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A Medical Director Details Ways To Avoid Decentralization

By Michael Gibbons

AMELIA ISLAND, Fl.­Respiratory care departments once ranked among the favorites of hospital administrators because therapists could bill for many services. Then came capitation, and that status quickly vanished into the mists of history. Managed care’s edict was brutally plain: fewer services, decreased expenses.

By the early 1990s, many administrators had hired ominous consultants to slash respiratory budgets. Some turned therapists’ duties over to nursing ­or decentralized departments.

As medical director of respiratory care at Jewish Hospital Heart and Lung Institute, Louisville, Ky., Judah Skolnick, MD, is an old hand at staring down such threats.

“Since the early-to-mid-1990s, I’ve had to justify our existence or face severe downsizing or decentralization,” Skolnick told his peers at the National Association of Medical Direction of Respiratory Care (NAMDRC) conference here last winter.

His advice: approach administrators before they approach you, conduct your own outcome studies to identify problems before consultants identify them for you, and demonstrate a compelling need to adopt therapist-driven protocols.

To keep his department intact, Skolnick took these steps:

* He made his staff of 52 FTEs more versatile to maximize their usefulness. “We knew we had to optimize staffing, cross-train, float personnel back and forth,” he said. Now, if caseloads are down in the department’s HBO or diagnostics units, RCPs assigned to those units can work instead in the ICU or med/surg unit.

* He added new, relatively inexpensive services such as ECG, ABGs, echo, Holter monitoring and stress testing. He also directed his therapists to become more involved in patient assessment, home care planning and patient education, a task traditionally done by nurses. It’s important to raise a department’s profile, Skolnick stressed. “We volunteer for every hospital committee and task force we can get on,” he said.

* He performed a cost/benefit analysis of respiratory equipment and learned that, at times, more expensive equipment saved money in the long run because it decreased personnel time spent with patients.

But implementing therapist-driven protocols saved more money than any other solution. The department moved slowly, developing one protocol at a time, setting aside a period for comments, monitoring the quality-of-care and economic impact of each.

A TDP is a living document, constantly subject to revision, Skolnick emphasized.

Some results:

* A 1993 early extubation protocol for coronary artery post-op patients reduced length of time on the ventilator from 30 hours to fewer than 8.

* A nebulized bronchodilator protocol dropped treatments from 17,000 a month to 7,000 a month, decreasing use of hand-held small volume nebs by 33 percent.

* An NPPV protocol on 31 patients had a 73-percent success rate in keeping patients off long-term mechanical ventilation.

Right now, the department has an 85-percent overall compliance rate with protocols, Skolnick said. He’s striving for 100-percent compliance. His best protocol therapist is an OJT who has developed great people skills during 20 years with the department.

(When he surveyed other departments nationwide on TDP compliance, Skolnick found two positive correlations: the greater the percentage of a department’s procedures covered by protocols, the greater the compliance. And the more positive the feedback from administrators, the greater the compliance. No other factors mattered­not hospital size, nor ratio of RRTs to CRTTs.)

Skolnick foresees smaller departments in the future, with qualified therapists performing more high-tech work and leaving less complex tasks to nursing. RCPs will become more involved in seamless care, extending their domain into patients’ homes, he believes.

“As medical directors, we need to learn how to be consultants,” he concluded. “Do outcome studies, benchmark results and formulate strategies to save money. That’s how we ensure survival of respiratory care departments.”

Michael Gibbons is an ADVANCE associate editor.

Decentralized Staff Remains a ‘Department Without A Department’

By Michael Gibbons

Therapists at St. Peter’s Hospital in Albany, N.Y., started 1998 off with a bang­their own personal Big Bang.

They were flung to the farthest corners of a new universe. They were decentralized.

The move came as part of a patient-focused care effort at the 447-bed acute care hospital to enhance teamwork and bring caregivers closer to patients.

Things were tough initially. And a few negatives remain. But a year-and-a-half into it, St. Peter’s Hospital appears to offer a habitable, even congenial, setting in which to practice respiratory care.

“It was frustrating at first,” admitted Bill Fazioli, RRT, who, like all therapists at St. Peter’s, had to re-interview for his position. “That first year was unknown territory, both for us and for the nurse managers who were taking on the therapists as new personnel.”

At the time, the department had about 25 FTEs. “No jobs were lost, but people did leave in possible anticipation of what decentralization might mean,” Fazioli said. “Many stayed within the system and some have since come back (to respiratory care).”

In the new landscape, therapists were re-deployed to three cost centers: Cardiovascular (ICU), Women’s and Children’s (which includes the NICU and pediatrics) and Med/Surg. But therapists aren’t confined to those areas; they cross-cover if one area gets busy. And they still respond to codes throughout the hospital.


