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Egans-Fundamentals-of-Respiratory-Care-11th-Edition-B01BL7R38M.pdf

Fundamentals oF Respiratory Care

ROBERT M . I JA'MES K . I ALBERT J . KACMAREK STOLLER HEUER

V FR E WITH TEXTBOOK PURCHASE EVOLVE.ELSEVIER.COM

Δ change in µ micro- µg microgram µm micrometer µV microvolt A alveolar a arterial AARC American Association for Respiratory Care ABG(s) arterial blood gas(es) A/C assist/control ACBT active cycle of breathing technique ADH antidiuretic hormone AIDS acquired immunodeficiency syndrome AII airborne infection isolation ALI acute lung injury ALV adaptive lung ventilation ANP atrial natriuretic peptide AOP apnea of prematurity APRV airway pressure release ventilation ARDS acute respiratory distress syndrome ARF acute respiratory failure ASV adaptive support ventilation ATC automatic tube compensation ATM atmospheric pressure ATPD ambient temperature and pressure, dry ATPS ambient temperature and pressure, saturated

with water vapor auto-PEEP unintended positive end expiratory pressure AV arteriovenous AVP arginine vasopressin B barometric BAC blood alcohol content BE base excess bilevel PAP bilevel positive airway pressure BiPAP registered trade name for bilevel PAP device BP blood pressure BPD bronchopulmonary dysplasia BSA body surface area BTPS body temperature and pressure, saturated with

water vapor BUN blood urea nitrogen C compliance c capillary C′ pulmonary-end capillary ° C degrees of Celsius CaO2 arterial content of oxygen C a v O( )− 2 arterial-to-mixed venous oxygen content

difference CC closing capacity cc cubic centimeter Cc′O2 content of oxygen of the ideal alveolar capillary CD dynamic characteristic or dynamic compliance CDC U.S. Centers for Disease Control and Prevention CDH congenital diaphragmatic hernia CHF congestive heart failure CI cardiac index CINAHL Cumulative Index to Nursing and Allied Health

Literature CL lung compliance (also CLung) cm centimeters cm H2O centimeters of water pressure CMS Centers for Medicare and Medicaid Services CMV controlled (continuous) mandatory or mechanical

ventilation CNS central nervous system CO carbon monoxide

ABBREVIATIONS

CO2 carbon dioxide COHb carboxyhemoglobin COLD chronic obstructive lung disease COPD chronic obstructive pulmonary disease CPAP continuous positive airway pressure CPG Clinical Practice Guideline CPOE computerized physician order entry CPP cerebral perfusion pressure CPPB continuous positive pressure breathing CPPV continuous positive pressure ventilation CPR cardiopulmonary resuscitation CPT chest physical therapy CPU central processing unit CQI continuous quality improvement CRCE continuing respiratory care education Cs static compliance CSF cerebrospinal fluid CSV continuous spontaneous ventilation CT computed tomography CT tubing compliance (also Ctubing) CV closing volume CvO2 venous oxygen content CvO2 mixed venous oxygen content CVP central venous pressure D diffusing capacity d diameter DC discharges, discontinue DC-CMV dual controlled–continuous mandatory

ventilation DC-CSV dual controlled–continuous spontaneous

ventilation DIC disseminated intravascular coagulation Dm diffusing capacity of the alveolocapillary

membrane DO2 oxygen delivery DPAP demand positive airway pressure DPPC dipalmitoyl phosphatidylcholine DVT deep venous thrombosis E elastance EAdi electrical activity of the diaphragm ECCO2R extracorporeal carbon dioxide removal ECG electrocardiogram ECLS extracorporeal life support ECMO extracorporeal membrane oxygenation EDV end-diastolic volume EE energy expenditure EEP end expiratory pressure EHR electronic health record EIB exercise-induced bronchospasm EMR electronic medical record EPAP end positive airway pressure ERV expiratory reserve volume ET endotracheal tube ETCO2 or etCO2 end-tidal CO2 F fractional concentration of a gas ° F degrees Fahrenheit f respiratory frequency, respiratory rate FDA U.S. Food and Drug Administration FEF forced expiratory flow FEFmax maximal forced expiratory flow achieved during

FVC FEFX forced expiratory flow, related to some portion

of FVC curve FETX forced expiratory time for a specified portion of

FVC FEV1 forced expiratory volume at 1 second

FiCO2 fractional inspired carbon dioxide FIF forced inspiratory flow FiO2 fractional inspired oxygen FIVC forced inspiratory vital capacity FRC functional residual capacity FVC forced vital capacity FVS full ventilatory support f/VT rapid shallow breathing index (frequency divided

by tidal volume) Gaw airway conductance g/dl grams per deciliter [H+] hydrogen ion concentration HAP hospital-acquired pneumonia Hb hemoglobin HBO hyperbaric oxygen (therapy) HCAP health care–associated pneumonia HCH hygroscopic condenser humidifier HCO3− bicarbonate H2CO3 carbonic acid He helium He/O2 helium/oxygen mixture; heliox HFFI high-frequency flow interrupter HFJV high-frequency jet ventilation HFNC high-flow nasal cannula HFO high-frequency oscillation HFOV high-frequency oscillatory ventilation HFPV high-frequency percussive ventilation HFPPV high-frequency positive pressure ventilation HFV high-frequency ventilation HHb reduced or deoxygenated hemoglobin HMD hyaline membrane disease HME heat and moisture exchanger HMEF heat and moisture exchange filter H2O water HR heart rate ht height Hz hertz IBW ideal body weight I inspired IC inspiratory capacity ICP intracranial pressure ICU intensive care unit ID inner diameter I:E inspiratory-to-expiratory ratio ILD interstitial lung disease IMPRV intermittent mandatory pressure release

ventilation IMV intermittent mandatory ventilation INO inhaled nitric oxide IPAP inspiratory positive airway pressure IPPB intermittent positive pressure breathing IPPV intermittent positive pressure ventilation IR infrared IRB institutional review board IRDS infant respiratory distress syndrome IRV inverse ratio ventilation IRV inspiratory reserve volume IV intravenous IVC inspiratory vital capacity IVH intraventricular hemorrhage IVOX intravascular oxygenator kcal kilocalorie kg kilogram kg-m kilogram-meters kPa kilopascal KPI key performance indicator L liter LAP left atrial pressure

lb pound LBW low birth weight LED light emitting diode LFPPV-ECCO2R low-frequency positive pressure ventilation with

extracorporeal carbon dioxide removal LMS learning management system LTACH long term acute care hospital LV left ventricle LVEDP left ventricular end-diastolic pressure LVEDV left ventricular end-diastolic volume LVSW left ventricular stroke work m2 meters squared MABP mean arterial blood pressure MAlvP mean alveolar pressure MAP mean arterial pressure or mean airway pressure MAS meconium aspiration syndrome max maximal MDI metered dose inhaler MDR multidrug resistant mEq/L milliequivalents per liter MEP maximum expiratory pressure metHb methemoglobin mg milligram mg% milligram percent mg/dl milligrams per deciliter MI myocardial infarction MICP mobile intensive care paramedic MI-E mechanical insufflation-exsufflation MIF maximum inspiratory force MIGET multiple inert gas elimination technique min minute MIP maximum inspiratory pressure ml milliliter mm millimeter MMAD median mass aerodynamic diameter mm Hg millimeters of mercury mmol millimole MMV mandatory minute ventilation mo month MOV minimal occluding volume mPaw − Paw mean airway pressure MRI magnetic resonance imaging msec millisecond MV mechanical ventilation MVV maximum voluntary ventilation NaBr sodium bromide NaCl sodium chloride NAVA neurally adjusted ventilatory assist NBRC National Board of Respiratory Care NEEP negative end expiratory pressure nHFOV nasal high-frequency oscillatory ventilation NICU neonatal intensive care unit NIF negative inspiratory force (also see MIP and MIF) NIH National Institutes of Health NIV noninvasive ventilation nM nanomole nm nanometer NMBA neuromuscular blocking agent nM/L nanomole per liter NO nitric oxide NO2 nitrous oxide NP nasopharyngeal NPO nothing by mouth NPV negative pressure ventilation NPPV noninvasive positive pressure ventilation NSAIDs nonsteroidal antiinflammatory drugs nSIMV nasal synchronized intermittent mandatory

ventilation

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EGAN’S Fundamentals OF Respiratory Care

Robert M. Kacmarek, PhD, RRT Professor of Anesthesiology

Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School;

Director of Respiratory Care Respiratory Care Services

Massachusetts General Hospital Boston, Massachusetts

James K. Stoller, MD, MS, FAARC, FCCP Jean Wall Bennett Professor of Medicine

Cleveland Clinic Lerner College of Medicine; Chair, Education Institute

Cleveland Clinic Cleveland, Ohio

Albert J. Heuer, PhD, MBA, RRT, RPFT Program Director and Professor

Masters of Science in Health Care Management & Respiratory Care Program Rutgers, School of Health Related Professions

Newark, New Jersey

Consulting Editors

EDITION 11

Robert L. Chatburn, MHHS, RRT-NPS, FAARC

Adjunct Professor Department of Medicine

Cleveland Clinic Lerner College of Medicine; Clinical Research Manager

Department of Respiratory Therapy Cleveland Clinic Cleveland, Ohio

Richard H. Kallet, MS, RRT

Director of Quality Assurance Respiratory Care Division Department of Anesthesia

University of California, San Francisco; San Francisco General Hospital

San Francisco, California

3251 Riverport Lane St. Louis, Missouri 63043

EGAN’S FUNDAMENTALS OF RESPIRATORY CARE, ELEVENTH EDITION ISBN: 978-0-323-34136-3

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, and 1969.

Library of Congress Cataloging-in-Publication Data

Egan’s fundamentals of respiratory care / [edited by] Robert M. Kacmarek, James K. Stoller, Albert J. Heuer ; consulting editors, Robert L. Chatburn, Richard H. Kallet.—Eleventh edition. p. ; cm. Fundamentals of respiratory care Includes bibliographical references and index. ISBN 978-0-323-34136-3 (hardcover : alk. paper) I. Kacmarek, Robert M., editor. II. Stoller, James K., editor. III. Heuer, Albert J., editor. IV. Chatburn, Robert L., editor. V. Kallet, Richard H., editor. VI. Title: Fundamentals of respiratory care. [DNLM: 1. Respiratory Therapy–methods. 2. Respiratory Tract Diseases–therapy. WF 145] RM161 615.8′36–dc23 2015036692

Content Strategist: Sonya Seigafuse Content Development Manager: Billie Sharp Content Development Specialist: Heather Yocum Publishing Services Manager: Catherine Jackson Senior Project Manager: Rachel E. McMullen Design Direction: Renee Duenow

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

http://www.elsevier.com/permissions

For Robert, Julia, Katie, and Callie, who all make it worthwhile, and for Cristina who has

made me whole again.

RMK

I dedicate this work to the memory of my parents, Norma and Alfred Stoller, who instilled

the values of rigor and commitment that inform this book; to my wife, Terry Stoller, whose

love and support have been the foundation upon which my contribution to this book is

possible; to our son, Jake Fox Stoller, whose shining promise gives purpose and

illuminates the world; and to generations of Respiratory Therapists, whose

daily activities and commitment better our health and give hope.

JKS

To my mother, who is long gone from this earth, but continues to be the most dominant,

positive influence in my life. Mom taught me many lessons, including that failure is

to be expected on the way to success, and excellence can only be achieved through

hard work, sacrifice, and perseverance. These lessons have proven invaluable and,

hence, my work on this text is dedicated to my mother, Edith; as well as

my wife, Laurel; my faculty and students; fellow respiratory therapists;

and the patients we tirelessly serve.

