At Sparrow Hospital, new programs in pulmonary care have systematically maximized respiratory therapists skills, resulting in improvements for patients, practitioners, and the hospitals bottom line.
Left to right: Mark Wehner, PMP, RRT, David Young, DO, Larry Rawsthorne, MD, and Stephen Guertin, MD. Next page: Sparrow Hospital in Lansing, Mich.
When patients go into respiratory arrest, the RTs are the first ones who are called, says Mark Wehner, PMP, RRT, at Sparrow Health System. When it comes to looking at airways, who better to deal with it than an RT? In this field we have the ability to increase our value by providing service to the doctors, serving more and more as a physicians assistant.
Sparrow has begun relying on RTs for the full breadth of their skill setto the benefit of the therapists, patients, and facility overall. Three years ago, the Lansing, Mich, health system installed a number of programs that represented a strategic commitment from pulmonary services and the facilitys physicians to maximize the use of RTs in the hospital. Since their inception, those four programs have proven so successful that Sparrow plans to add two more programs next year, one for tracheotomy patients and one offering assessment-driven treatment.
These programs have really created a revolution in the way we care for respiratory patients in this institution, says Stephen Guertin, MD, medical director of the Regional Childrens Center at Sparrow. They have enabled us to produce standardized care based on the best medical evidence, and have brought about a dramatic change in the role of RTs.
Faced with increased financial constraints brought on by the Balanced Budget Act, Sparrows senior vice president of operations, Dennis Swan, asked each department several years ago what they could do to better regulate cost and improve patient care.
We knew that RTs could be better utilized in providing pulmonary care, Wehner says. The RTs skills werent being fully utilized in favor of doing procedure-based things, such as giving aerosol. We have been able to shift that paradigm so that our role is now outcome-oriented. Today, these programs are structured to let us ask, What is the length of stay? Are we improving patients? Are we utilizing our skills to the best possible level? We have tried to maximize our professional relationship to the physicians. They are our customers, and thats an interesting way to look at the profession, Wehner says.
Programs at Work
The impetus for the programs was a tremendous variability in how we were taking care of asthma patients and the regimen in which they were discharged, Guertin says. The initial pediatric asthma project was a collaboration with the RT department, and it relied on their expertise because they actually see the child far more frequently than either nurses or residents.
The protocols relied on evidence-based medicine and best practices, and Sparrow did its own research and took recommendations from the National Institutes of Health, the American Lung Association, and the American Academy of Pediatrics. It also did a search from an evidence-based instrument to make sure those recommendations had an adequate evidence base, and found tremendous support in the medical literature for the programs that have evolved, according to Guertin.
We also asked the physicians what they wanted from us, and they said they want information, like whether their patient is progressing and, if not, what the immediate options would be for that patient, Wehner says.
The scoring system on patient performance is objective, with a collaborative decision made between the physicians and the RTs concerning each individuals progress.
The success of the new approach led to a similar standard of care being adopted by the pediatrics and family practice departments, and a new adult asthma treatment center program, a second pediatric program for the care of patients with bronchiolitis, and an adult program in COPD. Each program makes use of the respiratory therapy departments staff, which consists of 80 members. Ten to 16 therapists are at work each day, based on the season.
The RT-to-adult asthma patient ratio is one to five; for COPD, its one to three or four; and for the pediatric programs, its one to four or five, depending on where the pediatric patients are in their progression of care, Wehner says.
In the pediatric asthma program, the average length of stay decreased from 2.61 days in 1999 to 1.7 days in 2002. For the COPD program, the average inpatient length of stay dropped from 4.7 days for the control group to 3.6 days for the group of patients enrolled.
David Young, DO, medical director for respiratory services, says it is remarkable how much more quickly Sparrow has been able to move patients through the system since adopting the programs.
Thinking back, having physicians come by once a day, start to wean patients from the ventilators, then disappear for 24 hours was not efficient, Young says. The RTs and nurses are here all the time, so they can monitor the patients ups and downs. As a result, patients are off the ventilator quicker and its easier for us because we dont have to write every single order.
Pediatric patients are being rapidly advanced in the intensity of therapy to more rapidly break asthma attacks. There are standardized discharge instructions as well, so now those kids are going home on a maintenance therapy consisting of an inhaled steroid and long-acting beta-agonists, Guertin says. Their families have been very well educated, and we are seeing a dramatic increase in the use of inhalers and spacers in young asthmatics. The bronchiolitis program allows us to challenge children and, based on their response, stop giving them dilators, Guertin says. Because of that, we have dramatically reduced the use of bronchodilators during the high season, which is good for kids and good for the hospital.
While the facility does focus on numbers it can measure, such as length of stay and cost per patient, pulmonologist Larry Rawsthorne, MD, notes that the standardization of care and a decrease in variation of care are other benefits of the programs.
Patients are learning more about their disease states and how to better manage them, but that is a hard thing to measure, says Rawsthorne, vice president of medical affairs. However, we know patients know more about their illness than when they came into the hospital.
Because the collaboration has been so successful, the respiratory therapy and adult critical care departments are developing other programs for Sparrow. Those include a ventilator weaning program, a tracheotomy program, and a program on assessment-driven treatments.
Every place Ive worked, people dont like taking care of the tracheotomy patients, Young says. There is never a good standardized handle on what to do with those patients, and there is no great literature on what to do with them either. We have to fly by the seat of our pants and that is a real frustration. The other programs have worked so well, and Mark Wehner really singled this area out as a good niche to target next. I think it will be a boon for our patients.
Rawsthorne adds that these programs are springboards for looking at pneumococcal and flu vaccines for the hospitals patients.
They are helping outside the spectrum of care of pulmonary diseases, he says.
Moving RTs into the Future
Presentations on the programs have garnered interest from institutions throughout the United States. There may be an element that is unique to Sparrow, however, and that is the quality of the RT staff.
RTs are typically younger, single people who are going on to do something else, but here we have high-seniority, experienced RTs, Young says. They are motivated RTs who seek out what other institutions are doing, and are comfortable taking care of sick patients. We have a really great crew here, and because of that we are able to do a lot of things that are typically done only at bigger tertiary care places with more funding.
One of the biggest challenges facing the RTs is posteducation. There have been a lot of advances in disease management since I graduated in 1995, so education for RTs needs to be on a rolling basis so we can keep up with the latest medical practices and clinical outcomes, Wehner says. Ultimately, RTs have to decide: Are we going to be ancillary and provide procedures, or are we going to be professional and provide a benefit and become a physician assistant?
We are talented and well educated, and luckily the genie is out of the bottle at Sparrow, Wehner says. Physicians are telling therapists to do what they do best: provide pulmonary care for their patients. Were moving forward.
And according to Sparrows physicians, such advanced utilization of RTs is something that can and should be happening in other institutions as well.
RTs have talent and expertise that institutions should structure themselves to take advantage of, Rawsthorne says. At Sparrow we take advantage of that talent as well as their technical knowledge and expertise, and I do think thats a model that institutions should follow.
Elizabeth Finch is a contributing writer for RT.