American Association for Respiratory Care's

Summer 2004

Editor
Delancy Gardner
breathtrac@eudoramail.com
S. Lande Lambert, RCP
PFT Lab Coordinator
Magic Valley Regional Medical Center
Twin Falls, ID 83303
(208) 737–2686
landel@mvrmc.org

Chair
Catherine Foss, BS, RRT, RPFT Duke University Health Systems (919) 668–3599

FAX (919) 668–0494 foss0005@mc.duke.edu

 

In This Issue...

Notes from the Chair Catherine Foss, BS, RRT, RPFT
Quality Spirometry in the Physician’s Office: Opportunities and Pitfalls Dale Mayers, RRT
Is Your Lab Waiting to “Exhale”? Catherine Foss, BS, RRT, RPFT
Section Connection
 
 
 
 
 


Notes from the Chair

by Catherine Foss, BS, RRT, RPFT

The 50th Anniversary of the AARC International Congress is coming up soon. The time and place: December 4–7 in New Orleans, LA. I hope to see many of you at the Diagnostic Section meeting so we can share ideas.

You will soon be receiving a ballot in the mail for the section’s chair–elect election. Please take the time to read over the information on the two members of our section who have been nominated and are willing to serve you in this position. Be sure to follow the instructions and mail back the ballot before the deadline. We should have results by the December meeting, and will be looking forward to introducing our new chair–elect at that time.

The section is currently accepting nominations for our Specialty Practitioner of the Year award. The deadline this year is August 31. Please consider nominating a fellow diagnostician for this important award.

We are continuing to work to expand our membership. Everyone’s help and ambassadorship is appreciated in spreading the word to peers and gathering others into our ranks. Please continue your good work, and remember that you can e–mail me anytime with your ideas for the section or issues of concern.

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Quality Spirometry in the Physician’s Office: Opportunities and Pitfalls

by Dale Mayers, RRT, PFT Lab, St. Mary's Hospital, Grand Junction, CO

Any discussion on how to help physicians’ offices perform quality spirometry testing must begin with a look at why those of us in pulmonary function laboratories should be motivated to do so.

True, we don’t work in physicians’ offices. But we should feel a professional obligation to promote the image of respiratory care, our hospitals, our respiratory departments and our pulmonary function labs.

In my lab at St. Mary’s Hospital in Grand Junction, CO, I accomplish these goals in multiple ways: by presenting classes to our therapists, nurses, pulmonary rehab program, and medical residents; by staffing the spirometry booth at five or six health fairs a year; and by making presentations to the RT programs at colleges in Utah and Colorado. I also invite rural hospitals to send their PFT lab staff to spend a day with me in the PFT lab as part of our “outreach education,” and we always provide spirometry testing to hospital staff and visitors during Respiratory Care Week.

Teaching physician office staff to perform quality spirometry is a logical extension of these activities. We need to take to heart the suggestions and position statements made by the AARC, American Thoracic Society (ATS), and Drs. Tom Petty, David Pierson, Paul Enright, Neil MacIntyre, and others that “all physicians’ offices should be doing regular spirometry on all their smoking patients along with the patients with known or suspected lung disease” and “RTs should take an active role in education of staff at physicians’ offices.” Slogans like, “know your numbers” or “spirometry should be as common as measuring blood pressure” will only grow in prominence if we step up and offer our services to assist physicians’ offices in providing quality testing.

Anyone working in a pulmonary function lab has, at one time or another, seen horribly inaccurate PFTs resulting from poor quality testing. We can only hope the physician recognized them as worthless and did not use poor results to diagnose or treat patients. We’ve also found completely normal PFT results in patients sent for more complete testing because of erroneous, abnormal spirometry testing results from the physician’s office. And we’ve all seen end–stage COPD patients and asthmatics that have regular office visits but have never had even a simple spirometry.

All these issues call for improved spirometry testing in all areas outside the PFT lab, and most especially in the physician’s office setting. I recently embarked on such a mission, and hope my experiences — both good and bad — can help others to do the same.

I began my efforts to improve spirometry outside the lab by evaluating the equipment and spirometry results as performed by RTs in the hospital. When we developed policies and procedures, including competencies for calibration and quality testing, retrained the RT staff, and bought new equipment, the spirometry results improved dramatically. Then I did the same thing in other hospital areas where spirometry was performed, such as pulmonary rehab, occupational health, and our family practice residency program.

