respiratory care
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AARCI1.pptxCreating a Vision for Respiratory Care: Future of Health Care—2015 And Beyond, Part I
AARc Initiative 2015
I. history
Profession is approximately 70 years old
Earliest therapists were not even therapists
Called “oxygen orderlies” or “oxygen technicians”
Most hospitals in mid-20th century did not have wall O2
Patients got O2 either via mask, nasal cannula or Oxygen Tent
O2 came from H-cylinders which had to be changed out every few hours
Initially all received only on the job training (OJT)
Early training programs
Hospital-based and appeared in the late 1940’s and 1950’s
Graduates called themselves “Inhalation Therapists” to separate themselves from the OJT’s
American Association of Inhalation Therapists formed in Chicago in 1954
Credentials (RRT) were first awarded in 1961 (oral exams by 2 physicians, then later by a physician and therapist). Later (1983) other credentials were added (CITT and CRTT) which could be passed by written examination. In 1978 the Clinical Simulation Exam replaced the oral examination for the RRT
Standards for the first educational programs established in 1962
All candidates for a credential had to be a graduate of an accredited education program after 1975—no more OJT’s taking the tests.
History continued…
The American Association of Inhalation Therapists became the American Association for Respiratory Therapy (AART) in 1972
AART became the AARC in 1986
Florida was the first state to gain licensure in 1984; Ohio licensure in 1988; 49/50 states now require RT’s to be licensed
All states recognize the CRT as the minimum credential required for licensure
The NBRC will only allow graduates of accredited Associate and Baccalaureate degree programs to sit for the written exam
Approximately 455 respiratory care programs are accredited in the US—a few more in Canada
History continued…
The Inhalation Therapist as a clinician began because many early inhalation therapists were interested in cardiopulmonary disease processes and their treatment and because of the support of a group of anesthesiologists—there has always been a strong bond between anesthesia and Respiratory Care
The Inhalation Therapist as a clinician also was stimulated by the appearance of new therapeutic modalities that depended on mechanical devices in the late 1940’s and 1950’s.
Patients on O2 required assessment and weaning
Earliest bronchodilators delivered by nebulization appeared in the late 1950’s.
Since nebulizers were driven by compressed gas, oxygen orderlies/inhalation therapists performed the task
Assessment skills required here to administer bronchodilators, especially since the early bronchodilators had many side effects.
History continued…
The IPPB treatment was developed
First appeared in 1949
Most common device was the Bird Mark V, VI, and VII
Nursing wanted nothing to do with the machines—too complicated
Since they required compressed gas, logical for oxygen orderlies/inhalation therapists to perform
Assessment skills required to give IPPB treatments
Earliest mechanical ventilators appeared in the 1950’s
Nursing wanted nothing to do with them—too complicated.
They required too much constant attention for physicians to run them full time
They required even more compressed O2 than cannulas or tents, so oxygen orderlies were required even more to keep them running. Was a natural progression for oxygen orderlies to take over running the vents (we are more mechanically inclined than RN’s???). Later hospitals added in the wall O2
Even greater assessment skills required to run vents
PB 7200 introduced in 1983 (first with microprocessors)
Earliest blood gas machines appeared in about 1949.
Also required compressed gases for calibration
They were incredibly challenging to keep up and running so either RT’s or lab personnel ran them (depending upon the hospital)
Physicians caring for patients on mechanical ventilation quickly realized that they needed ABG’s for effective ventilator management. Since the respiratory therapist was already right there, it was more likely that RT would maintain blood gas analyzers
History continued…
The field of Respiratory Care has been a leader in the adoption of evidence-based practice.
This began with the “Sugarloaf Conference” in 1974 which examined the scientific basis for a number of respiratory therapy practices
The use of IPPB to deliver bronchodilator treatments on nearly all respiratory patients was demonstrated to have no more medical value that the use of a small volume nebulizer to deliver the bronchodilator
O2 therapy and bronchodilator therapy were shown to be effective, however.
The emphasis on evidence-based practice has led to things like the
AARC’s Clinical Practice Guidelines. Clinical practice guidelines are common throughout various areas of medicine today, but Respiratory Care was the first allied health field to make extensive use of them.
Respiratory Care Journal Conferences—Extensive expert review of various burning questions in Respiratory Care with expert commentary. Published in Respiratory Care Journal
History continued…
The Respiratory Care profession which began and was confined entirely to hospitals in the early days has now moved out into a number of other venues including:
Long-term care facilities
Nursing homes
Long-term Acute Care Hospitals (LTAC’s)
Military
Front-line combat critical care (respiratory therapists have been killed in action)
Support and care of military dependents and veterans
Physicians’ offices
Evaluation of outpatients (e.g. PF testing)
Patient education
Home care
Case management and discharge planning—still very few doing this
Disaster response teams; all DMAT (Disaster Medical Assistance Team) teams now include respiratory therapists
Medical devices sales
History continued…
15. The educational process for Respiratory Care has become more and more demanding over the years.
The primary factor driving the increase in education level has been the increasing complexity of medical care, especially devices over the years.
The first BS programs were introduced in the 1980’s.
A small number of Master’s programs in Respiratory Care have become available within the last 10 years.
Specialized credentials have been developed
CPFT
RPFT
NPS
SDS
ACCS
The NBRC has developed a matrix of skills and knowledge areas which are tested on each of the credentialing exams.
