president;
• ambulatory services—pulmonary research assistant director and asthma-cystic fibrosis specialist;
• discharge facilitator;
• operating room-advanced care practitioners (OR-ACPs);
• special projects and research coordinator; and
• staff development and education.

A common characteristic of each of these nontraditional roles is an absolute requirement for the individual to be self-directed and possess excellent critical thinking skills. This contrasts with a more task-oriented mentality of doing what is ordered. In order for the individuals in these nontraditional roles to be effective, there is also much greater reliance on network-building throughout the organization, excellent written and verbal communication skills, and thinking “outside the box.” These individuals must be both consensus builders as well as decision-makers while achieving organizational goals. Individuals possessing these characteristics are more likely to be successful in a nontraditional role.

Seilheimer, who is also chief of pediatric pulmonology for the Baylor College of Medicine, has been affiliated with Texas Children’s Hospital for 22 years. He has actively participated in the evolution of the respiratory care services department over those 22 years and believes that the greatest asset possessed by RCPs before and during care role redesign was their proactive approach. Each of these nontraditional roles has its own unique challenges.

Administrator for Transport Services and Transport Specialist
The transport of critically ill patients occurred without a formalized transport program for approximately 15 years at Texas Children’s Hospital. In September 1998, Garry Sitler, RRT, was approached by the hospital administration, and asked to consider assuming the role of administrator for transport services—a formalized program that did not yet exist. The administration recognized that Sitler was an individual who worked well in a multidisciplinary environment, was a consensus builder, and exercised good judgment. Additionally, Sitler had previous flight transport experience with another institution and possesses a pilot’s license.

The Transport Services Program has undergone a phased implementation process beginning with the neonatal intensive care unit (NICU), which began accepting transported patients in March 1999. The Kangaroo CrewSM, the official name of the transport team, initially transported patients only to the NICU. In August 1999, the transport team also began transporting patients to our pediatric intensive care unit (PICU). The program transports patients by ground within a 90-mile radius and by fixed wing aircraft beyond that radius. The transport team is composed of a nurse practitioner, pediatric/neonatal respiratory care practitioner, and nurse. A physician may also be involved as a member of the transport team, if indicated by the needs of the patient.

The program is composed of approximately 80 specially trained nurse practitioners, respiratory care practitioners, physicians, and nurses. The unit medical directors of the NICU and PICU, James Adams, MD, and Larry Jefferson, MD, respectively, provide medical direction for the transport program. Patients are transported from locations throughout Texas and occasionally from neighboring states including Louisiana, Oklahoma, and New Mexico.

Administration—Assistant Vice President
Tim Chafin, RRT, has been an employee of Texas Children’s Hospital since 1983 when he was hired as the assistant director of a respiratory care department that serviced two hospitals with different patient populations. Back then, Texas Children’s Hospital and St Luke’s Episcopal Hospital, which primarily serves adult patients, were a joint venture.

By 1985, the hospitals had become separate entities and Chafin became director of respiratory care at Texas Children’s Hospital. In 1998, Chafin’s final year in that position, he was also managing physical medicine and rehabilitation, and the Pulmonary Diagnostic Laboratory.

Today Chafin is assistant vice president with operational responsibility for 20 ambulatory clinics, the wellness center, the learning support center, and the Pulmonary Diagnostic Laboratory. These areas are responsible for approximately 155,000 annual patient visits, and the greatest challenge he currently faces is familiar to health care administrators throughout the United States—how to provide for growth in outpatient services with constrained resources. Chafin is meeting this challenge by working with his management team to provide more efficient use of available resources using process reengineering.

Strategic management is something that Chafin has been well acquainted with throughout his career. He offered some insight into his management approach by sharing his philosophy regarding expansion of services while he was director of respiratory care: assess the gaps in patient care and offer to provide services, if it makes sense, in terms of added value.

According to Chafin, the future of the respiratory care profession lies in the ability of its leadership to build relationships with other health care provider organizations, assume continued responsibility as a patient advocate, and enthusiastically challenge the profession itself to provide answers to issues of concern.

Operating Room—Advanced Care Practitioners (OR-ACPs)
Prior to care role redesign at Texas Children’s Hospital in 1996, the administration of the anesthesia department projected a reduction in the number of available anesthesia residents. The projected shortfall of anesthesia residents and a limited number of anesthesia faculty members posed problems because this scenario would result in an insufficient number of trained personnel to provide necessary preoperative services. As this problem was studied by anesthesia administration, the RCPs were identified as a group that possessed many of the desired skills.

Two RCPs, Jill Gouvion, RRT, and Vicki Hall, RRT, volunteered to fill the role of OR-ACPs. The anesthesia department provided these two individuals with additional specialized training, including operating room preparation, intubation, intravenous line placement, patient transport services, and preoperative assessments.

