Vol. 15 •Issue 10 • Page 42
The Future of Respiratory Therapy
are you ready?
Thanks to the widespread adoption of therapist-driven protocols, respiratory therapists have evolved from task-doers to well-educated critical thinkers, making decisions formerly reserved for physicians alone.
That growth is far from over, leaders in the field believe. Five of them shared their vision of RTs in the future.
As the demand for RTs increases, their advancement as clinicians will follow naturally, said David C. Shelledy, PhD, RRT, FAARC, who helmed the American Association for Respiratory Care in 2003.
“I think we need to be thinking about the RT as a physician extender,” Dr. Shelledy said. “That’s another way of saying cardiopulmonary physician assistant, someone who can develop and apply care plans and advanced protocols.”
Reining in misallocation of services
Protocol-based respiratory care will increase as the population ages and as hospitals continue to lose money by misallocating a significant amount of respiratory care services, said Dr. Shelledy, now associate dean for academic and student affairs for the College of Health Related Professions, University of Arkansas for Medical Sciences, Little Rock.
“Some studies indicate that up to 40 percent of respiratory care is misallocated,” he said. “We need to have RTs doing patient assessment and care plan development based on approved protocols.”
Ohio’s famous Cleveland Clinic was among the first hospitals to chisel out the field’s future by creating and using evidence-based respiratory therapistd-driven care protocols.
Back in 1992, Cleveland Clinic developed an RC consult service that uses sign- and symptom-based branching logic algorithms for administering aerosol therapy, bronchopulmonary hygiene, hyperinflation techniques, oxygen therapy and other services.
What drove Cleveland Clinic to develop a respiratory care consult service “was the realization of a misallocation problem, that some patients not only here but elsewhere we’re getting treatments that wouldn’t benefit them, and others were not getting respiratory treatments they needed,” said James Stoller, MD, head of the section of respiratory therapy in the department of pulmonary, allergy and critical care medicine at Cleveland Clinic.
“The vision of a consult service was the realization that patients needed to have an RT see them, along with using evidence-based care algorithms to make appropriate decisions on patients’ behalf, and not depending on the physician to make every recommendation,” Dr. Stoller said. “Over the years, we’ve studied it and shown consistent findings. It enhances the allocation of RC services. Treatments that don’t need to get done don’t, and those that do, do.”
Ohio’s famous Cleveland Clinic was among the first hospitals to chisel out the field’s future by creating and using evidence-based respiratory therapist-driven care protocols.
Back in 1992, Cleveland Clinic developed an RC consult service that uses sign- and symptom-based branching logic algorithms for administering aerosol therapy, bronchopulmonary hygiene, hyperinflation techniques, oxygen therapy, and other services.
What drove Cleveland Clinic to develop a respiratory care consult service “was the realization of a misallocation problem, that some patients not only here, but elsewhere, were getting treatments that wouldn’t benefit them, and others were not getting respiratory treatments they needed,” said James Stoller, MD, head of the section of respiratory therapy in the department of pulmonary, allergy, and critical care medicine at Cleveland Clinic.
“The vision of a consult service was the realization that patients needed to have an RT see them, along with using evidence-based care algorithms to make appropriate decisions on patients’ behalf, and not depending on the physician to make every recommendation,” Dr. Stoller said. “Over the years, we’ve studied it and shown consistent findings. It enhances the allocation of RC services. Treatments that don’t need to get done don’t, and those that do, do.”
Disease management specialists
The road from “oxygen jockeys” to clinicians should lead to disease management specialists in the future, offered Garry Kauffman, MPA, CHE, RRT, an adjunct faculty member of the RT program at Harrisburg Area Community College, Pa.
“If you look back at where we started, we were primarily ‘treaters,’ IPPB, for example,” he said. “We then added various diagnostics, pulmonary rehab, and began breaking out of the hospital into post-acute care and home care. The last iteration is to add disease management: prophylaxis, managing asthma, smoking cessation. The dream I have is to put all those together: to detect, treat, and manage.”
That dream is still a ways off in many areas, though. RTs treat chronic obstructive pulmonary disease with bronchodilators and achieve short-term goals, but they’re less involved than Kauffman would like with managing its chronic symptoms – and with prevention, wellness, and disease management in general.
“We tend to continue to do the tasks and duties, but we’re not really wrapped into the whole patient-care-and-management package in the way I’d hoped,” he said. “We never will replace doctors and nurses, but we are the best qualified and the best educated to detect, treat, and manage lung disease.”
