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.

Developing Treatment Guidelines During a Pandemic Health Crisis: Lessons Learned From COVID-19.

The development of the National Institutes of Health (NIH) COVID-19 Treatment Guidelines began in March 2020 in response to a request from the White House Coronavirus Task Force. Within 4 days of the request, the NIH COVID-19 Treatment Guidelines Panel was established and the first meeting took place (virtually-as did subsequent meetings). The Panel comprises 57 individuals representing 6 governmental agencies, 11 professional societies, and 33 medical centers, plus 2 community members, who have worked together to create and frequently update the guidelines on the basis of evidence from the most recent clinical studies available. The initial version of the guidelines was completed within 2 weeks and posted online on 21 April 2020. Initially, sparse evidence was available to guide COVID-19 treatment recommendations. However, treatment data rapidly accrued based on results from clinical studies that used various study designs and evaluated different therapeutic agents and approaches. Data have continued to evolve at a rapid pace, leading to 24 revisions and updates of the guidelines in the first year. This process has provided important lessons for responding to an unprecedented public health emergency: Providers and stakeholders are eager to access credible, current treatment guidelines; governmental agencies, professional societies, and health care leaders can work together effectively and expeditiously; panelists from various disciplines, including biostatistics, are important for quickly developing well-informed recommendations; well-powered randomized clinical trials continue to provide the most compelling evidence to guide treatment recommendations; treatment recommendations need to be developed in a confidential setting free from external pressures; development of a user-friendly, web-based format for communicating with health care providers requires substantial administrative support; and frequent updates are necessary as clinical evidence rapidly emerges.

Resilience and Burnout Resources in Respiratory Care Departments.

BACKGROUND: Burnout is a major problem in health care, with rates of approximately 33% and 50% in nurses and physicians, respectively, prior to the COVID-19 pandemic. Respiratory therapist (RT) burnout rates and drivers have not been specifically examined. The purpose of this project was to determine resilience and burnout resources available within respiratory care departments and to provide an estimate of pre- and post-COVID-19 RT burnout rates. METHODS: A survey was developed to evaluate resilience and burnout resources in respiratory care departments. The survey was posted online to the AARConnect management, education, adult acute care, neonatal/pediatrics, COVID-19, and help line communities. Data analysis was descriptive. Key drivers of burnout among RTs were identified from qualitative answers. RESULTS: There were 221 responses, and 72% reported experiencing burnout. Ten percent of the departments that responded measured burnout; 36% utilized resilience tools, and 83% offered free employee assistance for those struggling with burnout. In January 2020, 30% of departments reported an estimated burnout rate > 40%, which increased to 44% of departments (P = .007) in the COVID-19 pandemic period. The most common drivers reported were poor leadership (32%), high work load (31%), and staffing (29%); 93% of respondents agreed that burnout is a major problem in health care, 33% agreed that burnout is primarily driven by external factors, 92% agreed that RTs have a similar risk of burnout as other health care professionals, 73% agreed that they were comfortable discussing challenging situations with colleagues, 32% agreed that their leadership provided adequate support for those suffering from burnout, and 79% agreed that they would be open to utilizing resilience tools from the AARC or other professional organizations. CONCLUSIONS: Most respondents experienced burnout and few respiratory care departments measured burnout. Resilience resources were not commonly used but employee assistance and wellness programs were common. Key drivers of burnout identified were poor leadership, staffing, and high workloads.

Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework.

Background: Post-intensive care syndrome (PICS) is a constellation of new or worsening impairments in physical, mental, or cognitive abilities or a combination of these in individuals who have survived critical illness requiring intensive care. Purpose: The 2 purposes of this systematic review were to identify the scope and magnitude of physical problems associated with PICS during the first year after critical illness and to use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to elucidate impairments of body functions and structures, activity limitations, and participation restrictions associated with PICS. Data Sources: Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, CINAHL Plus with Full Text (EBSCO), Web of Science, and Embase were searched from inception until March 7, 2017. Study Selection: Two reviewers screened titles, abstracts, and full text to independently determine study eligibility based on inclusion and exclusion criteria. Data Extraction: Study methodological quality was assessed using the Newcastle-Ottawa Scale. Data describing study methods, design, and participant outcomes were extracted. Data Synthesis: Fifteen studies were eligible for review. Within the first year following critical illness, people who had received intensive care experienced impairments in all 3 domains of the ICF (body functions and structures, activity limitations, and participation restrictions). These impairments included decreased pulmonary function, reduced strength of respiratory and limb muscles, reduced 6-minute walk test distance, reduced ability to perform activities of daily living and instrumental activities of daily living, and reduced ability to return to driving and paid employment. Limitations: The inclusion of only 15 observational studies in this review may limit the generalizability of the findings. Conclusions: During the first year following critical illness, individuals with PICS experienced physical impairments in all 3 domains of the ICF.