The AARC plays a major role in education of clinicians, the public, and students
II. The 2015 and Beyond conferences
Three conferences organized by the AARC in 2008, 2009, 2010 to envision the RT of the future. Goals of the three conferences were to:
Identify long-term future trends in health care that will impact the RT profession
Identify the competencies that will be required of RT’s in order to the profession to continue to be a player in the health care arena
Identify the educational processes which must be developed in order to allow RT’s to master those competencies
II. Conference 1– the healthcare system
As population ages more patients will be diagnosed with chronic and acute respiratory illnesses
Increased accuracy in diagnosis due to better technology
Treatment will be aimed more and more at outpatient management and avoidance of hospital admissions to decrease costs
Increasing numbers of comorbid conditions will be identified that will require simultaneous management with the respiratory illness, requiring more interdisciplinary care
Health promotion and prevention rather than acute treatment will become the goal of care
Cost of medical care will continue to increase in spite of increased efficiency of care
Individual consumers will pay an increasing percentage of health care costs
Consumers, industries, and governments will find it increasingly difficult to keep up with increased costs
The personal electronic health record will be increasingly used, even in the home
Information technology will take an increasingly important role in the health care arena
Health care informatics will become a specialty area of allied health care
There will be a shift out of acute care hospitals as much as possible
Hospitals will continue to provide expensive, episodic care, including cutting-edge respiratory life support. Level of patient acuity and complexity will continue to increase in hospitals
Wherever possible acute care will move to sub-acute facilities and even patients’ homes
Sub-acute and chronic care will increase in volume and complexity
New care delivery models will be developed
Retail health clinics (e.g. urgent care centers) and mass-marketed care centers (e.g. some chain pharmacies have opened walk-in clinics in conjunction with their pharmacy operations) will be developed
Telemedicine and telecare will be used increasingly
Healthcare delivery system which are today unheard of (e.g. hospital-at-home and medical-home) will appear. Some will succeed and some will fail
Main driver of this movement will be decreased costs and cost competition will continue to intensify, at times to the detriment of patient care
Medical care will undergo increasing scrutiny for quality and cost effectiveness
Reimbursement will be linked to outcomes and there will be pay-for-performance type incentives for medical care practitioners
Systems to decrease rate of medical errors will become more important
More emphasis on the team approach with improved communication among team members in order to better coordinate care
Government will become increasingly involved in monitoring and setting of quality standards
II. Conference 1– the Healthcare Workforce
The healthcare workforce is aging, and this trend will continue
Older healthcare workers will leave the workforce in increasing numbers
As the US population ages, increased numbers of healthcare workers will be needed, even when increased efficiencies of the system are taken into account
The result of all of this will be shortages of all healthcare workers, those who work at the bedside and those who have supporting roles (e.g. lab techs, medical records). These shortages are being projected by the US Bureau of Labor Statistics
Shortages that were predicted to occur during the 2005-2010 period have not materialized, however. In 2000 the national rate of unfilled positions in RC departments was 5.9%. In 2005, the rate was 8.6%. Today it is probably about 2%.
Shortages of teaching faculty and programs will limit the number of new graduates, and the educational system will be unable to meet the demand
New educational models will be required to reduce the cost of education and allow for fewer educators to more efficiently prepare more graduates
Healthcare organizations may begin to develop educational programs to help meet the shortage
II. Conference 1 – The RC Profession
Respiratory care will continue to increase in complexity
Clinical decisions will become increasingly reliant upon data—evidence based medicine
Published studies
Internal organizational outcomes data
The use of protocols will become the most common way to deliver respiratory care, including complex tasks such as ventilator management
Research shows that protocolized care is more efficient and cost-effective
Protocols allow lower level clinical decisions to be shifted from physicians to RT’s
Interdisciplinary care teams (including even patients and patient families) will become more predominant, and RT’s will need to learn to work effectively in this environment
The US population will become more diverse ethnically and culturally. RT’s will need to develop cultural competencies
RT’s will be required to function in an environment with increased levels of computerization and information technology
As evidence based medicine becomes more important, RT’s will need to be able to function in research
II. Conference 1– Factors Driving Change
Cost
We have the most expensive health care system in the world, but our outcomes are not the best in the world
Healthcare costs are rising faster than the rate of inflation
Most health insurance comes from private corporations—they are cutting back on coverage to reduce costs
Number of retirees is increasing. Medicare Part A is projected to have only about 10 years of funding left at current expenditure rates and projected population changes
Demographics
Population is aging
Baby boomers are just reaching retirement age and will not be gone from the system for another 20-30 years.
As a result the burden of chronic disease is expected to rise rapidly during this period
The US population is projected to grow by about 20-25% during the period 2000 to 2025. Means increased healthcare capacity will be needed.
II. Conference 1– Factors Driving Change
Shift in disease patterns
US population is living 35 years longer than it did 100 years ago
Means progressive increase in chronic disease
Our health care system is designed to focus on acute disease management, not to manage or prevent chronic
Technology
New treatment and diagnostic modalities will be created
Even more important, however, is changes in information technology. Information will flow from medical experts to patients and families; this will result in patients and families becoming more involved in their own care
Technology will also aid in development of new health care delivery models
Telemedicine and telecare will become more widely used.
Consumers
Health care will become a commodity driven by price, marketing, convenience, customer satisfaction
Healthcare delivery organizations will compete for patients in the same way that department stores and auto dealership do.