As a result of our hospital–based site surveys, word spread among physicians and we had little problem getting into their offices to perform the same analysis. In fact, many physicians called me to set up an appointment. However, I did personally call the physician offices identified as the worst offenders of poor quality spirometry and tactfully asked if they would like me to come check the accuracy of their equipment and give a short in–service on performing good spirometry in their offices.

The physician office site visits proved to be a real eye–opener. I learned from experience to make a pre–visit first, just to get an idea of what kind of equipment they had and what shape it was in. The first order of business in most offices was simply to clean the equipment.

I was also amazed by the age of the equipment I found — some of the spirometers were so old I had never even seen them before. If they had an owner’s manual, I would read it from cover to cover and then try to calibrate the device before doing a test on myself to make sure the device was working and the measurements were at least close. If the spirometer was broken, I would have them fix it prior to the formal office visit and in–service. But some of the office spirometers were so old that parts were no longer available. And, unfortunately, resistance to purchasing new equipment was strong. Even when I told them they could recoup every dollar spent in billing for spirometry and that it would only take one to two months to pay for a new system, they would balk.

But assuming that the equipment was salvageable, I would then write up a one–page or less calibration and patient testing procedure. Keeping the procedure short is key, because, as with any correspondence with physicians, anything longer than half a page probably won’t be read.

After completing these steps, I would contact the office manager to schedule a two–hour formal site visit with the selected staff. These formal visits included reevaluation of the repaired or, hopefully, new equipment, QA, QC, documentation, and a short PFT review in–service for the staff on correct spirometry testing using ATS standards and the AARC’s Clinical Practice Guideline on spirometry. I tried to teach them the tricks of the trade, how to identify common problems, and normal and abnormal loops.

I found all the problems you would expect:

  1. The spirometer was never reconfigured for our location in GJ (4,500 feet above sea level and low humidity). Many devices were still set at sea level barometric pressure factory settings. I had the staff call the airport, or get online for current pressure and humidity readings. I also gave them a sheet listing all the barometric pressures, converting inches of water to mm Hg because inches of water is what is usually reported at the airport weather station.
  2. Calibration was rarely performed, much less documented. Some sites did not own a cal syringe.
  3. Biological controls were not being performed.
  4. Little, if any, instruction was given to the staff about QC or actual testing.
  5. No filters or infection controls were being used.
  6. Staff had no knowledge of ATS standards and QA of results. Reproducibility produced blank, “what’s that?” looks.
  7. Many different predicted equations were being used for the same demographic area. (We all now use Crapo for adults and Polgar for children. That will be changing again as the national predicted set starts to become standard.)
  8. Patients were not weighed and measured. They trusted the patient to report accurate weight and height!
  9. They did not know that because thermal paper turns black after a year so, reports must be photocopied. (You should have seen their faces when we started pulling chart after chart of blank–blackened ECG reports.)

In my experience, the best way to overcome these problems is to:

  • Encourage the physician or office manager to assign only one or two staff members to perform spirometry. Too many people will decrease the repetition necessary to develop skill and comfort with the equipment.
  • Convince the physician to order more testing. Having trained staff and nice equipment does not do much good if spirometry is never ordered. During the site visit I asked the physician to start ordering ten spirometries every day so the staff can get in more reps. This didn’t exactly endear me to the office staff, but it is very hard to learn any procedure by doing it only once a month. You almost have to pull out the manual and relearn every time.
  • Remind the doctor who balks at ordering spirometry that it is easy to justify these tests in every smoker and that they will receive $30–40 for each test, which quickly pays for a new spirometer, if that is an issue. Once the dollars start rolling in, the office manager and physician are more than convinced.
  • Specifically ask the doctor or office manager NOT to select an employee who won’t enjoy the responsibility of performing spirometry. If the physician only hears complaints when testing is ordered, he or she eventually stops ordering spirometry. The ideal candidate will be interested and enthusiastic at the prospect of learning this new skill.

After the office physicians saw what was involved in doing good QC– and QA–driven testing (drilling into their staff “do it right or not at all,” “wrong results are worse than no results”) they often realized their staff needed more time to complete these activities, which resulted in better testing and fewer complaints from the office staff. Physician and staff appreciation of the RT’s knowledge and skill in pulmonary function improved tremendously as well. I am constantly fielding questions about patient test results, problems with equipment, and advice in purchasing new equipment. The quality of office testing has really improved. I rarely waste my time testing a “normal” patient anymore, as these are being successfully screened out at the offices, and I often cannot get better results than the reported office spirometry results. This is probably the most satisfying part of the site visits.

