The Methodist Hospital in Houston keeps RTs educated and takes the lead in respiratory care initiatives.
It is not surprising that respiratory care has taken on a whole new dimension at Houston-based Methodist Hospital. As home of the internationally acclaimed heart surgeon Michael E. De Bakey, MD, Methodist not only has a reputation for providing state-of-the-art cardiovascular care, it also is known for relying heavily on its multidisciplinary team, of which the RCP is a vital member. As a result, veteran RCPs at Methodist have watched their jobs change dramatically over the years, from being mere oxygen jockeys in the early days of the profession to becoming physician extenders in today’s cost-conscious health care environment.
“Today we are required to be more patient-focused, and we rely heavily on critical thinking skills, compared to the past when all we did was simple tasks,” says Cathy Meents, BS, RRT, co-manager of respiratory care services. “Due to so many different options in treating patients with cardiopulmonary disease, therapists at Methodist–and other large tertiary teaching hospitals–need to be knowledgeable on so many different fronts.”
According to Joe Rodarte, MD, co-medical director of respiratory care services, and professor and chief of pulmonary and critical care medicine at Baylor College of Medicine, and chief of pulmonary medicine at Methodist Hospital, one of the biggest changes is that RCPs have become important physician extenders at Methodist. “Physicians here have tremendous respect for respiratory therapists and they want them closely involved in assessing patients, particularly in alerting them to potential problems,” Rodarte says.
In addition to this strong collaboration between RCPs, physicians, and other health care professionals, Methodist also has the distinction of being one of the nation’s leading centers for medical education and research. As a result, Methodist therapists have enormous professional and educational opportunities that do not exist in many smaller institutions. Methodist is the adult teaching site for Baylor College of Medicine and has been named among the country’s top centers for urology, otolaryngology, geriatrics, ophthalmology, gynecology, and neurology/neurosurgery in US News and World Report‘s 1998 annual guide to “America’s Best Hospitals.”
The Hub of Respiratory Care
The Respiratory Care Services Department consists of two major divisions: diagnostic (with 16 FTEs) and therapeutics (with 104 FTEs). The diagnostic or pulmonary function area offers inpatient and outpatient pulmonary diagnostic testing, including spirometry with and without bronchodilators, diffusion studies, lung volume studies, airway resistance studies, pulmonary-graded exercise studies, metabolic studies, and blood gas collection, analysis, and reporting. Therapists also provide 24-hour support to physicians performing fiber-optic bronchoscopies. A unique feature of registered therapists providing assistance with bronchoscopies at Methodist Hospital is that they are hospital-credentialed to administer and monitor for conscious sedation.
Methodist’s pulmonary function laboratory not only is one of the most sophisticated in the country, it also handles one of the largest volumes of pulmonary tests. It is not uncommon for Methodist’s pulmonary laboratory to conduct as many as 25 pulmonary function tests in 1 day. The laboratory has five full testing stations, four of which have body plethysmographs and all have gas dilutional/lung volume capabilities in addition to plethysmographic volume determination capabilities. All of the laboratory functions are networked together into a server, and the data derived from these tests are placed into a fully relational clinical database.
RCPs in Methodist’s therapeutic division are assigned primarily to the hospital’s intensive care units, which represent about 120 beds. In addition to one coronary care ICU, Methodist also has three postoperative surgical ICUs, a medical ICU, a neurosurgical ICU, and a smaller neurology/ear nose and throat ICU. The department has one director, two managers, nine supervisors, an education coordinator, and two programmer/analysts. Three different computer networks are used within the department: for clinical respiratory care, the blood gas laboratories, and the pulmonary function laboratory. Methodist has an enviable inventory of equipment with 92 ventilators, all of which will be upgraded in June. In addition, the department has 14 noninvasive bilevel positive airway pressure ventilators.