There were skeptics who did not feel they would be successful in this nontraditional role, recalls Hall. However, critical support was provided by Burdett Dunbar, MD, chief of anesthesia, and Sylvia Doyle, RN, director of OR services. According to Hall and Gouvion, they are now an accepted part of the operating rooms and have a great working relationship with the physicians and other coworkers. The program has proven to be so successful that a third position was added in July 1999 with the possibility of additional positions as surgical growth at the hospital continues.

Ambulatory Services—Pulmonary Research Assistant Director and Asthma-Cystic Fibrosis Specialist
Like other large pediatric facilities, Texas Children’s Hospital has a large number of outpatient clinics and related diagnostic services. The Pulmonary Diagnostic Laboratory, the Pulmonary Medicine Clinic, and the Children’s Asthma Center are located on the same floor adjacent to one another. The physical proximity of these areas allows cross-coverage between the Pulmonary Medicine Clinic and Children’s Asthma Center, where therapeutic services are provided, and the diagnostic laboratory, according to Denise Treece, RRT, assistant director of Ambulatory Services—Pulmonary Research.

Treece manages approximately 25 employees who are licensed RCPs, RNs, statisticians, and database administration staff. Many of the RRTs possess additional credentials (ie, CPFT and RPFT) and cross-cover the Pulmonary Medicine Clinic and Pulmonary Diagnostic Laboratory. There is an emphasis on patient/family education by the RCPs in the Pulmonary Medicine Clinic and Children’s Asthma Center where RCPs teach equipment, medications, and various aspects of disease management. Additionally, many of the RCPs in the Pulmonary Diagnostic Laboratory serve as primary clinical research study coordinators, primarily working with patients who have cystic fibrosis and asthma.

Services provided to the various clinics have been steadily expanding, according to Cindy Hannah, CRTT, asthma-cystic fibrosis specialist for the outpatient clinics. Hannah has been instrumental in the provision of respiratory therapeutic services, including family/patient education to multiple clinics, such as the Pulmonary Medicine Clinic and Hematology Clinic. Hannah has collaborated with our pulmonologists and the inpatient asthma-cystic fibrosis specialist, Charles Wehring, CRTT, to develop formalized protocols for alternative airway clearance techniques such as positive expiratory pressure.3-9 After a thorough patient assessment, the protocol governing airway clearance techniques allows selection of the technique that best suits the patients’/families’ needs.

Discharge Facilitator
Planning the discharge from the hospital of a child who requires home care can be a challenging task, according to Toni Sloane, RRT, a discharge facilitator for Texas Children’s Hospital.

Two years ago, Sloane was searching for a job within our system that would let her use her skills as an RCP, yet have a schedule that would better fit her family responsibilities. Sloane had worked as an RCP for 12 years and wanted to remain employed with Texas Children’s Hospital, so she decided to respond to a job posting for a discharge facilitator.

The department Sloane works for has eight discharge facilitators with three of the eight individuals possessing RRT credentials. A typical day for a facilitator starts with multidisciplinary rounds where patient discharge plans are discussed. The discharge facilitator then contacts the necessary agencies, which might range from home care companies to a rehabilitation facility. “Having a background in mechanical ventilation is an enormous asset when I’m coordinating the discharge of a ventilator-dependent child,” Sloane says.

One of the greatest challenges is obtaining required home health services for children that are being discharged from the hospital but are uninsured, Sloane says. According to the Texas Health and Human Services Commission data for 1998, 42% of the children in Texas (about 1,411,907) are uninsured and it is estimated that 238,503 of those children reside in Harris County where Texas Children’s Hospital is located.10 Because of the large number of uninsured children, the State of Texas is instituting a Children’s Health Insurance Program (CHIP), which would conditionally insure all children 18 years of age and less who are at or below 200% of the Federal Government’s poverty level. The CHIP program will begin May 1, 2000 and Mark Wallace, CEO, of Texas Children’s Integrated HealthCare System was instrumental in creating it as a legislative advocate of this program.

Special Projects and Research Coordinator
The fact that Texas Children’s Hospital is a primary teaching facility for Baylor College of Medicine means there are ongoing research projects throughout the hospital. Many of these projects involve some aspect of Respiratory Care Services.

The Respiratory Care Services Department has made a commitment to supporting and being actively involved in research within the institution. We are participating in several research projects, including a prospective, randomized, multicenter trial using nitric oxide in older infants and the study of patients randomized to receive specific bronchodilators and anti-inflammatory agents with concomitant genotype identification. Additionally, we are using outcome data, provided by our Quality Outcome Management Department, to assist in the development of therapist-directed protocols.

Many employees at the hospital believe that a major direction of future research in respiratory care should be focused on outcome measures. The profession has found itself in a situation where respiratory services provided to patients are being significantly reduced or eliminated and it is difficult to prove our worth because we lack outcome data. Those individuals involved with respiratory research can help the profession now by collecting necessary outcome data using well-designed, prospective, multicenter trials where possible.