Impact of an Electronic Medical Record Screening Tool and Therapist-Driven Protocol on Length of Stay and Hospital Readmission for COPD.

BACKGROUND: In the United States, care for COPD patients is frequently delivered by respiratory therapists (RTs). After implementing a therapist-driven protocol for COPD treatment, we sought to improve identification of COPD patients. We hypothesized that using an electronic medical record screening tool to identify subjects with COPD combined with a therapist-driven protocol would positively impact length of stay (LOS) and readmission rates. METHODS: Utilizing the electronic medical record to search the provider's admission notes for the terms COPD/Asthma, a report was generated. Subjects already receiving RT services were removed. An RT evaluated identified subjects using a therapist-driven protocol combining clinical assessment and FEV1 to calculate an air-flow obstruction score. Scores ≥7 received 24 h of bronchodilator therapy by RTs. Scores <7 received assessment by RTs but bronchodilator therapy administered by nursing staff. An RT performed medication reconciliation and education for both groups. ICD-9 discharge codes identified primary and secondary diagnoses of COPD. LOS and 30-d readmission rates were measured for a 14-month period. Respiratory-triggered rapid response data were also collected. RESULTS: The pre-intervention period was from December 2013 to June 2014, and the post-intervention period was from July 2014 to January 2015. There were 142 subjects in total, 68 pre-intervention and 74 post-intervention. For primary COPD, mean LOS decreased from 4.37 to 2.96 d (P = .10), and 30-d readmission rates decreased from 13.6 to 6.1%. Respiratory-triggered rapid response data were as follows: The pre-intervention span was from January 2014 to June 2014, and post-intervention was from July 2014 to December 2015. For primary COPD, there were 61 pre-intervention subjects and 63 post-intervention with a decrease in respiratory-triggered rapid responses from 21 pre-intervention (34.4%) to 8 post-intervention (12.7%) (P = .004). For secondary COPD (1,168 pre-intervention, 1,267 post-intervention), there was a change from 318 (27.2%) pre-intervention to 296 (23.4%) post-intervention (P = .03). CONCLUSION: Utilization of the electronic medical record to identify subjects with likely COPD combined with a therapist-driven protocol directed by RT assessment was associated with a trend toward decreased LOS and reduction in readmission rates. There was a significant reduction of respiratory-triggered rapid responses in subjects with a primary diagnosis of COPD.

Impact of offering continuing respiratory care education credit hours on staff participation in a respiratory care journal club.

BACKGROUND: Journal clubs are employed by education and healthcare institutions to facilitate learning about study design, to teach critical reading of the literature, and to help trainees and practitioners keep abreast in their fields. Our respiratory care department initiated a journal club that was open to all respiratory therapists in the community. The articles were selected by the journal club coordinator and posted on the club's web site. However, attendance remained poor despite changes in venue, time, and day of the week. In Washington State, respiratory therapists are required to obtain continuing respiratory care education credits (CRCEs), so we hypothesized that offering American Association for Respiratory Care CRCEs for journal club attendance would increase participation. METHODS: We measured journal club attendance during the 8 months preceding and the 8 months following introduction of CRCE credit for journal club attendance. The journal club meetings were held during same time frame, on the same day of the week, and in the same geographic region during the pre-CRCE and CRCE periods. Advertising for the journal club was the same during both periods as well. RESULTS: Pre-CRCE attendance ranged from 5 to 8 persons per meeting (mean ± SD 6 ± 1 persons), and CRCE-period attendance ranged from 7 to 10 persons (mean ± SD 8 ± 1) (P = .01). CONCLUSIONS: Providing CRCE credits for attendance was associated with increased participation in our departmental journal club.