AJH

Contributors

Loutfi S. Aboussouan, MD Staff Respiratory Institute Cleveland Clinic Cleveland, Ohio

Neila Altobelli, BA, RRT Respiratory Therapist, Clinical Scholar, Clinical Educator Department of Respiratory Care Massachusetts General Hospital Boston, Massachusetts

Arzu Ari, PhD, RRT, PT, CPFT, FAARC Associate Professor Department of Respiratory Therapy Georgia State University Atlanta, Georgia

Rendell W. Ashton, MD Pulmonary and Critical Care Fellowship Program Director Department of Critical Care Medicine Cleveland Clinic Cleveland, Ohio

Joseph T. Azok, MD Staff Radiologist Section of Thoracic Imaging, Imaging Institute Cleveland Clinic Cleveland, Ohio

Jami E. Baltz, RD, CNSC Clinical Dietitian Department of Clinical Nutrition Stanford Health Care Stanford, California

Lorenzo Berra, MD Assistant Professor of Anesthesia Department of Anesthesia Harvard Medical School; Anesthesiologist and Intensivist Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Boston, Massachusetts

Thomas A. Barnes, EdD, RRT, FAARC Professor Emeritus of Cardiopulmonary Sciences Master of Science in Respiratory Care Leadership Program Northeastern University Boston, Massachusetts

Will Beachey, PhD, RRT, FAARC Professor and Chair Department of Respiratory Therapy University of Mary/CHI St. Alexius Health Bismarck, North Dakota

Jason Bordelon, MHA, RRT Director Department of Respiratory & Clinical Diagnostics Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates

Jeffrey T. Chapman, MD Chief Respiratory & Critical Care Institute Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates

Robert L. Chatburn, MHHS, RRT-NPS, FAARC Adjunct Professor Department of Medicine Cleveland Clinic Lerner College of Medicine; Clinical Research Manager Department of Respiratory Therapy Cleveland Clinic Cleveland, Ohio

Daniel W. Chipman, BS, RRT Assistant Director Respiratory Care Massachusetts General Hospital Boston, Massachusetts

Zaza Cohen, MD, FCCP Medical Director, Respiratory Care Program—North Rutgers School of Health Related Professions Newark, New Jersey; Director, Intensive Care Unit Hackensack University Medical Center—Mountainside Montclair, New Jersey

Contributors vii

Douglas D. Deming, MD Professor and Chief Division of Neonatology Department of Pediatrics Loma Linda University School of Medicine Loma Linda, California

Anthony L. DeWitt, RRT, CRT, BHA, JD Partner Bartimus, Frickleton, Robertson & Goza, PC Jefferson City, Missouri

Enrique Diaz-Guzman, MD Associate Professor of Medicine Division of Pulmonary, Critical Care and Sleep Medicine University of Alabama at Birmingham Birmingham, Alabama

Patrick J. Dunne, MEd, RRT, FAARC President/CEP HealthCare Productions, Inc. Fullerton, California

Raed A. Dweik, MD, FACP, FRCP(C), FCCP, FCCM, FAHA Professor of Medicine Cleveland Clinic Lerner College of Medicine; Director, Pulmonary Vascular Program Departments of Pulmonary and Critical Care Medicine/

Respiratory Institute Cleveland Clinic Cleveland, Ohio

Patricia English, MS, RRT ECMO Program Coordinator Department of Respiratory Care Massachusetts General Hospital Boston, Massachusetts

Matthew C. Exline, MD, MPH Assistant Professor; Medical Director, Medical Intensive Care

Unit Division of Pulmonary, Allergy, Critical Care, and Sleep

Medicine The Ohio State University Columbus, Ohio

James B. Fink, RRT, NPS, PhD, FAARC, FCCP Adjunct Professor Division of Respiratory Therapy Georgia State University Atlanta, Georgia

Daniel F. Fisher, MS, RRT Assistant Director Respiratory Care Services Massachusetts General Hospital Boston, Massachusetts

Crystal L. Fishman, BS, RRT Faculty Instructor Respiratory Care Program Rutgers School of Health Related Professions Newark, New Jersey

Thomas G. Fraser, MD Vice Chairman Department of Infectious Disease Cleveland Clinic Cleveland, Ohio

Douglas S. Gardenhire, EdD, RRT-NPS, FAARC Chair and Clinical Associate Professor Department of Respiratory Therapy Georgia State University Atlanta, Georgia

Donna D. Gardner, Dr(c)PH, RRT, FAARC Chair, Department of Respiratory Care Interim Chair, Department of Clinical Laboratory Sciences University of Texas Health Science Center at San Antonio San Antonio, Texas

Michael A. Gentile, RRT, FAARC, FCCM Associate in Research Department of Critical Care Medicine Duke University Medical Center Durham, North Carolina

Umur Hatipoğlu, MD Quality Improvement Officer Respiratory Institute Cleveland Clinic Cleveland, Ohio

Albert J. Heuer, PhD, MBA, RRT, RPFT Program Director and Professor Masters of Science in Health Care Management & Respiratory

Care Program Rutgers, School of Health Related Professions Newark, New Jersey

viii Contributors

R. Duncan Hite, MD Chairman Department of Critical Care Medicine Respiratory Institute Cleveland Clinic Cleveland, Ohio

Robert M. Kacmarek, PhD, RRT Professor of Anesthesiology Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School; Director of Respiratory Care Respiratory Care Services Massachusetts General Hospital Boston, Massachusetts

Richard H. Kallet, MS, RRT Director of Quality Assurance Respiratory Care Division Department of Anesthesia University of California, San Francisco; San Francisco General Hospital San Francisco, California

Danai Khemasuwan, MD, MBA Fellow Department of Interventional Pulmonary Medicine Henry Ford Hospital Detroit, Michigan

Euhan John Lee, MD Clinical Assistant Professor of Medicine Division of Pulmonary, Allergy, and Critical Care Medicine University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

David L. Longworth, MD Lahey Health System and Lahey Hospital and Medical Center Division of Primary Care Lahey Health System Burlington, Massachusetts

Sarah A. Longworth, MD Clinical Fellow Department of Infectious Disease Hospital of University of Pennsylvania Philadelphia, Pennsylvania

Scott P. Marlow, BA, RRT Pulmonary Rehabilitation Coordinator Respiratory Institute Cleveland Clinic Cleveland, Ohio

Peter J. Mazzone, MD, MPH, FCCP Director of Lung Cancer Program Respiratory Institute Cleveland Clinic Cleveland, Ohio

Atul C. Mehta, MBBS, FACP, FCCP Professor of Medicine Cleveland Clinic Lerner College of Medicine; Staff Physician Department of Pulmonary Medicine, Respiratory Institute Cleveland Clinic Cleveland, Ohio; Senior Editor Journal of Bronchology and Interventional Pulmonology

Michele Messam, BSMT(ASCP), CIC Infection Preventionist Infection Prevention, Quality and Patient Safety Institute Cleveland Clinic Cleveland, Ohio

Eduardo Mireles-Cabodevila, MD Assistant Professor of Medicine Department of Pulmonary, Allergy and Critical Care Medicine Cleveland Clinic Lerner College of Medicine; Program Director, Critical Care Medicine Fellowship Department of Critical Care Medicine, Respiratory Institute Cleveland Clinic Cleveland, Ohio

Ariel M. Modrykamien, MD, FACP, FCCP Clinical Associate Professor of Medicine Department of Medicine Texas A&M University—Health Science Center; Medical Director, Respiratory Therapy and Pulmonary

Function Laboratory Department of Pulmonary and Critical Care Medicine Baylor University Medical Center Dallas, Texas

Kimberly N. Otsuka, MD Assistant Professor of Pediatrics Division of Allergy, Immunology, and Pulmonology Loma Linda University School of Medicine Loma Linda, California

Hilary Petersen, MPAS, PA-C Physician Assistant Respiratory Institute Cleveland Clinic Cleveland, Ohio

Contributors ix

Thomas Piraino, RRT Assistant Clinical Professor (Adjunct) Department of Anesthesia, Division of Critical Care McMaster University; Best Practice Clinical Educator Department of Respiratory Therapy Services St. Joseph’s Healthcare Hamilton, Ontario, Canada

Narciso E. Rodriguez, BS, RRT-NPS, ACCS, RPFT, AE-C Adjunct Faculty Respiratory Care Program Rutgers, School of Health Related Professions Newark, New Jersey

Madhu Sasidhar, MBBS, FCCP Section Head Department of Respiratory Therapy Respiratory Institute Cleveland Clinic Cleveland, Ohio

Steven K. Schmitt, MD Associate Professor of Medicine Cleveland Clinic Lerner College of Medicine; Staff Physician Department of Infectious Diseases, Medicine Institute Infectious Disease Cleveland Clinic Cleveland, Ohio

James K. Stoller, MD, MS, FAARC, FCCP Jean Wall Bennett Professor of Medicine Cleveland Clinic Lerner College of Medicine Chair, Education Institute Cleveland Clinic Cleveland, Ohio

Charlie Strange, MD Professor of Pulmonary and Critical Care, Allergy, and Sleep

Medicine Department of Medicine Medical University of South Carolina Charleston, South Carolina

Patrick J. Strollo, Jr, MD Professor of Medicine and Clinical and Translational Science Divistion of Pulmonary, Allergy and Critical Care Medicine University of Pittsburgh Pittsburgh, Pennsylvania

Clorinda Suarez, BS, RRT-NPS Senior Registered Respiratory Therapist Department of Respiratory Care Massachusetts General Hospital Boston, Massachusetts

Adriano R. Tonelli, MD Staff Respiratory Institute Cleveland Clinic Cleveland, Ohio

David L. Vines, MHS, RRT, FAARC Chair, Respiratory Care Program Director Department of Cardiopulmonary Science Rush University Medical Center Chicago, Illinois

Teresa A. Volsko, MHHS, RRT, FAARC Director, Respiratory Care and Transport Department of Nursing Administration Akron Children’s Hospital Akron, Ohio

Purris F. Williams, BS, RRT Respiratory Therapist, Senior Clinician Respiratory Care Services Massachusetts General Hospital Boston, Massachusetts

Kenneth A. Wyka, MS, RRT, AE-C, FAARC Director of Clinical Education and Associate Dean Respiratory Therapy Program Independence University Salt Lake City, Utah

Reviewers

Catherine Bitsche EdS, RRT-NPS,RCP Program Director Catawba Valley Community College Respiratory Therapy Hickory, North Carolina

Greg Carter BS, RRT Program Chair/Director Tacoma Community College Respiratory Care Tacoma, Washington

Donna Davis, BS, RRT Program Director Butte Glenn Community College Respiratory Care Oroville, California

Kathleen Geier, M.Ed, RRT Instructor Southeast Community College Health Science Division Lincoln, Nebraska

Robert L. Joyner, Jr., PhD, RRT, RRT-ACCS, FAARC Professor of Health Sciences Associate Dean, Henson School of Science & Technology Director, Respiratory Therapy Program Salisbury University Department of Health Sciences Salisbury, Maryland

Stephen F. Wehrman RRT, RPFT Professor Emeritus University of Hawaii Kapi’olani Community College Health Sciences Honolulu, Hawaii

Peggy Wells, RRT, RCP, MAED Program Director Respiratory Therapy Program Grossmont College Respiratory Therapy El Cajon, California

Preface

Donald F. Egan, MD, the original author of Egan’s Fundamentals of Respiratory Care, sought to provide a foundation of knowl- edge for respiratory students learning the practice in 1969. However, the scope of the respiratory care profession is ever- expanding, and the skills and information needed to be an effective respiratory therapist have expanded with it. With improved technology and vast scientific and medical advances, the body of knowledge required for respiratory therapists has increased greatly since the first edition of the text was published.

Now in its eleventh edition, Egan’s Fundamentals of Respi ratory Care encompasses the most relevant information to date and has provided a comprehensive knowledge base for students and professionals for more than 45 years. While these updated editions of Egan’s Fundamentals of Respiratory Care still accomplish Dr. Egan’s original goal—“to present what is felt to be the minimum knowledge for the safe and effective administration of inhalation therapy”—this text also goes far beyond the minimum, delving into important concepts and providing detailed information and resources to enhance stu- dent comprehension.

Every editor, guest editor, and contributor to the book is a leading figure in respiratory care, and the vast experience of these individuals ensures that critical content is covered accu- rately. Using the combined knowledge of these individuals, Egan’s Fundamentals of Respiratory Care covers the role of respi- ratory therapists, the scientific bases for treatment, and clinical application skills. With 56 detailed chapters all focused on a unique aspect of respiratory care, Egan’s Fundamentals of Respi ratory Care is without equal in providing the prerequisite infor- mation required of a respiratory therapist today.

ORGANIZATION

This edition of the text is organized in a logical sequence of sections and chapters that build on each other to facilitate com- prehension of the material. The earlier sections provide a basis for the profession and cover the physical, anatomic, and physi- ologic principles necessary to understand succeeding chapters. The later chapters address specific cardiopulmonary diseases and the diagnostic and therapeutic techniques that accompany them. Details on preventive and long-term care are also pro- vided in the later chapters. In order of presentation, the seven sections are: I. Foundations of Respiratory Care II. Applied Anatomy and Physiology

III. Assessment of Respiratory Disorders IV. Review of Cardiopulmonary Disease V. Basic Therapeutics VI. Acute and Critical Care VII. Patient Education and Long-Term Care

FEATURES

There are many characteristic features throughout the book designed with the student in mind, making Egan’s Fundamen tals of Respiratory Care unique and engaging as a primary text- book. Each chapter begins in a similar manner, outlining the content and drawing attention to what should be mastered through the use of: • Chapter Objectives • Chapter Outlines • Key Terms The most important features within each chapter are accented by the ample use of figures, boxes, and tables containing key information and by the use of: • “Rules of Thumb”—“pearls” of information highlighting

rules, formulas, and key points necessary to the study of respiratory therapy and to future clinical practice

• “Mini-Clinis”—critical thinking case studies illustrating potential problems that may be encountered during pa- tient care

• Clinical Practice Guidelines—statements of care extracted from the AARC list of guidelines defining evidence-based practice

• Therapist-Driven Protocols—examples of decision trees developed by hospitals and used by respiratory therapists to assess patients, initiate care, and evaluate outcomes

Also, each chapter concludes with: • A “Summary Checklist” of key points that the student should

have mastered on completion of the chapter • A complete list of references

NEW TO THIS EDITION

This edition has been updated to reflect the most current infor- mation in the National Board for Respiratory Care (NBRC) Therapist Exam Content Outline. Also featured is an expanded role for the NBRC Exam Matrix Correlation chart within all of the student and instructor offerings. Several chapters have been added, including Fundamentals of Respiratory Care Re- search; Flexible Bronchoscopy and the Respiratory Therapist;

xii PREFAcE

Extracorporeal Life Support (ECLS); Patient Ventilator Inter- action; and Trauma, Obesity, Burns, and Near Drowning; and many other chapters have been substantially revised or com- pletely rewritten to reflect the dynamic and expanding field of respiratory care. Furthermore, the content of the entire text has been refined and simplified to be more easily understood and relevant to our key audiences: respiratory therapy students, faculty, and therapists throughout the world.

LEARNING AIDS

Workbook

The Workbook for Egan’s Fundamentals of Respiratory Care is an exceptional resource for students. Offering a wide range of activities, it allows students to apply the knowledge they have gained using the core text. Presented in an engaging format, the workbook breaks down the more difficult concepts and guides students through the most important information. Beyond the many NBRC-style multiple-choice questions in the workbook, students are challenged with exercises such as fill-in-the-blanks, matching, case studies, short answers, and more. Answers to the Workbook are available on the Evolve site.

