Fall/Winter 2019 Adult Acute Care Bulletin

Fall/Winter 2019 Adult Acute Care Specialty Section Bulletin

Chair
Carl Hinkson, MSRC, RRT, RRT-ACCS, RRT-NPS
Providence Regional Medical Center
Everett, WA
Carl.hinkson@providence.org

Editor
Karsten Roberts, MS, RRT, RRT-ACCS, RRT-NPS
Hospital of the University of Pennsylvania
Philadelphia, PA
karsten.j.roberts@gmail.com

In this issue:


Notes from the Chair

Carl Hinkson, MSRC, RRT, RRT-ACCS, RRT-NPS

Our section Bulletin is back! Feedback from the section membership was that they valued the Bulletin and wanted to see it continue. This edition contains articles on scope of practice and professionalism.

The Bulletin will be published twice a year. Karsten Roberts will be taking over as editor. If you would like to see a particular topic discussed or would like to write an article yourself please feel free to reach out to him at the contact information on the masthead in this issue.

Kartsen was also recognized as this year’s Adult Acute Care Section Specialty Practitioner of the Year at the AARC Congress in New Orleans. Congratulations to Karsten.

I recently got back from the Congress, and I can tell you it was a fantastic four days of networking, excellent lectures, OPEN FORUM sessions, and opportunities to network. It was wonderful to meet many of you in person after reading your comments online. The section meeting was great and well attended. A variety of topics were discussed.

Even though we just finished the 2019 Congress, it is already time to submit proposals for lectures for the 2020 Congress in Orlando, FL. They are due in to the AARC by Dec. 16. If you need advice or help please don’t hesitate to reach out to me through AARConnect. It is not too early to start planning for our trip to the land of the mouse! I hope to see you there.


Scope of Practice: Pop the “Top”

Madison Fratzke, RRT, RRT-ACCS, University of Virginia Medical Center, Charlottesville, VA

Since 1943 respiratory therapy has evolved from rudimentary inhalation therapy to complex management of the critically ill.1,2 On-the-job training was eventually replaced by formal education and credentialing, laying the professional groundwork for specialists in airway management and the cardiopulmonary system.3,4 Respiratory therapists are now regarded as highly valued members of the critical care team, and the role continues to expand while reaching for top-of-license initiatives.5

The American Association for Respiratory Care’s most recent position statement on scope of practice describes the current role and specific responsibilities to which the role “is not limited.”6 Respiratory therapists continue to take on more responsibilities through various post-graduate training and by performing in-hospital procedures such as arterial line placement, central line placement, lung ultrasound, or bronchoscopy. Furthermore, on some transport teams the respiratory therapist serves in the same role as other team members and is credentialed to perform procedures such as needle decompression of the chest, surgical cricothyrotomy, administration of blood products, giving sedation medications prior to intubation, insertion and management of intravenous lines, and management of ventricular assist devices.

In facilities where resources may be scarce, inconsistent, or delayed, there may be a great value in training respiratory therapists to perform certain procedures that will result in improved patient safety.5 For example, often the nurse is waiting to have central and arterial lines placed in a septic shock patient, the respiratory therapist is monitoring a dyspneic patient while waiting for a physician to ultrasound the chest after suspicion of a large pleural effusion or after signs of mucous plugging in an intubated patient, or the bronchoscopy is scheduled in four hours.

Delay of care can lead to delay of treatment and intervention – line insertions, ultrasounds, and bronchoscopies should be completed in a more timely manner so that appropriate patient care can continue.7 The Joint Commission lists “improving access to care” as one solution to avoid delay of treatment and improve patient safety, and respiratory therapists could be part of that solution.7

Several studies, for example, have demonstrated that central and arterial line insertion by respiratory therapists is safe and feasible.1 In 1993, Gronheck and Miller evaluated insertion of 500 arterial lines by respiratory therapists, with results demonstrating safety of nonphysician placement. In 2000 Rowley reported a successful initial experience of a respiratory therapist-based arterial line placement service.8,9 More recently, in 2017 Pack et al. demonstrated feasibility of a respiratory therapist-managed arterial line insertion program at a non-teaching hospital.10

Of course, convincing decision-makers to allow us to practice beyond our “current scope” may require not only interdepartmental collaboration and persistence from team leaders but also RTs to acquire advanced credentials. The National Board for Respiratory Care created the Adult Critical Care Specialty exam in order to establish a minimum level of competency for adult critical care. As they have for other medical professions, some institutions are now requiring RTs to have this specialty credential in order to work in critical care. As of December 2018, more than 3,700 practitioners have been awarded the RRT-ACCS credential, accounting for 2.2% of all Registered Respiratory Therapists (RRTs). The pass rate in 2018 was 68%, which was similar to the 66% pass rate for the Neonatal Pediatric Specialty exam.11

Furthermore, the Commission on Accreditation for Respiratory Care, which oversees accreditation of respiratory therapy programs, has begun approving Advanced Practice Respiratory Therapist (APRT) programs. Objectives for the graduates of these programs include the ability to serve as a physician extender in pulmonary or critical care medicine, providing more accessible, high quality, cost effective, and best-practice care while improving outcomes, hospital length of stay, and readmissions.12 These advanced credentials demonstrate a higher level of commitment and long-term dedication to the critical care world through continuing education and credential maintenance.

Berlin stated in his 2017 editorial, “A great opportunity awaits RTs who can expand their skill set and work diligently to optimize utilization of services based upon the benefit they provide to each individual patient.”5 Respiratory therapists have the education, the expertise, and the opportunity to establish competency through advanced credentials. These attributes describe an ideal clinician to provide expert, efficient, and safe care in all areas of critical care, therefore removing limitations on scope of practice for greater progress of the profession.

