Emergency Department Initiative to Decrease High-flow Nasal Cannula Use for Admitted Patients with Bronchiolitis.

Background: Despite limited evidence, a high-flow nasal cannula (HFNC) is often used to treat mild to moderate (m/m) bronchiolitis. We aimed to decrease the rate of HFNC use in the pediatric emergency department (PED) for m/m bronchiolitis from a baseline of 37% to less than 18.5%. Methods: A multidisciplinary team created a bronchiolitis pathway and implemented it in December 2019. A respiratory score (RS) in the electronic medical record objectively classified bronchiolitis severity as mild, moderate, or severe. We tracked HFNC utilization in the PED among patients with m/m bronchiolitis as our primary outcome measure between December 2019 and December 2021. We monitored the percentage of patients with an RS as a process measure. Interventions through four plan-do-study-act cycles included updating the hospital oxygen therapy policy, applying the RS to all patients in respiratory distress, modifying the bronchiolitis order set, and developing a bronchiolitis-specific HFNC order. Results: Three hundred twenty-five patients were admitted from the PED with m/m bronchiolitis during the 11-month baseline period and 600 patients during the 25-month intervention period. The mean rate of HFNC utilization decreased from 37% to 17%. Despite a decrease in bronchiolitis encounters after the pandemic, in the spring of 2021, when volumes returned, we had a sustained HFNC utilization rate of 17%. RS entry increased from 60% to 73% in the intervention period. Conclusions: A clinical pathway for bronchiolitis can lead to decreased use of HFNC for m/m bronchiolitis. Consistent RS, order set development with decision support, and education led to sustained improvement despite pandemic-related volumes.

Characteristics, Identification, Training, and Perception of Leaders in Respiratory Care.

BACKGROUND: Leadership is critical to high-functioning teams; however, data are lacking for what defines successful respiratory therapist (RT) leadership. Leaders need a wide range of skills to be successful, although the exact characteristics, behaviors, and accomplishments of successful RT leaders are unknown. We performed a survey of respiratory care leaders to evaluate different aspects of RT leadership. METHODS: We developed a survey of RT leaders to examine respiratory care leadership in a variety of professional settings. Different aspects of leadership and the relationships between perceptions of leadership and well-being were assessed. Data analysis was descriptive. RESULTS: We received 124 responses, with a response rate of 37%. Respondents had a median 22 y of RT experience, and 69% were in leadership positions. The most-important skills identified for potential leaders were critical thinking (90%) and people skills (88%). Self-initiated projects (82%), intradepartmental education (71%), and precepting (63%) were noted accomplishments. Reasons for exclusion from leadership included poor work ethic (94%), dishonesty (92%), difficulty getting along with others (89%), unreliable (90%), and not being a team player (86%). Most respondents (77%) agreed American Association for Respiratory Care membership be a requirement for leadership; however, 31% required membership. Integrity (71%) was noted consistently as a characteristic of successful leaders. There was no consensus for behaviors of successful versus unsuccessful leaders or what defines successful leadership. Ninety-five percent of leaders had received some leadership training. Respondents reported that well-being is affected by leadership, departmental culture, peers, and leaders with burnout; 34% of respondents felt people with burnout received good support at their institution, whereas 61% felt maintaining well-being is left to individuals. CONCLUSIONS: Critical thinking and people skills were the most-important skills for potential leaders. Limited consensus existed on characteristics, behaviors, and defined success of leaders. Most respondents agreed leadership influences well-being.

Enhancing Respiratory Therapists' Well-Being: Battling Burnout in Respiratory Care.

Burnout is a major problem in health care and is associated with adverse sequelae for patients, health care workers, and organizations. Burnout among respiratory therapists (RTs) is as high as 79% and is associated with poor or ineffective leadership, inadequate staffing, high work load, non-leadership position, and work environment. An understanding of burnout is necessary for both staff and leadership to ensure RT well-being. This narrative review will discuss the psychology of burnout, prevalence, drivers, mitigation strategies, and future directions for research.

Burnout Among Respiratory Therapists Amid the COVID-19 Pandemic.