FOR THE INSTRUcTOR

Evolve Resources

Evolve is an interactive learning environment designed to work in coordination with this text. Instructors may use Evolve to provide an Internet-based course component that expands the concepts presented in class. Evolve can be used to publish the class syllabus, outlines, and lecture notes; set up “virtual office hours” and e-mail communication; and encourage student par- ticipation through chatrooms and discussion boards. Evolve also allows instructors to post exams and manage their grade books.

The intuitive and comprehensive Evolve Learning Resources associated with this text provide instructors with valuable resources to use as they teach, including: • More than 3000 test bank questions available in ExamView • Comprehensive PowerPoint presentations for each chapter • An image collection of the figures in the book • Lesson plans • Workbook answer key For more information, visit http://evolve.elsevier.com/Egans or contact an Elsevier sales representative.

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xiii

Contents

I Foundations of Respiratory Care, 1

1 History of Respiratory Care, 2 Patrick J. Dunne

2 Delivering Evidence-Based Respiratory Care, 18 James K. Stoller and Ariel M. Modrykamien

3 Quality, Patient Safety, Communication, and Recordkeeping, 35 Scott P. Marlow and Umur Hatipoğlu

4 Principles of Infection Prevention and Control, 59 Michele Messam and Thomas G. Fraser

5 Ethical and Legal Implications of Practice, 81 Anthony L. DeWitt

6 Physical Principles of Respiratory Care, 102 Daniel F. Fisher

7 E-Medicine in Respiratory Care, 126 Narciso E. Rodriguez, Albert J. Heuer, and Madhu Sasidhar

8 Fundamentals of Respiratory Care Research, 146 Robert L. Chatburn

II Applied Anatomy and Physiology, 157

9 The Respiratory System, 158 Crystal L. Fishman and Narciso E. Rodriguez

10 The Cardiovascular System, 209 Narciso E. Rodriguez

11 Ventilation, 226 Eduardo Mireles-Cabodevila and Robert L. Chatburn

12 Gas Exchange and Transport, 247 Zaza Cohen

13 Solutions, Body Fluids, and Electrolytes, 269 Daniel F. Fisher

14 Acid-Base Balance, 285 Will Beachey

15 Regulation of Breathing, 308 Will Beachey

III Assessment of Respiratory Disorders, 319

16 Bedside Assessment of the Patient, 320 Richard H. Kallet

17 Interpreting Clinical and Laboratory Data, 345 Richard H. Kallet

18 Interpreting the Electrocardiogram, 356 Albert J. Heuer

19 Analysis and Monitoring of Gas Exchange, 369 Michael A. Gentile, Albert J. Heuer, and Richard H. Kallet

20 Pulmonary Function Testing, 400 Zaza Cohen

21 Review of Thoracic Imaging, 428 Joseph T. Azok and James K. Stoller

22 Flexible Bronchoscopy and the Respiratory Therapist, 456 Danai Khemasuwan and Atul C. Mehta

23 Nutrition Assessment, 474 Jami E. Baltz

IV Review of Cardiopulmonary Disease, 493

24 Pulmonary Infections, 494 Sarah A. Longworth, Steven K. Schmitt, and David L. Longworth

25 Obstructive Lung Disease: Chronic Obstructive Pulmonary Disease, Asthma, and Related Diseases, 514 Enrique Diaz-Guzman and James K. Stoller

26 Interstitial Lung Disease, 540 Jeffrey T. Chapman and Jason Bordelon

27 Pleural Diseases, 554 Charlie Strange

28 Pulmonary Vascular Disease, 570 Adriano R. Tonelli and Raed A. Dweik

29 Acute Respiratory Distress Syndrome, 588 Matthew C. Exline, Eduardo Mireles-Cabodevila, and R. Duncan Hite

xiv Contents

30 Respiratory Management of Trauma, Obesity, Near Drowning, and Burns, 615 Lorenzo Berra

31 Lung Cancer, 634 Peter J. Mazzone and Hilary Petersen

32 Neuromuscular and Other Diseases of the Chest Wall, 650 Rendell W. Ashton

33 Disorders of Sleep, 670 Euhan John Lee and Patrick J. Strollo, Jr.

34 Neonatal and Pediatric Respiratory Disorders, 688 Douglas D. Deming and Kimberly N. Otsuka

V Basic Therapeutics, 715

35 Airway Pharmacology, 716 Douglas S. Gardenhire

36 Airway Management, 739 Neila Altobelli

37 Emergency Cardiovascular Life Support, 790 Thomas A. Barnes

38 Humidity and Bland Aerosol Therapy, 820 James B. Fink and Arzu Ari

39 Aerosol Drug Therapy, 843 James B. Fink and Arzu Ari

40 Storage and Delivery of Medical Gases, 884 David L. Vines

41 Medical Gas Therapy, 905 Albert J. Heuer

42 Lung Expansion Therapy, 937 Daniel F. Fisher

43 Airway Clearance Therapy (ACT), 951 David L. Vines and Donna D. Gardner

VI Acute and Critical Care, 971

44 Respiratory Failure and the Need for Ventilatory Support, 972 Loutfi S. Aboussouan

45 Mechanical Ventilators, 987 Robert L. Chatburn and Teresa A. Volsko

46 Physiology of Ventilatory Support, 1016 Robert M. Kacmarek

47 Patient-Ventilator Interactions, 1058 Robert M. Kacmarek

48 Initiating and Adjusting Invasive Ventilatory Support, 1078 Robert M. Kacmarek

49 Noninvasive Ventilation, 1111 Purris F. Williams

50 Extracorporeal Life Support (ECLS), 1136 Clorinda Suarez and Patricia English

51 Monitoring the Patient in the Intensive Care Unit, 1154 Thomas Piraino

52 Discontinuing Ventilatory Support, 1190 Robert M. Kacmarek

53 Neonatal and Pediatric Respiratory Care, 1216 Daniel W. Chipman

VII Patient Education and Long-Term Care, 1249

54 Patient Education and Health Promotion, 1250 Donna D. Gardner

55 Cardiopulmonary Rehabilitation, 1264 Kenneth A. Wyka

56 Respiratory Care in Alternative Settings, 1284 Albert J. Heuer

Glossary, 1312

S E C T I O N I

FOUNDATIONS OF RESPIRATORY CARE

C H A P T E R 1

History of Respiratory Care

PATRICK J. DUNNE

CHAPTER OBJECTIVES

After reading this chapter you will be able to: ◆ Define respiratory care. ◆ Summarize some of the major events in the history of science and medicine. ◆ Explain how the respiratory care profession began. ◆ Describe the historical development of the major clinical areas of respiratory care. ◆ Name some of the important historical figures in respiratory care. ◆ Describe the major respiratory care educational, credentialing, and professional associations. ◆ Explain how the important respiratory care organizations began. ◆ Describe the development of respiratory care education. ◆ Predict future trends for the respiratory care profession.

CHAPTER OUTLINE

Definitions History of Respiratory Medicine and Science

Ancient Times The Middle Ages, the Renaissance, and the

Enlightenment Period Nineteenth and Early Twentieth Centuries

Development of the Respiratory Care Profession Clinical Advances in Respiratory Care

Professional Organizations and Events American Association for Respiratory Care (AARC) Respiratory Care Week

Fellow of the American Association for Respiratory Care (FAARC)

Board of Medical Advisors (BOMA) American Respiratory Care Foundation (ARCF) International Council for Respiratory Care (ICRC) National Board for Respiratory Care (NBRC) Committee on Accreditation for Respiratory Care

(CoARC) Respiratory Care Education Future of Respiratory Care

2015 and Beyond

KEY TERMS

aerosol medications airway management American Association for

Respiratory Care (AARC) American Respiratory Care

Foundation (ARCF) Board of Medical Advisors (BOMA) cardiopulmonary system

Committee on Accreditation for Respiratory Care (CoARC)

Fellow of the American Association for Respiratory Care (FAARC)

International Council for Respiratory Care (ICRC)

mechanical ventilation National Board for Respiratory Care

(NBRC)

oxygen therapy physician assistant pulmonary function testing respiratory care respiratory care practitioner(s) respiratory therapist(s) (RTs) respiratory therapy

T he history of science and medicine is a fascinating topic, which begins in ancient times and progresses to the twenty-first century. Although respiratory care is a newer discipline, its roots go back to the dawn of civilization. The first written account of positive pressure ventilation using mouth-to-mouth resuscitation is thought to have been recorded

more than 28 centuries ago.1 Air was thought to be one of the four basic elements by the ancients, and the practice of medi- cine dates back to ancient Babylonia and Egypt. The progres- sion of science and medicine continued through the centuries, and development of the modern disciplines of anesthesiology, pulmonary medicine, and respiratory care during the twentieth

History of Respiratory Care • CHAPTER 1 3

A human resources survey conducted in 2014 by the Ameri- can Association for Respiratory Care (AARC) revealed that there were approximately 172,000 RTs practicing in the United States3; this represented a 19% increase over a similar study conducted 4 years earlier in 2009. As the incidence of chronic respiratory diseases continues to increase, the demand for RTs is expected to be even greater in the years ahead. Although the RT as a distinct health care provider was originally a uniquely North American phenomenon, since the 1990s there has been a steady increase in interest of other countries in having spe- cially trained professionals provide respiratory care. This trend is referred to as the globalization of respiratory care.

HISTORY OF RESPIRATORY MEDICINE AND SCIENCE

Several excellent reviews of the history of respiratory care have been written, and the reader is encouraged to review these pub- lications.1,4-6 Summaries of notable historical events in science, medicine, and respiratory care are provided in Tables 1-1 and 1-2. A brief description of the history of science and medicine follows.

Ancient Times

Humans have been concerned about the common problems of sickness, disease, old age, and death since primitive times. Early cultures developed herbal treatments for many diseases, and surgery may have been performed in Neolithic times. Physicians practiced medicine in ancient Mesopotamia, Egypt, India, and China.1,4,7 However, the foundation of modern Western medi- cine was laid in ancient Greece with the development of the Hippocratic Corpus.1,4,7,8 This ancient collection of medical treatises is attributed to the “father of medicine,” Hippocrates,

century depended on the work of many earlier scientists and physicians. This chapter describes the history and development of the field of respiratory care and possible future directions for the profession.

DEFINITIONS

Respiratory care, also known as respiratory therapy, has been defined as the health care discipline that specializes in the pro- motion of optimal cardiopulmonary function and health.2 Respiratory therapists (RTs) apply scientific principles to prevent, identify, and treat acute or chronic dysfunction of the cardiopulmonary system.2 Respiratory care includes the assess- ment, treatment, management, control, diagnostic evaluation, education, and care of patients with deficiencies and abnor- malities of the cardiopulmonary system.2 Respiratory care is increasingly involved in the prevention of respiratory disease, the management of patients with chronic respiratory disease, and the promotion of health and wellness.2

RTs, also known as respiratory care practitioners, are health care professionals who are educated and trained to provide respiratory care to patients. Approximately 75% of all RTs work in hospitals or other acute care settings.3 However, many RTs are employed in clinics, physicians’ offices, skilled nursing facilities, cardiopulmonary diagnostic laboratories, and public schools. Others work in research, disease management pro- grams, home care, and industry. RTs also are employed by col- leges and universities to teach students the skills they need to become RTs. Regardless of practice setting, all direct patient care services provided by RTs must be done under the direction of a qualified physician. Medical directors are usually physicians who are specialists in pulmonary medicine, anesthesiology, and/or critical care medicine.

TABLE 1-1

Major Historical Events in Science, Medicine, and Respiratory Care from Ancient Times to the Nineteenth Century

Dates Historical Event

Ancient Period 1550 BC What may be the world’s oldest medical document, known as Ebers Papyrus, describes an ancient Egyptian inhalational

treatment for asthma. 800 BC Biblical reference to what may be the first recorded episode of mouth-to-mouth resuscitation. 500-300 BC Hippocrates (460-370 BC; Greece) describes diseases as “humoral disorders” and speculates that an essential substance

in air enters the heart and is distributed throughout the body. 304 BC Erasistratus of Alexandria describes the pneumatic theory of respiration, in which air travels through the lungs to the heart

and then through the air-filled arteries to the tissues of the body. 100-200 AD Galen (130-199 AD) in Asia Minor identifies “pneuma” as the vital substance in inspired air that enters the heart and then

the blood.

Middle Ages (500-1500 AD) and Renaissance (1450-1600) 500-1500 AD The Middle Ages brings a period of little scientific progress in the West; however, this period coincides with the Golden

Age of Arabian medicine (850-1050 AD). 1400s-1500s da Vinci (1452-1519; Italy) performs human dissections and physiologic experiments on animals, learning that

subatmospheric intrapleural pressures inflate the lungs and that there is a vital substance in air that supports combustion. 1542 Vesalius (1514-1564; Belgium), one of the great early pioneers in human anatomy, performs a thoracotomy on a pig,

placing a reed tracheotomy tube for ventilation of the animal, and resuscitates an apparently dead person.

Continued

4 SECTION I • Foundations of Respiratory Care

Dates Historical Event

Seventeenth Century (1600s) 1628 Harvey (1578-1657; England) describes the arterial and venous circulatory systems. 1643 Torricelli (1608-1647; Italy) builds the world’s first barometer for measurement of atmospheric pressure. 1648 Pascal (1623-1662) describes the relationship between altitude and barometric pressure. 1662; 1666 Boyle (1627-1691; England) explains the inverse relationship between gas pressure and volume (Boyle’s law: pressure [P]

× volume [V] = k or [P1V1] = [P2V2]). Boyle also describes a mysterious substance in air that supports combustion. 1683 van Leewenhoek (1632-1723; Holland) improves the microscope and begins the science of microbiology.

