Respiratory Therapy 101: Just Keep Breathing

A nurse speaks on the proposed JCAHO regulations. From CountyRat, reader and commentor extraordinaire:

This is insane! JCAHO is so removed fom the realities of patient care, and so ignorant of the capabilities of those who provide it, that their recommendations are becoming more absurd and distructive every year. I am a registered nurse, and I am ashamed that I, and my fellow nurses, are being implicated in this insult to you, who I am proud to call colleagues. I apologize on behalf of my profession for this outragous attack on yours. JCAHO has now passed beyond the realm of irrelevancy, deap into the domain of idiocy! This nonsence will hurt patients, and no thoughtful nurse will support it.

“Nurse managers and nursing directors: you know you just want the ancillary staff to kowtow to you. Don’t deny it.”

No, we do NOT want that. Please do not think that the JCAHO represents nurses. NO! They do not. No more than they represent RTs, PharmDs, or anyone else who actualy provides patient care. We respect our colleagues in respiratory therapy and pharmacy. As a profession that still struggles to defend its own boundries, we support you in maintaining yours. I promise you, the typical clinical nurse (real nurses, not JCAHO drones) will support you in maintaining the professional autonomy that you have clearly earned.

I understand why you are angry. As a registered nurse, I am angry too. But let’s attack the real problem: JCAHO and its drones. We are not enemies. Whatever disagreements there may be between us, we are on the same side on this issue. Let’s put any other differences aside and stand together on this one. It is wrong. We all know it. We agree on it. Please, we are not enemies. You are in the right, and we will stand with you!

Thank you, CountyRat. I mean no offense to real nurses everywhere, and we stand together with you in our fight against the idiocy that is the Joint Commission. Solidarity, providers!

Has anyone else seen the new ad for Celebrex on TV? The one with a man and his dog made entirely of fine print? The ad that is basically a two-minute warning on how Celebrex or any other NSAID can kill you, but how Celebrex is a more fashionable way to die?

What the hell was that? Seriously, it confused me beyond words. Somebody please explain to me how this is effective marketing.

If you think about it, JCAHO has no incentive to promote quality because if healthcare wasn’t perceived as a problem they’d have no reason to exist. I’ve ranted about my dislike of the joint commission before.

Apparently the latest shenanigans from JCAHO include an attempt to make ancillary services such as respiratory care, physical therapy, radiology, and lab/path report to a nursing director instead of reporting to their own directors. This effectively removes any hope that RT, rads, or path can have of being run by managers who have any interest in their departments beyond how they can serve the needs of nursing*.

Fortunately for those of us in the “ancillary world,” the AARC has sent a scathing letter to JCAHO informing them that they are in fact morons. I quote from their scathy wrath (emphasis mine):

On behalf of the American Association for Respiratory Care (AARC) and its 46,000
members, I want to take this opportunity to provide comment regarding the proposed
revision of Standard/EP: NR.01.01.01,EP2. As the Standard reads, if adopted, ancillary
services such as pharmacy, physical therapy and respiratory therapy will be required to
provide service under the coordination of the nurse executive. This requirement, if
adopted, will eliminate flexibility in organizational structure for hospitals. The standard
as currently written is flexible enough to permit the organization of ancillary services
under the nurse executive or under another individual such as a vice president for clinical
services who is not a credentialed nurse, but rather holds a graduate degree in health care
administration, or another related area.
Under the current rule, hospital CEOs have options to exercise based on the needs of the
institution. Why eliminate flexibility when it’s unnecessary to do so? It makes no sense
for the Joint Commission to virtually micromanage the tables of organization for
hospitals providing a wide range of clinical services which include both nursing services
as well as ancillary services under the umbrella term “patient care programs.” The
standard does not have to be revised to permit the nurse executive to accept
administrative responsibility for all clinical services, and therefore only requires revision
if the goal of the Joint Commission is to eliminate qualified persons acting in the role of executive vice president for clinical services from doing what they’re currently employed to do.

Why not take a moment of your time and send an e-mail to Mr. Bill Dubbs of the AARC and thank him for taking a stand for respiratory therapists everywhere? Advocates like Mr. Dubbs help to develop our profession and help to protect the best interests of us RTs, and their hard work should not go unrewarded.

*Nurse managers and nursing directors: you know you just want the ancillary staff to kowtow to you. Don’t deny it.

I had a day off today. After pulling so much overtime, it’s refreshing to just sit for a day. Working so much can really burn a person out, especially as hard as they push us here at Sunny Flats–we work damn hard for our meager paychecks, and I’ve been increasingly vocal to management about that fact lately. We’ve lost more than a dozen RTs in the last three weeks to higher-paying hospitals that don’t work their RTs as hard, and frankly if management wants to retain employees they need to give us more money or less work. Expecting someone to do 18 hours of work in 12 for pay just slightly better than what I could be making in some other dead-end place is not a good way to keep employees happy.

