by Nick Widder, RRT

I recently had the chance to meet a nurse with whom I have had an ongoing correspondence over a number of years. She is currently a night house nursing supervisor of a moderately–sized, somewhat rural community hospital in Northern California.

As you may or may not know, California law now mandates break and lunch relief for nurses by a nurse without another assignment, along with nurse–to–patient ratios based on patient acuity. This is impacting not only the number of nurses caring for patients, but also the number of ancillary staff available. As you can imagine, with the number of nurses now mandated by the state, the only way to keep personnel costs down is to reevaluate the number of non–nurses who are employed.

As a nurse who is rather enlightened to the concept of a health care team, my friend asked me if I had any experience with the downsizing of a respiratory department. If so, how would I recommend handling such a situation?

Specifically, she noted several emergency department nurses who had suggested they be tasked with delivering nebulizer treatments in the ED. Never one to be shy about stepping up on a soapbox— especially when asked—I did my best to give an answer that would make members of my profession proud.

First, I told my nurse friend that I am always concerned when I am asked which of our patients require our care less than others. Certainly, there are many who do not need to be seen every four hours by a respiratory therapist just so they can receive maintenance bronchodilator therapy. Bob Kacmarek once asked an audience I was in if, in a time of limited resources, a formal respiratory education was required to administer routine drugs to floor patients. Certainly, he added, two or three days from now, many of our floor patients will be self–administering their treatments in the home, and they always seem to do pretty well.

My answer was simple. An ED nurse is certainly able to administer bronchodilator therapy. The ED nurse is NOT, however, formally educated in the assessment of the respiratory patient and is not generally equipped to deal with an effective “assess and treat” protocol, which asthmatic patients in an ED deserve. Leaving the respiratory therapist out of the loop in an ED until the patient requires continuous nebulization, rare gas administration, NPPV, or intubation (based upon someone else’s assessment) only delays higher levels of treatment.

I really see no reason not to have ED nurses administer routine bronchodilator treatments. I do, however, see a multitude of reasons why a respiratory therapist should ASSESS the effectiveness of said treatments and be prepared to continue, expand upon, or discontinue therapy as indicated by patient response.

My friend quickly saw the light. It is not that we therapists are needed to GIVE the therapy. We are needed to ASSESS the effectiveness of the therapy, and to amend the therapy based upon our assessment. THAT is why we need to be in an ED.

In a past life, I worked in an institution where nurses gave all bronchodilator therapy in the ED, unless continuous nebulization was required. Frequently, we were not paged to see patients until they were ready to be intubated. I can remember standing there, listening to the bedside report in the ICU, hearing how the patient received 2.5 mg. albuterol at one time, 30 minutes later another 2.5 mg., and then seeing no response after an hour, 0.5 mg. ipratropium was given, and then 15 minutes after that another 2.5 mg. albuterol. ABG results were reported (drawn by the nurse, run by the lab), which were marginal. No effort at peak flow or FEV1 was made. The patient was transferred to the ICU due to a lack of improvement.

I would almost throw my hands up in frustration, because the patient, who had been in my institution for over three hours and was only then seeing a respiratory therapist for the first time, was FINALLY getting a chance at receiving the aggressive care he deserved. Having come from an institution where therapists were in the ED full time, with assess and treat protocols, this was certainly below the standards I had come to expect.

In the critical care and emergency areas, patients deserve evaluation of every therapy we offer, as we are giving it, so that we can assess the need for changes in approach. Likewise, stable floor patients receiving therapy deserve routine, daily assessments of therapy and progress. This would allow a therapist to reinforce the proper technique, and to change or recommend changes in frequency or modality.

So, my short answer is, yes, perhaps we can get away from the need for a therapist at the bedside for EVERY form of respiratory therapy, especially on the stable floor patient. HOWEVER, we do our patients a grave disservice if we allow others to do our jobs with respect to the assessment of our patients’ respiratory status and the efficacy of our therapy. We as therapists need to be careful about what we agree to delegate. We must make an extreme effort to show our worth on a daily basis.

