AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting.

Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines. In recent years, clinicians worldwide have demonstrated a renewed interest in the management of patients with tracheostomy due to the recognition that more effective and efficient management of this patient population is necessary to decrease morbidity and mortality and to optimize the value of the procedure. Commensurate with the goal of enhancing the care of patients with tracheostomy, we conducted a systematic review to facilitate the development of recommendations relevant to the care of adult patients with tracheostomy in the acute care setting. From our systematic review, clinical practice guidelines were developed to address questions regarding the impact of tracheostomy bundles, tracheostomy teams, and protocol-directed care on time to decannulation, length of stay, tracheostomy-related cost, tracheostomy-related adverse events, and other tracheostomy-related outcomes in tracheostomized adult patients in the acute care setting. Using a modification of the RAND/UCLA Appropriateness Method, 3 recommendations were developed to assist clinicians with tracheostomy management of adult patients in the acute care setting: (1) evidence supports the use of tracheostomy bundles that have been evaluated and approved by a team of individuals experienced in tracheostomy management to decrease time to decannulation, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, improved tolerance of oral diet; (2) evidence supports the addition of a multidisciplinary tracheostomy team to improve time to decannulation, length of stay, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, increased speaking valve use; (3) evidence supports the use of a weaning/decannulation protocol to guide weaning and removal of the tracheostomy tube to improve time to decannulation.

Predicting Respiratory Therapists' Intentions to Use the Modified Early Warning Score by Using an Enhanced Technology Acceptance Model.

BACKGROUND: The modified early warning score (MEWS) is used to detect early clinical deterioration and to escalate care as needed. Respiratory therapists (RTs) usually do not use the MEWS even when it is implemented as a default in the electronic health record system. This study explored whether the technology acceptance model could predict the intentions of RTs to use the MEWS. METHODS: A validated survey that uses a pretest/posttest design was used to determine the effect of an educational intervention (lecture and interactive small group session) on RTs' MEWS knowledge. We also measured key determinants of the intention by RTs to use the MEWS based on the constructs of the technology acceptance model. The survey was distributed to 75 RTs employed at a Midwestern academic medical center. RESULTS: There was a 61% survey response rate. Statistical analysis of the survey data demonstrated that the educational intervention increased the MEWS knowledge score from 2.0 before education to 4.0 after education (P < .001). Moreover, there was a statistically significant increase in the behavioral intention score, from 3.0 before education to 4.0 after education (P < .001). Partial least squares structural equation modeling revealed that MEWS knowledge influenced perceived ease of use, which influenced attitude, which influenced behavioral intention. CONCLUSIONS: Numerous studies have demonstrated that a change in behavioral intention is a good predictor of change in behavior. The increase in the RTs' knowledge, attitude, and behavioral intention scores after MEWS education indicated that these RTs may be more inclined to use the MEWS if they were educated about its clinical relevance and if their attitude toward using it were favorable. Analysis of the study results also indicated that the technology acceptance model could serve as a framework to guide respiratory care managers in the development of strategies to successfully implement new systems or processes that are intended to be used by RTs.

Respiratory care informatics and the practice of respiratory care.

Recently I reported the results of a study that was conducted to determine how respiratory care information is managed and processed in respiratory care departments. Data obtained from the respiratory care departments surveyed indicated that their information systems (paper-based or automated) do not manage and process respiratory care information effectively or efficiently. Since the goal of an information system is to improve delivery of services, any useful information system must mirror business processes (or professional activities) to achieve that goal. Consequently, I suggested that, in addition to inadequate database management systems, the shortcomings of the information systems surveyed may have stemmed from a failure to accurately define and describe the data, information, and knowledge unique to the respiratory care profession. Accurate description and definition of respiratory care data, information, and knowledge, however, require a formal language and taxonomy for the respiratory care profession. This article explores the concept of respiratory care informatics and its relevance to the practice of respiratory care.

Perceived Satisfaction With Long-Term Oxygen Delivery Devices Affects Perceived Mobility and Quality of Life of Oxygen-Dependent Individuals With COPD.