I’ve also been feeling a lot more burned out at work lately, I suspect as a result of the overtime and the workload. I read somewhere once that burnout rates in the helping professions tend to peak at around five years, especially among young idealistic people whose hopes of making a difference have been crushed by the realization that you can’t help the ones who don’t want it and the ones who do are often too sick to be helped.

One thing that I’m fed up with is the tendency of families lately to be hostile and accusatory towards us. I was confronted again (second time in a week) by an angry family member the other day who was convinced that the hospital was deliberately keeping her degenerate unemployed drug-addicted immunocompromised son sickly so we could suckle the teat of his “gov’mint insurance.” She was right up in my face and she was angry, and I could feel my temper rising, which is unusual because normally I’m slow to anger. As she confronted me and continued her angry screaming rant, I fought hard on the urge to unleash my frustrations on her and ultimately settled on cutting her off, telling her that the biggest problem in the room was her, and walking out. Good customer service? Maybe not, but it could have been worse, and there’s no way to please a psychopath like that anyway.

I guess the point of this post is that I’m loving my day off today, and I don’t really want to go back in the morning. I’m starting to feel pretty burned out, but after two more days of this I’ll have some time off. I suspect that it will do me good to get away for a while.

One of my favorite prognostic signs is the equipment-to-patient ratio. If you have a patient who is only mildly ill, the equipment-to-patient ratio might be low…say, two IV pumps and an oxygen cannula for an equipment-to-patient ratio (EPR) of 3:1. With a 3:1 EPR, recovery seems likely.

Or you might have a patient with twelve pumps, a ventilator, the arctic sun machine, a balloon pump, an ICP bolt, and the continuous dialysis machine for an EPR of 17:1. That is what we in the business call a negative prognostic indicator.

This is illustrated very well by The Happy Hospitalist. Go and see.

I was surfing the web and I stumbled across this collection of strangely compelling photos. This is a series called Life Before Death, and it is 22 photos of hospice patients before and after their death. Small vignettes about their lives appear on the right-hand side of the screen.

It is strangely compelling. I don’t quite know what to make of it.

911Doc over at  M.D.O.D. has an excellent piece on how JCAHO (the Joint Commission on Accrediting Healthcare Organizations) and their evil companion Press-Ganey are really little more than modern-day protection rackets that prey on hospitals.

Back when I was a “newbie,” I used to believe in the mission of organizations like JCAHO and Press-Ganey. I thought that the idea of making organizations meet certain standards to ensure that patient outcomes would improve was a good idea. And on some level I still believe that making hospitals and healthcare providers meet certain standards of care is an excellent idea. And in theory, this is what JCAHO is all about.

However! What JCAHO actually does is very, very different from that. What JCAHO does is generate paperwork and foolish policies that have little to no impact on patient care. JCAHO misidentifies problems and then demands vast oceans of paperwork to prove that the problem is going away. They are a complete and utter failure of an organization.

The problem of inadequate care is simple, really. Inadequate patient care is a result of providers having too much work to do and not enough resources to do it with. My hospital is an excellent example: we routinely send RTs out to the medical floors with 60 to 70 treatments to complete in 12 hours, which if the RT follows our P&P manual would result in a 15 to 18 hour workday with no breaks. There is simply no way to complete that assignment. Treatments will be missed, patients will not be seen, and it adversely affects patient safety.

A normal human being looks at that scenario and quickly identifies the problem: too much work, not enough staff. The solution is to either reduce the workload (in theory our protocols do this) or to increase the number of RTs (a complex problem to solve).

A JCAHO-oriented person would look at that same scenario, but instead of recommending ways to reduce workload or increase staffing, they will implement a new tracking system that means that every time an RT misses a treatment, they must notify the supervisor and complete a piece of paper. This means that the supervisor spends hours each day writing down who missed what treatment, and the already overworked RTs must take time away from patient care to document missed therapy. This actually happened here. RTs have been having to fill out papers for months, which solves no problems and inconveniences everybody.

To summarize: JCAHO is a humongous waste of time. They do very little to help improve care while going out of their way to make the jobs of those of us in the trenches more mired in paperwork and foolish policies. Managers have less time to focus on problem solving and operations because they are spending more time making sure that JCAHO won’t fine them. The Joint Commission is a great idea that’s been badly misapplied, and I for one have a low opinion of that particular organization. They misidentify problems, contribute to the worsening of real problems, and suck money out of hospitals in return for shoddy services. We’d all be better off without them, and I for one hope that hospitals and providers start to tell them that.