Nor are therapist-driven protocols as widespread as Kauffman prefers, even though the science backing them up is irrefutable.
“We have seen an increase in respiratory care departments using TDPs, but we don’t have as many as we should,” he said. “RTs using TDPs have been documented as providing equal to or better patient outcomes at equal to or lower costs. Protocols really free up physicians from their historical roles to a new role in which they write an order for RTs to consult, develop, and implement a patient care plan to maximize patient care. It lets everyone work to their highest level of skill.”
Rapid response team
In the coming years, RTs should find themselves increasingly immersed in another emerging area of health care: the rapid response team.
Rapid response teams need one member adept at creating and maintaining a stable airway. Only RTs fill that role on the rapid evaluation team at Bridgeport Hospital, Bridgeport, Conn., which the hospital created to take part in the Institute for Healthcare Improvement’s 100,000 Lives Campaign.
“On Oct. 1, we went live with the team,” said Evelyn Tkacs Cimmino, RRT, RN, manager of respiratory therapy services and sleep medicine. “It’s a real plus for the staff. The team consists of a critical care nurse, an RT, a medical resident, and some patient care technicians. The team is averaging about 20 calls a month.”
To earn their place on the team, Cimmino wants all her staff members to complete Fundamental Critical Care Support certification, a credential sponsored by the Society of Critical Care Medicine. She’s a big believer in RTs picking up extra credentials.
Cimmino insists her RTs have basic life support certification. She prefers them to also have Advanced Cardiac Life Support and Pediatric Advanced Life Support certification, plus Neonatal Resuscitation Program certification, a credential offered by the American Academy of Pediatrics.
“Critical care, that’s where my focus is,” she said. “I would love to see a level of ‘critical care RCP.’ I plug our staff as critical care therapists. They feel strongly that they could work anywhere once they work here.”
‘A stepping-stone career’
Cimmino fairly erupts with ideas on where RTs can take their knowledge. She “absolutely” sees RTs securing a more prominent role in sleep medicine, helped along by last year’s decision by the Commission on Accreditation of Allied Health Education Programs to allow accredited respiratory care programs to offer a polysomnography certificate of completion option as an add-on to their existing programs.
“These days, everybody’s into sleep,” Cimmino said. “It’s a nice feature for them to expand their role. Right now, they are limited in that role. Sleep labs are hiring LPNs and EEG techs because RTs are in short supply right now.”
Several of Cimmino’s staff members have moved on to become advanced registered nurse practitioners. They’re qualified to perform nursing duties and to give physical exams, take patients’ health history, order tests, and formulate care plans, she said.
Educating other providers on the basics of mechanical ventilation, up to and including medical residents, is another role Cimmino sees latent in her staff members.
“We will have a clinical educator to make sure our staff is competent, but also educate our physicians and our physician assistants,” she said. “More RC departments will move in this direction, hiring people for use on competencies.”
Lastly, what’s stopping therapists from moving into the world of clinical trials to help drive the industry-wide crusade to establish evidence-based standards of care? “We could always use a group of RTs in research,” Cimmino said. “Why do we have these new modes of ventilation? Who comes up with pressure release ventilation modes? When you read our clinical journals, how do you know if this is a good or a poorly designed trial? Research hopefully is something people will find interesting.”
Respiratory care, she concluded, “can be a stepping-stone career.”
Cessation counselor
With COPD, the fourth leading cause of death in America, claiming the lives of 122,283 Americans in 2003, smoking cessation offers yet another direction for RTs to grow.1
“The advantage for RTs is they are experts in respiratory disease,” said Jonathan Foulds, PhD, who directs a program at the University of Medicine and Dentistry of New Jersey, Newark, that teaches RTs, nurses, doctors, dentists, mental health professionals, and others to become certified tobacco treatment specialists.
“They are trained clinicians so they know about treatments. And they have credibility with patients. Also, they routinely see patients with smoking-caused illnesses, so it comes naturally with their role.”
The big question about smoking cessation as a career move, though, is funding. “There is no profession of smoking counselor right now,” Dr. Foulds said. “For people to work in the field, which is the single most cost-effective intervention on the face of the planet besides child inoculation, we need to get funding.”
