Reining in costs while maximizing patient care is the goal at Arkansas Children’s Hospital.

When Patty Munro, RRT, first arrived at Arkansas Children’s Hospital (ACH) in Little Rock in 1980, the respiratory care services department was only 5 years old. The hospital, which treats patients from across Arkansas and surrounding states, operated less than 150 beds, including 20 intensive care unit (ICU) beds.

Back in 1975, when the respiratory care services department opened, it employed a staff of six and owned one MA1 ventilator, says Munro, who has served as the department’s director since 1989. Today, the same department boasts 137 employees, 114 of them full time. The respiratory care services department staffs the entire hospital (now 258 inpatient beds), which includes 94 ICU beds; the cardiovascular, pediatric, and level III neonatal ICUs; a burn unit; and a four-bed freestanding extracorporeal membrane oxygenation (ECMO) unit.

There are also 94 specialty outpatient clinics, many of which require respiratory care services. Diagnostic services, staffed by RCPs and operating under respiratory care services, include the STAT lab, the sleep disorders center (one of only six pediatric sleep labs in the United States fully accredited by the American Sleep Disorders Association), and the pulmonary function lab. The STAT lab team analyzes more than 80,000 blood samples a year. In addition to providing standard pulmonary functions and bronchoscopy, the pulmonary lab is cultivating innovative cardiopulmonary stress and infant/toddler lung function programs.

A DIFFERENT APPROACH

“We are a very busy department,” Munro says. During the past fiscal year, ACH-which ranks among the top 10 children’s hospitals in the nation-treated more than 9,000 inpatients and 166,000 outpatients. “When you compare us with other children’s hospitals, we are very, very different,” Munro says of the respiratory care services department. “On a very slow day, we may have 28 ventilators running. On an average day, we have 40 ventilators running, and on very busy days, we’ve had as many as 52 ventilators running,” she says.

The phenomenal growth, however, has resulted in some growing pains, and the department has had to overcome a series of challenges. First, it needed to catch up in terms of technology and cutting-edge treatments. More recently, the respiratory care services department has faced the more mundane but no less challenging need to streamline and improve its financial bottom line.

RCPs at ACH have succeeded on both fronts. They now help staff a busy ECMO program, systemize respiratory care plans, serve on the helicopter flight team, and participate in diverse ongoing research projects. Concurrently, the respiratory care services department has been aggressively reorganizing to improve function and efficiency.

THE PERFECT BALANCING ACT

ACH’s mission is to provide the best patient care while developing and implementing the most effective treatment protocols. To do so, it relies on a strong education and research ethic. Mike Anders, RRT, MPH, who serves as the department’s education and diagnostics manager, points out that the facility is affiliated with the University of Arkansas for Medical Sciences, also in Little Rock. “Education and research have always been part of the philosophy here,” he says.

For RCPs, the education begins with a 4-week orientation that every new departmental employee must participate in. “Even experienced therapists will do better in the long run with this type of orientation because, if nothing else, it makes them comfortable in each patient-care area,” Anders says. The orientation is structured to provide newcomers with education too, Anders says. The program features formal classes, clinical time, and a final skills validation period. “We want to ensure that therapists can leave orientation and be safe and competent and follow departmental and hospital policies,” Anders says.

Staff education does not end once a new employee completes orientation, however. “We really believe in education,” Anders says, noting that the department stresses continuing education programs that allow staff members to pursue career growth. “We also feel an obligation to evaluate cutting-edge therapies. Cutting-edge therapies will be introduced here at some point, so we’d like to have as much education on the front end as we can,” he says.

Guest speakers visit ACH as frequently as once a week to participate in grand rounds, and the respiratory care services department organizes regular continuing education programs in addition to sponsoring an annual regional meeting, the Diamond Conference. “We strive to develop consistency within the department,” Anders continues. “Consistency is important in pediatrics because it’s confusing to parents if two therapists do things differently-even if both do things right.” The department also coordinates hospital- and community-wide training programs in areas such as pediatric advanced life support, advanced cardiac support, and basic life support education.

Respiratory department staff members also benefit from the many research projects conducted by the department. “We have experimental research that therapists are involved in, and then we have ongoing research,” Anders says. “Our therapists enjoy participating in the protocols we have in place and collecting data.” Four ongoing study protocols are evaluating the use of nitric oxide in various patient populations; other current research focuses on extubation parameters in the pediatric ICU (PICU), bronchoalveolar lavage and bronchoscopy, and infant pulmonary function testing. A clinical trial of RCP-protocol weaning of mechanical ventilation is scheduled to soon begin in the PICU.

SEVERAL GIANT STEPS FORWARD

Much of the change respiratory care services has undergone centers around technological and therapeutic advancement. In addition to the expansion of its ventilator support capabilities, ACH provides high-frequency ventilation, nitric oxide therapy (as part of its research program), nationwide helicopter transport, and ECMO support. In some areas, particularly ECMO support, ACH is a national leader in terms of the treatment breadth it provides.

Similar to other ECMO support units nationwide, ACH’s unit supports neonatal patients. Unlike the other centers, though, ACH treats a high percentage of pediatric patients and even a small percentage of adults. “Many ECMO centers focus solely on neonatal [care]; pediatric ECMO is a great challenge,” Anders says.

ACH is among the top three ECMO units in the country in terms of the number of pediatric and cardiac patients it treats each year. Anders explains that pediatric and cardiac patients are not as reversible as neonates, and usually experience acute respiratory distress syndrome or cardiac failure. ACH also uses ECMO to support patients as a bridge to transplant. “In other words, if a child goes into cardiac failure, but there’s no heart available, we may place the child on ECMO when the clock is ticking and we’re looking for a heart,” Anders says.

