Respiratory therapists Long Nguyen and Connie Park evaluate a critical care neonate in the level III NICU.
When he was a student, respiratory care practitioner Long Nguyen completed a semester-long residency at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif, and knew immediately he had found his number one choice for employment. The growth opportunities, thorough, ongoing training, and—most of all—the people convinced him that this hospital was the best place to work.
SCVMC, a 524-bed public teaching hospital, is one of the largest medical centers in Northern California. The facility runs its own residency program and also partners with a program out of Stanford University. The hospital serves as the hub of emergency medical services in this part of the state, and its patient population includes nearly 75% medically indigent adults.
SCVMC provides a range of services, including inpatient, outpatient, and acute care and comprises six adult intensive care units and a neonatal intensive care unit; a burn center; a rehabilitation trauma unit; and a spinal cord unit. One of the hallmarks of the hospital is its close collaborative relationship with its respiratory care department, which plays an integral role in managing and maintaining the health of all its patients.
Craig Ivie, RCP, manager of the department, started working at SCVMC in 1991 and assumed his current position in 2004. He reports that the respiratory therapy department includes close to 90 therapists who perform, on average, 800 procedures every day within every area of the hospital. The department’s positive impact on patient care throughout the facility—particularly in the ICUs—can be attributed to several protocols, the first of which was developed and implemented in 1994.
PROTOCOLS BENEFIT PATIENTS AND STAFF
According to Ivie, 90% of the department’s work—from ventilator management and oxygenation therapy to specific intrapulmonary percussive ventilation (IPV) and bronchodilator treatment—is protocol driven. “This puts respiratory therapy in the middle of the multidisciplinary team in the ICUs. We round with the team and provide input. These protocols have improved communication between team members,” he says.
The first protocols, which were written over a 2-day period by a group of 17 respiratory care therapists, were implemented in the medical intensive care unit (MICU) and surgical intensive care unit (SICU). “We figured out where the care should go. We went through the approval process and took changes from the physicians. There are so many disciplines, and we had to develop protocols accepted by all areas. Our therapists did a great job making it work,” Ivie says. All protocols have been developed according to American Association for Respiratory Care (AARC) effective guidelines, based on outcomes. “If the protocols didn’t benefit the patients, we couldn’t grow the program in all adult areas,” he adds.
Respiratory care practitioner John Dietrich, a 19-year veteran of SCVMC who administers the protocol in the MICU and cardiac intensive care unit (CICU), says, “The protocol saves time and moves the patient quicker than a nonventilator care protocol.”
From left, Long T, Steven Tam, and Sue Rodriguez discuss a ventilated spinal cord injury patient in the rehabilitation trauma unit.
Within 1 year of implementation, the protocols were expanded to all units throughout the hospital, except for the neonatal and pediatric units where a lead pediatric respiratory therapist acts as a liaison between the nursing staff and the respiratory therapy department. “We respond to high-risk deliveries and have a high level of involvement,” says Ivie. “Because respiratory therapy works so well with the nurses, our suggestions are readily accepted. Through patient rounds, we figure out how best to treat.”
Ivie points out that standardizing procedures has expedited care and improved staff efficiency. “After the first year, we compared data using the protocols. We had reduced the length of stay by 2.7 days. Every year since then, we’ve continued to reduce the lengths of stay. Now we are down to 3.78 days per patient. A reduced ICU stay usually means a reduced overall hospital stay,” he says. “But the biggest impact has been the increased communication between everyone in the medical center. The protocols give residents, nurses, and doctors a guide as to what to do next to wean the patient from a ventilator.”
The respiratory department is especially pleased with the outcomes in the spinal cord unit. “The respiratory therapist has to spend an hour to an hour and a half doing secretion management, bronchodilation, ventilation, T-tube insertion, and monitoring vital capacities. We do a lot of huddles—multidisciplinary meetings—looking at total care of the patient,” says Ivie. “Someone with a fresh injury can spend between 21 and 28 days in the spinal cord ICU. We try to get them off the ventilator or to best case scenario as soon as we can.”
POSITIVE OUTCOMES IN-HOSPITAL AND AT HOME
While the protocol is achieving its goal of restoring a spinal cord patient’s normal breathing pattern as soon as medically possible, it has proven to have additional benefits. Ivie says, “Getting the ventilator home care company to take on an indigent patient [upon discharge] had been challenging. It could take up to 3 weeks to get approval. Then we needed to bring in the equipment and train the family and patient to use it. That took another week or two. So now we were up to 5 weeks,” he says.
With the protocol in place, patients begin using LTV1200 ventilators as soon as they pass the initial injury phase. Ivie says, “We start the training and approval process right then. When the patient is ready to go home, it eliminates 5 extra weeks of being an inpatient. This makes a big difference in patient satisfaction. Physicians and staff are also much happier.”
Therapists have the luxury of choosing from several equipment options, including VDR4 high frequency ventilators for patients with acute respiratory distress syndrome (ARDS), which have increased survival rate to home by as much as 65%. Therapists also use online IPV for patients with pneumonia, mucus plugs, and asthma; continuous IPV for aggressive treatment designed to move patients out of the ICU within 24 hours; and SenTec monitors to treat the sickest patients.
“Our therapists are proud of the work they are doing as a county hospital. We are fortunate administration allows us to obtain state-of-the-art equipment. We have a fleet of 60 Servo-i ventilators and 10 GE Carestations for use in the nursery,” Ivie says. “Our therapists have a wide choice when it comes to equipment to treat.”
