The only constant within business and life is change. Across the country, healthcare systems are attempting to balance the evolution of regulations and costs with revenue. The ultimate goal is to consume the fewest resources without compromising patient care. Because of this, internal auditors or outside consulting companies are being hired to review every expense. These groups suggest improvements to raise the bottom line, but how do these decisions affect the quality of care provided? One such inquiry has been the need for respiratory therapists (RT) in medical transport. This has spurred the debate, are RTs really needed on transport?
The Questions
The six most common questions that come up during this discussion are:
• Why is this important?
• What are the costs?
• What knowledge, skills, and abilities are needed?
• What is included in a RT’s scope of practice and licensure?
• What are the quality outcomes for teams with RTs?
• What can we do about it?
Why is this important? The industry of medical transport is rapidly growing and resource allocation is forcing patients to travel to receive higher levels of care. Hospitals are searching for new revenues and increasing their referral regions for new patients. Currently, the primary providers of medical transport are paramedics and nurses. Both groups are actively working to be the standard critical care and specialty care providers. So for RT’s to continue to provide hospital level care on the road or in the air, we need to define our role and our value to the system and the patient.
What are the costs? In transport there are two routes to the hospital: emergency medical services (EMS) and inter-facility transport. Typically, paramedics make up the bulk of EMS providers for 911 or emergent scene responses, like car accidents. This makes sense because this is what they have been trained for and are equipped to handle. When it comes to inter-facility transports, paramedics make up a large percentage of the providers because many patients can be effectively managed by Basic Life Support (BLS) or Advanced Life Support (ALS) providers. These providers offer a valuable service and have lower costs compared to the reimbursement received.
On the other hand, there are patients who require providers with advanced training and complicated equipment to stabilize and treat while en route to another hospital. Neonatal patients are a great example of a “specialty care” or “critical care” patients that need advanced equipment and providers to care for them. But every age group has patients that need advanced care. This type of transport requires a nurse to assume care of the patient and another provider who brings specialized skills to the team. These advanced level transports do result in an increased cost, but also have higher expenses due to the personnel and equipment needed to safely care for these patients. Ultimately, reimbursement depends on the insurance that covers the patient, but these transports typically have higher rates of return than ALS or BLS transports. This is why the medical helicopter business has grown exponentially in the last few decades.
It is a fact that paramedics are typically paid less than RNs, RTs, NPs and physicians, who often make up the other members of a specialty or critical care team. According to the Bureau of Labor and Statics the difference between the median wage of an RT and paramedic was about $23,920 in 2010.1 The bottom line is every dollar spent takes away from the potential profit, so many systems are tempted to utilize less expensive providers to partner with an RN for these teams.
What knowledge, skills, and abilities are needed? Paramedics bring exceptional skills to the table, and they have a critical role in patient care for the majority of patients that require transport. For the patients that need specialty or critical care services, the knowledge base and skill set of the providers need to be such that they can ensure they can provide for the patient’s needs. The typical approach of a specialty or critical care team is to bring hospital level care to the patient. This means you must bring the providers that care for the patient in the hospital. Most intensive care units and emergency departments do not use paramedics to assess and treat critical patients – they use RNs, RTs, mid-level providers and physicians. The RNs and RTs are the most common team caring for the critically ill within the hospital, with a physician providing medical oversight. The complex nature of these patients requires expert assessment skills, very specialized equipment and a strong skill set to effectively manage them. In fact, the very definition of specialty care includes the verbiage “above the skill set of a paramedic.”
To be fair, there are some that feel the RT knowledge base is not as extensive as paramedics. They believe RTs are just useful for managing a ventilator or giving nebulizer treatments. While it’s true that these functions are a significant part of an RT’s role in the hospital, it does not take into account the capacity RTs have to contribute to the stabilization and ongoing care of the acutely ill. Every patient has an airway and needs to effectively oxygenate, ventilate and perfuse to live. Many institutions have expanded the role of RTs for transport. In North Carolina, a transport RT can administer over thirty-five IV medications, place femoral and external jugular IV lines, needle chest decompression, intubate and perform other procedures on transport. A well trained and experienced RT is a cardiopulmonary specialist that can provide PALS, ACLS or NRP, but also provides goal-directed, evidence-based therapy.
What is included in a RT’s scope of practice and licensure? As RT scope of practice varies from state to state, learn what RTs are allowed to do under their scope of practice and licensure. Some states have a standalone respiratory board that is able to make declaratory rulings, as in NC. While in other states, there is an advisory board to the state’s board of medicine that ultimately makes the final decisions, which is the case in Virginia. Some licensure acts do not recognize RTs outside the hospital setting while others have a wider scope of practice and have specific language that addresses RT participation on transport. Some restrictive states, like Maryland, require paramedics on most ALS and specialty/critical care transports. Wisconsin is currently questioning if RTs can function outside of the hospital under the supervision of a physician. Unlike our nursing counter parts, RTs do not have a compact practice act that allows them to practice in varying states while on transport. As a transport therapist, you should be aware of laws in the states you may cross into.
This structure can pose a problem for the continuation of RT’s on transport teams as they could theoretically need multiple licenses in any state they could transport into or out of. This is not a problem without a solution, as many states are currently writing reciprocity agreements with neighboring states allowing RTs to practice temporarily in another state while on a transport.
What are the quality outcomes for teams with RTs? A single center study which was conducted from January 2001 to September 2002 reviewed the benefit that specialty care transport teams have with pediatric patients.2 This team was made up of RNs and RTs with a minimum of three years’ experience. The study concluded that specialty care teams resulted in safer transports than non-specialty care teams. While this study is not completely definitive, it does show that including RTs in specialty/critical care transport teams can improve outcomes or reduce the chances of a negative outcome.
What can we do about it? There are many efforts currently underway by paramedics and RNs to establish their place on specialty and critical care teams. RTs need to pull together to work toward the same goal. We need to work with our individual respiratory boards or medical boards to update the state regulations to allow RTs to more actively participate on transport. We need recommendations from our professional organizations that support interstate reciprocity agreements for the purpose of medical transport, set standards for didactic and clinic education and have academic institutions create programs for transport RTs to fill the gaps between what RTs and paramedics are taught. RTs need to work towards the same certifications as RNs and paramedics such as “Flight Certified.” We also need to have national benchmarks to showcase the quality outcomes that are associated with having an RT on transport teams, which means as an RT community we need to do the research that may show RT benchmarking.
It’s only by showcasing what value that RTs bring to the table that we will be able to justify the added expense for hiring, maintaining and utilizing RTs for specialty and critical care transport. There are leaders in the field of transport who are working on an initiative to accomplish these goals, but more RT involvement will help transport RTs meet these goals. If you, as a reader, want to get involved and make a difference in your profession, our first suggestion is to become a member of the American Association of Respiratory Care. Consider joining the Transport Section to help the therapists who are working towards advancing RTs in the transport role. By becoming involved, you can help make this initiative a reality.
Alex Brendel is a transport team member and research coordinator at Carilion Clinic in Roanoke, Va. Last year, he was AARC’s Transport Specialty Section Therapist of the Year. Tabatha Dragonberry is a transport respiratory therapist in northern Virginia. They are working together to address their belief that RTs on transport provide better outcomes in the specialty care/critical
References:
1. US Labor Board of Statistics. http://www.bls.gov/oes/current/oes291126.htm; http://www.bls.gov/oes/current/oes292041.htm
2. Orr RA, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics. 2009;124(1):40-48.