Despite the success I had with the program, however, pitfalls have arisen that have made it difficult to continue the service in its original form. After we began the site visits, business in our pulmonary lab really started picking up, enough so that it impacted other hospitals in our area and they started complaining about our free site visits. The chief of staff was concerned that the hospital might be sued over inurement issues, because someone could argue that the doctors felt obligated to refer to us after we spent time upgrading their spirometry programs.

My director came up with the clever solution of charging a minimal site visit fee of $20 to avoid this issue. But even at this price, the doctors refused to pay and all requests for site visits stopped. I have continued to do some site visits, but often on my own time to avoid hospital inurement issues. I am very selective about the offices I visit, mainly going only to those that refer patients to the PFT lab, as a favor to my medical director, and to the offices of our residents when they start up their own practices.

Regardless of the pitfalls, I still found this experience very rewarding. Most importantly, the quantity and quality of spirometry in our community is now better than what you’ll find in most other places, and that means higher quality of care for our respiratory patients.

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Is Your Lab Waiting to “Exhale”?

by Catherine Foss, BS, RRT, RPFT

Exhaled breath testing has become the new, non-invasive hot item in pulmonary labs and offices around the country. Exhaled Nitric Oxide (ENO) and Exhaled Breath Condensate (EBC) are the two new tests on the block. As mentioned in a past Bulletin, the Food and Drug Administration has approved one device, made by Aerocrine, for clinically measuring ENO. Some labs have successfully used a miscellaneous respiratory code to get reimbursed for the test. Formal codes are currently being petitioned from the American Medical Association.

Both tests are relatively simple to coach and to perform. The American Thoracic Society (ATS) has set standards for the performance of ENO in adults and children in both testing formats. One method is called “online” testing, where a patient exhales directly into an instrument. In “offline” testing the subject blows into a Mylar bag with a resistor attached to regulate flow.

ENO is believed to indicate the level of airway inflammation and thus can be used to monitor disease states such as asthma. A poster presented at ATS recently compared three vendors’ equipment for measuring NO and found consistently different data readings. However, the readings did have a high degree of correlation within the disease states. The abstract is titled, “A Comparison of Exhaled NO Analyzers in Health Subjects, Asthma and COPD Patients,” by D.J. Clough, Z.L. Borrill, N. Truman, S.J. Langley, and S.D. Singh.

Another very interesting abstract also found variability between the analyzers that were evaluated, but attributed the variation to non-standard calibration gases. Also presented at ATS, this abstract is titled, “Comparison of Different Analyzers for Measuring Exhaled Nitric Oxide (NO),” by K.C. Muller, O. Holz, K. Paasch, H. Magnussen, and R.A. Jorres.

EBC is a simple test wherein a subject/patient breathes into a plastic tube that is cooled, causing condensation to form. Several commercial brands and methods are available to perform the testing, although some laboratories are putting together their own equipment. The condensate collected after the patient has breathed into the cooled tubing for 10-15 minutes has the potential to provide a lot of information. Inflammatory markers such as hydrogen peroxide, 8-isoprostane, nitrite, ammonia, adenosine, eicosanoids, and cytokines, along with pH, can be measured from the condensate. Several studies have shown that pH can indicate an asthma exacerbation in children.

An ATS abstract concerning EBC discussed the effects of food intake, fasting, and the time of day testing was performed. These issues are especially important if serial testing is to be performed on the same patient over various time points to compare the effects of treatment or disease improvement. The researchers suggest that subjects rinse their mouths several times prior to testing. The abstract is titled, “Food Intake May Influence Daytime Variation of Hydrogen Peroxide Levels in Exhaled Breath Condensate,” by R. Gajdocsi, C Brindicci, P.J. Barnes, and S.A. Kharitonov.

A potential disadvantage to EBC testing is that the investigator cannot discriminate between the sample origination: alveoli or bronchiole. The main advantage is that EBC is a noninvasive test that can easily gather lower airway samples from a patient without the need to perform invasive testing such as a bronchoscopy, with all its associated risks and exposure to conscious sedation.

These up-and-coming tests may be knocking on your doors soon (if they haven’t already). So read up, pull some abstracts, and find out what is coming.

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Section Connection

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

JCAHO Accreditation Report: Please consider sharing information about your most recent site visit by filling out the form on the AARC web site.

Recruit a new member: Know an AARC member who could benefit from section membership? Direct them to section 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.

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

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