Everything Respiratory Care Services does is tracked and measured through an elaborate, computer-based management information system. Therapists do their charting on mobile point-of-care computers, and progress notes are printed from the database. “All of the data are dumped into a fully relational clinical database, so if we want to look at some aspect of a project retrospectively or concurrently, we have the capability to see who’s doing what and when, and we can measure according to which variables are available in the database field,” says David Wheeler, RRT, director of respiratory care services. “As a simplified example, we can measure adverse reactions by practitioner, by physician, by diagnosis, by unit, or by time of day in addition to just measuring the reaction by medication type and dose,” Wheeler adds.
The Heart Care Database the hospital currently uses in assessing outcomes for cardiovascular surgery was actually created and launched by the Respiratory Care Services Department several years ago. Based on the New York State’s Heart Care Database, the Methodist database was created after respiratory care staff started collecting postoperative outcomes data and then teamed up with the hospital’s quality management department to obtain additional data. “It was extremely foresighted of Respiratory Care Services to put this together, and they did this without a charge to do so,” Rodarte says. “By using this database, we’ve been able to make some significant changes in how we provide care.”
According to Wheeler, staffing is usually a challenge as it is for most large tertiary care centers. “We’re always trying to attain a favorable ratio of staff to workload, but it’s not always possible,” Wheeler says. Methodist’s respiratory department is part of a very high-volume hospital. Once billed as the world’s largest adult acute care, nonprofit, private hospital, Methodist today is still extremely large with 35,000 annual inpatient admissions and more than 4 million outpatient visits in 1998. Compared to smaller, community-based hospitals, Methodist also has a high percentage of very sick patients. All of these factors create an atmosphere where adequate staffing means everything when outcomes are being tracked.
Even with certain staffing constraints, Wheeler stresses that Methodist has been able to staff critical care areas adequately enough to make some incredible achievements in patient care. “By utilizing our multidisciplinary team to the fullest degree, we’ve been able to maintain and, in some instances, substantially improve clinical efficacy,” Wheeler says.
One recent example of Methodist’s focus on professional collaboration was the permanent pairing of RCPs and nurses to help wean patients from mechanical ventilatory support postoperatively. According to Wheeler, after implementing clinical pathways that incorporate ventilator and oxygen weaning protocols in the mid-1990s, Methodist was able to reduce its intubation time for heart surgery patients by about two-thirds to 12 to 14 hours. Since this time was still relatively high in comparison to those in other large tertiary centers, Methodist became more aggressive with its protocol, and subsequently was able to reduce intubation time to approximately 9 hours. But it was not until February 1999 when the RCP/nurse postoperative team was in place that the intubation time was reduced to 2 to 3 hours.
“One of the challenges our nurses had prior to the creation of these teams was that they usually were assigned to two patients–one who was an immediate postop patient but was stabilized, and then another who was very ill,” Wheeler explains. “Since the patient who was very sick required so much of the nurse’s time, the most natural thing for the nurse to do was to let the immediate postop patient stay on the ventilator longer than necessary, so she could devote more attention to the sicker patient.” Now the RCP working closely with the nurse can help with the patient who needs to be weaned, as well as other tasks such as obtaining the anesthesiologist’s report and making sure patients get admitted to the floors. “The most important aspect is that the RCP working in cooperation with the nurse member of the weaning team can help prevent a situation where a patient is being oversedated just because it’s the only way the regular attending nurse can handle the workload,” Wheeler says.
According to Kelley Oliphint, vice president of professional and surgical services, the RCP/nurse teams were made possible by simply adding two FTEs to the respiratory care department. “This came about because a specific problem was identified, and a demonstration project was created to show how we could improve patient outcomes,” Oliphint says. “We’re pleased with the fact that not only do our patients not have to stay on the ventilators longer than necessary, but that we’re also able to make improvements based on a collaborative effort.”
Methodist’s RCPs are frequently involved in demonstration projects to determine if there are better ways to provide care while still maintaining quality outcomes. Currently discussions are under way with a manufacturer of metered-dose inhaler (MDI) companion products to determine the feasibility of conducting a joint study to measure and compare the effectiveness of patient self-administered MDIs to therapist-administered nebulizers, which are currently used more frequently at Methodist. Many hospitals, however, have successfully switched over to MDIs, resulting in sizable cost savings. “Even though the Respiratory Care Services Department has supported the switch to MDIs, we recognize that in order to obtain high physician compliance, we need to demonstrate to physicians that we can make MDIs work in a self-administered regimen for our patient population while still maintaining quality care,” Wheeler says.