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The Combicath™ is a dual catheter device used to retrieve a broncho–alveolar lavage, or lung washing. It was presented to us in the fall of 2002 as a viable device to achieve a more accurate C&S. Some of the literature that was provided implied that standard suction techniques for sampling Gram Stain and C&S might be responsible for false positive cultures due to upper airway contamination when sampling from intubated patients.

We are a 55–bed, post-operative cardiothoracic intensive care unit (CVICU). We see 75 to 100 OHS cases a week. Unfortunately, not all of our patients are extubated in four hours. We do see a small number of failure–to–wean patients who require mechanical ventilation for multiple days, putting them at risk for ventilator-associated pneumonia (VAP).

Our cardiothoracic anesthesia (CTA) intensivist staff and infectious disease (ID) staff became very intrigued with the notion of better diagnosis of VAP, and the thought of decreasing inappropriate antibiotic therapy also piqued the interest of our pharmacists. Now, suddenly, we had a multidisciplinary group looking at a possible hospital–wide initiative for VAP diagnosis. Would it work?

First we had to see if using the Combicath™ actually made a difference in diagnosing VAP. I started off with a 10-patient pilot where we performed mini–BAL and compared results to standard bag and suction sampling techniques. The results were significant enough that we decided to make this the standard sampling tool for all sputum cultures in the CVICU. Along with this initiative, we had to meet certain criteria before we could even send a culture. Specifically, there had to be a new or progressive infiltrate on CXR or purulent secretions. Secondary consideration was made for temperature spikes and elevated WBCs.

The kicker, however, was that these mini–BAL cultures could ONLY be ordered by ID or CTA staff. This was presented to, and agreed upon by, the cardiothoracic surgery (CTS) staff. Next, we had to convince the residents, fellows, nurse clinicians, RNs, and housekeeping staff that this was the new standard of care in the CVICU. Not only that, but I worked with a staff of 55 full–time RRTs, and they needed to (1) buy into this new program and (2) become proficient in performing the mini-BAL. Not a small undertaking.

Over the course of the first quarter of 2003, we trained the therapists on the policy and procedure set up for the mini–BAL. A proficiency sheet was designed, and the therapists were observed performing five mini–BAL samples each. Then they could observe others. It was determined that due to the skill and practice required to perform the mini–BAL, it would be restricted to respiratory therapy exclusively. The therapists took great pride in this and truly took ownership of this procedure. Within two months, I found myself doing fewer and fewer mini–BAL procedures as the staff therapists became proficient.

Overcoming obstacles: we have been utilizing this technique of sputum sampling for a year now. Still, “pan culture” orders from the CTS residents or the nurse clinicians come daily. Recently, they have wised up to ordering a mini–BAL instead of just a pan culture to include sputum. The nurses are figuring it out also. Less standard cultures are being sent from the CVICU. The therapists know to take all sputum culture orders and run them past the ID or CTA staff. They make the exclusive decision. While we feel we are improving patient care by utilizing this technique, we have yet to institute a procedure for antibiotic ordering and adjustments. So it’s still a work in progress.

E-mail Jeffery Davis for more information about his mini-BAL experience.

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Last December, I had the privilege of attending the AARC International Respiratory Congress in Las Vegas and joining the AARC. This is unique because I am not a respiratory therapist. I am a critical care nurse and a graduate nursing student studying acute care.

I volunteered to write this article on RT–RN relationships because I have spent the last five–and–a–half years working with other health care professionals in a grassroots effort to improve interdisciplinary relationships at Duke University Medical Center. We have come a long way and learned a lot during the journey. I would like to share some of these lessons with you.

There are four steps in improving RT–RN relationships. The first is to accept responsibility for your involvement—or lack of involvement—in the problems that exist at your workplace. Remember, if you aren’t part of the solution, then you are part of the problem. The second step is to get to know your coworkers and their involvement in the problem or solution. They are your teammates and the only individuals you can rely on to help you effectively change health care. The third step is to get involved in both the local educational aspects of other disciplines and the collaborative practice efforts at your workplace. The final step is to encourage others to get involved and support those who are already involved.