Eighteenth Century (1700s) 1738 Bernoulli (1700-1782; Switzerland) determines that as the velocity of a liquid or gas increases, the pressure decreases

(Bernoulli principle). Bernoulli also proposed that gases are composed of tiny particles in rapid, random motion. This idea became the basis of the modern kinetic theory of gases, which was developed further by Maxwell (1831-1879; Scotland) in 1860.

1744 Fothergill (1712-1780; England) reports successful resuscitation methods. 1754 Black (1728-1799; Scotland) rediscovers carbon dioxide, which he calls “fixed air” (prior work had been done by van

Helmot in the 1600s). 1771 Scheele (1742-1786; Sweden) makes “fire air” (oxygen) by heating magnesium oxide; Scheele’s findings are published in

June 1774. 1774 Priestley (1733-1804; England), usually credited with the discovery of oxygen, publishes his work on “dephlogisticated air”

(oxygen) 3 months after Scheele’s report. 1775 Lavosier (1743-1794; France) renames “dephlogisticated air” “oxygen,” or “acid maker” and shows that oxygen is

absorbed by the lungs and consumed by the body, producing carbon dioxide and water vapor, which are exhaled. 1776 Hunter (1728-1793; England) recommends use of a fireplace bellows for artificial ventilation. 1787 Charles (1746-1823; France) describes the relationship between gas temperature and volume; Charles’ law: volume (V)/

temperature (T) = constant; or (V1/T1) = (V2/T2). 1794 Lavosier (1743-1794; France) describes oxygen absorption by the lungs and carbon dioxide production. 1798 Beddoes (1760-1808; England) establishes the Pneumatic Institute in Bristol and uses oxygen to treat various disorders.

Nineteenth Century (1800s) 1800 Henry (1774-1836; England) determines that the amount of gas dissolved in a liquid is directly proportioned to its partial

pressure (Henry’s law). 1800s Fick (1829-1911) describes a method to calculate cardiac output based on oxygen consumption and arterial and venous

oxygen content: Qt = ( �VO2)/(CaO2 − CvO2). 1801-1808 Dalton (1766-1844; England) describes his atomic theory and the relationship between the partial pressures and total

pressure of a gas mixture; Dalton’s law: P1 + P2 + P3 . . . PN = PTotal, where P = pressure. 1806 de LaPlace (1749-1827; France) describes the relationship between pressure and surface tension in fluid droplets. 1808 Gay-Lussac (1778-1850; France) describes the relationship between gas pressure and temperature; Gay-Lussac’s law:

pressure (P)/temperature (T) = constant; or (P1/T1) = (P2/T2). 1811 Avogadro (1776-1856; Italy) describes “Avogadro principle,” in which equal volumes of all gases (at the same temperature

and pressure) contain the same number of molecules. 1816 Laennec (1781-1826; France) invents the stethoscope for chest auscultation and lays the foundation for modern

pulmonology with his book Diseases of the Chest. 1831 Graham (1805-1869; Scotland) describes diffusion of gases (Graham’s law). 1837 Magnus (1802-1870; Germany) measures arterial and venous blood oxygen and carbon dioxide content. 1846 Hutchinson (1811-1861; England) develops the spirometer and measures the vital capacity of more than 2000 human

subjects. 1864 Jones (United States) patents a negative pressure device to support ventilation. 1865 Pasteur (1822-1895; France) describes his “germ theory” of disease. 1876 Woillez develops the spirophore negative pressure ventilator. 1878 Bert (1833-1886; France) shows that low inspired oxygen levels cause hyperventilation. 1880 MacEwen reports success with oral endotracheal intubation. 1885 Miescher-Rusch demonstrates that carbon dioxide is the major stimulus for breathing. 1886; 1904 Bohr (1855-1911; Danish) describes the oxyhemoglobin dissociation curve. 1888 The Fell-O’Dwyer device combines a foot-operated bellows with a laryngeal tube for ventilatory support. 1895 Roentgen (1845-1923; Germany) discovers the “x-ray.” A direct vision laryngoscope is introduced by Jackson in the United

States and Kirstein in Germany.

Data from references 1, 3-9, 11-14, and 17.

TABLE 1-1

Major Historical Events in Science, Medicine, and Respiratory Care from Ancient Times to the Nineteenth Century—cont’d

History of Respiratory Care • CHAPTER 1 5

TABLE 1-2

Major Historical Events in Science, Medicine, and Respiratory Care in the Twentieth and Twenty-First Centuries

Twentieth Century Early 1900s Bohr (1855-1911; Denmark), Hasselbach (1874-1962; Denmark), Krogh (1874-1940; Denmark), Haldane (1860-1936;

Scotland), Barcroft (1872-1947; Ireland), Priestly (1880-1941; Britain), Y. Henderson (1873-1944; United States), L. J. Henderson (1878-1942; United States), Fenn (1893-1971; United States), Rahn (1912-1990; United States), and others make great strides in respiratory physiology and the understanding of oxygenation, ventilation, and acid-base balance.

1904 Bohr, Hasselbach, and Krogh (1874-1940) describe the relationships between oxygen and carbon dioxide transport. Sauerbruch (1875-1951; Germany) uses a negative pressure operating chamber for surgery in Europe.

1907 von Linde (1842-1934; Germany) begins large-scale commercial preparation of oxygen. 1909 Melltzer (1851-1920; United States) introduces oral endotracheal intubation. 1910 Oxygen tents are in use, and the clinical use of aerosolized epinephrine is introduced. 1911 Drager (1847-1917; Germany) develops the Pulmotor ventilator for use in resuscitation. 1913 Jackson develops a laryngoscope to insert endotracheal tubes. 1918 Oxygen mask is used to treat combat-induced pulmonary edema. 1919 Strohl (1887-1977; France) suggests the use of forced vital capacity as a measure of pulmonary function. 1920 Hill develops an oxygen tent to treat leg ulcers. 1926 Barach develops an oxygen tent with cooling and carbon dioxide removal. 1928 Drinker develops his “iron lung” negative pressure ventilator. 1938 Barach develops the meter mask for administering dilute oxygen. Boothby, Lovelace, and Bulbulian devise the BLB mask at

the Mayo Clinic for delivering high concentrations of oxygen. 1940 Isoproterenol, a potent beta-1 and beta-2 bronchodilator administered via aerosol, is introduced. Most common side effects

are cardiac (beta-1). 1945 Motley, Cournand, and Werko use intermittent positive pressure breathing to treat various respiratory disorders. 1947 The ITA is formed in Chicago, Illinois. The ITA later becomes the AARC. 1948 Bennett introduces the TV-2P positive pressure ventilator. 1948 FEV1 is introduced as a pulmonary function measure of obstructive lung disease. 1951 Isoetherine (Bronkosol), a preferential beta-2 aerosol bronchodilator with fewer cardiac side effects, is introduced. 1952 Mørch introduces the piston ventilator. 1954 The ITA becomes the AAIT. 1958 Bird introduces the Bird Mark 7 positive pressure ventilator. 1960 The Campbell Ventimask for delivering dilute concentrations of oxygen is introduced. 1961 Jenn becomes the first registered respiratory therapist. Also, metaproterenol, a preferential beta-2 bronchodilator, is

introduced 1963 Board of Schools is formed to accredit inhalation therapy educational programs. 1964 The Emerson Postoperative Ventilator (3-PV) positive pressure volume ventilator is introduced. 1967 The Bennett MA-1 volume ventilator is introduced, ushering in the modern age of mechanical ventilatory support for routine

use in critical care units. 1967 Combined pH-Clark-Severinghaus electrode is developed for rapid blood gas analysis. 1968 Fiberoptic bronchoscope becomes available for clinical use. The Engström 300 and Ohio 560 positive pressure volume

ventilators are introduced. 1969 ARDS and PEEP are described by Petty, Ashbaugh, and Bigelow. 1970 Swan-Ganz catheter developed for measurement of pulmonary artery pressures. The ARCF is incorporated. The JRCITE is

incorporated to accredit respiratory therapy educational programs. 1971 Continuous positive airway pressure is introduced by Gregory. Respiratory Care journal is named. 1972 Siemens Servo 900 ventilator is introduced. 1973 IMV is described by Kirby and Downs. The AAIT becomes the AART. 1974 IMV Emerson ventilator is introduced. 1974 NBRT is formed. 1975 Bourns Bear I ventilator is introduced. 1977 The JRCITE becomes the JRCRTE. 1978 Puritan Bennett introduces the MA-2 volume ventilator. The AAR Times magazine is introduced. 1979 AIDS is recognized by the Centers for Disease Control (CDC [later, Centers for Disease Control and Prevention]). 1982 Siemens Servo 900C and Bourns Bear II ventilators are introduced. 1983 The NBRT becomes the NBRC. 1983 President Reagan signs proclamation declaring National Respiratory Care Week 1984 Bennett 7200 microprocessor controlled ventilator is introduced. 1984 The AART is renamed the AARC. 1991 Servo 300 ventilator is introduced. 1992, 1993 The AARC holds national respiratory care education consensus conferences. 1994 The CDC publishes the first guidelines for the prevention of ventilator-associated pneumonia. 1998 The CoARC is formed, replacing the JRCRTE.

Continued

6 SECTION I • Foundations of Respiratory Care

a Greek physician who lived during the fifth and fourth centu- ries bc.1,7,8 Hippocratic medicine was based on four essential fluids, or “humors”—phlegm, blood, yellow bile, and black bile—and the four elements—earth (cold, dry), fire (hot, dry), water (cold, moist), and air (hot, moist). Diseases were thought to be humoral disorders caused by imbalances in these essential substances. Hippocrates believed there was an essential sub- stance in air that was distributed to the body by the heart.1 The Hippocratic Oath, which admonishes physicians to follow certain ethical principles, is given in a modern form to medical students at graduation.1,8

Aristotle (384-322 bc), a Greek philosopher and perhaps the first great biologist, believed that knowledge could be gained through careful observation.1,8 Aristotle made many scientific observations, including observations obtained by performing experiments on animals. Erasistratus (~330-240 bc), regarded by some as the founder of the science of physiology, developed a pneumatic theory of respiration in Alexandria, Egypt, in which air (pneuma) entered the lungs and was transferred to the heart.1,7 Galen (130-199 ad) was an anatomist in Asia Minor whose comprehensive work dominated medical thinking for centuries.1,6,7 Galen also believed that inspired air contained a vital substance that somehow charged the blood through the heart.1

The Middle Ages, the Renaissance, and the Enlightenment Period

The Romans carried on the Greek traditions in philosophy, science, and medicine. With the fall of the Western Roman Empire in 476 ad, many Greek and Roman texts were lost and Europe entered a period during which few advances were made in science or medicine. In the seventh century ad, the Arabians conquered Persia, where they found and preserved many of the works of the ancient Greeks, including the works of Hip- pocrates, Aristotle, and Galen.1,7 A Golden Age of Arabian medi- cine (850-1050 ad) followed.

An intellectual rebirth in Europe began in the twelfth century.1,7 Medieval universities were formed, and contact with the Arabs in Spain and Sicily reintroduced ancient Greek and Roman texts. Magnus (1192-1280) studied the works of Aristo- tle and made many observations related to astronomy, botany, chemistry, zoology, and physiology. The Renaissance (1450- 1600) ushered in a period of scientific, artistic, and medical advances. Leonardo da Vinci (1452-1519) studied human anatomy, determined that subatmospheric intrapleural pres- sures inflated the lungs, and observed that fire consumed a vital substance in air without which animals could not live.1,4 Vesa- lius (1514-1564), considered to be the founder of the modern field of human anatomy, performed human dissections and experimented with resuscitation.1 In 1543, the date commonly given as the start of the modern Scientific Revolution, Coper- nicus observed that the Earth orbited the sun.8 Before this time, it had been accepted that the Earth was the center of the universe.

The seventeenth century was a time of great advances in science. Accomplished scientists from this period include Kepler, Bacon, Galileo, Pascal, Hooke, and Newton. In 1628, Harvey fully described the circulatory system.4,8 In 1662, the chemist Boyle published what is now known as Boyle’s law, governing the relationship between gas volume and pres- sure.8 Torricelli invented the barometer in 1650, and Pascal showed that atmospheric pressure decreases with altitude.1,4 van Leeuwenhoek (1632-1723), known as the “father of mi- crobiology,” improved the microscope and was the first to observe and describe single-celled organisms, which he called “animalcules.”7

The eighteenth-century Enlightenment Period brought further advances in the sciences. In 1754, Black described the properties of carbon dioxide, although the discovery of carbon dioxide should be credited to van Helmont, whose work occurred approximately 100 years earlier.1 In 1774, Priestley described his discovery of oxygen, which he called

Twenty-First Century 2002 The NBRC adopts a continuing competency program for respiratory therapists to maintain their credentials. 2002 The Tripartite Statements of Support are adopted by the AARC, NBRC, and CoARC to advance respiratory care education

and credentialing. 2003 The AARC publishes its white paper on the development of baccalaureate and graduate education in respiratory care. Asian

bird flu appears in South Korea. 2004 The Fiftieth AARC International Congress is held in New Orleans. 2005 Number of working respiratory therapists in the United States reaches 132,651. 2006 The National Heart, Lung and Blood Institute (NHLBI) of the U.S. Department of Health and Human Services begins national

awareness and education campaign for COPD. The AARC works with government officials to recruit and train respiratory therapists for disaster response

2007 The first AARC president to serve a 2-year term begins term of office. 2008 First of three conferences held for 2015 and Beyond strategic initiative of the AARC. 2010 The Patient Protection and Affordable Care Act is signed into law by President Barak Obama.

