A computer-aided audit system for respiratory therapy consult evaluations: description of a method and early results.

BACKGROUND: Use of respiratory therapist (RT)-guided protocols enhances allocation of respiratory care. In the context that optimal protocol use requires a system for auditing respiratory care plans to assure adherence to protocols and expertise of the RTs generating the care plan, a live audit system has been in longstanding use in our Respiratory Therapy Consult Service. Growth in the number of RT positions and the need to audit more frequently has prompted development of a new, computer-aided audit system. METHODS: The number and results of audits using the old and new systems were compared (for the periods May 30, 2009 through May 30, 2011 and January 1, 2012 through May 30, 2012, respectively). In contrast to the original, live system requiring a patient visit by the auditor, the new system involves completion of a respiratory therapy care plan using patient information in the electronic medical record, both by the RT generating the care plan and the auditor. Completing audits in the new system also uses an electronic respiratory therapy management system. RESULTS: The degrees of concordance between the audited RT's care plans and the "gold standard" care plans using the old and new audit systems were similar. Use of the new system was associated with an almost doubling of the rate of audits (ie, 11 per month vs 6.1 per month). CONCLUSIONS: The new, computer-aided audit system increased capacity to audit more RTs performing RT-guided consults while preserving accuracy as an audit tool. Ensuring that RTs adhere to the audit process remains the challenge for the new system, and is the rate-limiting step.

An analysis of features of respiratory therapy departments that are avid for change.

BACKGROUND: Models of organizational change-readiness have been developed, but little attention has been given to features of change-avid health-care institutions, and, to our knowledge, no attention has been given to features of change-avid respiratory therapy (RT) departments. METHODS: We conducted an exploratory study to compare RT departments we deemed change-avid or non-change-avid, to identify differentiating characteristics. Our assessments regarding change-readiness and avidity were based on structured, in-person interviews of the technical directors and/or medical directors of 8 RT departments. Based on a priori criteria, 4 of the 8 RT departments were deemed change-avid, based on the presence of > or = 2 of the following 3 criteria: (1) uses a management information system, (2) uses a comprehensive RT protocol program, (3) uses noninvasive ventilation in > 20% of patients with exacerbation of chronic obstructive pulmonary disease. Our ratings of the departments were based on 2 scales: one from Integrated Organizational Development Inc, and the 8-stage change model of Kotter. RESULTS: The ratings of the 4 change-avid departments differed significantly from those of the 4 non-change-avid departments, on both the Integrated Organizational Development Inc scale and the Kotter scale. We identified 11 highly desired features of a change-avid RT department: a close working relationship between the medical director and the RT staff; a strong and supportive hospital "champion" for change; using data to define problems and measure the effectiveness of solutions; using redundant types of communication; recognizing resistance and minimizing obstacles to change; being willing to tackle tough issues; maintaining a culture of ongoing education; consistently rewarding change-avid behavior; fostering ownership for change and involving stakeholders; attending to RT leadership succession planning; and having and communicating a vision for the department. CONCLUSIONS: In this first exploratory study we found that change-avid RT departments can be differentiated from non-change-avid RT departments with available assessment tools. Highly desired features of a change-avid RT department were identified but require further study, as does the relationship between change-avidity and clinical outcomes.

Concordance of respiratory care plans generated by protocols from different hospitals: a comparative study.

OBJECTIVE: To assess whether respiratory care protocols from different hospitals result in similar care plans for identical patients, we asked: 1. Does applying respiratory care protocols from different hospitals to standardized patient vignettes produce identical care plans? 2. If there are differences in the care plans produced, what is the extent of the difference, and for which modalities are the differences greatest? 3. Does installing the protocol in a computerized information management system to generate the respiratory care plan improve the level of agreement? 4. Do protocols from different hospitals agree with regard to indications for respiratory care treatments and use of the Clinical Practice Guidelines from the American Association for Respiratory Care? METHODS: Protocols were compared by applying each of 4 hospitals' protocols to 15 patient vignettes that we developed, with various respiratory problems. With each vignette, 3 experienced respiratory therapist evaluators developed respiratory care plans, using both a manual (paper-based) and a computer-aided approach. RESULTS: The overall degree of agreement among the 4 protocols was moderate (kappa 0.60, 95% confidence interval 0.46-0.71). The degree of concordance differed for the individual respiratory care modalities; concordance was generally highest for oxygen, aerosol delivery, and pulse oximetry, and was lower for bronchopulmonary hygiene and hyperinflation. Concordance regarding indications for therapy also differed among the modalities; concordance was greatest for the indications for incentive spirometry, bronchodilator use, and pulse oximetry. The concordance of care plans developed with the computer-aided approach resembled that of the manual approach (kappa 0.62, 95% confidence interval 0.45-0.77). CONCLUSIONS: Our results suggest moderate agreement between care plans generated with respiratory care protocols from different hospitals. The sources of differences included differences in the indications for therapy, different degrees of protocol compliance with the American Association for Respiratory Care Clinical Practice Guidelines, and subjectivity in the indications for therapy. This study identifies opportunities to lessen regional variation in respiratory care, by encouraging uniform application of protocols and evidence-based guidelines.

