AHH’s goals are achieved through decentralizing ancillary and support services, encouraging family involvement, and cross-training its staff to ensure caregiver continuity

photoWhen Arkansas Heart Hospital (AHH) opened in March 1997, it was something of a belated Valentine’s Day gift to heart patients in the Little Rock, Ark, area. Designed with the input of heart specialists and clinical staff, AHH focuses on seamless, comfortable, and cutting-edge cardiac patient care from admission until discharge. The facility’s goals are achieved through decentralization of ancillary and support services, an atmosphere of privacy for the patient, encouragement of family involvement, and cross-training of staff to ensure caregiver continuity.

The respiratory therapy department is a key component of this specialized environment, and respiratory care team leader David Batcheller, RRT, was involved with the respiratory department’s design, function, and equipment choices 6 months before AHH opened its doors.

“We simplified the process, which is so complex elsewhere,” he says. “By being a specialty facility and focusing on ways to reduce cost while enhancing patient care, we have what we feel is an advantage over other facilities, in that we can narrow our clinical expertise to these specialty procedures. This not only reduces patient length of stay but also reduces patient and hospital costs, which benefits both parties.”

AHH is the second specialized hospital opened by MedCath Inc, Charlotte, NC, a provider of cardiology and cardiovascular services through the development, operations, and management of heart hospitals and other specialized cardiac care facilities and management of physician practices. The first heart hospital opened in McAllen, Tex, about a year before AHH, and more are on the way in several major southwestern cities.

photoJason Henry, RRT (left), and Jamie Shahan, RN, clinically assessing a postoperative ventilated patient.

AHH covers a very wide geographical area and takes many outlying referrals. Those patients typically will have diagnostics done elsewhere and are referred to AHH for treatment, such as cardiac catheterization or open heart surgery. The bulk of patients are seen for chest pain, shortness of breath, and history of heart disease, and more than 70% are Medicare/Medicaid patients. AHH also operates a full-service emergency center that is open 24 hours a day, 7 days a week.

The hospital is equipped with 84 private inpatient beds, eight recovery beds, and 17 private day-patient beds. There are close to 400 staff members at AHH, and the respiratory therapy department has a staff of 14. A pulmonologist is the respiratory therapy department’s medical director and the department has a particularly close alliance with the hospital’s anesthesia group.

Respiratory therapists’ primary duties are ventilator management, arterial blood gas drawing and analysis, metered dose inhaler and aerosol therapy, postoperative spirometry testing, and patient education on such subjects as changing lifestyles (how to cope with life after heart surgery). A small aspect of their work is preoperative screening.

photoDavid Batcheller, RRT, director of respiratory care services.

“We meet the patients, make them comfortable, and explain the process and equipment that will be involved and the weaning process,” Batcheller says. “These are some reassurances as to our level of care. The patient is never left alone. Many people are reluctant to ask questions, so we put the questions before them and they open up and feel more comfortable. There are a lot of unknowns out there when people go into surgery that they don’t know or don’t want to know.”

Though there is no formal program of cross-training at AHH, everything is based on the team concept. In the respiratory therapy department, however, everyone is expected to be able to do the same job. Respiratory therapists are not on different levels at AHH. The same therapist who conducts the initial screening or function testing will likely set up the ventilator and manage the patient from extubation to postoperative routine therapy. This type of treatment puts patients on a first-name basis with the therapist, and puts them at ease when approached postoperatively for therapy. Batcheller’s expectations for his therapists also include high visibility in the recovery room and progressive critical care unit.

“I expect RTs to help the nurses turn patients, give them a drink of water, and perform basic vital signs,” he says. “I expect them to do anything they can to stay busy and help the nursing staff, which has a phenomenal amount of work to do.

“I would consider hiring a CRTT with documented critical care experience and an open mind to learning and participating in the point-of-care concept. All staff must have ACLS state licenses and be members of the American Association for Respiratory Care,” he says. “The hiring is based on clinical experience rather than credentialing. Some applicants are more skilled, of course, so if a patient is in distress or acutely sick, a therapist who is less experienced will notify a primary therapist to make sure they are doing the right thing. We don’t hang anyone out to dry that way.”

Though there is a slight difference in salaries between registered and certified therapists, Batcheller says that is meant to encourage RTs to get registered and take advantage of tuition reimbursement that the hospital offers.

The AHH respiratory therapy department does a lot of obstructive sleep apnea screenings, as well as pulmonary function testing. The hospital also is looking at the possibility of doing sleep studies because of an increased demand for them.

The respiratory care department is located within the heart of the hospital on the second floor and all rooms are designed and equipped for every stage of patient care. This facilitates all work being done at the point of care as much as possible. Batcheller says the only time patients are transported is to undergo computed tomography or magnetic resonance imaging. Otherwise, everything is done at the bedside.

“That way a patient in room 202 can stay in room 202 no matter what their acuity level is,” Batcheller says. “Every room becomes an intensive care unit if needed. If they need an intra-aortic balloon pump, that will be changed within the room. This exhibits a true point-of-care concept.”

A key component of point-of-care service is the 14 new ventilators used by the respiratory therapy department, which can be transported from the surgical suite to the patients being extubated in their rooms. The ventilators are also compliant with treatment of long-term care patients.

