The pioneering spirit of its namesake still resonates at Ohio’s Kettering Medical Center today
Charles F. Kettering was a world-renowned American scientist, humanitarian, and “screwdriver and pliers” inventor, who created the first spark plug, the electric cash register, and freon for refrigerators and air conditioners. In 1945, Kettering and another visionary, Alfred Sloan, established the New York City-based Sloan-Kettering Institute for Cancer Research, which later became one of the world’s premier cancer institutions.
Throughout his life, Kettering believed strongly in the importance of hard work, ingenuity, and technology. Today, this focus on innovation is pervasive at the Kettering Medical Center, a not-for-profit hospital that was named for him, in Kettering, Ohio. In the pioneering spirit of its namesake, the center, which opened in 1964, offers the latest diagnostic and treatment therapies.
Novel Respiratory Care
Kettering’s respiratory care department has maintained its reputation for delivering cutting-edge services. In fact, Kettering was the first hospital in the Dayton area to develop respiratory therapist-driven protocols and one of the first in Ohio to have several protocols in place by the mid-1990s. “We started planning for our protocols in 1991, and by 1993 they were launched,” says Roger Rickel, RRT, director of Respiratory Care Services. By 1995, therapist-driven protocols were phased in throughout the hospital. Currently, the department uses protocols for oxygen therapy, medication aerosol, post heart surgery, lung expansion, long-term hygiene, pulse oximetry, and pulmonary rehabilitation.
According to Rickel, developing protocols was not easy as there were few models available at the time to serve as guides. With the help of the department’s medical director, George Burton, MD, and resources from the National Association for Medical Direction of Respiratory Care, (NAMDRC), Rickel and his staff were able to create protocols that were easily accepted by physicians. “We started by analyzing all of our care paths in order to establish eight different areas that would lend themselves to protocols,” Rickel says. “The reason we succeeded was that from the very beginning, we were committed to obtaining physician buy-in.” Today, 94 percent of Kettering’s physicians use the protocols, and Rickel points out that the minority currently not using them is gradually embracing them as they come to recognize their value.
It did not take long before the therapist-driven protocols proved successful from both a financial and a clinical standpoint. Rickel and his staff assess outcomes semi-annually to determine the effectiveness of the protocols. “For the past couple of years, the protocols have saved us approximately $1.3 million annually,” Rickel says. “This net savings comes from the fact that we’re not overutilizing care; we’re providing the appropriate level of care based on patients’ needs,” he says. A fairly extensive look at clinical data has also revealed an 80 percent improvement rating in clinical outcomes across the board.
David Minge, RRT, a staff therapist at Kettering, notes that therapists now have a more active role in patient care because of the protocols. “The physicians rely heavily on our knowledge and assessment skills to inform them of important developments,” Minge says. “Protocols have made the scope of our job greater as well as more satisfying.”
Rickel concurs that protocols have given RCPs greater control in caring for their patients than in the past. “Protocols succeed best when there’s strong teamwork between therapists and physicians,” he says. “Doctors at Kettering recognize that the only way to ensure that patients receive the appropriate level of care is to entrust decisions to therapists who are involved in the patients’ day-to-day care.”
A Focus on Teamwork
Kettering Medical Center offers RCPs a wealth of professional opportunities in six different patient care areas within the institution. In addition to the 522-bed Charles F. Kettering Memorial Hospital, Kettering Medical Center also includes 184-bed Sycamore Hospital, which offers most of the center’s cardiopulmonary services. Therapists are staffed at both Kettering Memorial Hospital and Sycamore Hospital, as well as the diagnostic laboratory, the pulmonary rehabilitation program (both inpatient and outpatient), skilled nursing facilities, and the hyperbaric laboratory. The department currently has 83 full-time employees, which include both clinical and administrative staff.
The 5-South floor in Kettering Memorial Hospital is devoted solely to pulmonary patients. In addition to housing patients with COPD, pneumonia, respiratory tract infections, and tracheotomies, 5-South also serves as a step-down unit where patients are often weaned from ventilators and tracheotomy tubes.
Minge, who works primarily on 5-South and in the hyperbaric laboratory, stresses that therapists are assigned daily to the same general area, which allows them to get to know their patients well. But at the same time, therapists are trained to work in other areas. “One of the big pushes at Kettering is a focus on multidisciplinary care, which means all therapists need to be competent in many different areas,” he says. “If one area is short on staff, every respiratory therapist needs to be able to quickly step in to help out.”