Impact of an annual retreat on process improvement in a respiratory therapy section.

BACKGROUND: In order to fulfill the mission of providing superb respiratory care, managing respiratory care services requires communication and collaboration. To enhance communication and collaboration in our Section of Respiratory Therapy at the Cleveland Clinic Foundation, and to generate ideas for improvement, since 1996 we have conducted annual retreats for the Section, during which important challenges and opportunities are discussed in a large-group forum. The current report describes the retreat process and outcomes, namely the ideas generated during these retreats and the frequency with which ideas were implemented successfully. METHODS: The annual retreat brings together all clinical specialists, supervisors, and managers in the Section of Respiratory Therapy, along with the medical director of Respiratory Therapy and representatives of the staff from each shift. In advance of the annual half-day retreat, supervisors and clinical specialists are asked to write a brief description of things that need improvement and actionable proposed solutions to these challenges. These documents are reviewed by the supervisors, managers, education coordinator, and medical director, and a list of discussion topics for the retreat is formulated. The retreat day begins with a brief introduction and summary of the year's activities and then encourages open-ended discussions regarding the various topics, with the explicit, repeated goal of generating solutions. Minutes are kept to identify specific action items, a list of which is visited repeatedly throughout the year, to assess progress toward successful completion of each action item. In the current analysis, the primary outcome measures are the number of ideas generated as action items during the retreats and the frequency with which these ideas have been implemented. RESULTS: Over the 8 years of annual retreats, 103 action items have been generated, of which 84% (n = 87) have been successfully implemented or completed. As evidence of the importance of this group-based activity, we cite several examples of suggestions and action items that were felt to uniquely represent group process and wisdom and which were not proposed beforehand by individuals. CONCLUSIONS: On the basis of this experience, we recommend conducting annual respiratory therapy department retreats. We believe the benefits include collective problem-solving in a public forum to identify solutions not advanced by individuals. Also, we believe that the direct communication in such retreats contributes to enhanced morale, further evidence of which is the very low turnover rate among our respiratory therapists during the 8 years in which we have conducted annual retreats.

Changing patterns of inpatient respiratory care services over a decade at the Cleveland Clinic: challenges posed and proposed responses.

INTRODUCTION: Changing characteristics of hospitalized patients over the last decade have created challenges for all health-care providers in delivering optimal care. In the specific case of respiratory care, trends that hospitalized patients have generally become sicker over time and that average lengths of stay have generally become shorter have posed the challenge of meeting demands for more services delivered with greater immediacy. We undertook the current analysis to assess how the delivery of respiratory care services at a tertiary-care academic medical center, the Cleveland Clinic Foundation Hospital, has evolved over the decade 1991 to 2001. In this observational study, we examined concurrent departmental trends and speculated that the capability to increase clinical activity with maintained or improved clinical outcomes, preserved costs, and a lower turnover rate among respiratory therapists reflects features of the professional environment within our Section of Respiratory Therapy. METHODS: This analysis compares patterns of respiratory care service delivery in two 5-year intervals: from 1991 to 1996 and from 1996 to 2001. Data were collected using a respiratory care information-management system and an inpatient hospital information system, which track the volume and actual cost of services provided. These analyses accounted for the actual time-based cost of the services, including labor (with benefits), necessary equipment and supplies, medications, and equipment maintenance and depreciation. Hospital case-mix index values were determined according to guidelines from the Centers for Medicare and Medicaid Services, as the weighted average of resource allocation scores assigned to diagnosis-related-group categories of hospitalized patients. RESULTS: From 1991 to 2001, there were important expansions in the scope of respiratory care practice by our Section of Respiratory Care, while the volume of respiratory care services delivered per year increased 1.96-fold (from 339,600 to 665,921 services/y). The number of respiratory therapy consults performed yearly, beginning in 1992 when the service was first implemented, rose to over 10,000/y by 2001. At the same time, the cost of respiratory therapy services delivered per patient decreased by 4.2%. Regarding staffing trends, the number of full-time-equivalent employees increased by 50% (from 65 to 97.5). However, the percent turnover rate among respiratory therapists decreased by 2.3-fold (from 11.5% to 5%). In the face of these trends, the hospital mortality rate for patients with diagnosis-related group 088 (high users of respiratory care services) decreased by 53%, and the length of hospital stay for all patients receiving respiratory treatments decreased by 30%. CONCLUSIONS: This analysis shows that trends of growing demands for respiratory care services have been accompanied by generally improving clinical outcomes and favorable retention of respiratory therapists in our section. We believe that a focus on the process of care, including enhanced professionalism, communication, and participation, has permitted a favorable response to these rising demands.