Data from references 1, 3-9, 11-14, and 17.

TABLE 1-2

Major Historical Events in Science, Medicine, and Respiratory Care in the Twentieth and Twenty-First Centuries—cont’d

History of Respiratory Care • CHAPTER 1 7

niques that matured in the twentieth century. As the scientific basis for oxygen therapy, mechanical ventilatory support, and administration of medical aerosols became well established, the need for a health care practitioner to provide these services became apparent. Concurrent with this need was the continu- ing development of specialized cardiopulmonary diagnostic tests and monitoring procedures, which also required health care specialists to perform.

The first health care specialists in the field were oxygen tech- nicians in the 1940s.1,4,5 The first inhalation therapists were oxygen technicians or oxygen orderlies who could haul cylin- ders of oxygen and related equipment around the hospital and set up oxygen tents, masks, and nasal catheters. The develop- ment of positive pressure breathing during World War II for breathing support of high-altitude pilots led to its use as a method to treat pulmonary patients and deliver aerosol medi- cations during the 1950s, expanding the role of the inhalation therapist. Inhalation therapists began to be trained in the 1950s, and formal education programs began in the 1960s.1,4,5 The development of sophisticated mechanical ventilators in the 1960s naturally led to a further expansion in the role of RTs, who soon also found themselves responsible for arterial blood gas and pulmonary function laboratories. In 1974, the designa- tion respiratory therapist became standard, and the RT became the allied health professional primarily concerned with the assessment, diagnostic testing, treatment, education, and care of patients with deficiencies and abnormalities of the cardio- pulmonary system. The historical development of several clini- cal areas of respiratory care is described next, followed by an overview of the establishment of the major professional orga- nizations in the field. The evolution of respiratory care educa- tion is also described.

“dephlogisticated air.”1,4 Before 1773, Scheele performed the laboratory synthesis of oxygen, which he called “fire air”; a general description of his discovery appeared in 1774, and a more thorough description appeared in 1777.1,4 Shortly after the discovery of oxygen, Spallanzani worked out the relation- ship between the consumption of oxygen and tissue respira- tion.1 In 1787, Charles described the relationship between gas temperature and volume now known as Charles’ law.8 In experi- ments performed between 1775 and 1794, Lavoisier showed that oxygen was absorbed by the lungs and that carbon dioxide and water were exhaled.1,4 In 1798, Beddoes began using oxygen to treat various conditions at his Pneumatic Institute in Bristol.1,4

Nineteenth and Early Twentieth Centuries

During the nineteenth century, important advances were made in physics and chemistry related to respiratory physiology. Dalton described his law of partial pressures for a gas mixture in 1801 and his atomic theory in 1808.8 Young in 1805 and de LaPlace in 1806 described the relationship between pressure and surface tension in fluid droplets.8 Gay-Lussac described the relationship between gas pressure and temperature in 1808; in 1811, Avogadro determined that equal volumes of gases at the same temperature and pressure contain the same number of molecules.1,8 In 1831, Graham described his law of diffusion for gases (Graham’s law).8

In 1865, Pasteur advanced his “germ theory” of disease, which held that many diseases are caused by microorganisms.8 Medical advances during this time included the invention of the spirometer and ether anesthesia in 1846, antiseptic techniques in 1865, and vaccines in the 1880s.1,4,7 Koch, a pioneer in bac- teriology, discovered the tubercle bacillus, which causes tuber- culosis, in 1882, and the vibrio bacterium, which causes cholera, in 1883.7 He also developed Koch’s postulates, which are criteria designed to establish a causative relationship between a microbe and a disease. Respiratory physiology also progressed with the measurement in 1837 of blood oxygen and carbon dioxide content, description around 1880 of the respiratory quotient, demonstration in 1885 that carbon dioxide is the major stimu- lant for breathing, and demonstration in 1878 that oxygen partial pressure and blood oxygen content were related.1,4,9 In 1895, Roentgen discovered the x-ray, and the modern field of radiologic imaging sciences was born.8 Pioneering respiratory physiologists of the early twentieth century described oxygen diffusion, oxygen and carbon dioxide transport, the oxyhemo- globin dissociation curve, acid-base balance, and the mechanics of breathing and made other important advances in respiratory physiology (see Table 1-2).

DEVELOPMENT OF THE RESPIRATORY CARE PROFESSION

Clinical Advances in Respiratory Care

The evolution of the respiratory care profession depended in many ways on developments in the various treatment tech-

RULE OF THUMB

When looking for information about the respiratory care profession, the best place to look is the AARC (see www.AARC.org). The AARC’s newly constructed Virtual Museum can be accessed through the AARC Web site.

Oxygen Therapy The therapeutic administration of oxygen first occurred in 1798, and in 1878 Bert showed that lack of oxygen caused hyperventilation. But the physiologic basis and indications for oxygen therapy were not well understood until the twentieth century.1,4 Large-scale production of oxygen was developed by von Linde in 1907. The use of a nasal catheter for oxygen administration was introduced by Lane in the same year.1,4 Oxygen tents were in use in 1910, and an oxygen mask was used to treat combat gas–induced pulmonary edema in 1918.1 In 1920, Hill developed an oxygen tent to treat leg ulcers, and in 1926, Barach introduced a sophisticated oxygen tent for clinical use. Oxygen chambers and whole oxygen rooms were designed.1,4 In 1938, a meter mask was developed by Barach to administer dilute oxygen.1,4 The BLB mask (named for Boothby, Lovelace, and Bulbulian) to administer 80% to 100% oxygen to pilots was

http://www.AARC.org

8 SECTION I • Foundations of Respiratory Care

Mechanical Ventilation Mechanical ventilation refers to the use of a mechanical device to provide ventilatory support for patients. In 1744, Fothergill advocated mouth-to-mouth resuscitation for drowning victims.1,6 During the mid to late 1700s, there was a great deal of interest in resuscitation and additional procedures for car- diopulmonary resuscitation were developed.1,4,6 Positive pres- sure ventilation using a bag-mask system or bellows was suggested. However, the observation that a fatal pneumothorax may result caused this technique to be rejected around 1827.1,4 Interest in negative pressure ventilation developed, and the first negative pressure tank ventilator was described in 1832.6 Other negative pressure ventilators began to appear in the mid-1800s; in 1928, the iron lung was developed by Drinker, an industrial hygienist and faculty member at Harvard University.1 Emerson developed a commercial version of the iron lung that was used extensively during the polio epidemics of the 1930s and 1950s (Figure 1-1).1,12 The chest cuirass negative pressure ventilator was introduced in the early 1900s, and a negative pressure “wrap” ventilator was introduced in the 1950s.13 Other early noninvasive techniques to augment ventilation included the rocking bed (1950) and the pneumobelt (1959).13

Originally, positive pressure ventilators were developed for use during anesthesia and later were altered for use on hospital wards.14 Early positive pressure ventilators included the Drager Pulmotor (1911), the Spiropulsator (1934), the Bennett TV-2P (1948), the Morch Piston Ventilator (1952), and the Bird Mark 7 (1958) (Figure 1-2).1,14 More sophisticated positive pressure volume ventilators were developed in the 1960s and included the Emerson Postoperative Ventilator, MA-1 (Figure 1-3), Eng- strom 300, and Ohio 560.1,14 A new generation of volume ven- tilators appeared in the 1970s that included the Servo 900, Bourns Bear I and II, and MA-II. By the 1980s, microprocessor- controlled ventilators began to appear, led by the Bennett 7200 in 1984; in 1988, the Respironics bilevel positive airway pressure (BiPAP) device was introduced for providing noninvasive posi- tive pressure ventilation in a wide variety of settings.1 During

introduced during World War II and later used on patients.1,4 By the 1940s, oxygen was widely prescribed in hospitals, although there was still no good way to measure blood oxygen levels routinely until the mid-1960s, with the introduction of the Clark electrode, followed by the clinical use of the ear oxim- eter in 1974 and the pulse oximeter in the 1980s.1,4,5 The Camp- bell Ventimask, which allowed the administration of 24%, 28%, 35%, or 40% oxygen, was introduced in 1960, and modern ver- sions of the nasal cannula, simple oxygen mask, partial rebreath- ing mask, and nonrebreathing mask were available by the late 1960s. Portable liquid oxygen systems for long-term oxygen therapy in the home were introduced in the 1970s, and the oxygen concentrator soon followed. Oxygen-conserving devices, including reservoir cannulas, demand pulse oxygen systems, and transtracheal oxygen catheters, were introduced in the 1980s.

The 2000s saw further advances in home oxygen therapy equipment with the introduction of oxygen concentrators used in conjunction with a pressure booster to allow for the transfill- ing of small, portable oxygen cylinders in the home. Smaller, lightweight portable oxygen concentrators were also intro- duced. Both of these advances have greatly enhanced the ability of patients receiving long-term oxygen therapy to ambulate beyond the confines of their home. Furthermore, the National Institutes of Health launched the Long-Term Oxygen Treatment Trial (LOTT) as a randomized trial to explore the benefits of supplemental oxygen in patients with chronic obstructive pulmonary disease (COPD) and only mild resting hypoxemia (SpO2 89% to 93%) or with exercise desaturation.

Aerosol Medications Aerosol therapy is defined as the administration of liquid or powdered aerosol particles via inhalation to achieve a desired therapeutic effect. Bland aerosols (sterile water, saline solutions) or solutions containing pharmacologically active drugs may be administered. In 1802, the use of inhaled Datura leaf fumes, which contain atropine, to treat asthma was described.11 Early use of aerosol medications dates to 1910, when the first use of aerosolized epinephrine was reported. Later, other short-acting bronchodilators such as isoproterenol (1940), isoetharine (1951), metaproterenol (1961), albuterol sulfate (1980), and levalbuterol (2000) were introduced, primarily for the emer- gency treatment of acute asthma attacks.11 In the late 1990s, long-acting bronchodilators—administered twice daily—were introduced for the maintenance treatment of COPD. Oral and injectable steroids were first used in the treatment of asthma in the early 1950s, and the use of aerosolized steroids for the main- tenance of patients with moderate to severe asthma began in the 1970s.11 Newer medications continued to be developed for aerosol administration, including even longer acting broncho- dilators (once every 24 hours), mucolytics, antibiotics, antiin- flammatory agents, and combination drugs such as long-acting bronchodilators and antiinflammatories in a single dose. Along with newer respiratory drugs, newer delivery devices such as dry powder inhalers and innovative designs for small-volume nebu- lizers have been introduced.

FIGURE 1-1 Iron lung patients in a 1950s polio ward. (From the Associated Press and Post-Gazette.com Health, Science and Environment. http://www.post-gazette.com/pg/05094/482468.stm.)

http://Post-Gazette.com

http://www.post-gazette.com/pg/05094/482468.stm

History of Respiratory Care • CHAPTER 1 9

FIGURE 1-2 Bird Mark 7, introduced in 1958 by Bird (A), and Bennett PR-2, introduced in 1963 by Bennett (B), were pneumatically powered, pressure-limited positive pressure ventilators that could provide assist-control ventilation and were used to deliver intermittent positive pressure breathing treatments.

FIGURE 1-3 Bennett MA-1 ventilator, introduced in 1967, played a major role in making mechanical ventilatory support routinely available in intensive care units throughout the world.

the 1990s and early 2000s, new ventilators have continued to be developed, including the Hamilton G5, Servo-i, PB 980, and Drager V500 and VN500 series (see Chapter 45). Between 1970 and 2004, more than 50 new ventilators with various character- istics were introduced for clinical use.15,16

Early mechanical ventilators provided modes for which breaths were delivered according to a preset frequency and

inspiratory time, regardless of any inspiratory effort on the part of the patient (what anesthesiologists of the time called “con- trolled” ventilation). The early Bird and Bennett ventilators invented in the 1950s allowed for initiating inspiration by detecting the patient’ inspiratory effort, called “assist.” This feature was incorporated in later modes that also had preset breath frequency (called assist/control, a term that is anachro- nistic but persistent to this day). The terminology related to modes of ventilation has evolved along with the complexity of ventilator technology (see Chapter 45). In 1967, the addition of positive end expiratory pressure (PEEP) as a mode feature was introduced for use in patients dying from the newly described acute respiratory distress syndrome (ARDS). The use of PEEP helped stabilize and keep alveoli from collapsing at the end of exhalation. Other forms of modern ventilation include inter- mittent mandatory ventilation (IMV), introduced in 1971, fol- lowed by synchronized IMV, in 1975, and mandatory minute volume ventilation in 1977.1,4 Pressure support ventilation and pressure-controlled ventilation were introduced in the 1980s, followed by airway pressure release ventilation and inverse ratio ventilation. In the 1990s, volume support ventilation, pressure- regulated volume control, and adaptive support ventilation were introduced. Automatic tube compensation, proportional assist ventilation, neutrally adjusted ventilatory assist, and other modes of ventilation occurred in the twenty-first century. In fact, there are now hundreds of names of modes of ventilation, making a classification system essential for understanding ven- tilator technology (see Chapter 45).

