Restructuring’s Next Wave: The Time To Prepare Is Now

by Sam Giordano, MBA, RRT, AARC executive director and William H. Dubbs, MHA, RRT, AARC associate executive director Respiratory care managers remember all too well the restructuring frenzy that took hold of the nation’s hospitals earlier in this decade. Things have settled down in the last year or two — indeed, in many cases coming full circle as hospitals watched such initiatives fail to live up to expectations — but recent developments suggest that they are heating up again. The general failure of health care reforms to contain costs, along with new provisions in the Balanced Budget Act of 1997 aimed at cutting another $115 billion out of Medicare spending by 2002, virtually guarantee a second wave of restructuring in hospitals. If you haven’t heard rumblings along these lines in your hospital yet, expect them at any time.

What can RC managers do now to prepare for the inevitable onslaught of consultants likely to be in their futures? Fortunately, we have learned some important lessons from the first wave of restructuring that can help us position our departments for success during the second.

In the absence of competency, misallocation occurs

The most important lesson we learned is that unless respiratory services are provided by practitioners with documented competency, misallocation will occur. Misallocation (the provision of services that are not indicated) increases both the cost and risk of providing care. Since cost reduction and control is a primary goal of restructuring, reducing misallocation is consistent with the goals of your organization.

In the September 1998 issue of Respiratory Care: “The Rationale for Respiratory Care Protocols: An Update,” James K. Stoller, MD, identifies three reasons why misallocation occurs:

1. Respiratory care conditions are frequently misdiagnosed, leading to the prescription of inappropriate therapies.
2. Respiratory care treatments are prescribed more cavalierly than drugs, with inadequate attention to appropriate dose and frequency.
3. Health care providers who are empowered to order respiratory care services lack appropriate knowledge about underlying principles to make optimal prescribing decisions.

For these reasons, it is critical that those providing respiratory services have documented competency and a thorough understanding of clinical practice guidelines.

Differentiating RC

How can we convince key decision-makers that misallocation occurs in the absence of documented competency? First and foremost, we must differentiate respiratory care from the other ancillary services in the hospital. We cannot let organizational decision makers (administrators) and consultants who come into our hospitals work under the assumption that respiratory therapy is simply a collection of motor skills and, as such, easily assumed by others without specific training and competency documentation in respiratory care — or, worse yet, by untrained, non-credentialed assistive personnel.

Administrators and consultants must understand that:

• Orders for respiratory therapy are not static, but dynamic, and thus often need to be changed or adjusted from treatment to treatment or sometimes even during a treatment to appropriately match the needs of the patient. (Conversely, orders for an X-ray or other diagnostic tests do not usually require modification after they are written.)
• Because patients are labile, even the most competent physician cannot write an order for respiratory therapy that is guaranteed to remain appropriate over the course of the patient’s care.
• In most cases, therapy has to change as the patient’s condition changes.
• Physicians rely on the documented competency of respiratory therapists to assess their patients during the delivery of respiratory services and contact them when these changes are necessary.

In short, the message we must send to these consultants — as well as our own administrators — is that respiratory therapy is a combination of psychomotor skills and the cognitive ability to assess the patient at each encounter and influence appropriate changes in physicians’ orders.

A simple solution: Keep track of what you are already doing

Fortunately, most respiratory care departments are well-positioned to send this message. Their therapists are already assessing patients at the bedside before, during, and after treatments, and phoning physicians to get updated orders based on the patient’s condition. Unfortunately, what most departments are not doing is documenting that fact.

So what should you, as an RC manager, do to ensure that you have the necessary data in hand when the consultants come knocking on your door? A simple first step is to start keeping track of what you are already doing. Your therapists routinely document the care they deliver. Simply have them document how they influence that care as well by having them record each and every time they convince a physician to change an order — to decrease or increase the frequency of therapy or to use an alternative form of therapy — based on the RT’s assessment of the patient. Consultants generally come into hospitals with the assumption that all orders are written correctly, and that all a respiratory therapist does is go through the hands-on steps required to deliver the treatment. This documentation will serve as the linchpin of your efforts to change that thinking, because it will show how often your cognitive skills directly influence the care ultimately received by the patient. Start collecting this information today to ensure that you will have several months worth of data on hand when restructuring again surfaces in your hospital. This is an added-value we must document if we are to succeed in differentiating ourselves from other ancillary services.

Support from the literature

You can support your own numbers documenting misallocation with a range of studies published in the literature over the past decade that clearly demonstrate the large percentage of misallocated treatments in respiratory care and the impact that respiratory therapists have on this misallocation. The following chart (source: September 1998 issue of Respiratory Care: “The Rationale for Respiratory Care Protocols: An Update,” James K. Stoller, MD) lists these studies and their major findings. RC managers would be well-advised to acquire copies of them all to have ready as evidence that the assessment skills of respiratory therapists make a major impact on utilization. A bibliography of the citations in this chart is found at the end of this article.