Respiratory care continuing education.

The need for continuing education for respiratory therapists as well as other for health care practitioners is well established. The changing nature and increased volume of medical information, along with the rapid growth of technology related to respiratory care, demand that professionals engage in continuing education. Educational activities may be formal lectures or seminars, or self-directed studies, teleconferences, or video presentations. Recent studies indicate that interactive workshops, alone or in combination with other educational methods, are more likely to be effective that didactic lectures alone. Evaluation methods for continuing education programs have focused on attendees' ratings but should be revised to emphasize the impact of the educational program on beneficial changes in practice.

Respiratory therapists' attitudes about participative decision making: relationship between managerial decision-making style and job satisfaction.

BACKGROUND: Studies of non-health-care work environments indicate that non-managerial employee job satisfaction is higher in companies that use participative (as opposed to autocratic) decision making. It has not been determined whether managerial decision-making style influences job satisfaction among respiratory therapists (RTs) and which managerial decision-making style RTs prefer. METHODS: We surveyed Nebraska RTs' attitudes regarding their job satisfaction, their perceptions of their managers' decision-making styles (autocratic, consultative, and/or delegative), and which decision-making style they would prefer their managers to use. We sought to determine whether there is a significant correlation between RTs' perceptions of their managers' decision-making styles and the RTs' job satisfaction. The study population was 792 licensed and practicing non-managerial RTs in Nebraska, from which we randomly selected 565 RTs to survey. The self-administered, descriptive survey used 2 Likert scales (one for decision-making style and one for job satisfaction) and inquired about 57 items. The survey was mailed on October 1, 1999. On October 28, 1999, we sent a second mailing to RTs who had not responded. RESULTS: We received 271 responses (response rate 47.9%). The respondents were generally satisfied with their jobs (mean +/- SD Minnesota Satisfaction Questionnaire score 73.46 +/- 11.63). The sub-scale scores ranged from 20 ("very dissatisfied") to 100 ("very satisfied"). The respondents did not want autocratic managerial decision making (mean +/- SD autocratic sub-scale score 4.29 +/- 0.60). Autocratic decision making was associated with lower job satisfaction (r = 0.49), whereas consultative and delegative decision making were associated with higher job satisfaction (r = -0.31 and -0.48, respectively). RTs who worked in departments that had < 25 RT employees reported higher job satisfaction than did RTs in larger departments (p = 0.029). CONCLUSIONS: Our survey data indicate that (1) RTs prefer delegative and consultative managerial decision making, (2) job satisfaction was highest in departments that had < 25 RTs in the department and in which the manager practiced participative decision making. These findings offer guidance for organizing optimal work environments for RTs.

Weekly versus daily changes of in-line suction catheters: impact on rates of ventilator-associated pneumonia and associated costs.

