The increasing practice of heavily relying on protocol-driven patient care among respiratory care departments nationwide has elevated the respiratory care profession and increased the need for higher skill standards. For some of the nation’s top hospitals, that means a preference toward hiring registered respiratory therapists (RRTs). We spoke with three premier facilities regarding scope of practice, minimum hiring requirements, and the general organization of their departments to see how they compared and where they differed. Here’s what we found.

Johns Hopkins Bayview

Johns Hopkins Bayview (JHB), founded in 1773, is part of the famed Johns Hopkins Health System and one of the oldest, continuous health care systems on the East Coast. The more than 700-bed facility in Baltimore has a comprehensive neonatal intensive care unit, a sleep disorder center, a trauma center, and a regional burn center.

Johns Hopkins Bayview’s Respiratory Care Systems and Programs employs 73 full-time and three part-time respiratory therapists along with two full-time equipment techs, a department director, a systems and program manager, an adult acute care supervisor, a neonatal intensive care/pediatrics supervisor, a pulmonary rehabilitation coordinator, and a department secretary. Frank Miller, BS, RRT, manager of the department, says that each shift requires a minimum of seven respiratory therapists for adult acute care, two for the neonatal ICU, and four for the long-term ventilator unit. “Each shift consists of a charge therapist,” Miller says. “The remainder is core respiratory staff.”

Johns Hopkins Bayview requires that, at a minimum, its therapists be certified. Only those who work in the neonatal ICU must be registered respiratory therapists. “But there are high expectations that all staff obtain their RRT credential,” says Miller. “We have just recently made significant changes to our pay structure that distinguishes between the CRT and RRT credential.” The pay premium for registered therapists begins at 10% and increases from there based on a therapist’s experience level.

The scope of practice and skills Bayview requires of its therapists differs for each area of patient care. Likewise, clinical skill requirements are based on a therapist’s area of care and build on the minimum skills required of any therapist who has passed a national competency exam. “We believe that specific clinical skills required and necessary for the independent areas of service can be taught to any nationally credentialed therapist,” says Miller. “The skills that we are really looking for and require are behavioral skills: customer relations, self-management, teamwork, communication, ownership and accountability, and the ability and desire for continuous improvement.”

Kelly Gerhardt, RRT, and Greg Shelton, BS, RRT, NPS, setting up a high-frequency jet ventilator in JHB’s NICU.

Bayview’s therapists work independently through extensive use of protocols and are able to adjust patient care. Specific protocols include: oxygen titration, ventilator weaning, ARDS ventilator management protocol, nebulized antibiotics, small-volume nebulizer/metered dose inhaler conversion, and rapid response assess/treat. At any time, any member of a health care team can call upon a respiratory therapist to address questions or concerns about a patient’s pulmonary status, and each area of the hospital is assigned a designated respiratory therapist to respond to questions or needs. If something more formal is required, a member of a health care team can initiate a rapid response team call.

“Our rapid response team comprises a critical care nurse and a respiratory therapist. Since the literature and our practice indicate that more than 50% of all rapid response calls are respiratory related, our therapists are relied upon for their clinical expertise,” says Miller. “We also receive consult calls from our discharge planners to help with patients who are being discharged with ongoing respiratory needs.”

Johns Hopkins Bayview prides itself on having a strong retention strategy. “We do not just want to rely upon our reputation as being one of the best. We want to consistently and continuously demonstrate that we are the best,” says Miller. “We also want to make our [therapists] feel valued and let them know that what they are doing is making a difference,” he says. To this end, therapists are given quality tools and proper direction so they can provide superior patient care. “We are building a department in which therapists are not going to want to leave,” Miller says. A strong reputation also helps when recruiting, and Bayview draws heavily from the graduates of Salisbury University and the Community College of Baltimore County, Essex, both of which have internship programs set up with Bayview’s Respiratory Care Systems and Programs.

UC San Diego Medical Center

Timothy Morris, MD, medical director of respiratory care, on rounds with respiratory care staff at UCSD Medical Center.

The University of California, San Diego, Medical Center’s setup is unique in that a single respiratory care department serves two hospitals: Thornton Hospital in La Jolla and Hillcrest in downtown San Diego. Rick Ford, BS, RRT, is the director of respiratory services for the hospitals. “We are one department across two sites,” says Ford. The department also includes two pulmonary function laboratories and pulmonary rehabilitation.

The department consists of 115 people, of which approximately 40 are part-time. Thornton Hospital is a 125-bed luxury facility that runs two 12-hour shifts. As many as five respiratory therapists handle the day shift, with approximately three assigned to the night shift. The much larger Hillcrest facility is staffed with as many as 15 therapists by day and eight by night. “Downtown we have all kinds of shifts,” says Ford. “We have people working 12s and people working 8s.”