“Before the hospital opened, I went to Duke University and looked at its ventilators,” Batcheller says. “They were an unknown quantity at the time, and we were the first hospital in the nation to take full delivery. Now those RTs who practice at other hospitals wonder why they don’t have full-delivery ventilators.

“The ventilators allow for a very seamless route,” he adds. “As soon as the patient is taken off of the surgical bed and off anesthesia, they are hooked to a ventilator that is attached to the patient’s bed in the operating room. That means anesthesiologists don’t have to hook them to an ambu bag and go to their room with them to switch them over to the ventilator. The ventilator also uses the same circuitry as the anesthesiologist’s equipment, which reduces patient and hospital costs. We have been very fortunate in developing this type of operation.”

photoBob Clark, MD, staff anesthesiologist.

Another key area of patient comfort is the Fast-Trac weaning process, which was developed in conjunction with AHH’s chief anesthesiologist, Bob Clark, MD. Batcheller says the challenge of managed care led AHH to reassess its methods and equipment utilized to deliver optimum patient care. Fast Trac Weaning—defined by the Journal of Anesthesiology as extubation within 1 to 6 hours after cardiac surgery—was a key to meeting that challenge.

“Dr Clark enlightened me while we were planning this process. He said that most hospitals treat the tube and not the patient,” Batcheller says. “When a patient wakes up, their anxiety level and blood pressure go up and they are usually chemically restrained. Then the ventilator settings go back up and they are caught in a vicious cycle.

“We begin the weaning process before the patient is awake and aware that an endotracheal tube is in place,” he says. “We do not wean below an intermittent mandatory ventilator rate of 4, nor do we utilize ET/CP, T-tubes, T-bar, or other conventional weaning methods. Our goal is to keep the fresh, postoperative heart patient in a nonstressed state, or as labile as possible. To do this, we utilize the parameters displayed on the ventilators to assess the patient’s spontaneous ventilation abilities rather than increase their stress level with questionable trials.”

The greatest benefit of this method is experienced by AHH’s patients, who are spared multiple endotracheal tube handling and stimulation at the point of transport and up to extubation. Fast-Trac Weaning has resulted in decreased inadvertent extubations, decreased elective reintubations, and decreased adverse reactions. The respiratory care department tracks ventilator times as well as needed reintubations to assure it is working toward the best interest of the patient. Batcheller says the current reintubation rate is below 3% of total ventilated cases, and it has never been more than 4.5% for any quarter.

“I talk to a lot of patients after they are extubated and many remember the tube but not feeling anxious or upset about it. They only remember coughing a bit at the time we do final suction and actually extubate the tube,” he says. “They are not awake, thrashing and gagging on the tube. They are extubated long before that time.”

Batcheller says AHH has received some criticism about not doing T-bar and ET/CP trials, but says the respiratory therapy department has proven that those elements are not necessary on routine, noncomplicated cases. Among the benefits of Fast-Trac Weaning, he cites increased patient satisfaction, decreased length of stay, decreased patient and hospital costs, and increased staff productivity.

“This saving has been valued at $11,640 per 1,000 patients in disposable equipment alone,” he says. “Other facilities do this; how-

ever, the weaning process is a little different. The majority of facilities in this area are not utilizing the process in the same way we are.”

Arkansas Health Hospital

  • AHH operates a full-service heart attack emergency center that is open 24 hours a day, 7 days a week.
  • The hospital is equipped with 84 private inpatient beds, eight recovery beds, and 17 private day-patient beds.
  • There are close to 400 staff members at AHH and the respiratory therapy department has a staff of 14.
  • A pulmonologist is the respiratory therapy department’s medical director and the department has a particularly close alliance with the hospital’s anesthesia group of physicians.

Another unique facet of AHH is its encouragement of family members to stay with patients in their rooms. Each room is equipped with a lounge chair that folds out into a cot. Because of the geographical layout of the state, many families stay overnight either in the hospital or at a facility next door.

“In our experience, patients are noticeably relieved to have everything performed at their bedside,” Batcheller says. “The family is always accessible to whoever is in the room. Patients don’t usually feel isolated in the clinical setting when their family is present.”

Batcheller estimates that 75% to 80% of families are in the room when the health care team arrives with the patient from the recovery room.

“When the patient wakes up, the family is right there,” he says. “The first thing the patient sees is a familiar smile and they feel better right away.”

There is an occasional backlog of patients at AHH, but, Batcheller says, the longest diversion lasts 24 hours.

“We are what I like to call a shake-and-bake operation,” he says. “The patient is in and out of the hospital in 3 to 4 days. If someone is waiting that morning, others are being discharged postoperatively at that same time. Sometimes we will check waiting patients in at the hotel next door if they are not acute, then start their treatment at 5 am the following morning.”

AHH’s specialty care has led not only to happy patients but to contented staff members as well. Batcheller says there is an extremely low turnover of RTs at AHH—much lower than he had anticipated.

“Initially, it was a little difficult because we were the new kid on the block and there was a lot of uncertainty with people leaving their jobs after a long time,” he says. “Then therapists found out about our continuity of care, our patient focus, and how uncomplicated it can be. They are able to practice their critical care skills here, so now we have no problems recruiting a qualified staff.

“What speaks most strongly is the fact that nurses who come from other facilities to work, end up bringing their own families and friends here for cardiac care because they feel it’s the best place for them.”

Liz Finch is a contributing writer for RT Magazine.