BACKGROUND: An earlier randomized, controlled trial showed that weekly or as-needed (as opposed to daily) changes of in-line suction catheters were associated with substantial cost savings, without a higher rate of ventilator-associated pneumonia (VAP). To examine the impact of decreasing the frequency of in-line suction catheter changes in our medical intensive care unit, we conducted an observational study, comparing the catheter costs and frequency of VAP during (1) a control period, during which in-line suction catheters were changed daily, and (2) a treatment period, during which the catheters were changed every 7 days or sooner if needed, for mechanical failure or soilage. METHODS: All adult patients admitted to our 18-bed medical intensive care unit were evaluated for the 3-month interval 1 year prior to the practice change (May through July 1998) and for the 3 months after implementing the new policy (May through July 1999). To avoid bias related to usual seasonal variation in VAP frequency, we also determined (via medical records) the VAP rate during May through July 1997. The occurrence of VAP was ascertained by an infection control practitioner, using criteria established by the Centers for Disease Control and applied in a standard fashion. The VAP rate was calculated as the mean number of VAPs per 100 ventilator-days for each 3-month interval. Use of ventilators, humidifiers, and non-heated-wire, disposable circuits was uniform during the study, as were policies regarding humidity, temperature settings, and frequency of routine ventilator circuit changes. RESULTS: During the control period 146 patients accounted for 1,075 ventilator-days and there were 2 VAPs (0.19 VAPs per 100 ventilator-days). During the treatment period 143 patients accounted for 1,167 ventilator-days and there were no VAPs. The mean +/- SD duration of in-line suction catheter use during the treatment period was 3.8 +/- 0.8 days, and 51% of the patients had the same catheter in place for > 3 days (range 4-9 days). The actual cost of catheters used during the treatment period was lower than during the control period ($1,330 vs $6,026), predicting annual catheter cost savings of $18,782. CONCLUSIONS: We conclude that (1) a policy of weekly (vs daily) change of in-line suction catheter is associated with substantial cost savings, with no significant increase in the frequency of VAP, and (2) to the extent that these findings confirm the results of prior studies they support a policy of changing in-line suction catheters weekly rather than daily.

Missed bronchodilator medication treatments in respiratory therapy: frequency and underlying causes.

BACKGROUND: In the context of increasing attention to medical errors, missed therapies have become a subject of focus both for optimizing clinical care and for assuring appropriate institutional performance during external review by accrediting bodies. Because the issue of missed treatments in respiratory therapy has received little attention to date, we undertook to describe the frequency and causes of missed respiratory therapy bronchodilator medication treatments at the Cleveland Clinic Hospital. METHODS: Between August 2000 and August 2001, using a respiratory therapy management information system, we recorded the number of respiratory therapy bronchodilator medication treatments ordered and delivered (via small-volume nebulizer and metered-dose inhaler) and the reason(s) for each missed treatment. RESULTS: Over the 12-month study interval 113,554 bronchodilator medication treatments (74,921 via small-volume nebulizer and 38,633 via metered-dose inhaler) were ordered. Overall, 4,012 medication treatments were missed (3.5% of the total), with variation by month ranging from 2.0% to 5.0%. The commonest reason for failure to administer the ordered bronchodilator treatment was the patient being out of the room at the time of the therapist's visit, which accounted for nearly one third of missed therapies. Next most common was the patient refusing treatment (24.6%), followed by the patient being unavailable because of ongoing activities or therapy (eg, physical therapy or a medical procedure). The least common reason was the respiratory therapist being called away to administer therapy to another patient (1.4%). CONCLUSIONS: Overall, the frequency of missed bronchodilator treatments was relatively low in this series. The next steps include developing strategies to lower the frequency of missed treatments, so as to optimize the allocation of respiratory therapy services, and studying the clinical consequences of missed therapies.

Impact of a radio frequency management information system on the process and timing of providing respiratory care services.

BACKGROUND: Although radio frequency (RF) systems have proliferated and are designed to simplify care delivery in many clinical settings, little information is available on the impact of such RF systems on the delivery of patient care. Having used a hand-held-device-based management information system in our Respiratory Therapy Section for 16 years, we assessed the impact of an RF system on the delivery of respiratory therapy (RT) services. METHODS: A single nursing unit dedicated to pulmonary and ear, nose, and throat care was selected for the RF system trial. Baseline (pre-RF) data were collected over 2 separate 1-month intervals (February 1999 and February 2000). The main outcome measures were (1) the amount of time needed at the beginning of the shift to organize and assign orders for RT services, (2) the time interval between notification of an RT consult order and completion of the RT consult, and (3) the time interval between notification of an RT treatment order and completion of the RT treatment. The activities required for organizing and assigning the orders were manually timed. Starting 6 weeks after therapists were trained to use the RF system, similar data were collected while using the RF system for two 1-month intervals (February and March 2001). RESULTS: The mean +/- SD time interval between receiving an RT consult order and completing the consult was reduced from 7.8 +/- 18.9 h to 2.8 +/- 2.4 h (p = 0.002). The percentage of patients who waited longer than 8 hours between receipt of a consult order and completion of the consult decreased from 18% to 4.7% (p = 0.026). The total time required for organizing and assigning RT work was reduced from 81.6 min to 43.6 min. CONCLUSIONS: The RF system had several advantages over the hand-held-device-based system: (1) shorter interval between the order for and completion of an RT consult, (2) lower percentage of patients for whom the interval between the order and the consult exceeded 8 hours, and (3) less time required to make shift assignments. These results invite assessment of whether accelerated delivery of RT services confers clinical benefits.