Ford also has a management team that floats between the two hospitals. The management team consists of a technical director, three shift coordinators, two ICU coordinators, a protocol manager, an educator, and an information technology systems specialist. “All of these people are clinical people as well who do patient care,” says Ford. “Only the technical director, information technology systems specialist, and I do not do clinical care.” All of Ford’s respiratory therapists have a work permit issued by the California Respiratory Care Board. “I require a 2-year associate degree. I hire CRTs and RRTs, but we have a preference for RRTs,” Ford notes. “If we hire CRTs, we provide them with educational support and a timeline in which to get their RRT. We usually give them a year.”

Currently, approximately 90% of the respiratory therapists in Ford’s department are registered therapists. RRTs can work independently in ICUs as dictated by the skills set required by the State of California. “They have to have a high level of critical thinking to manage care delivery through patient-driven protocols,” Ford notes. About 90% of the care provided by Ford’s therapists is protocol driven. “They decide the frequency and the type of care a patient is going to get,” he says. “Our therapists need to be go-getters. Some people like to come to work and get a list of things to do, but that’s not what happens here. You get a list of patients and you decide what to do.”

Even the management team works with a great deal of administrative autonomy. “My staff does the interviewing and then tells me who to hire and why.” The UC San Diego Medical Center recruits therapists by presenting to both high school students and respiratory care programs. It also runs an internship program for Grossmont Community College. “We put on our best for those students,” says Ford. The medical center offers competitive wage and benefit packages to attract respiratory therapists and retains them by providing the time, equipment, and training resources they need to do their jobs well. Plus, Ford adds, they get lots of recognition for a job well done.

Cox Health Systems

Cox Health Systems’ therapist Shana Morrison doing an assess-and-treat evaluation on a patient.

Cox Health Systems consists of three hospitals with a total of 986 beds that serve 25 counties in Missouri. Cox South in Springfield is the largest of the hospitals, with 563 beds, 102 full-time respiratory therapists, and 24 part-time therapists. Unlike the UC San Diego Medical Center, Cox Health Systems hospitals have separate respiratory care departments. Cox South is by far the largest. Together, the other two hospitals, Cox North and Walnut Lawn, have 15 respiratory therapists.

Cox South is staffed with 22 respiratory therapists by day and 15 at night. Each shift has a shift supervisor, and a team leader is assigned to each of the hospital’s three adult critical care units, a step-down unit, a pediatric critical care unit, and a neonatal critical care unit. The chain of command from top to bottom is floor shift supervisor, alternate shift supervisor, team leaders, and therapists, says Jack Edge, RRT, alternate day shift supervisor at Cox South.

Cox South requires that, at a minimum, its therapists be certified respiratory therapists. “We look at the competency of individuals rather than credentials,” says Edge. “We generally hire RRTs, but we are not opposed to hiring CRTs if they have high skill levels.” Currently, 100 of Cox South’s therapists are RRTs, and 26 are CRTs. The CRTs at Cox fall into two categories, says Edge: Those who have gone through the registry program but have not taken their test, and others who have been at the hospital for a long time and who perform at a very high level throughout the facility.

All new hires at Cox South who work in one of the hospital’s critical care units, regardless of whether they are new graduates or have years of experience, need to go through an extensive training program in which they work closely with a team leader before they are allowed to work independently. “Whether they are a CRT or an RRT, they go through the same training in critical care units and are considered to have the same skills when they are done,” Edge notes. Floor therapists also work at a high level of autonomy and go through a similar in-house noninvasive training program.

Like Bayview and San Diego Medical, Cox has developed a comprehensive set of protocols, which began with a general assess and treat protocol. This protocol was so successful that the nursing staff and administration asked the respiratory care department to develop a postoperative assess and treat protocol. Patients with a potential to run into postoperative problems, such as those on narcotics, the obese, and those with COPD, were flagged for the protocol, says Edge. That led to even more protocols. “Emergency services requested an assess and treat for trauma patients. We arranged our protocols so they overlap and progress from one protocol to another as a patient’s condition changes,” Edge notes. For example, he says, a patient assessment is triggered with a FiO2 threshold of 0.50. Patients that meet the criteria are placed on the noninvasive protocol, but if they do not show adequate improvement in 4 hours, a physician contact is triggered for intubation. If an order is obtained, the patient moves to the invasive protocol. On extubation, the patient returns to the general assess and treat for oxygen.

“One of the things I personally like best about working at our facility is that we enjoy a great deal of autonomy, and it is all due to the comprehensive protocols,” says Edge. “It is very rare that a physician writes a specific invasive or noninvasive order. When physicians come through on rounds, we discuss goals and strategies with the physician at bedside. We enjoy a great deal of respect from our nurses and physicians, which makes for a very pleasant working environment,” Edge says. Most of the therapists at Cox are recruited through Ozark Technical College in Springfield. Students complete a clinical rotation with Cox, and graduates of the program are eligible for the registry exam.

Fran Howard is a contributing writer for  RT. For further information, contact [email protected]