Nevertheless, the cataclysmic change took a hard toll, especially on long-timers. “It was very difficult and very anxious,” 10-year veteran Mark Myers, RRT, remembered. “Fear of the unknown was definitely there. You’re no longer under respiratory management. There was a fear of working under the nursing department, although we’d had a very good relationship with them in the past. There was a fear of losing one’s position, a fear of being relegated to lesser jobs and positions. It created many personal problems that extended to home life.”

Sue Lapp, RN, a patient care services director, acknowledges those rough early times. “At the beginning, we did not do it with enough planning,” Lapp said. The transition, I think, may have been somewhat smoother had we taken those steps.”

Overall, though, the experience “hasn’t been negative,” according to Fazioli, who serves as a clinical coordinator.

“Some therapists who’ve worked here a while desire a department back because it was home,” he said. “But we haven’t lost our independence. That’s what most of them were scared about. We do all our own scheduling. The only thing that has changed is our physical environment. We have no department manager or supervisors. But we still have our medical director.

“In a sense, we’ve remained a department without a department.”


To help prepare for its transition, St. Peter’s sent a team to visit Lehigh Valley Hospital, a 600-bed facility in nearby Allentown, Pa., that switched to patient-focused care in 1996.

Lehigh Valley had received so many inquiries about how to proceed that it had begun offering all-day seminars covering various aspects of patient-focused care such as clinical issues, hiring, training and administrative policies.

“After we made the transition, hospitals wanted to come in, find out what we did, how we did it, and would we do it again?” recalled George Ellis, MBA, RRT, Lehigh’s Administrative Director of Respiratory Services.

Ellis has this advice for respiratory managers about to undergo decentralization:

* Have upper-level administrators state affirmatively, in writing, that Respiratory Care will continue to maintain its identity in the institution.

* Make sure the education of your therapists will be enhanced. They must not be sent hither and yon with no training.

* While there needn’t be an increase, there must be no decrease in the quality of respiratory care the institution provides.

“We validate the RNs every year on how they provide respiratory therapies,” Ellis said.


Heeding this and similar advice, St. Peter’s officials created a Respiratory Therapy Council, a body that meets monthly and allows all RCPs to resolve issues, vent frustrations, evaluate equipment, make decisions as a group, in essence, to almost direct themselves. For Fazioli, the Council is a “wonderful” outcome of decentralization.

“Those monthly meetings retain a sense of unity,” he said. “We make sure everything is a group decision. The Council is wonderful to have, to essentially know what is going on and to have therapists direct respiratory care issues.”

On the down side, since the equipment area was also decentralized, equipment is now spread out all over the hospital. “Going to an area expecting to find a piece of equipment and not finding it resulted in delays of service,” Fazioli said. “We’re in the process of semi-recentralizing our equipment area to remedy some of those frustrations.”

The Biomedical department continues to clean, maintain and turn around the ventilators, he added.

Also, therapists no longer analyze blood gases but draw blood samples and shoot them down pneumatic tubes for the blood gas lab to study. “It’s not as quick as when we reported the results. But it’s still quick,” Fazioli said. “The lab is very open to working with us. I’m sure they weren’t happy to take on this responsibility. We generate a great many blood gases. On the positive side, we don’t have to leave the floor now. We can stay with the patient.”


Lapp wants to continue to fill open respiratory positions to enhance therapist participation in care teams. Several therapists left in 1998 and St. Peter’s hasn’t succeeded in replacing them all yet due to a small local applicant pool. “We have a significant volume of respiratory patients, many of whom have COPD and/or pneumonia, she said. One unit is dedicated to the pulmonary population, with the ability to care for eight ventilator patients.

Thanks to their expertise and role on the team, RCPs have decreased complications of pneumonia, lowered the need for patients to return to the ICU and helped achieve positive outcomes with thoracic surgery patients, Lapp noted.

As a result, therapists are gaining autonomy. The Respiratory Therapy Council has just crafted an RRT/RN-driven O2 protocol and is currentlyworking with an interdisciplinary team to develop a weaning protocol for chronic pulmonary patients on ventilators. The goal is to localize these patients and provide a therapist/RN care team to aggressively wean them from the ventilator and establish a care plan to improve their quality of life and prevent reintubation.

“Our overall plan is to optimize the respiratory therapists’ role by enhancing their ability to practice at their highest level,” Lapp said. “Currently, we are focusing on strengthening their role in respiratory assessment and the continued development of skills such as insertion of arterial lines.”

Michael Gibbons is an ADVANCE associate editor.

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