According to Rodarte, physicians for the most part do not believe that nebulizers are any better than metered-dose inhalers. “Most physicians prefer nebulizers over metered-dose inhalers because respiratory therapists are required to interact more frequently with patients when they are using nebulizers,” Rodarte says. “Physicians want therapists interacting with patients four times a day because they have been trained, unlike many nurses, to detect the early warning signs of respiratory distress, facilitating timely intervention and preventing problems such as a costly return to the ICU.”
Whether Methodist chooses to use MDIs or nebulizers, physicians and other members of Methodist’s multidisciplinary team recognize that therapists still need to stay actively involved in patient care. According to Wheeler, peer-reviewed literature has shown that 80 percent of patients taking self-administered medication by MDI take it incorrectly. These patients frequently take more puffs than necessary, causing more side effects without good therapeutic response. “If therapists have the opportunity to teach patients in the hospital how to self-administer MDIs properly with spacer devices, patients might be more likely to continue to use them correctly at home. This in turn might possibly lead to reductions in unnecessary doctor or emergency department visits due to otherwise preventable exacerbations (or at least that is what we hope),” Wheeler says.
Working at one of the country’s premier medical research facilities, RCPs are exposed to clinical situations that are not available at most other hospitals. The Methodist Heart Center has attained international recognition for performing the world’s first successful surgical treatment of an aneurysm of the thoracic ascending aorta/aortic arch, the world’s first multiple-organ transplant, and numerous minimally invasive surgery procedures that repair hearts and arteries with significantly reduced recovery times. In an environment with these types of milestones, therapists participate in many clinical situations that are considered experimental and state-of-the-art.
Because of the constant need for learning on the job, a wide array of in-services and educational programs are offered to RCPs and other health care professionals at Methodist. One full-time and one part-time educational coordinator assist the Respiratory Care Services Department in creating staff development programs, covering everything from fundamental concepts to more advanced topics on respiratory care. “We’re proud of the fact that we have one of the best department-based educational programs available among major teaching hospitals,” Wheeler says. In fact, the educational capabilities of the Respiratory Care Services Department are so in demand throughout the hospital that it frequently assists other departments in preparing educational materials, including videos, slide presentations, and other multi-media resources.
Another professional opportunity for Methodist RCPs is their exposure to new devices and equipment, as well as major research studies. Many manufacturers work closely with Methodist to test new equipment, and Methodist’s therapists are often among the first RCPs in the country to conduct evaluations on cutting-edge devices. A notable example of a major research study involving respiratory care at Methodist is the National Emphysema Treatment Trial (NETT) headed by Rodarte and Rafael Espada, MD, professor of surgery. This trial, sponsored by the National Institutes of Health (NIH) and the Health Care Financing Administration, is a precedent-setting cooperate effort between NIH and Medicare to determine whether lung volume reduction surgery has any benefit in addition to optimal medical care. NIH selected 17 centers around the country from among many applicants to participate in the program. This study involves state-of-the-art pulmonary diagnostics and, for half of the patients, respiratory care after bilateral lung resections. Other research projects include the evaluation of the use of inhaled nitric oxide, including an upcoming study for its use in heart transplant patients postoperatively, and a study to evaluate the efficacy of a sternum support harness post median sternotomy vs traditional splinting with pillow.
Recruitment of RCPs
As with any prominent urban-based tertiary care center, Methodist experiences some difficulties with employee retention due to staff burnout. “For some staff, the pressure involving high-level responsibilities and high-risk tasks sometimes takes a toll on them, and they eventually leave for less stressful environments at smaller facilities,” Wheeler says. Fortunately, though, there usually is a constant supply of experienced applicants who seek the challenges that Methodist offers. Wheeler admits that the biggest problem exists in hiring recent graduates of respiratory therapy schools, since they often are unprepared for the level of expertise with which they must perform their jobs at Methodist. According to Wheeler, many respiratory care managers in large tertiary care hospitals share this concern regarding recent graduates who require further preparation before assuming high-level assessment and intervention responsibilities. “Students graduating from respiratory therapy schools do not often have the appropriate skills necessary to assume the role of staff therapist at Methodist Hospital, particularly in the areas of pulmonary mechanics/mechanical ventilation, assessment, and critical care protocol duties,” Wheeler says. “We’re asking them to do complex, highly risk-prone procedures, and they frequently can’t handle that level of responsibility without additional training,” Wheeler remarks.