A porcine model for initial surge mechanical ventilator assessment and evaluation of two limited-function ventilators.

OBJECTIVES: To adapt an animal model of acute lung injury for use as a standard protocol for a screening initial evaluation of limited function, or "surge," ventilators for use in mass casualty scenarios. DESIGN: Prospective, experimental animal study. SETTING: University research laboratory. SUBJECTS: Twelve adult pigs. INTERVENTIONS: Twelve spontaneously breathing pigs (six in each group) were subjected to acute lung injury/acute respiratory distress syndrome via pulmonary artery infusion of oleic acid. After development of respiratory failure, animals were mechanically ventilated with a limited-function ventilator (simplified automatic ventilator [SAVe] I or II; Automedx, Germantown, MD) for 1 hr or until the ventilator could not support the animal. The limited-function ventilator was then exchanged for a full-function ventilator (Servo 900C; Siemens-Elema, Solna, Sweden). MEASUREMENTS AND MAIN RESULTS: Reliable and reproducible levels of acute lung injury/acute respiratory distress syndrome were induced. The SAVe I was unable to adequately oxygenate five animals with Pao2 (52.0±11.1 torr) compared to the Servo (106.0±25.6 torr; p=.002). The SAVe II was able to oxygenate and ventilate all six animals for 1 hr with no difference in Pao2 (141.8±169.3 torr) compared to the Servo (158.3±167.7 torr). CONCLUSIONS: We describe a novel in vivo model of acute lung injury/acute respiratory distress syndrome that can be used to initially screen limited-function ventilators considered for mass respiratory failure stockpiles and that is intended to be combined with additional studies to definitively assess appropriateness for mass respiratory failure. Specifically, during this study we demonstrate that the SAVe I ventilator is unable to provide sufficient gas exchange, whereas the SAVe II, with several more functions, was able to support the same level of hypoxemic respiratory failure secondary to acute lung injury/acute respiratory distress syndrome for 1 hr.

The effects of apparatus dead space on P(aCO2) in patients receiving lung-protective ventilation.

BACKGROUND: Lung-protective ventilation using tidal volume (V(T)) of 4-6 mL/kg (predicted body weight) reduces mortality (compared with traditional V(T)) in patients with acute respiratory distress syndrome and acute lung injury. Standardized use of lower V(T) can result in respiratory acidosis and has raised new concerns about the appropriate configuration of the ventilator circuit, especially in regard to the dead space (V(D)) of the apparatus. We hypothesized that, with a patient receiving lung-protective ventilation, the removal of all apparatus dead space from the circuit would reduce P(aCO2) and allow a reduction in minute ventilation. METHODS: All the studied patients met the American-European consensus-conference criteria for acute respiratory distress syndrome/acute lung injury, were receiving a lung-protective ventilation strategy, were > 18 years of age, and were hemodynamically stable. We prospectively tested 3 different ventilator-circuit configurations, in random sequence, for 15 min each: (1) standard hygroscopic heat-and-moisture exchanger (HME) with 15-cm flexible tubing, (2) 15-cm flexible tubing only, (3) no HME or flexible tubing. V(T), respiratory rate, positive end-expiratory pressure, and fraction of inspired oxygen were maintained constant throughout the study, and exhaled CO2 was measured continuously. Physiologic dead space (V(D)/V(T)) was calculated using the Enghoff modification of the Bohr equation. RESULTS: Seven patients were studied. Removal of the HME from the circuit significantly decreased V(D)/V(T) (by approximately 6%) and P(aCO2) (by approximately 5 mm Hg). Removal of both the HME and flexible tubing from the circuit reduced V(D)/V(T) by an additional 5%, and P(aCO2) by an additional 6 mm Hg. With both circuit-configuration changes, minute ventilation fell from a mean of 11.51 L/min to 10.35 L/min, and pH increased from 7.30 to 7.38. Carbon-dioxide production did not change significantly. CONCLUSION: In patients receiving lower-V(T) ventilation, removing all the apparatus V(D) from the ventilator circuit reduces P(aCO2) and increases pH, at a lower minute ventilation. This information will help guide ventilator-circuit configuration for patients receiving lung-protective ventilation.