Respiratory care work assignment based on work rate instead of work load.

BACKGROUND: We previously reported a new management variable, work rate, defined as work load due per hour, based on cumulative standard treatment times. We found that work rates were unachievable (ie, exceeded 1 hour of scheduled work per hour of available labor) for 75% of scheduled due times, despite presumed achievable average work load. OBJECTIVE: To determine the optimal strategy for creating work assignments based on work rate. METHODS: A focus group used root-cause analysis to identify ways to balance assignments based on work rate. We surveyed employees to assess their willingness to start earlier. We determined the ratio of scheduled to unscheduled work during a 12-month period. The scheduled work comprised administering small-volume nebulizer, metered-dose inhaler, noninvasive ventilation, and mechanical ventilation. The unscheduled work consisted of all other modalities. We also developed a spreadsheet model to assess the effect of shifting the start time on work-rate distribution in a representative 24-hour period. RESULTS: The focus group determined that starting treatments 1 hour earlier would help. Fifteen of the 24 clinicians surveyed responded, and 13 of the respondents were willing to start earlier. The scheduled work load averaged approximately 55% of the total work load, but there was high variability per assignment area (range 0-99%). The spreadsheet model showed that shifting treatment start times improved the distribution of work rate throughout the day, but did not guarantee that labor demand never outstrips supply. CONCLUSIONS: Our studies to date suggest that: basing assignments on average work load leads to periods of unachievable work rate, resulting in missed treatments and staff dissatisfaction. We have only limited ability to reduce peaks in work rate, but staggering treatment times is effective. Fair assignment of work should differentiate scheduled from unscheduled work.

A comparison of respiratory care workload with 2 different nebulizers.

UNLABELLED: Aerosol therapy via small-volume nebulizer (SVN) accounts for a large proportion of the respiratory care workload. Treatment time is mostly nebulization time, which is highly variable, depending on SVN design. We studied the workload effect of adopting a faster nebulizer. We hypothesized that time saved by faster SVN treatment can be used by respiratory therapists for other patient-care activities. METHODS: We compared day-shift workload distribution in a post-thoracic-surgery ward during 2 consecutive 30-day periods. To deliver bronchodilators (3 mL unit dose), during the baseline period we used the VixOne nebulizer (average nebulization time 9 min), and during the intervention period we used the NebuTech HDN (nebulization time limited to 3 min). We recorded the per-shift number of various respiratory-therapy procedures, which have been assigned standard treatment times, and compared the per-shift numbers of procedures during the baseline and intervention periods. RESULTS: The per-shift number of procedures were similar during the baseline and intervention periods (33.8/shift vs 33.3/shift, P = .68), as was the per-shift number of SVN treatments (11.9/shift vs 11.8/shift, respectively, P = .81). The per-shift time required for the procedures was greater during the baseline period (4.7 h vs 3.6 h, P < .001). The per-shift time available to deliver optional value-added respiratory therapies was higher in the intervention period (0.75 h vs 0.50 h, P < .04). The time savings from the faster nebulizer corresponded to 1.8 full-time equivalents and theoretical net annual savings of $66,491. We did not use treatment "stacking" (ie, simultaneous administration of SVN treatments to multiple patients). CONCLUSIONS: The NebuTech HDN substantially reduces SVN-administration time, without adverse effects or events, and the time savings were used for value-added patient-care activities. Shorter treatment times can play a role in coping with the national shortage of qualified respiratory therapists.

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.

Use of noninvasive positive-pressure ventilation on the regular hospital ward: experience and correlates of success.

BACKGROUND: Though noninvasive positive-pressure ventilation (NPPV) is efficacious in treating patients with exacerbations of chronic obstructive pulmonary disease, little attention has been given to the optimal venue in which to provide NPPV. The aim of this prospective observational study was to assess the outcomes of NPPV initiated for acute respiratory failure on the regular in-patient ward. METHODS: Starting in May 2004, all patients started on NPPV for acute respiratory failure on regular nursing floors of the Cleveland Clinic Hospital were identified. Patients were divided into 2 groups: do-not-intubate (DNI) and non-DNI. NPPV failure was defined as the need to transfer the patient to the intensive care unit (ICU). RESULTS: Seventy-six patients were enrolled. The most common cause of acute respiratory failure was exacerbation of chronic obstructive pulmonary disease (41%), followed by pulmonary edema, pneumonia, obesity-hypoventilation, and neuromuscular illness. Of the 62 non-DNI patients, 19 (31%) failed NPPV on the regular ward and required transfer to the ICU. Variables associated with NPPV failure were amount of secretions (p = 0.04), etiology of respiratory failure (pneumonia was associated with the highest failure rate, p = 0.015), and infiltrate on the chest radiograph (p = 0.036). Seven of the 14 (50%) DNI patients died during hospitalization. CONCLUSIONS: Results of this observational study show that noninvasive positive-pressure ventilation is frequently used on the regular hospital ward and that the success rate is similar to that reported in series in which NPPV is used in the ICU.

Impact of a program to provide patients with comparative information about providers of durable medical equipment for home respiratory care.

BACKGROUND: How patients are informed regarding their choices of durable medical equipment (DME) providers for home-going respiratory equipment may affect their decisions about which vendor to use. When a new enhanced information program to inform home-going patients about all available respiratory DME providers was implemented, we hypothesized that patients' utilization of providers would change and that satisfaction with service would be enhanced. METHODS: The enhanced information program consisted of offering detailed descriptions of the many available providers to home-going patients. To characterize available providers, we administered a questionnaire to all respiratory DME providers listed in our area. We assembled information about the scope of services, the number and types of providers, the geographic range of service, and the providers' contact information, on a 1-page information sheet about the DME providers, which was given to all home-going patients. Case managers, who routinely help patients make such DME arrangements, were oriented about the questionnaire and given the information sheets to distribute. The study compared responses from Medicare insurees prescribed to receive home-going respiratory care equipment on discharge from The Cleveland Clinic Hospital during the periods before and after implementing the enhanced information program. Consecutive eligible patients in the before and after groups were called by two of the study investigators (ERH, DAM), at least 2 weeks after discharge, and, on their granting consent, were asked to complete a telephone survey. RESULTS: Responses were available from 75 patients in each group. Both before and after implementing the enhanced information program, patients' satisfaction with their respiratory DME service providers' services was high. The number of providers selected increased after the program from 12 to 18, and though the differences between the before and after scores were not statistically significant, there was a trend toward prompter visits to patients in their homes by DME-provider respiratory therapists. CONCLUSIONS: The enhanced information program was associated with a larger number of DME providers being selected, with preservation of a high level of patient satisfaction with DME services. The trend toward prompter respiratory therapists' visits to the home and better availability of oxygen canisters for at-home patients suggested benefits from the enhanced information program.