BACKGROUND: Burnout is a major challenge in health care and is associated with poor overall well-being, increased medical errors, worse patient outcomes, and low job satisfaction. There is scant literature focused on the respiratory therapist's (RT) experience of burnout, and a thorough exploration of RTs' perception of factors associated with burnout has not been reported. The aim of this qualitative study was to understand the factors associated with burnout as experienced by RTs amid the COVID-19 pandemic. METHODS: We performed a post hoc, qualitative analysis of free-text responses from a survey of burnout prevalence in RTs. RESULTS: There were 1,114 total and 220 free-text responses. Five overarching themes emerged from the analysis: staffing, workload, physical/emotional consequences, lack of effective leadership, and lack of respect. Respondents discussed feelings of anxiety, depression, and compassion fatigue as well as concerns that lack of adequate staffing, high workload assignments, and inadequate support from leadership contributed to feelings of burnout. Specific instances of higher patient acuity, surge in critically ill patients, rapidly evolving changes in treatment recommendations, and minimal training and preparation for an extended scope of practice were reported as stressors that led to burnout. Some respondents stated that they felt a lack of respect for both the RT profession and the contribution of RTs to patient care. CONCLUSIONS: Themes associated with burnout in RTs included staffing, workload, physical and emotional exhaustion, lack of effective leadership, and lack of respect. These results provide potential targets for interventions to combat burnout among RTs.

Factors Associated With a Positive View of Respiratory Care Leadership.

BACKGROUND: Burnout within health care is prevalent, and its effects are detrimental to patient outcomes, organizations, and individuals. Effects stemming from burnout include anxiety, depression, excessive alcohol and drug use, cardiovascular problems, time off work, and worse patient outcomes. Published data have suggested up to 50% of health care workers experience burnout and 79% of respiratory therapists (RTs) experience burnout. Leadership has been cited as a key driver of burnout among RTs. We aimed to identify factors associated with a positive or negative leadership perception. METHODS: A post hoc analysis of an institutional review board-approved survey to evaluate RT burnout, administered via REDCap by convenience sample to 26 health care centers (3,124 potential respondents) from January 17-March 15, 2021, was performed to identify factors associated with a positive view of leadership. Survey questions included validated tools to measure leadership, burnout, staffing, COVID-19 exposure, and demographics. Data analysis was descriptive, and logistic regression was performed to evaluate factors associated with leadership perception. RESULTS: Of 1,080 respondents, 710 (66%) had a positive view of leadership. Univariate analysis revealed those with a positive view of leadership were more likely to be working with adequate staffing, were rarely unable to complete all work, were less likely to be burned out, disagreed that people in this work environment were burned out, were less likely to miss work for any reason, more likely to be in a leadership position, worked fewer hours in intensive care, worked in a center affiliated with a medical school, worked day shift, were less likely to care for adult patients, and were more likely to be male. Logistic regression revealed providing care to patients with COVID-19 (odds ratio [OR] 5.8-10.5, P < .001-.006) was the only factor associated with a positive view of leadership, whereas working without adequate staffing (OR 0.27-0.28, P = .002-.006), staff RTs (OR 0.33, P < .001), work environment (OR 0.42, P = .003), missing work for any reason (OR 0.69, P = .003), and burnout score (OR 0.98, P < .001) were associated with a negative view of leadership. CONCLUSIONS: Most RTs had a positive view of their leadership. A negative leadership score was associated with higher burnout and missing work. This relationship requires further investigation to evaluate if changes in leadership practices can improve employee well-being and reduce burnout.

Prevalence of Burnout Among Respiratory Therapists Amidst the COVID-19 Pandemic.

Background: Burnout is a major challenge in health care, but its prevalence has not been evaluated in practicing respiratory therapist (RTs). The purpose of this study was to identify RT burnout prevalence and factors associated with RT burnout.Methods: An online survey was administered to 26 centers in the United States and between January and March 2021. Validated, quantitative, cross-sectional surveys were used to measure burnout and leadership domains. The survey was sent to department directors and distributed by the department directors to staff. Data analysis was descriptive and logistic regression analysis was performed to evaluate risk factors, expressed as odds ratios (OR), for burnout.Results: The survey was distributed to 3,010 RTs, and the response rate was 37%. Seventy-nine percent of respondents reported burnout, 10% with severe, 32% with moderate, and 37% with mild burnout. Univariate analysis revealed those with burnout worked more hours per week, worked more hours per week in the ICU, primarily cared for adult patients, primarily delivered care via RT protocols, reported inadequate RT staffing, reported being unable to complete assigned work, were more frequently exposed to COVID-19, had a lower leadership score, and fewer had a positive view of leadership. Logistic regression revealed burnout climate (OR 9.38, p<0.001), inadequate RT staffing (OR 2.08 to 3.19, p=0.004 to 0.05), being unable to complete all work (OR 2.14 to 5.57, p=0.003 to 0.20), and missing work for any reason were associated with increased risk of burnout (OR 1.96, p=0.007). Not providing patient care (OR 0.18, p=0.02) and a positive leadership score (0.55, p=0.02) were associated with decreased risk of burnout.Conclusion: Burnout was common among RTs in the midst of the COVID-19 pandemic. Good leadership was protective against burnout while inadequate staffing, inability to complete work, and burnout climate were associated with burnout.