Smoking cessation “is not integrated very well into mainstream health care,” he continued. “HMOs have resisted increasing costs and not wanted to cover more treatments. That’s the big thing one can never control. But all the evidence suggests that dollars are extremely well spent helping smokers quit. You prevent a lot of health care costs down the line.”
Hyperbaric oxygen therapy
Yet another promising field for RTs that remains limited by funding is hyperbaric oxygen therapy (HBO). Never mind that the science behind hyperbarics dates to 1855. HBO is a hot new blip on medicine’s radar screen, according to Kauffman, who’s also administrative director of Hyperbaric, Wound Care, and Renal Services at Lancaster General, Lancaster, Pa.
“Respiratory therapists can and should be working in hyperbarics, both in the clinical and managerial roles,” he said.
What holds RTs back from colonizing this new turf, however, is that until a few years ago, Medicare reimbursed for only a few clinical indications for HBO. Within the last three years, though, the Centers for Medicare and Medicaid Services has increased the list of indications to 14.
Ongoing research attests to its effectiveness in many other areas, including follow-up care for heart attack patients, Kauffman said.
“HBO services are sprouting up all around the country, presumably because awareness and reimbursement are no longer the obstacles they once were,” he said. “As the list of clinical indications approved by CMS has grown, the commercial insurers are catching on.”
RTs throughout the continuum of care
Also, a shortage of funding, specifically Medicare reimbursement, is to blame for the profession’s inability to gain traction in another field: home care. Cimmino hopes to see that change but isn’t as sanguine on this prospect.
“I would really like to see insurance companies reimburse RTs for their services in the home,” she said. “Visiting Nurse Associations do a lot of follow-up in home care but, if a patient has some pulmonary problem, the RT should be able to go out there, do the treatment, and get reimbursed.”
As the U.S. population ages, the country will face a much greater need for long-term ventilatory support in extended-care facilities, Dr. Stoller added. “Right now, the evidence is sparse for RT roles in those areas,” he said. “But I think there will be growth in those arenas: extended care facilities, sleep labs, rehab.”
Reference
1. National Center for Health Statistics. Report of final mortality statistics, 2003.
Michael Gibbons is senior associate editor of ADVANCE. He can be reached at [email protected].
Moving to Higher Educational Ground
Nothing is free.
Climbing the ladder toward advanced diagnostics, disease management, and other weighty clinical responsibilities won’t happen unless respiratory therapists move beyond the current two-year associate’s degree to advanced levels of training and education, the field’s leaders acknowledge.
“We need to increase the number of bachelor’s and master’s degrees in RT, and doctoral degrees in related fields such as physiology or health sciences,” said David Shelledy, PhD, RRT, FAARC, associate dean at the University of Arkansas for Medical Sciences’ College of Health Related Professions, as well as a professor in its department of respiratory and surgical technologies.
Upping educational requirements poses a risk, though: It might hurt student recruitment and exacerbate the already acute shortage of practicing RTs.
That’s why Dr. Shelledy, while obviously high on education, doesn’t endorse the idea of making a bachelor’s degree the minimum educational requirement for respiratory care at this time. But he would like to see several other things happen.
“I think we need, for the short run, to dramatically increase the number of baccalaureate programs,” he said. And we need “a proliferation of collaborative programs” between universities and community colleges.
“Community colleges produce the bulk of the (RC) work force,” he pointed out. “I would like to see them partner with universities so students could stay at the community college and complete their bachelor’s degrees. We have a career ladder program on the Web here in Little Rock. A community college can collaborate with it.”
Master’s degree programs
The other piece of the puzzle is graduate education, Dr. Shelledy continued.
“Let’s get some master’s degree programs,” he said. “PT went to a doctorate. OT went to a master’s entry level. PA (physician assistants) is in the process of moving to a master’s entry level. Why don’t we have something like that for RTs?
“Why not a master’s for pulmonary physician assistants? Imaging science is doing it. Nuclear medicine is right behind them. We’re sitting here arguing about an associate’s versus a bachelor’s. We need more bachelor’s-trained folks, but we also need to get on the ball and get more master’s degree folks.”
Virtually every other health care profession is moving to higher ground educationally because the body of medical knowledge is “growing by leaps and bounds,” agreed Garry Kauffman, MPA, CHE, RRT, adjunct faculty member of the RT program at Harrisburg Area Community College, Pa.