Because traditional short-term mechanical ventilation, re- gardless of mode, necessitates using an endotracheal tube, there is always the potential for one or more serious complications

10 SECTION I • Foundations of Respiratory Care

(FVC), and in 1948, forced expiratory volume in 1 second (FEV1) was suggested as a measure of obstructive lung disease by Tiffeneau.9

Arterial and venous oxygen and carbon dioxide contents were measured in 1837, and methods to measure blood oxygen and carbon dioxide levels were available in the 1920s. These early methods for measuring blood oxygen, carbon dioxide, and pH were slow and cumbersome. In 1967, the combined pH, Clark, and Severinghaus electrodes produced a rapid and practical blood gas analyzer for routine clinical use.1,4 The ear oximeter was introduced in 1974, and the pulse oximeter was introduced in the 1980s. Sleep medicine became well estab- lished in the 1980s, and polysomnography became a routine clinical test, often performed by RTs.

PROFESSIONAL ORGANIZATIONS AND EVENTS

American Association for Respiratory Care (AARC)

Founded in 1947 in Chicago, the Inhalational Therapy Associa- tion (ITA) was the first professional association for the field of respiratory care.1,4,5 The purpose of the ITA was to provide for professional advancement, foster cooperation with physicians, and advance the knowledge of inhalation therapy through edu- cational activities.5 The ITA provided a forum to discuss the clinical application of oxygen therapy, improve patient care, and advance the art and science of the field.1 There were 59 charter members of the ITA.1 The ITA became the American Associa- tion for Inhalation Therapists (AAIT) in 1954, the American Association for Respiratory Therapy (ARRT) in 1973, and the American Association for Respiratory Care (AARC) in 1982.4,5 By 2014, membership in the AARC had reached 50,000 RTs, RT students, physicians, nurses, and others interested in respiratory care. The AARC also has a formal affiliation with all 50 state respiratory societies (known as Chartered Affiliates), as well as with similar organizations in several foreign countries.17

During the 1980s, the AARC began a major push to intro- duce state licensure for RTs based on the National Board for Respiratory Care (NBRC) credentials.18 As of 2014, 49 states, the District of Columbia, and Puerto Rico have state licensure or some other form of legal credentialing required for the prac- tice of respiratory care. State licensing laws set the minimum educational requirements and the method of determining com- petence to practice. Competency is typically determined by obtaining a passing grade on a credentialing examination (administered by the NBRC) after graduation from an approved training program. State licensing boards also set the number of continuing education credits required to keep a license active.

The stated mission of the AARC is to “encourage and promote professional excellence, advance the science and prac- tice of respiratory care, and serve as an advocate for patients, their families, the public, the profession and the respiratory therapist.”19 The AARC serves as an advocate for the profession to legislative and regulatory bodies, the insurance industry, and

known as ventilator-associated events (VAEs). The most common (but preventable) VAE is an infection known as ventilator-associated pneumonia (VAP). VAP is a deadly and very costly complication of invasive mechanical ventilation that develops when external microorganisms accidentally enter the airway. There has been a concerted effort to try to support in- adequate ventilation noninvasively, by using a nasal or full-face mask, to avoid the need for endotracheal intubation. When noninvasive ventilation does not work and endotracheal or tra- cheostomy tubes are necessary, RTs must be constantly vigilant in their efforts to prevent VAP and all other VAEs.

Airway Management Airway management refers to the use of various techniques and devices to establish or maintain a functional air passageway. Tracheotomies may have been performed to relieve airway obstruction in 1500 bc.6 Galen, the Greek anatomist, described a tracheotomy and laryngeal intubation in 160 ad. Vesalius, the anatomist, described a tracheotomy in an animal in 1555.1,6 In 1667, Hooke described a tracheotomy and use of a bellows for ventilation.6 In 1776, tracheal intubation was suggested for resuscitation.6 In 1880, MacEwen reported success with oral endotracheal intubation in patients.6 O’Dwyer further described the technique for endotracheal tube placement. By 1887, Fell had developed a bellows–endotracheal tube system for mechan- ical ventilation, and this system was used in 1900 to deliver anesthesia.6

In 1913, the laryngoscope was introduced by Jackson. Addi- tional early laryngoscopes were designed by Kirstein, Janeway, and others.1,6 Endotracheal intubation for anesthesia adminis- tration was firmly established by World War I. After the war, Magill introduced the use of soft rubber endotracheal tubes, and this made blind nasal intubation possible, as described by Magill in 1930.6 In 1938, Haight advocated nasotracheal suc- tioning for secretion removal, and in 1941, Murphy described the ideal suction catheter, which included side holes known as “Murphy eyes.”6 The double-lumen Carlen tube for indepen- dent lung ventilation was introduced in 1940, followed by a double-lumen tube developed by Robertshaw in 1962. Damage to the trachea by the tube cuff was reduced with the introduc- tion of low-pressure cuffs in the 1970s.6

Cardiopulmonary Diagnostics and Pulmonary Function Testing Pulmonary function testing refers to a wide range of diagnos- tic procedures to measure and evaluate lung function. The volume of air that can be inhaled in a single deep breath was first measured in 1679, and the measurement of the lung’s residual volume was first performed in 1800.9 In 1846, Hutchin- son developed a water seal spirometer, with which he measured the vital capacity of more than 2000 subjects.9,17 Hutchinson observed the relationship between height and lung volume and that vital capacity decreases with age, obesity, and lung disease. Hering and Breuer described the effects of lung inflation and deflation on breathing—the Hering-Breuer reflex—in 1868.4 In 1919, Strohl suggested the use of forced vital capacity

History of Respiratory Care • CHAPTER 1 11

Directors, including Specialty Section chairpersons, are elected directly by the AARC membership. The AARC Board of Direc- tors meets three times per year to conduct the official business of the association.

Each year, the incoming AARC president assigns interested members to chair or serve on more than 50 standing or tempo- rary AARC committees. Many of the initiatives of the AARC are undertaken and eventually brought to completion through committee work. The AARC Board of Directors also receives input from each of the 50 Chartered Affiliates that constitute the House of Delegates. Each Chartered Affiliate elects two of their members to represent the interests of their state affiliate in the meetings of the House of Delegates. The 100 delegates elect their own leaders so that they can conduct the business of the House of Delegates. The House of Delegates meets twice per year. The efforts of the Board of Directors, the House of Dele- gates, and the numerous committees of the AARC are sup- ported by a staff of more than 35 employees of the AARC who work full time in the association’s executive offices, which are located in Irving, Texas.

Many volunteers who have been elected to the AARC or House of Delegates leadership positions or have been asked to chair important committees started by volunteering at the affili- ate level. Student members of the AARC are always welcomed as volunteers, especially at the affiliate level. Student members of the AARC have access to a wide array of resources that can greatly enhance the experience of becoming a professional RT.

Respiratory Care Week

In November 1982, President Reagan signed a proclamation declaring the third week of each October as National Respira- tory Care Week. Since then, Respiratory Care Week has become a yearly event to promote lung awareness and the work of RTs in all care settings. RTs (and students) around the United States use Respiratory Care Week to celebrate their profession and dedication to high-quality patient care. Many respiratory care departments use the opportunity to conduct special events in their hospitals to help raise awareness of the vital role the RT plays as a member of the health care team. Other departments plan community activities to help the public understand the importance of good lung health and the role RTs play in diag- nosing and treating breathing disorders. Respiratory Care Week is also an excellent opportunity for respiratory therapy students

the general public. To fulfill its mission, the AARC sponsors many continuing educational activities, including international meetings, conferences and seminars, publications, and a sophis- ticated Web site (see www.AARC.org).18 In addition to the monthly science journal Respiratory Care, the AARC publishes the monthly news magazine AARC Times and numerous elec- tronic newsletters. In the fall of each year, the AARC also spon- sors the International Respiratory Congress, the largest respiratory care scientific meeting in the world. Finally, in an effort to ensure that the unique practice interests of AARC members are addressed (e.g., neonatal/pediatrics, adult acute care, management, home care, diagnostics), members are invited to join one or more of 10 Specialty Sections (Box 1-1) within the AARC, designed to facilitate networking and the free exchange of ideas.

The leadership and direction of the AARC is provided by a Board of Directors, which comprises members who volunteer their time and services. The executive officers of the Board of Directors include the president, immediate past-president, president-elect, vice-president for internal affairs, vice-president for external affairs, and secretary-treasurer. The remainder of the Board of Directors consists of a minimum of six members- at-large plus the chairpersons of the Specialty Sections having at least 1000 members. At the present time, 6 of the 10 Specialty Sections meet this requirement. All members of the Board of

MINI CLINI Preparing a Presentation for Respiratory Care Week

PROBLEM: You are a staff therapist in a 300-bed hospital. Your supervisor asks you to prepare a 20-minute presentation on the history and development of the respiratory care profes- sion to be presented at the department’s annual Respiratory Care Week luncheon. How would you gather the information needed and develop your presentation?

SOLUTIONS: First, review this chapter to get an overview of the history and development of the respiratory care profession. You may also want to read one or two of the supplemental references that are cited. Next, go to the AARC Web site (see www.AARC.org) and review the “Resources” and “Site Map” sections, which list many helpful resources. You should be able to find sections on “The History of the AARC,” “Strategic Plan of the AARC,” “Position Statements,” and “White Papers.” There will also be a portal to AARC’s Virtual Museum. You should also find a section on Respiratory Care Week. Review the mate- rial that the AARC has provided and develop an outline for your presentation. Your outline may include a brief overview of the history of science and medicine, the development of the respiratory care profession, and the future of respiratory care in the twenty-first century. After you have your outline, decide on your delivery method. PowerPoint slides are easy to make and use. If you choose to do a PowerPoint presentation, a good rule of thumb is about one slide per minute, so you would need about 20 slides. Using your outline, begin to develop your presentation.

Box 1-1 AARC Specialty Sections

Adult Acute Care Continuing Care/Rehabilitation Diagnostics Education Home Care Long-Term Care Management Neonatal/Pediatrics Sleep Surface and Air Transport

http://www.AARC.org

12 SECTION I • Foundations of Respiratory Care

student members of the AARC. The ARCF awards and scholar- ships are presented at the awards ceremony held in conjunction with the annual International Respiratory Congress of the AARC. Respiratory therapy students who are interested in applying for an ARCF scholarship should visit the ARCF Web site (see www.arcfoundation.org) to learn more about this great opportunity.

International Council for Respiratory Care (ICRC)

The International Council for Respiratory Care (ICRC) is an AARC-sponsored organization dedicated to the globalization of high-quality respiratory care. As mentioned previously, having formally trained professionals working in a dedicated depart- ment to assume full responsibility for providing respiratory care under medical direction was a uniquely North American phe- nomenon (i.e., the United States and Canada). However, during the 1970s and 1980s, when many foreign physicians came to the United States to study, they became aware of what an RT was and the important role RTs played in hospitals nationwide. When these physicians returned to their native countries, they wished to have their own specialized team able to provide the same level of high-quality respiratory care. However, because the health care delivery system is structured differently in each country, the specially trained teams were most often nurses, physicians, or physical therapists, not RTs.

Formed in 1991, the ICRC (in close collaboration with the International Committee of the AARC) began to offer fellow- ships to interested foreign clinicians that provide the opportu- nity to visit the United States for 2 weeks before the annual International Respiratory Congress to observe how respiratory care is practiced in various settings. The idea is to allow these international fellows to observe how the various components of respiratory care are practiced in several cities. The interna- tional fellows can then take back to their home countries ideas and practices that can be integrated into their unique health care delivery systems. The program has been so successful that many countries (e.g., Mexico, Costa Rica, Taiwan) are starting to establish respiratory therapy training programs similar to the American model. As of 2014, participants in this program have included 142 international fellows from 54 countries.

National Board for Respiratory Care (NBRC)

The credentialing body for registered RTs began in 1960 as the American Registry of Inhalation Therapists (to test and creden- tial registered therapists), and a certification board was estab- lished in 1968 to certify technicians.1,4 These two groups merged in 1974 as the National Board for Respiratory Therapy, which became the National Board for Respiratory Care (NBRC) in 1983.1,4 Also in 1983, the National Board for Cardiopulmonary Technologists joined the NBRC, and the credentialing examina- tions for pulmonary function technology were brought in under the respiratory care umbrella.1,4 Currently, there are two levels of clinical practice credentialing examinations in the United States: the certified respiratory therapist (CRT) and the

to become ambassadors of the profession to the rest of the student body. Some respiratory therapy classes conduct free breathing tests on campus, in shopping malls, or in community centers.

Fellow of the American Association for Respiratory Care (FAARC)

In any given profession, there are always individuals who go above and beyond what is expected of the average practitioner. To recognize RTs and physician members who have achieved such distinction, in 1998, the AARC established the Fellow of the American Association for Respiratory Care (FAARC) award. To be considered for FAARC status, nominees must be either a registered RT or a licensed physician and have a minimum of 10 consecutive years of membership in the AARC. Of greater importance, nominees for FAARC demonstrate superior achievement, not only in patient care and research, but as a volunteer serving the profession. Individuals selected to receive this prestigious award are so noted by having “FAARC” appear after their name following educational degrees and credentials.

Board of Medical Advisors (BOMA)

Because RTs can practice only under medical direction, it is essential that the AARC leadership receive formal input from physicians on all matters and questions pertaining to patient care. The Board of Medical Advisors (BOMA) is the group of physicians who provide this valuable input. The BOMA com- prises approximately 18 physicians who are appointed by their respective professional medical associations (e.g., American College of Chest Physicians, American Thoracic Society, Society for Critical Care Medicine) to serve this cause voluntarily. The BOMA meets annually, but the chairperson of the BOMA attends all meetings of the AARC Board of Directors. Individual members of the BOMA are assigned by the AARC president to serve as a medical liaison to each of the 10 Specialty Sections of the AARC and to standing committees. Effective medical direc- tion at the hospital level is indispensable for the practice of safe, high-quality respiratory care.