One thing I learned at the section meeting and the Congress as a whole is the breadth of the misconceptions that exist about RT and RN training and certification. Until this past year, I never knew that a respiratory therapist’s educational training could be as high as the graduate degree level or that there are different levels of certification. Likewise, I have found that many RTs do not know that I only received six hours of training on respiratory care topics, despite being educated in one of the top ten BSN programs in the country.

I was fortunate that the Duke RTs at my first job recognized that a lack of education, not stupidity, prompted my steady stream of questions. Instead of being frustrated, they reacted with patience and took the time to get to know me and teach me what I needed to know. (Thank you Boyd, Bill, Barb, Wendy, Pat, Ricky, and Rodney). In order to be an effective team you need to know where each of the members is coming from. It is not enough to just listen to questions and concerns. To make headway, RTs and RNs must get to know and understand each other. If you do not know what kind of respiratory training experience the nurses on your unit have, ask them. Likewise, please do not neglect to tell them what your professional and educational background is as well.

I am now a member of the MICU team at Duke, and we have implemented several strategies to get to know each other and to better utilize our professional strengths. All of the nurses oriented to our unit spend a 12–hour shift shadowing the lead RT, Tate Bennett. I was the first nurse to do this, and it has tremendously impacted our ability to collaborate with one another and to improve patient care. Additionally, we have added ventilator classes, which also contain information about NPPV and oscillator therapy, to our nursing curriculum. Various health care professionals teach these classes, and all adult ICU nurses are required to take them.

This collaborative teaching strategy has also moved into the graduate nursing program. The director, Steve Talbert, has made it a point to have the pulmonary curriculum taught by the RT department educator, Bob Campbell, and practicing acute care nurse practitioners, Gary Macy and Bob Blessing. Graduate and undergraduate nursing students are invited to spend time shadowing an RT as part of their clinical training. Our respiratory therapy department incorporated an internship program to further train RT graduates and to assist them in obtaining all levels of certification. These interns do not specifically spend time shadowing nurses, but we have learned to use downtime on the unit and mixers outside work to get to know each other better.

In addition to increasing educational opportunities between the two professions, we have worked diligently to incorporate strategies for collaborative practice techniques. Patient rounds on every unit are now multidisciplinary. RTs and RNs have a voice and play a large role in directing patient care. We also work together on unit and hospital committees. Recently, we improved patient outcomes by working to create an intubation protocol and safer practice strategies for the use of sedation. We are currently working on a multidisciplinary care map for oscillator patients. A preview was presented at the NTI Critical Care Nursing Conference last spring.

The final aspect in strengthening RT–RN relationships at Duke has been encouraging scientific inquiry. The four core MICU therapists (Tate Bennett, Steve Hepditch, Paul Robins, and Pete Saunders), our adult RT research coordinator (John Davies), the respiratory therapy department medical director (Neil MacIntyre) and the MICU medical director (Joe Govert) have all been involved in assisting RTs and RNs who want to pursue clinical research projects. We have each been encouraged to work on projects of our own design and to seek the support of others pursuing research in our field of study.

In fact, it was originally because of the research project that I am involved with that I was encouraged by John and Tate to go to the Congress in Las Vegas. Going to that meeting had such a positive impact that I am planning to attend again this year in New Orleans and to invite other nurses and classmates to come with me. I would like to challenge all of the Adult Acute Care Section members to also find a nursing colleague or student to invite to the Congress this year. You will be amazed at what a positive impact it can have on building teamwork and improving patient care in your workplace.

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Recruit a New Member: Know an AARC member who could benefit from section membership? Direct them to online sign-up. It's the easiest way to add section membership to their overall membership package.

Section E-mail list: Start networking with your colleagues via the section e-mail list, and follow the directions to sign up.

Specialty Practitioner of the Year: Submit your 2004 nominations online.

Bulletin Deadlines: Winter Issue: December 10; Spring Issue: March 10; Summer Issue: June 10; Fall Issue: September 10.

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