As part of the ongoing reader response to my interesting airway scenario, one reader asked whether BiPAP had been considered as a post-extubation plan. The answer in short is no, but that does bring us to the interesting idea of extubating from the ventilator directly to BiPAP.

Recently, Respiratory Care Journal did a meta-analysis of the current research on BiPAP as an extubation strategy. The results were interesting: in patients who were extubated and then developed respiratory failure as a result of the extubation, BiPAP was shown to be ineffective; the best course of action for patients who fail after extubation would be immediate reintubation.

However, if you extubate a patient who is at risk for respiratory failure…as opposed to a patient who is extubated and subsequently is in respiratory failure…BiPAP could just be the strategy for you. To clarify that once more here is a chart:

Patient in respiratory failure —> BiPAP = NO! —> Reintubation = YES!

Patient at high risk of respiratory failure —> BiPAP = YES!

I think that my little illustration is pretty clear. If you have a patient who is borderline, extubation directly to BiPAP could be your answer–especially if you have a ventilator that can be configured to do noninvasive ventilation, such as the beloved Drager. And as far as reintubation goes, remember that contrary to your instincts you actually want to have a reintubation rate somewhere around 15%. If you’re not reintubating anybody, you’re not trying hard enough to get everybody extubated and that’s the hallmark of a failed weaning program.  That’s the subject of a whole other post though…

Getting back to the subject of my patient and his interesting airway, I’m not sure if BiPAP would have worked or not. He definitely meets the criteria: he was at high risk of reintubation but not actually in failure for some time after the tube came out. Next time I’m faced with a situation like this, I’ll think back to the professional journals and be glad of their thickly-worded, glossy-paged glory. Knowing more is always better.

As with all science and medicine on this blog, remember that this is my opinion. I’m not a physician and this shouldn’t be substituted for professional medical advice and you should really just go read the disclaimer.

Thank you, dear readers, for your responses to the previous post. Most of you guessed that the patient would end up being reintubated. One of you mentioned having seen this unusual technique used before as a temporary measure, which makes sense to me, but using this technique over several hours is a recipe for certain failure.

I know this because as you guessed, the patient was reintubated several hours after extubation. His airway was apparently very anterior and very small, making it difficult for our one-of-a-kind intensivist/anesthesiologist to place the tube. The patient was ultimately tubed with a 7.5 tube and returned to mechanical ventilation.

Prior to this, the patient had been on mechanical ventilation for a number of days. Tracheostomy had been debated but everyone involved seemed to be hesitant. The physicians didn’t really want to trache the patient, the patient’s family had some sort of mental block to it, and nursing seemed indifferent. Anyway, the patient will likely undergo bedside tracheostomy at some time in the near future, which should just about wrap up the difficult airway situation.

Today at work there was an interesting airway situation. We had a patient who had had a lengthy and complex course on the ventilator. The time had come to attempt an extubation.

However, because of the patient’s borderline respiratory status the attending physician was concerned that reintubation would occur. Reintubation would not normally be a terrible thing, but this patient had an extremely difficult airway; he had been intubated using fiber-optics by anesthesia in the OR, and even then the anesthesiologist had reportedly used the words “a f***ing doozy” when describing the airway.

To summarize: physician wants to extubate but is concerned about reintubation because of a fiendish airway.

The solution that the physician came up with was to insert a rubber ET tube changer into the ET tube, and then extubate the patient while leaving the tube changer in the airway. The theory was that if the patient crashed, we could simply slide a new ET tube over the changer and the problem would be solved. However, this poses some problems.

** First, the presence of an artificial catheter in the airway makes it impossible for the patient to swallow secretions. Even with application of continuous oral suctioning, secretion management is a concern.

** Second, leaving a catheter in the airway is going to increase airway resistance and make it more difficult for the patient to breathe, thus increasing the likelihood of reintubation.

** Third, leaving a catheter in the airway is likely to stimulate the cough and gag reflexes. If the patient vomits with a catheter in the airway, they are going to aspirate.

** Fourth, leaving a catheter in the airway for a prolonged period of time seems likely to lead to soft tissue damage or vocal cord irritation. Either of those problems could easily lead to total chaos.

Regardless, the attending physician wrote the order to extubate and leave the tube changer in the airway. The respiratory therapist (a colleague of mine; I was merely an interested observer) complied with the order. The patient was extubated to an aerosol mask, tube changer sticking unceremoniously out one of the holes in the front of the mask.

What do you think of this situation, dear readers? Drop me a note and tell me what your opinion is on this extubation strategy, and later on I’ll post the sequel to this, in which I reveal what happened to the patient.