Teamwork is also fostered between nurses and respiratory therapists. An example of this collaboration is in the intensive care unit, where both the RCP and the nurse help change the ties that hold the oxygen tubes in place as well as perform suctioning. “We share many jobs such as lung volume expansion, and if either a nurse or a therapist falls behind, the other is always there to help out,” Minge says. Still, if patients are being weaned from the ventilator, the RCP is completely in charge.
One of the reasons the RCP has a prominent position on the patient care team, Rickel says, is that years ago the department took a proactive stance to ensure an RCP is assigned to every unit. “Physicians and other members of the care team quickly recognized that therapists could contribute to patient care in a variety of ways,” he says. Now Kettering’s RCPs are responsible for electrocardiograms, phlebotomy, and intravenous units.
Managed Care Woes
Despite its success in delivering quality care, Kettering Medical Center has not been immune from the problems created by managed care companies. In fact, the respiratory care department has been hit hard during the past few years by budget cuts, resulting from hospital-wide cost-containment measures. In 1998, Rickel was forced to reduce staff by 17 full-time employees (FTEs). To continue providing quality care with fewer staff, the department launched Process Improvement Teams, which meet monthly to develop strategies for increasing productivity. “If we’re going to increase our workload, we need to make things easier and more efficient for staff,” Rickel says. “Therefore, we’re scrutinizing all the steps we’ve taken in the past when treating patients.” One Process Improvement Team discovered that the method of delivering aerosol medication could be changed to increase efficiency. “When we switched to different nebulizers, we were able to nebulize in 5 minutes or less while giving patients all the medicine they needed,” Rickel says. “Therapists can now be more productive when providing this therapy.”
The respiratory care department is also finding that managed care companies are becoming more interested in reviewing outcomes data, particularly for Kettering’s skilled nursing facilities. “We’ve been successful in getting reimbursement from private insurers by utilizing our protocols and then showing them patient outcomes data,” Rickel says. “We’re able to prove to them that we can get their members the appropriate care at a lower cost.” Outcomes data have also been effective in obtaining adequate reimbursement for pulmonary rehabilitation. “Once again, the protocol and outcomes data have been successful in showing insurers that we have a track record in getting pulmonary rehab patients better in a shorter period of time and at a lower cost to them,” Rickel says.
Kettering’s pulmonary rehabilitation program, which treats both inpatients and outpatients, is one of the oldest of its kind east of the Mississippi. According to Rickel, Kettering’s outcomes have been used as national standards for other institutions. Approximately 2,400 patients receive pulmonary rehabilitation annually. “We’ve found that published outcomes standards are important in disease management, as patients are then aware of how they can achieve their own health objectives,” Rickel says. “Many of these patients previously had chronic problems that forced them to keep being admitted to the hospital; however, after our program, many are able to live a more normal life with fewer hospital returns.”
Kettering is also well known for its hyperbaric therapy program. With two monoplace chambers, Kettering is the only civilian hospital in the Dayton area with hyperbaric medicine. (Dayton-based Wright-Patterson US Air Force Base has one of the largest chambers in the United States.) About six patients are treated each day in the hyperbaric program, and an RCP certified in hyperbaric therapy is staffed there at all times. One of the most common indications for hyperbaric therapy is nonhealing wounds, particularly those in diabetic patients; however, other conditions include osteoradionecrosis, osteomyelitis, gas gangrene, decompression sickness, and carbon monoxide poisoning.
The expanding role for Kettering’s RCPs–whether it involves hyperbaric therapy or routine inpatient bedside care–brings great satisfaction to most RCPs. According to Rickel, a greater focus on patient education has given therapists the opportunity to do what they wanted to do when they first selected their careers: work with patients to help them get better. “One of our biggest jobs now is to educate patients on how to use equipment and medications properly so they don’t have to return to the hospital,” Rickel says. “We’re constantly addressing that. If the therapist is in the patient’s room for 5 to 10 minutes, how can he use that time most effectively to both treat the patient and provide adequate education about different therapies?” One example of this situation involves metered-dose inhalers (MDIs). Kettering’s RCPs not only deliver MDIs to patients, but also educate them on the use of the equipment and medication.
Rickel stresses that RCPs are being viewed more as consultants or educators than as technicians. He adds that therapists with top-notch diagnostic and critical care skills will especially be in demand in the years ahead. “To be successful as a respiratory therapist, one must be very team-oriented and flexible to take on new roles,” he says. “There are more opportunities than ever before for respiratory care practitioners, but in today’s competitive, uncertain environment, therapists need to be motivated enough to make the necessary changes, so they don’t get left behind.”
Carol Daus is a contributing writer for RT.