American Respiratory Care Foundation (ARCF)

Established in 1970 by the AARC, the American Respiratory Care Foundation (ARCF) is a not-for-profit charitable founda- tion that helps promote and further the mission of the AARC. Commonly known as the Foundation, the ARCF collects and manages contributions from individuals, corporations, and other foundations to recognize individual achievements of excellence in clinical practice, chronic disease management, public respiratory health, scientific research, and literary excel- lence. A current focus of the ARCF is to promote the attain- ment of more advanced training among RTs to advance scientific inquiry in respiratory care. The ARCF also provides research grants to establish the scientific basis of respiratory care further. Finally, the ARCF oversees and distributes numer- ous scholarships for respiratory therapy students who are

http://www.arcfoundation.org

History of Respiratory Care • CHAPTER 1 13

degrees. There are approximately 300 associate, 50 baccalaure- ate, and 3 graduate-level degree programs in the United States; 19 programs in Canada; and a handful of respiratory care edu- cational programs in Mexico, South America, Japan, India, Taiwan, and other countries.23,24

registered respiratory therapist (RRT) (see www.NBRC.org). The NBRC also offers several specialty credentialing examina- tions for RRTs who satisfy additional requirements through experience in a specialized area of practice.

RULE OF THUMB

For requirements for testing, examination schedules, study guides, and requirements for maintaining your CRT or RRT credential, check with the NBRC (see www.NBRC.org).

In 1998, the NBRC renamed the lower level certified respira- tory therapist (CRT, or entry-level respiratory therapist); the advanced level remained registered respiratory therapist (RRT, or advanced-level respiratory therapist).20 The NBRC began offering specialty examinations for pulmonary function tech- nology in 1984 and neonatal/pediatrics in 1991. Because of the proliferation of new technology and innovative medical prac- tice, additional specialty credentialing examinations have been proposed in the areas of adult acute care and polysomnography.

Committee on Accreditation for Respiratory Care (CoARC)

In 1956, the first guidelines for respiratory care educational programs were published, followed by the formation of the Board of Schools to accredit programs in 1963.1 The Board of Schools was replaced by the Joint Review Committee for Inhala- tion Therapy Education (JRCITE) in 1970, led by its first chair- man, Helmholtz.1,4 The JRCITE became the Joint Review Committee for Respiratory Therapy Education (JRCRTE) in 1977 and then the Committee on Accreditation for Respira- tory Care (CoARC) in 1996 (see www.COARC.com).4 Today, respiratory care educational programs in the United States are accredited by the CoARC in collaboration with the Association of Specialized and Professional Accreditors.21,22

RESPIRATORY CARE EDUCATION

The first formal educational course in inhalation therapy was offered in Chicago in 1950.1 In the 1960s, numerous schools were developed to prepare students to become RTs. Early pro- grams concentrated on teaching students the proper applica- tion of oxygen therapy, oxygen delivery systems, humidifiers, and nebulizers and the use of various intermittent positive pres- sure breathing (IPPB) devices. The advent of sophisticated criti- cal care ventilators, blood gas analyzers, and monitoring devices in the 1960s and 1970s helped propel the RT into the role of cardiopulmonary technology expert.

Respiratory care educational programs in the United States are offered at technical and community colleges, 4-year colleges, and universities. These programs are designed to prepare com- petent RTs to care for patients. The minimum degree required to become an RT has traditionally been an associate degree.21 However, many associate degree graduates see great opportu- nity in pursuing their bachelor’s degree and some even higher

RULE OF THUMB

Jobs in management, education, research, or advanced clinical practice may require bachelor or graduate level educational preparation.

The AARC completed a Delphi study and held two impor- tant Education Consensus Conferences in the early 1990s to assess the status of respiratory care education and recommend future direction for the field.25-28 The first conference suggested that major trends affecting the field were advances in technol- ogy; demographic trends and the aging of the population; a need to provide better assessment, outcome evaluation, problem solving, and analytic skills; use of protocol-based care; and the need to increase the focus on patient education, prevention, and wellness, to include tobacco education and smoking cessation.27 The conference concluded that the curriculum should encom- pass a broad scope of clinical practice, a significant arts and science component, emphasis on communication skills, and a minimum of an associate degree to enter practice. The second Educational Consensus Conference, held in the fall of 1993, focused on strategies to implement the recommendations made at the first conference.28 Both conferences identified the need for more baccalaureate and graduate education in respiratory care. The view that programs should prepare students better in the areas of patient assessment, care plan development, proto- cols, disease management, pulmonary rehabilitation, research, and geriatrics/gerontology became well accepted.29,30

In 1997, Mishoe and MacIntyre31 described a profession as “a calling or vocation requiring specialized knowledge, meth- ods, and skills as well as preparation, in an institution of higher learning, in the scholarly, scientific, and historical principles underlying such methods and skills.” These authors noted that professional roles are different and more complex than techni- cal roles, which are oriented to performing specific tasks as ordered by the physician. Examples of professional roles in respiratory care include patient assessment and care plan devel- opment, ventilator management, disease management, pulmo- nary rehabilitation, and respiratory care consulting services. Technical roles may include basic task performance (e.g., oxygen, aerosol therapy, bronchial hygiene), routine diagnostic testing (e.g., electrocardiography, phlebotomy), and other rou- tine tasks in which little or no assessment is required and deci- sions are limited to device selection and fine-tuning therapy.31 In professional practice, the therapist may function as a physi- cian extender who applies protocols or guidelines.31 Examples include making protocol-based ventilator adjustments, apply- ing assessment-based care plans, and performance of advanced procedures such as arterial line insertion and management,

http://www.NBRC.org

http://www.COARC.com

14 SECTION I • Foundations of Respiratory Care

intubation and extubation of patients, application of ventilator weaning protocols, and application of advanced cardiopulmo- nary technologies (e.g., extracorporeal membrane oxygenation, nitric oxide therapy, aortic balloon pumps).

According to Mishoe and MacIntyre,31 economic, educa- tional, and institutional forces may limit respiratory care in certain settings to a task-oriented, technical role. There are many opportunities, however, for the RT to function as a physi- cian extender, in a role similar to that of the physician assistant. Working under the supervision of a physician, the physician assistant may perform many medical procedures that might otherwise be performed by a physician. In a similar way, the respiratory physician extender could improve the quality of care while controlling costs and minimizing unnecessary care. Many authorities believe that the critical thinking, assess- ment, problem-solving, and decision-making skills needed for advanced practice in the twenty-first century require advanced levels of education.31

In 1998, Hess32 observed that a task orientation has coin- cided with a pattern of overordering and misallocation of respi- ratory care services. Therapist-driven protocols and the increasing use of the RT as a consultant may allow physicians to order protocols as opposed to specific therapies. The thera- pist assesses the patient, develops a care plan, implements the plan, and evaluates and modifies care as appropriate.32 Protocol- based care has been shown to be safe and effective, while reduc- ing misallocation of care and helping to control costs.33,34 Acceptance by physicians of RTs as consultants depends on the professionalism, education, and skill of the therapists at the bedside.32

In 2001, a report of the Conference Proceedings on Evidence- Based Medicine in Respiratory Care was published.34 Evidence- based practice requires careful examination of the evidence for diagnosis, treatment, prognosis, and, in turn, practice using a formal set of rules.35 The best evidence is used for clinical deci- sion making, which should lead to optimal respiratory care.35 Evidence-based practice has been advocated for all respiratory care delivered.

In 2002, the AARC, NBRC, and CoARC published their “Tripartite Statements of Support,” which suggested that all RTs seek and obtain the RRT credential.36 An AARC white paper followed in 2003, which encouraged the continuing development of baccalaureate and graduate education in respiratory care.37

FUTURE OF RESPIRATORY CARE

In 2001, David Pierson, MD, a prominent pulmonary physician and one of the many physician supporters of RTs, set out to describe the future of respiratory care.38 Among other respon- sibilities, Pierson predicted a much greater use of patient assess- ment and protocols in chronic disease state management in all clinical settings. He also envisioned a more active role for RTs in palliative and end-of-life care, increasing emphasis on smoking COPD. Pierson also predicted an increase in the use of RTs acting as coordinators and caregivers in home care.

MINI CLINI Educational Program Advisory Committee

PROBLEM: You are asked to serve on your respiratory care educational program advisory committee. The committee wants to know how respiratory care education has developed and where it should be headed. You are appointed as a member of a subcommittee to research these issues. What should you do?

SOLUTIONS: You may want to read the sections in this chapter that cover the history and development of respiratory care education to get an overview. You may wish to obtain copies of some of the reference materials that are cited. Items that may be helpful are the AARC Delphi Study,26 reports of the AARC education consensus conferences,27,28 and articles about the future of respiratory care. 30-33,37-41 You may wish to review the AARC strategic plan (see www.AARC.org) and AARC statements regarding respiratory care education and credentialing.11,40,41 By reviewing these materials, you should be well-prepared to discuss the future direction of your educa- tional program.

2015 and Beyond

In 2005, recognizing that many national politicians were begin- ning to call for an overhaul of the U.S. health care delivery system, the AARC Board of Directors began to think strategi- cally, which led to the formation in 2007 of a special task force called “2015 and Beyond.” The task force was charged with the envisioning potential new roles and responsibilities of RTs by 2015 and beyond. The leadership of the task force decided to convene three strategic conferences to answer the following five key questions about the profession39: 1. How will most patients receive health care services in the

future? 2. How will respiratory care services be provided? 3. What new knowledge, skills, and attributes will RTs need to

be able to provide care that is safe, efficacious, and cost- effective in 2015?

4. What education and credentialing systems will be needed to ensure RTs acquire the new knowledge, skills, and attributes?

5. How should the profession transition from traditional prac- tice to the newer system without adversely affecting the exist- ing workforce? The initial 2015 and Beyond conference was held in the

spring of 2008, and a consensus was reached that there were likely to be40: • Eleven significant changes in how health care would be deliv-

ered (Box 1-2) • Nine changes likely to occur in the U.S. health care workforce

(Box 1-3) • Five expected changes in how respiratory care services would

be provided (Box 1-4)

http://www.AARC.org

History of Respiratory Care • CHAPTER 1 15

From Bunch D: 2015 and beyond. AARC Times 33:50, 2009.

Box 1-2 2015 and Beyond: 11 Predicted Changes in Health Care

1. More patients will receive diagnoses of chronic and acute respiratory diseases.

2. Cost increases will continue to grow, creating challenges for all payers of health care services.

3. Personal electronic health records will become more widely used in all health care settings.

4. Health care consumers will pay a greater percentage of costs but will have new options for obtaining care.

5. Retail storefront health care and the Internet will stimulate consumer-driven cost competition.

6. Acute care hospitals will continue to provide episodic, cutting-edge respiratory life support technology; however, subacute and home care providers will continue to play important roles.

7. Subacute and long-term care will increase in volume and complexity.

8. The disconnect between prevention and acute care treatment will lessen but not disappear.

9. All health care delivery will undergo increasing scrutiny for quality that will be linked to reimbursement under a new system called Pay for Performance.

10. New models for the delivery of health care will emerge, such as Accountable Care Organizations and Medical Home.

11. Reimbursement and costs will influence the development and success of these new models.

Box 1-3 2015 and Beyond: Nine Likely Changes in the Health Care Workforce

1. There will be national and regional shortages of certain providers in all sectors of health care.

2. There will be long-term competition for all health care professionals.

3. The clinical demand will increase at a faster pace than the workforce will be able to expand.

4. The imbalance in jobs and available workforce will be aggravated by the retirement of current providers.

5. Brutal work hours requiring 24/7 staffing will dissuade many individuals from pursuing health care careers.

6. Shortages of teaching faculty and a limited number of training programs will limit the number of entrants into allied health professional schools.

7. Traditional clinical sites will be limited in number and variety and will need to be expanded to alternative sites, such as physicians’ offices and patients’ homes.

8. Newer educational technologic resources will challenge traditional education.

9. Health care delivery organizations will find reinvestment in education an attractive way to secure competent and loyal workers.

From Bunch D: 2015 and beyond. AARC Times 33:50, 2009.

Box 1-4 2015 and Beyond: Five Changes Expected in Respiratory Care

1. The science of respiratory care will continue to evolve and increase in complexity, and clinical decisions will increasingly be data-driven.

2. Patient care teams will become the standard throughout health care.

3. New respiratory life-support technologies will be developed and deployed.

4. Reimbursement changes will be the most important impetus for more recognition of the importance of health promotion and disease state management.

5. Concerns over public health issues and military and disaster response will continue and require new skill sets for all respiratory care providers.

From Bunch D: 2015 and beyond. AARC Times 33:50, 2009.

Box 1-5 Seven Major Competencies Required by Respiratory Therapists by 2015

1. Diagnostics 2. Chronic disease state management 3. Evidence-based medicine and respiratory care protocols 4. Patient assessment 5. Leadership 6. Emergency and critical care 7. Therapeutics

From Barnes TA, Gale DD, Kacmarek RM, et al: Competencies needed by graduate respiratory therapists in 2015 and beyond. Respir Care 55:601, 2010.