Table 1 Frequency of Misallocation of Respiratory Care Services in Selected Series

Types of Service	Author(s)	Date	Patient Types	N	Frequency of Over-ordering	Frequency of Under-ordering
Supplemental oxygen	Zibrak et. al.	1986	Adult	NS	55% reduction in incentive spirometry after therapist supervision begun	NA
	Brougher et. al.	1986	Adult, non-ICU inpatients	77	38% ordered to receive O2 despite adequate oxygenation	NA
	Small et. al	1992	Adult, non-ICU inpatients		72% of those checked had PaO2 > 60 mm Hg or SaO2 > 90% but were prescribed oxygen	NA
	Kester and Stoller	1992	Adult, non-ICU inpatients	230	25.2% overall for 5 respiratory care services; 28% for supplemental oxygen	10.5% overall for 5 respiratory care services, 8% for supplemental oxygen
	Albin et. al.	1992	Adult, non-ICU inpatients	274	61% ordered to receive supplemental oxygen despite SaO2 > 92%	21% under-ordered, including 19% prescribed to receive inadequate O2 flow rates.
Bronchial hygiene techniques	Zibrak et. al	1986	Adult	NS	55% reduction in incentive spirometry after therapist supervision begun	NA
	Shapiro et. al.	1988	Adult, non-ICU inpatients	3400	61% reduction of bronchial hygiene after system implemented	NA
	Kester and Stoller	1992	Adult, non-ICU inpatients	230	32%	8%
	Alexander et. al.	1996	Adult, inpatients	177	59.6% over-ordering	NA
Bronchodilator therapy	Zibrak et. al.	1986	Adult	NS	50% reduction in aerosolized medication after therapist supervision begun
	Kester and Stoller	1992	Adult, non-ICU inpatients	230	12%	12%
Intermittent positive pressure breathing (IPPB)	Zibrak et. al.	1986	Adult	NS	92% reduction in IPPB after therapist supervision begun	NA
	Kester and Stoller	1992	Adult, non-ICU inpatients	230	40%	6.7%
Arterial blood gases	Browning et. al.	1989	SICU patients	724 ABGs	42.7% inappropriately ordered before guidelines implemented	NA
	Pilon et. al.	1997	Adult, inpatients in 5 periods	150	56% inappropriately ordered before guidelines, reduced to 21% inappropriate 13 months after	NA

Surviving the Swell

There are several other key strategies that managers can use to position themselves for success when the next wave of restructuring hits their departments, and we will go over these in upcoming issues of the Bulletin. But the two tactics presented here — keeping track of how your therapists influence the orders of individual patients and becoming knowledgeable about the scientific literature on misallocation of respiratory treatments — are the first steps in assuring the future of your department in today’s data-driven health care environment. The bottom line of any restructuring effort is to contain costs, and the manager who can demonstrate with hard, cold facts that his or her department is capable of doing just that will certainly survive and even thrive, regardless of the size of the swell.

Bibliography

1. Albin RJ, Criner GJ, Thomas S, Abou-Jaoude S. Pattern of non-ICU inpatient supplemental oxygen utilization in a university hospital. Chest 1992; 102(6): 1672-1675.
2. Alexander E, Weingarten S, Mohsenifar Z. Clinical strategies to reduce utilization of chest physiotherapy without compromising patient care. Chest 1996; 110(3): 430-432.
3. Brougher LI, Blackwelder AK, Grossman GD, Straton GW Jr. Effectiveness of medical necessity guidelines in reducing cost of oxygen therapy. Chest 1986; 90(5): 646-648.
4. Browning JA, Kaiser DL, Durbin CG Jr. The effect of guidelines on the appropriate use of ABG analysis in the intensive care unit. Respir Care 1989; 34(4): 269-276.
5. Kester L, Stoller JK. Ordering respiratory care services for hospitalized patients: practices of overuse and underuse. Cleve Clin J Med 1992; 59(6): 581-585.
6. Pilon CS, Leathley M, London R, McLean S, Phang PT, Priestly R, et al. Practice guideline for ABG measurement in the intensive care unit decreases numbers and increases appropriateness if tests. Crit Care Med 1997; 25(8): 1308-1313.
7. Shapiro BA, Cane RD, Peterson J, Weber D. Authoritative medical direction can assure cost-beneficial bronchial hygiene therapy. Chest 1988; 93(5): 1038-1042.
8. Small D, Duha A, Weiskopf B, Dajczman E, Laporta D, Kreisman H, et al. Uses and misuses of oxygen in hospitalized patients. Am J Med 1992; 92(6): 591-595.
9. Zibrak JD, Rossetti P, Wood E. Effect of reductions in respiratory therapy on patient outcome. N Engl J Med 1986; 315(5): 292-295.