References

  1. Becker EA, Hoerr CA, Wiles KS, Skees DL, Miller CH, Laher DS. Utilizing respiratory therapists to reduce costs of care. Respir Care 2018;63(1):102-117.
  2. Myers TR. (2013). Thinking outside the box: Moving the respiratory care profession beyond the hospital walls. Respir Care 2013;58(8):1377-1385.
  3. Smith GA. (Ed.). (1989). Respiratory Care: Evolution of a Profession DC. Applied Measurement Professionals.
  4. Kacmarek RM, Durbin CG, Barnes TA, Kageler WV, Walton JR, O’Neil EH. Creating a vision for respiratory care in 2015 and beyond. Respir Care 2009;54(3):375-389.
  5. Berlin TD. (2017). The first necessity of progress. Respir Care 2017;62(12):1613.
  6. AARC. Respiratory Care Scope of Practice. Retrieved from: https://www.aarc.org/wp-content/uploads/2017/03/statement-of-scope-of-practice.pdf
  7. Joint Commission Quick Safety. Preventing delays in treatment. Retrieved from: https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_Nine_Jan_2015_FINAL.pdf
  8. Gronheck III C, Miller E L. (1993). Nonphysician placement of arterial catheters: experience with 500 insertions. Chest 1993;104(6):1716-1717.
  9. Rowley DD, Mayo DF, Durbin JC. (2000). Initial experience with a respiratory therapist arterial line placement service. Respir Care 2000;45(5): 482-485.
  10. Pack S, Hahn PY, Stoller JK, Mummadi SR. (2017). Respiratory therapist-managed arterial catheter insertion and maintenance program: experience in a non-teaching community hospital. Respir Care 2017;62(12):1520-1524.
  11. NBRC Horizons. Examinations In Review. Retrieved from: https://www.coarc.com/CoARC/media/Documents/APRT-Standards-effective-11-13-16.pdf
  12. CoARC. Accreditation Standards for Advanced Practice Programs in Respiratory Care. Retrieved from: https://www.coarc.com/CoARC/media/Documents/APRT-Standards-effective-11-13-16.pdf

Professionalism as Respiratory Therapists

Maria Madden, MSRC, RRT, RRT-ACCS, University of Maryland Medical Center, Baltimore, MD

Professionalism is essential for every health care provider. As respiratory therapists, we must realize that we provide care assisting in the preservation of human life. The patients we treat are sometimes critically ill and at the most difficult time in their lives. We can make a difference with our skills and knowledge. Paramount to our professional lives is a passion for the care we provide, our inherent work ethic, strong ethical beliefs instilled in us, and a certain sense of selflessness as we always put our patients first. We must work tirelessly to provide the best possible care for all. Complacency, as a respiratory care practitioner, is not an option.

The clinical settings of our health care institutions and the advancement of medicine in general require us to play a much more significant role than ever before. We must prove to be value-added masters of our craft. We must seek out educational opportunities such as attending conferences and keeping up to date with research and evidence-based medicine. Respiratory therapy is constantly evolving with new therapies, modalities, lung protective strategies, and methods of liberation from mechanical ventilation. We must grow and we must evolve along with the changing evidence.

Professional practice requires us as respiratory therapists to increase our engagement in patient care. The physicians, providers, nurses, and all other members of the multidisciplinary team must no longer generically refer to us as “Respiratory.” The team must know us on a first name basis. Our participation in patient care bedside rounds, where we lead practice, making insightful and accurate recommendations to improve patient outcomes based on evidence-based medicine, will provide us instant credibility.1 Here we can teach other disciplines the art of respiratory care and learn from others such as nursing, pharmacy, clinical nutrition, and infectious disease as well. Doing so will improve both the strengths of the individual health care providers and also the overall team dynamic.

Increased professionalism on our part builds trust in our profession and each respiratory therapist. With that trust comes confidence, which in turn leads to increased autonomy. This provides platforms where respiratory therapy departments can build protocols in mechanical ventilation initiation and weaning, secretion clearance, bronchodilator therapy, oxygen titration, and critical care patient care transport, to name a few. Respiratory therapist-driven protocols enhance our professionalism as we demonstrate our knowledge, skills, expertise, and improved outcomes.2 This will provide us with new opportunities for growth and advancement in related fields such as extracorporeal membrane oxygenation, research, diaphragmatic pacing, and COPD programs at our facilities.

The rewards that our profession of respiratory therapy offer are immense. Although our presence at the bedside is sometimes taken for granted, we possess the ability to make a profound impact on our patients, their families, and even our coworkers. Every shift we must strive to provide something that is remembered. This can range from our expert care to assisting a visitor in finding their loved one’s hospital room.

Professional growth begins with a strong work ethic and a “can do” attitude. But we must also hold our peers accountable for providing the best care possible for every patient. For us to continue growing as a profession, and specifically as adult critical care respiratory therapists, it is essential that we continue presenting ourselves in a professional manner and demonstrating our needed expertise every day at the bedside. As respiratory therapists, we can make a difference.

References

  1. Statement Of Ethics And Professional Conduct For Respiratory Care By the AARC 4/14.
  2. Stoller JK. The effectiveness of respiratory care protocols. Respir Care 2004;49(7):761-765.

Section Connection

Section discussion list: Go to the Adult Acute Care Section on AARConnect to network with your fellow section members.

Next Bulletin: Spring/Summer Issue. Please email Karsten Roberts if you would like to contribute an article. He will be happy to help guide you through the process if you’re a new contributor!