Staff Development Coordinator
In a large modern Respiratory Care Services Department, keeping the staff proficient and competent in a multitude of procedures is always challenging, according to Tchernavia Williams, BAS, RRT, staff development coordinator at Texas Children’s Hospital.

Williams has been instrumental in implementing a 7-week orientation program, which all new employees must successfully complete prior to being assigned to clinical areas independently. New staff members must successfully complete clinical rotations with designated preceptors. This creates a more consistent interface between our practitioners and other clinical services, since each member of the clinical team is consistently oriented and taught performance expectations. Since failure to orient new employees properly can be costly later, Williams believes it is a wise investment in the future of the employee, the department, and the institution.

Williams, guest speakers, and Texas Children’s Hospital staff members provide staff in-services, an important component of any staff development program. Having staff members involved in teaching each other enhances the learning process, according to Williams, through frank discussions and having staff experts serve as resources. Materials presented during an in-service receive prior administrative approval to ensure a continued high standard of quality.

In addition to staff orientation, in-service coordination, and competency assessment, Williams serves as coordinator of the Infant CPR Program for the hospital. She also serves as an instructor for Basic Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program and assists with coordinating and providing these classes throughout our integrated health care delivery system.

Finally, Williams is responsible for managing the clinical affiliations with four local colleges, which use Texas Children’s Hospital as a primary affiliate for neonatal/pediatric learning opportunities. These students represent the future of our profession and are an important part of the overall mission of staff development, which is to provide excellent learning opportunities in a supportive environment. We all need to do what we can to make sure students are encouraged to learn all they can and reach their full potential; if not, the future of our profession is jeopardized.

As this millennium draws to a close, RCPs in the United States and elsewhere have been witness to incredible medical advances and changes within the health care system. We have seen tremendous growth in the demand for health care services while, at the same time, realizing there are fewer resources available to deliver those required services. This is a challenge to each of us to provide the highest quality of care in the most efficient manner possible.

This will necessarily require unconventional solutions to many problems and development of new and more efficient health care delivery models. Old roles will give way to new roles and change must be something we embrace where it makes sense.

The common thread, which will continue to run through the next millennium, as it did the last, is change. Our challenge as a profession is to become better educated, to remain on the cutting edge of technology, and to assume new roles, while maintaining the traits that define our profession. Some of these traits include compassion, humor, integrity, and, above all, hope for a better world in which all may live. Each of us can help to make this a reality in the new millennium by providing the best health care services to each of our patients.

Russell T. Reid, RRT, CPFT, is special projects and research coordinator at Texas Children’s Hospital, Houston.

1. US News & World Report. July 19, 1999.
2. Wooten-Moseley K, Deevers-Perdue J, Scales-Casillas C, et al. Perinatal and pediatric respiratory care. In: Barnhart SL, Czerzinske MP, eds. Family-Centered Health Care. Philadelphia: WB Saunders; 1995:1-9.
3. Falk M, Kelstrup M, Andersen JB, et al. Improving the Ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. Eur J Respir Dis. 1984;65:423-432.
4. Tonnesen P, Stovring S. Positive expiratory pressure (PEP) as lung physiotherapy in cystic fibrosis: a pilot study. Eur J Respir Dis. 1984;65:419-422.
5. Van Asperen PP, Jackson L, Hennesey P, et al. Comparison of a positive expiratory pressure (PEP) mask with postural drainage in patients with cystic fibrosis. Aust Paediatr J. 1987;23:283-284.
6. Falk M, Andersen JB. Positive expiratory pressure (PEP) mask. In: Pryor JA, ed. International Perspectives in Physical Therapy—Respiratory Care. Edinburgh: Churchill Livingstone; 1991;7:51-63.
7. Mortensen J, Falk M, Groth S, et al. The effects of postural drainage and positive expiratory pressure physiotherapy on tracheobronchial clearance in cystic fibrosis. Chest. 1991;100:1350-1357.
8. Lannefors L, Woumer P. Mucus clearance with three chest physiotherapy regimes in cystic fibrosis: a comparison between postural drainage, PEP, and physical exercise. Eur Respir J. 1992;5:748-753.
9. Mahlmeister MJ, Fink JB, Hoffman GL, Fifer LF. Positive-expiratory-pressure mask therapy: theoretical and practical considerations and a review of the literature. Respir Care. 1991;36:1218-1230.
10. Research Department, Fiscal Policy Division, Texas Health and Human Services Commission. Appendix D, Estimated Number of Uninsured Texas Children Ages 0-18 in 1998 by Poverty Category, Ethnicity and Age Group. In: Draft Request for Proposals for Community Based Organizations (CBO) Outreach Services. 1999; Austin, Tex.