Twice-Daily Huddles Improves Collaborative Problem Solving in the Respiratory Care Department.

BACKGROUND: Lean Six Sigma processes are used in health care systems to increase safety and efficiency. Daily huddles, one tool of the Lean Six Sigma process, have been used to increase patient safety, facilitate efficiency in problem solving, promote optimal patient outcomes, and reduce poor communication. Huddle utilization by respiratory care departments has not been previously reported. We describe our process of implementing daily huddles and the impact on departmental problem solving. METHOD: A descriptive study of a quality improvement intervention and a retrospective study of prospectively collected data were performed. The respiratory care department was trained in the utilization of a daily huddle process to resolve issues and identify process improvement opportunities. Huddles were performed at the beginning of each shift. Process improvement opportunities were raised by the respiratory therapy staff using the following categories: Safety/Service, Methods, Equipment, Supplies, and Associates. Opportunities were placed within 3 categories; quick hits (resolution in 1-3 d), complex problems (resolution in 3-7 d), and projects (resolution in > 7 d). All opportunities included a problem statement, an immediate countermeasure, a problem leader, and a due date. Items requiring interdisciplinary support were escalated to the organizational patient care services huddle. We evaluated the number and nature of process improvement opportunities raised in huddles from January 1 through December 31, 2018, to better understand the impact of daily huddles. RESULTS: A total of 366 process improvement opportunities were raised during huddles. Of those, 245 (67%) were quick hits, 77 (21%) were complex, and 44 (12%) were projects. Resolution of 174 (47.5%) opportunities was completed using only the resources of the respiratory care department, and 157 (43%) were resolved with additional interdisciplinary involvement. A small portion 35 (9.5%) of opportunities required escalation to the organizational multidisciplinary huddle for resolution. All process improvement opportunities were resolved at the end of the study period (mean ± SD of 30.5 ± 7.7 per month). CONCLUSIONS: Twice-daily huddles implemented by our respiratory care department allowed for identification and timely resolution of process improvement opportunities.

Impact of Helium-Oxygen Administered via High Velocity Nasal Insufflation on Delivery of Inhaled Nitric Oxide.

Inhaled nitric oxide (iNO) may be continued during the transition from invasive to noninvasive respiratory support. Upper airway obstruction from laryngeal edema following extubation and lower airway obstruction from asthma and bronchiolitis may be managed with inhaled helium. The coadministration of helium with iNO and the impact on delivered amounts of iNO have not been extensively studied. A bench model simulating a spontaneously breathing infant received iNO at varying preset doses delivered with either helium-oxygen or nitrogen-oxygen via a Vapotherm unit. iNO levels were measured at the simulated trachea. Results from the two conditions were compared using t-tests. When nitrogen-oxygen was used, there was no difference between preset and measured iNO levels. A significant difference was present when helium-oxygen was used, with a 10-fold increase in measured iNO levels compared with preset values. The use of helium resulted in a significant increase in measured iNO at the level of the simulated trachea. Clinicians must be aware that iNO will not be delivered at prescribed doses when used with helium under the conditions used in this study.

Occupational-Induced Secondary Traumatic Stress and Posttraumatic Stress Disorder in Respiratory Therapists.

BACKGROUND: Secondary traumatic stress (STS) may occur in the caretakers of individuals who have experienced traumatic events or are suffering and, when severe, may be associated with posttraumatic stress disorder (PTSD) at a diagnostic level due to STS. For respiratory therapists (RTs), the incidence of STS and PTSD at a diagnostic level due to STS has not been examined. We assessed the prevalence of self-reported STS and PTSD at a diagnostic level due to STS in licensed RTs. METHODS: Licensed RTs who were members of the American Association for Respiratory Care completed the Secondary Traumatic Stress Scale (STSS) based on feelings experienced over the preceding 30 days and 12 months. Results were evaluated on the basis of primary patient population (neonatal/pediatric vs adult), years of experience, and usual work location (ambulatory care, acute care, or ICU) using the McNemar chi-square analysis and the Fisher exact test. RESULTS: 201 licensed and practicing RTs completed the survey. 92% of the respondents worked ≥ 30 h/week, 75% worked in ICUs, 67% worked primarily with adults, and 89% had been in practice ≥ 6 years. PTSD at a diagnostic level due to STS was common in all respondents, occurring in 36% based on experiences from the prior 30 days and in 32% based on experiences from the prior 12 months. CONCLUSIONS: No difference in PTSD at a diagnostic level due to STS was noted between RTs caring for neonatal/pediatric versus adult patients or between RTs based on years of work experience or based on work environment. STS and PTSD at a diagnostic level due to STS was common in RTs.