BACKGROUND: Although routine physical activity for individuals with COPD is recommended, there are inherent limitations of available oxygen delivery devices that may result in hypoxemia during activity. Changes in Medicare laws have resulted in an increased use of oxygen cylinders and a reduction in the use of liquid oxygen devices. The aim of this survey was to assess the impact of perceived satisfaction with various oxygen delivery devices on perceived mobility and quality of life (QOL) of oxygen-dependent subjects with COPD. METHODS: A survey was developed to measure perceived satisfaction with current portable oxygen delivery devices, perceived mobility, and perceived QOL. The survey was deployed via a link posted on the COPD Foundation's COPD360SOCIAL social media site for 5 weeks, which resulted in the recruitment of 529 participants, of which 417 were included in the data analysis. RESULTS: Quantile regression analysis revealed that the median perceived device satisfaction score was significantly higher in the liquid oxygen device group (P < .001) compared with the portable oxygen cylinder and portable oxygen concentrator (POC) groups. The median perceived mobility score was significantly higher in the liquid oxygen device group (P < .001) compared with the portable oxygen cylinder group, but not the POC group. The median QOL score was significantly higher in the liquid oxygen device group (P < .001) compared with the POC and portable oxygen cylinder groups. Moreover, partial least-squares structural equation modeling regression analysis showed that perceived mobility is significantly affected by perceived satisfaction with the long-term oxygen therapy (LTOT) device (adjusted R2 = 0.15, P < .001), and perceived QOL is significantly affected by both perceived satisfaction with the LTOT device and perceived mobility (adjusted R2 = 0.45, P < .001). CONCLUSIONS: For individuals with COPD requiring LTOT, perceived satisfaction with a portable LTOT device significantly and positively affects perceived mobility and QOL.

Perspectives From COPD Subjects on Portable Long-Term Oxygen Therapy Devices.

BACKGROUND: Oxygen therapy for patients with COPD and severe hypoxemia requires the use of oxygen delivery devices that allow mobility as needed. However, the characteristics of some devices may limit the freedom of individuals to be as physically active as they desire. Limited mobility may negatively affect the perceived quality of life of individuals with COPD. The aim of this study was to understand perceived limitations that patients with COPD experience in using long-term oxygen therapy (LTOT) devices. METHODS: We performed a qualitative analysis of 311 responses to an open-ended question from a previously deployed electronic survey designed to investigate how LTOT devices affect oxygen-dependent patients with COPD. Our thematic analysis was facilitated by NVivo, a qualitative data analysis software package. This involved identifying patterns and themes within the robust, text-rich data from the open-ended survey question regarding the survey subjects' experiences with their LTOT devices. Cluster analysis was also performed to highlight relationships between various concepts. RESULTS: Themes generated revealed that subjects experienced decreased mobility, which resulted in feelings of decreased autonomy and isolation. We also found that subjects perceived a decrease in quality of life due to their described experience of portable oxygen cylinders being heavy and cumbersome. Subjects described feelings of fear and anxiety due to insufficient support for breathing provided by pulse-dose portable oxygen concentrators, as well as portable oxygen cylinders that run out before they are able to complete errands and other activities of daily living. Some subjects also reported that they willingly pay for liquid oxygen systems out-of-pocket because of the mobility it affords, which in their perception improves their quality of life. CONCULSIONS: Oxygen-dependent individuals with COPD may be at risk of adverse outcomes associated with decreased mobility encouraged by unsatisfactory physical and technical characteristics of portable oxygen cylinders and concentrators.

Management and processing of respiratory care information in respiratory care departments.

BACKGROUND: Though much research has been done to determine best practice and to examine the role of evidence-based guidelines and respiratory therapist (RT) driven protocols in enhancing patient care and reducing health care costs, very little attention has been paid to how respiratory care information is managed and processed. OBJECTIVE: To examine information systems currently used in respiratory care departments to determine if they are effective and efficient in managing and processing respiratory care information. METHODS: To 50 RTs at 16 respiratory therapy departments in New York, Houston, and Miami, we distributed questionnaires designed to determine the strengths, weaknesses, and usefulness of existing respiratory care information systems. There were 2 types of questionnaire: one for respiratory care managers and another for staff RTs. We used a combination of purposive and snowball sampling techniques to choose RTs to whom to send the survey. RESULTS: The response rate was 52%. Of the 26 respondents, 19 were staff RTs and 7 were managers. In the 16 departments that responded, 3 of the information systems were strictly paper-based, 12 were partially automated (combination of paper records and computer files), and 1 was fully automated. The respondents' opinions about the usefulness of their information systems were: 19% said "very useful," 23% said "useful," 46% said "somewhat useful," and 12% said "not useful." All the respondents said that they rely on colleagues, books, and manuals for decision support, rather than on computerized decision-support systems. CONCLUSIONS: This study suggests that the information systems used by the respondent RTs have marginal utility and have problems with data storage and retrieval, because either the systems do not employ computerized databases or the computerized databases do not have full-scale database management systems. Inadequate data storage and retrieval systems often lead to data redundancy and, ultimately, inaccurate information. Development of data models specific to the respiratory care profession may be necessary to build databases with conceptual schemas that accurately reflect the professional activities of RTs.