From left, Craig Ivie teaches John Dietrich, Joanne McKee, and Donna Nickolopoulos how to use the VDR4 high frequency ventilator.
In addition to working in the special units, respiratory therapists contribute significantly to care in the emergency room, very often running three or four ventilators simultaneously; administering metered dose inhalers, small valve nebulizers, and BiPAP; and starting initial ventilation. Additionally, four respiratory therapists perform as many as 1,500 studies annually in the pulmonary function department and also answer equipment-related questions.
SCVMC participates in a residency program with Stanford University and also sponsors its own. Respiratory therapists interact routinely with residents and attendings at bedside and during rounds, assisting with training at all levels and guiding interns as part of their education. Ivie says, “We have a dynamic relationship with residents.”
SCVMC has been involved in numerous studies throughout the years, specifically with the NICU and spinal cord rehabilitation therapies. Dietrich notes that in the respiratory field several studies have examined ways to successfully ventilate spinal cord patients. This year the respiratory care department is launching its first primary study, a lung recruitment trial that will research more viable ways to treat ARDS. “We hope to see how we can open lungs, keep them open, ventilate better, and wean the patient better. By venting more of the lung, we can use lower pressure, which is better for the lung,” says Ivie. “We’ll look at oxygenation to reduce length of stay.” The department’s therapists plan to measure functional residual capacity (FRC) and record outcome data, which will help identify more effective ways to wean patients off ventilators sooner.
NEW TECHNOLOGY AND ADDED SPACE INCREASE PRODUCTIVITY
Until 8 years ago, the respiratory therapy department utilized manual charting, a cumbersome, time-consuming, somewhat inefficient means of tracking procedures, care, and costs. “We partnered with rehabilitation services to purchase the [MediLinks] program from MediServe Corp in 2004. This purchase has brought tremendous benefits business wise and professionally,” says Ivie. “Notes are legible and concise. We have increased our charge capture by up to $200,000 a month. This has helped our overall productivity.”
Therapists use 200 wireless, full-size laptops on movable carts that can easily travel from one unit to another. Ivie notes that the county recently signed a contract with software company Epic and the entire medical facility will be fully integrated by May 2013.
In spring 2014, the respiratory care department will be on the move—to a new building on campus. The new structure will add 200 beds and 32 ICU beds to the existing ones at SCVMC. Respiratory care will occupy a larger space with 1,000 square feet for storing equipment. “The main report area will seat 48 staff members. There will be a locker/break room and computer workstations with AV equipment for educational in-service programs,” says Ivie. “We’ll have piped-in air and O2 as well as 60 vents.” He explains that the department uses more than 100 vents to test equipment so this will facilitate the task. “We can test several at a time and do routine maintenance.” A small conference room/library will accommodate 10 to 12 people.
PERKS LEAD TO LONGEVITY AND JOB SATISFACTION
While most of the therapists at SCVMC are veterans in the field, recent graduates sometimes join the team. “Hiring someone new is good because we have an opportunity to mold that person into the kind of therapist that works well for the institution,” Ivie says. “They have to be aggressive, use the skills they’ve been taught and what they learn here. We are so protocol driven, the person can’t fear talking to the doctors. They have to take the initiative and advocate for the patient.”
The respiratory care team at Santa Clara Valley Medical Center.
Due to the working environment, excellent benefits, and opportunities for growth, SCVMC has retained many of the same respiratory therapists for several years. “It’s quite common for staff to stay. We have fabulous benefits, the pay is okay, and we have a great retirement/medical package. Because of everything you see and can do, staff gets vested in the county system. We also enjoy autonomy that may not be afforded at other hospitals,” he says, citing a less than 2% turnover rate.
Staff also benefit from the department’s firm belief in ongoing training and education. An initial orientation of 6 weeks with more intense training for specific practice areas is just the beginning. Throughout the year, the department sponsors between eight and 12 lectures that offer CEUs. “For instance, a pulmonologist might come in to give a chest x-ray interpretation refresher,” Ivie says. He has been involved with the California Society for Respiratory Care (CSRC) in the greater Bay region and notes that the department encourages participation in conferences and classes and provides tuition reimbursement and leave to attend the session.
Ask Dietrich why he’s remained at SCVMC for nearly 20 years and he’ll immediately respond, “It’s the people I work with. Most of them have been here for 10 years or more. It’s like a family.” He adds that the opportunity to work in several different areas within the hospital keeps the job fresh and exciting. “You’re not pegged to one role. You can grow and do what you want,” he says. “Job satisfaction in this department is high. Several therapists have been here for 20+ years.”
Nguyen, a relative newcomer with 3 years under his belt, agrees completely. He has had the opportunity to work in rehabilitation, the burn unit, the ICU, med/surg, and the NICU and says he enjoys the challenge that each different area poses. “We see some interesting cases. We are encouraged to think about how we can solve a problem,” he says.
Nguyen plans to stay at SCVMC for the long haul and looks forward to learning more and growing professionally. “I’m still green, but the other therapists are helping me learn the ropes,” he says. “They’ve made me feel very welcome.”
Phyllis Hanlon is a contributing writer for RT. For further information, contact .
SANTA CLARA VALLEY MEDICAL CENTER
751 S Bascom Ave
San Jose, CA 95128