“Whether it’s pharmacists, nurses, or RTs, it’s clear you can’t cram all this into the old programs,” he said. “I predict we’ll see more post-grad programs for prevention and wellness. There is no way anyone will have the time in their clinical studies to learn how to be a good teacher and a good motivator.”
Potential dangers
Like others, Kauffman sees two potential dangers in gentrifying RC’s educational neighborhood.
First, the increased length and cost of an RC program might be too great for some to afford. Secondly, all this talk of increasing education comes at a time when hospitals need an estimated 5,000 newly graduated therapists per year.
“I don’t know if it will be an absolute barrier, but maybe a stiff challenge,” Kauffman said of requiring more education of RC students. “Not for the 18-year-old so much as for the second careerist, like mothers re-entering the work force. They are a wealth of great talent and maturity, and a two-year program is attractive to them. I certainly favor appropriate higher education, but each program will have to look carefully at it so we don’t preclude entry, especially by individuals from lower socioeconomic strata.”
As an interim measure, why not offer financial incentives to RTs to attend focused two-day or three-day workshops for subjects such as hemodynamic monitoring?
“We send staff to workshops, then mandate that they teach the rest of the staff what they learn,” explained Evelyn Tkacs Cimmino, RRT, RN, manager of respiratory care services and sleep medicine at Bridgeport Hospital, Bridgeport, Conn. “I think our staff members, especially if they are older, gravitate toward that type of program.
“If people want to advance themselves they could get a bachelor’s in allied health, in management, in business, in microbiology,” Cimmino said. “But a bachelor’s in RT? Unless they’re going to be guaranteed a significant salary boost, they don’t seem to be that interested. But they do come to me with requests to attend seminars and workshops.”
–Michael Gibbons
Super-smart Ventilators Versus the Human Factor
Sophisticated chess computers such as Deep Blue now routinely defeat the game’s highest-ranked grandmasters. Are mechanical ventilators evolving at a similar clip?
Computerized weaning protocols built into ventilators significantly outperform the weaning efforts of physicians and respiratory therapists, according to a study published in October. In head-to-head competition, computer-driven weaning decisively undercut clinician-guided weaning in parameters such as time on vent, length of ICU stay, reintubation rate, need for noninvasive ventilation, and tracheotomy.1
A question squats like an elephant in the room and begs to be asked: Will mechanical ventilators, at some point in the future, grow so sophisticated, with so many built-in safeguards, with so many complex processes activated at the push of a few buttons, that other providers with far less training (and smaller salaries) than RTs could operate them safely and effectively?
In other words, even as they colonize new turf, will RTs in the future lose ground in their bread-and-butter area, mechanical ventilation? Will they suffer the chess grandmaster’s fall from grace?
More knowledge needed
Two leading respiratory care experts answer a reassuring, “No.” They don’t predict technological progress will reduce the role of RTs in ventilator management.
“Unless there is an incredible change in technology, I don’t think that’s likely,” said David Shelledy, PhD, RRT, FAARC, College of Health Related Professions, University of Arkansas for Medical Sciences, Little Rock.
“If the past is any predictor of the future, the more sophisticated ventilators get, the more complicated they get, and the more they need folks knowledgeable about full ventilatory support.”
One might foresee such an incredible leap in technology that ventilators themselves might be supplanted by some other mechanism that enables oxygen to enter and carbon dioxide to leave the body, Dr. Shelledy speculated. “But as long as we continue to be cardiopulmonary specialists, whatever evolves, we will be the experts,” he said.
Garry Kauffman, MPA, CHE, RRT, Harrisburg Area Community College, Pa., stressed the intangibles that dedicated human caregivers bring to critical care.
“If you think back to when vents had just a few knobs, the eyes, ears, and critical thinking skills of RTs and others made the difference,” Kauffman said. “All those perspectives should be superior to machinery. A patient sweating, the anxious looks on a patient’s face — these things are not addressed yet (by technology).”
Plus, the microprocessor feedback loops and other features of today’s ventilators “have yet to be documented as to whether they provide better outcomes,” he noted.
“If the technology takes care of minor changes and allows the therapist as physician-extender to manage the big picture, more power to it. But we’re not there yet.”
Reference
1. Lellouche F, Mancebo J, Jolliet P, et al. A multicenter randomized trial of computer-driven protocolized weaning from mechanical ventilation. Am J Resp Crit Care Med. 2006;174(8):894-900.
–Michael Gibbons