In 1997, a team of 15 RNs and 15 RCPs treated 55 patients receiving ECMO support. “We’re one of the more active ECMO centers internationally,” Anders notes. This is because, in part, the facility is centrally located in an area that does not boast many other ECMO support units. ACH’s ECMO unit has had patient referrals from Tennessee, Louisiana, Texas, Oklahoma, and even New York.

Many of these long-distance patients arrive via the facility’s mobile ECMO support program, which many consider to be the most unique aspect of the ECMO program at ACH. “To my knowledge, we’re the only hospital in the country that offers ECMO support for all types of patients via either a helicopter, lear jet, or ground transport,” Anders says. Most mobile ECMO patients arrive from other ECMO centers, Anders says. “We typically won’t go out into Arkansas and put them on ECMO to bring them back here, because we’ll bring them back to ACH [first] and try to maximize their support before going to ECMO.”

In addition to its mobile ECMO service, ACH operates a full-scale helicopter and ground transport program called Angel Flight, which maintains two helicopters and a staff of 10 RNs and 10 RCPs. It averages 124 transports a month. The program began in 1978 in response to Arkansas’s high premature infant and newborn mortality rates. According to Don Caple, an ACH administrator, “It was felt that a speedy transport system would help bring this rate down, and after several years, we accomplished that goal.” The mortality rate in Arkansas is now below the national average.

REINING IN COSTS, MAXIMIZING CARE

As ACH’s respiratory care services department grew, so did the cost of providing care. The department has spent the past several years implementing new programs designed to improve its efficiency and minimize costs while maintaining its commitment to high-quality patient care. “We are a very strong entity within the hospital, and always have been,” Munro says. “I’ve had to justify that over the last few years, with us being hit by managed care.” As part of these efforts, the department developed a productivity tracking system based on relative value units (RVUs). Each RVU equals 10 minutes of patient care. Every procedure is weighted by the number of RVUs required to complete it. “In other words, we looked at ventilator monitoring, setting up a cannula-every single thing that we do in the department is weighted by this RVU,” Munro says. Even nonchargeable procedures have an RVU designation, which allows respiratory care services to account for each moment of staff time. “Therefore, we can look at any snapshot of time and determine whether we’re on track in terms of productivity,” she says.

The department also automated its documentation by using handheld computers and incorporating records into the ACH mainframe. Time is charged-and RVUs assigned-at the moment of documentation. “That way, we can look at yesterday’s activity and see the number of therapists we had on staff and the amount of work they accomplished.” Munro also uses the system to estimate future workload in comparison with the number of therapists assigned for that particular day. She can add or subtract staff to that day’s roster ahead of time, reducing staffing inconsistencies.

The department also decreased costs by relying on primarily reusable equipment and restructuring staff for greater efficiency: Individuals who used to work at a desk are now at bedside. “Basically, we don’t have many desk jobs anymore; mine is one of the very few we have left,” Munro says. The department also employs a large group of zero-based employees in addition to its full-time staff, who help meet additional staffing needs during busy times. “I guess you could say they’re our own little contract service,” Munro says. As employees of ACH rather than an outside company, these flexible staff members have attended the orientation and are familiar with the facility. “We have used outside companies, but because [their employees] are mainly trained in the adult world, they were in a completely new environment when they came to ACH,” Munro explains

IMPLEMEMNTING THERAPIST-DRIVEN PROTOCOLS

Perhaps one of the biggest efficiency-minded departmental changes was the implementation 3 years ago of therapist- driven protocols, called care plans at ACH. “We had data showing that for approximately 20%our patients, the intensity or the type of therapy that they were on was inappropriate,” Anders says, explaining the reason for the change. The facility decided to implement care plans in an effort to reallocate resources and improve consistency of care.

So far, the care plans have worked well. “We’ve dramatically reduced the number of treatments we do, and we’ve done so without any adverse effect on patient outcomes,” Anders says. Overall, 800of respiratory care patients outside the ICU receive treatment under a respiratory care plan and, of those, the care plan is followed to the letter 909of the time-a high success rate by any measure. Lengths of stay have decreased across the board, and the department’s cost-effectiveness has demonstrated a parallel upturn.

The department also improved its consistency, a benefit Anders particularly appreciates. “Studies have indicated that variation in care alone will cause poorer patient outcomes, so one of our goals was to reduce variations,” he says.

To implement a successful care plan, which empowers RCPs to adjust therapy based on assessment and preestablished guidelines, a respiratory department must collaborate with the medical staff and have a strong medical director, Munro explains.

“First, we developed guidelines to introduce to the medical staff. Then, in large part due to respect for our medical director, Robert Warren, MD, and because of the effort that went into development, we received quite a bit of support from the medical staff,” Anders says.

The real challenge, though, came after the initial implementation of the protocols. “Once a department assumes this responsibility, it requires a real objective look at how things are going,” Anders says. Six therapists, trained as patient care coordinators, implement and direct the care plans. They perform all tasks associated with each patient’s care protocol, from initial assessment through monitoring and patient education, which extends through discharge planning. These patient care coordinators interact extensively with physicians and even accompany the medical staff on patient rounds. “They’re considered part of the team,” Anders explains. “They are actually given quite a bit of responsibility for outlining the plan of care and communicating with Dr. Warren and all the physicians,” he says.

As for the future, “We are not done changing,” Munro says, noting that ACH will continue to present both challenges and opportunities to its RCPs.

Kathryn Olson is a contributing writer for RT.