As an adjunct faculty member of a local respiratory therapy school, Ken Hargett, BS, RRT, co-manager of respiratory care services, stresses the importance of schools working with hospitals to help ensure adequate training of new therapists. “Schools have not done enough to help students develop critical thinking skills, nor have they helped them learn how to operate today’s sophisticated equipment,” Hargett says. “Too often graduates have to learn most of these things on the job.” One recent action Methodist took to help solve this problem was to give respiratory therapy students on clinical rotation at Methodist a chance to work one-on-one with a staff RCP, as opposed to placing all clinical rotation students with just one clinical instructor.
The Effects of Managed Care
With managed care companies forcing hospitals nationwide to take drastic steps to achieve cost containment, it came as no surprise in the mid-1990s when Methodist was required to downsize. Wheeler will never forget the date–September 19, 1994–when he had to lay off 22 of his staff. “Up until that time, Methodist had boasted that it had never had a layoff since its founding in 1919,” Wheeler says. “But that staff reduction was necessary in order to get us in line with other large tertiary facilities.” Since that black day in 1994, no additional layoffs have been made. In addition, eight FTE positions were eventually added back, and earlier this year two FTEs were added to the department to create the RCP/nurse weaning teams. The hospital administration has also allowed the Respiratory Care Services Department to create a supplemental pool of temporary employees who work according to fluctuating workload needs.
“When you have the type of flexibility that Respiratory Care Services has developed with staffing, you don’t have to worry about more layoffs,” Oliphint says. “By having this temporary pool available, we were actually able to increase our labor hours by 7.7 percent last year.”
An Expanding Role
In an environment that continues to focus on cost containment and cost-efficiency, Wheeler is confident that RCPs will play a larger role as physician extenders in the years ahead. He likes to use the example of the coronary artery bypass graft, which currently is a multibillion-dollar industry in the United States. After patients undergo this procedure, the first objective is to discharge them from the critical care area as quickly as can be done safely. The second major goal is to discharge them from the hospital as quickly as possible. “If you look at these two goals, it’s clear that the respiratory care practitioner is a type of gatekeeper that has the opportunity to make a substantial impact related to these two major objectives during the course of treatment,” Wheeler says. “If you have a strong weaning protocol in place to effectively remove patients from mechanical ventilation, you can decrease the time spent in the ICU, and if an oxygen weaning protocol is used on the floor, you can get them off oxygen more quickly and reduce their overall hospital length of stay.” Wheeler stresses that in an environment where Medicare reimbursements are static and managed care companies create their own reimbursement cuts, a respiratory therapy department’s ability to ensure faster discharges means the difference between whether the hospital loses or makes money.
Finally, Wheeler notes that in a capitated market where physicians are increasingly paid a fixed amount for treating a specified patient population, physicians will have a financial incentive to rely more heavily on RCPs who can help them with the care of their patients. “If a physician is not paid on a per patient visit and is responsible for a large volume of patients, he will be more motivated to have a therapist check on selected pulmonary patients in his absence, thereby freeing him to accomplish other tasks mandated by a large capitated practice,” Wheeler says. “From an economics standpoint, respiratory therapists will truly become physician extenders.”
Hargett concurs that the RCP’s role will become more critical in the future as cost containment continues to grow in importance. “Respiratory therapists will become important decision-makers, rather than just treatment-givers,” Hargett says. “We will be actively involved in designing care plans and will be relied on by physicians for making more comprehensive patient assessments. It’s a challenging and exciting time for respiratory therapists.”
Carol Daus is a contributing writer for RT.