In the words of one conference organizer, “the take home message was that indeed the scope and depth of respiratory care practice will increase by 2015.”39 The second conference was held in the spring of 2009 and built on the findings of the 2008 conference by identifying the competencies needed by graduate RTs and the educational content and curriculum that would be needed to practice in 2015 and beyond. Conference participants agreed that there would be seven major competencies (Box 1-5) that future RTs would need to practice effectively by 2015.40,41 The third conference was held in the summer of 2010 to deter- mine how the educational programs for entry-level RTs would have to be structured to accomplish the seven major competen- cies identified during the 2009 conference. The recommenda- tions of the third conference were published in 2011.42

Although the respiratory care profession is undergoing sub- stantial change, there will be a continuing demand for respira- tory care services well into the future because of advances in treatment and technology, increases in the general population, and increases in the elderly population (the baby boomers). A growing population will result in increases in asthma, COPD, and other chronic respiratory diseases. There will also be a continuing demand for controlling costs and ensuring that care

16 SECTION I • Foundations of Respiratory Care

provided is evidence-based, safe, and effective. Respiratory care will need to be provided using carefully designed protocols to ensure that patients get the appropriate care at the right time and that unnecessary care is reduced or eliminated. Aggressive steps to prevent disease and control the cost of chronic respira- tory disease will be essential. Effective smoking cessation and tobacco education programs and aggressive disease manage- ment and pulmonary rehabilitation for patients with moderate to severe asthma, COPD, and other chronic respiratory disease will continue to be needed.

As exemplified by the 2015 and Beyond project, the knowl- edge, skills, and attributes needed by RTs will continue to expand, and it will become increasingly difficult to prepare RTs for expanded practice within the credit hour limitations of many existing programs. To alleviate this situation, associate degree programs may develop articulation agreements with 4-year colleges and universities to allow their graduates to com- plete the bachelor degree in respiratory care without leaving their home campus; distance education technology will play an important role and allow this to occur at minimal cost.

Bachelor degree programs often seek to provide students with a foundation for leadership in the profession in the areas of management, supervision, research, education, or clinical specialty areas. To meet the leadership needs of the profession, some baccalaureate programs have already implemented post- baccalaureate certificates or master degree programs. Clinical areas in which more graduate education programs could be beneficial include critical care, cardiopulmonary diagnostics, clinical research, sleep medicine, rehabilitation, and preparation as a pulmonary physician assistant. There also will be an increas- ing demand for RTs with master and doctoral degrees to serve as university faculty, educators, and researchers.

◗ Use of aerosolized medications for the treatment of asthma began in 1910, with numerous new drugs being developed in the twentieth century and continuing up to the present.

◗ Mechanical ventilation was explored in the 1800s. In 1928, Drinker developed his iron lung; this was followed by the Emerson iron lung in the 1930s, which was used extensively during the polio epidemics of the 1940s and 1950s, and the modern critical care ventilator, which became available in the 1960s.

◗ The ITA was founded in 1947, becoming the AAIT in 1954, the AART in 1973, and the AARC in 1982.

◗ The AARC now has 10 Specialty Sections to provide resources to members based on where they are employed and practice.

◗ The ARCF offers many scholarships and grants to respiratory therapy students and is promoting advanced training for RTs.

◗ Although originally found only in the United States and Canada, the practice of respiratory therapy is quickly expanding around the world.

◗ Respiratory Care Week is a yearly event to promote the profession and raise awareness of the importance of good lung health.

◗ In the future, there will be an increase in demand for respiratory care because of advances in treatment and technology; increases in and aging of the population; and increases in the number of patients with asthma, COPD, and other cardiopulmonary diseases.

The RT of the future will be focused on patient assessment, care plan development, protocol administration, disease man- agement and rehabilitation, and patient and family education, to include tobacco education and smoking cessation.

References

1. Ward JJ, Helmholtz HF: Roots of the respiratory care profession. In Burton GG, Hodgkin JE, Ward JJ, editors: Respiratory care: a guide to clinical prac- tice, ed 4, Philadelphia, 1997, Lippincott.

2. American Association for Respiratory Care: Definition of respiratory care. <http://www.aarc.org/resources/position_statements/defin.html>, Decem- ber 2006 (Accessed October 5, 2014.)

3. Dubbs WH: AARC’s 2009 human resources survey. AARC Times 33, 2009. 4. Smith GA: Respiratory care: evolution of a profession, Lenexa, KS, 1989, AMP. 5. Weilacher RR: History of the respiratory care profession. In Hess DR,

MacIntyre NR, Mishoe SC, et al, editors: Respiratory care: principles and practice, Philadelphia, 2002, Saunders.

6. Stoller JK: The history of intubation, tracheotomy and airway appliances. Respir Care 44:595, 1999.

7. Medicine, history of. Encyclopaedia Britannica Premium Service. <http:// www.britannica.com/eb/article-9110313>, 2006 (Accessed October 5, 2014.)

8. Verma S: The little book of scientific principles, theories and things, New York, 2005, Sterling.

9. Cotes JE: Lung function assessment and application in medicine, ed 4, Oxford, 1979, Blackwell Scientific.

10. Stoller JK, Panos R, Krachman S, et al: Oxygen therapy for patients with COPD: evidence for current therapy and the Long-term Oxygen Treatment Trial (LOTT). Chest 138:179, 2010.

SUMMARY CHECKLIST

◗ RTs apply scientific principles to prevent, identify, and treat acute or chronic dysfunction of the cardiopulmonary system.

◗ Respiratory care includes the assessment, treatment, management, control, diagnostic evaluation, education, and care of patients with deficiencies and abnormalities of the cardiopulmonary system.

◗ The AARC is the professional association for the profession.

◗ RTs work under the direction of a physician who is specially trained in pulmonary medicine, anesthesiology, and critical care medicine.

◗ The NBRC, the credentialing board for RTs, was founded in 1974. The American Registry of Inhalation Therapists was founded in 1960.

◗ The CoARC accredits respiratory care educational programs. The first Board of Schools was established in 1963.

◗ As the physiologic basis for oxygen therapy became understood, use of oxygen to treat respiratory disease became established by the 1920s, and oxygen was used routinely in hospitals by the 1940s.

http://www.aarc.org/resources/position_statements/defin.html

http://www.britannica.com/eb/article-9110313

History of Respiratory Care • CHAPTER 1 17

28. American Association for Respiratory Care: An action agenda: proceedings of the Second National Consensus Conference on Respiratory Care Education, Dallas, 1993, AARC.

29. Meredith RL, Pilbeam SP, Stoller JK: Is our educational system adequately preparing respiratory care practitioners for therapist-driven protocols? (editorial). Respir Care 39:709, 1994.

30. Kester L, Stoller JK: Respiratory care education: current issues and future challenges (editorial). Respir Care 41:98, 1996.

31. Mishoe SC, MacIntyre NR: Expanding professional roles for respiratory care practitioners. Respir Care 42:71, 1997.

32. Hess DR: Professionalism, respiratory care practice and physician accep- tance of a respiratory care consult service (editorial). Respir Care 43:546, 1998.

33. Stoller JK, Mascha EJ, et al: Randomized controlled trial of physician- directed versus respiratory therapy consult service-directed respiratory care to adult non-ICU inpatients. Am J Respir Crit Care Med 158:1068, 1998.

34. Mishoe SC, Hess DR: Forward: evidence-based medicine in respiratory care. Respir Care 46:1200, 2001.

35. Montori VM, Guyatt GH: What is evidence-based medicine and why should it be practiced? Respir Care 46:1201, 2001.

36. American Association for Respiratory Care: Respiratory care: advancement of the profession tripartite statements of support. <http://www.aarc.org/ resources/cpgs_guidelines_statements/>, (Accessed April 4, 2007.)

37. American Association for Respiratory Care, Barnes TA, Black CP, et al: A white paper from the AARC Steering Committee of the Coalition for Bac- calaureate and Graduate Respiratory Therapy Education: development of baccalaureate and graduate degrees in respiratory care. Respir Care Educ Annu 12:29, 2003.

38. Pierson DJ: The future of respiratory care. Respir Care 46:705, 2001. 39. Bunch D: 2015 and beyond. AARC Times 33:50, 2009. 40. Kacmarek RM, Durbin CG, Barnes TA, et al: Creating a vision for respira-

tory care in 2015 and beyond. Respir Care 54:375, 2009. 41. Barnes TA, Gale DD, Kacmarek RM, et al: Competencies needed by gradu-

ate respiratory therapists in 2015 and beyond. Respir Care 55:601, 2010. 42. Barnes TA, Kacmarek RM, Kageler WV, et al: Transitioning the respiratory

therapy workforce for 2015 and beyond. Respir Care 56:2011.

11. Rau JL: Respiratory care pharmacology, ed 5, St Louis, 1998, Mosby. 12. Branson RD: A tribute to John H Emerson. Respir Care 43:567, 1998. 13. Hill NS: Use of negative pressure ventilation, rocking beds and pneumo-

belts. Respir Care 39:532, 1994. 14. Mushin WW, Rendell-Baker L, Thompson PW, et al: Automatic ventilation

of the lungs, ed 3, Oxford, 1980, Blackwell Scientific, pp 184–249. 15. Chatburn RL: Mechanical ventilators. In Branson RD, Hess DR, Chatburn

RL, editors: Respiratory therapy equipment, ed 2, Philadelphia, 1999, Lippincott Williams & Wilkins, pp 395–525.

16. Cairo JM, Pilbeam SP: Mosby’s respiratory care equipment, ed 7, St. Louis, 2004, Mosby.

17. Petty TL: John Hutchinson’s mysterious machine revisited. Chest 121:219S, 2002.

18. American Association for Respiratory Care: Member services. <www.aarc .org/member_services>, (Accessed October 10, 2014.)

19. American Association for Care: Strategic plan. <www.aarc.org/members _area/resources/strategic.asp>, (Accessed October 10, 2014.)

20. Wilson BG: Delivering “the promise.” NBRC Horizons 25:1, 3, 5, 1999. 21. Commission on Accreditation of Allied Health Education Programs: Stan-

dards and guidelines for the profession of respiratory care, Bedford, TX, 2003, Committee on Accreditation for Respiratory Care.

22. Committee on Accreditation for Respiratory Care: Respiratory care accredi- tation handbook, Bedford, TX, 2001, Committee on Accreditation for Respi- ratory Care.

23. American Association for Respiratory Care: Accredited programs. <http:// www.aarc.org/education/accredited_programs/>, (Accessed October 10, 2014.)

24. Canadian Society for Respiratory Therapy: Education: respiratory therapy programs approved by a CSRC. <http://www.csrt.com/en/coarte/index.asp>, (Accessed October 10, 2014.)

25. O’Daniel C, Cullen DL, Douce FH, et al: The future educational needs of respiratory care practitioners: a Delphi study. Respir Care 37:65, 1992.

26. Douce HF: A critical analysis of respiratory care scope of practice and education: past, present, and future. In American Association for Respiratory Care: Delineating the educational direction for the future respiratory care practitioner: proceedings of a National Consensus Conference on Respiratory Care Education, Dallas, 1992, AARC.

27. American Association for Respiratory Care: Delineating the educational direction for the future respiratory care practitioner: proceedings of a National Consensus Conference on Respiratory Care Education, Dallas, 1992, AARC.

http://www.aarc.org/member_services

http://www.aarc.org/members_area/resources/strategic.asp

http://www.aarc.org/education/accredited_programs/

http://www.csrt.com/en/coarte/index.asp

http://www.aarc.org/resources/cpgs_guidelines_statements/

C H A P T E R 2

Delivering Evidence-Based Respiratory Care

JAMES K. STOLLER AND ARIEL M. MODRYKAMIEN

CHAPTER OUTLINE

Elements of a Hospital-Based Respiratory Care Program: Roles Supporting Quality Care Medical Direction Respiratory Therapists Designations and Credentials of Respiratory

Therapists

Professionalism Technical Direction Respiratory Care Protocols

Evidence-Based Medicine Summary Checklist

KEY TERMS

algorithms Committee on Accreditation for

Respiratory Care (CoARC) evidence-based medicine The Joint Commission (TJC)

misallocation National Board for Respiratory Care

(NBRC) performance improvement

quality respiratory care protocols respiratory therapy consult service therapist-driven protocols

Q uality is defined as a characteristic reflecting a high degree of excellence, fineness, or grade. Ruskin, a nineteenth-century British author, stated, “Quality is never an accident. It is always the result of intelligent effort.” Conclusions drawn from the assessment of quality are only temporary because the components of quality are constantly changing. Specifically, quality, as applied to the practice of respi- ratory care, has many dimensions. It encompasses the people who administer the respiratory care, the equipment used, and the manner in which the care is provided. Determining the quality of services provided by a respiratory care department requires intelligent efforts to establish guidelines for delivering high-quality care and a method for monitoring the care. The conclusions about how respiratory care has been delivered

change as clinical practice and expectations change. In the current cost-attentive era of health care, quality can be chal- lenged by pressures to minimize cost, making the measurement and monitoring of quality even more important. There is a new emphasis on the value of the care that is provided, where value is defined as quality/cost. The higher the quality and the lower the cost, the higher the value will be of the care delivered.

This chapter reviews systems for delivering respiratory care and the evidence that supports providing high-quality respira- tory care. In particular, we review the elements of a hospital- based respiratory care program, focusing on medical direction, practitioners, and technical direction. With the goal of high quality being the competent delivery of care that is appropriate, we then discuss respiratory care protocols as an important way

CHAPTER OBJECTIVES

After reading this chapter you will be able to: ◆ Understand the elements for delivering high-quality respiratory care. ◆ Explain how respiratory care protocols improve the quality of respiratory care services. ◆ Understand evidence-based medicine.

Delivering Evidence-Based Respiratory Care • CHAPTER 2 19

method, or failing to provide therapy that is clinically indi- cated.5 Table 2-1 reviews studies evaluating the allocation of respiratory care services and the frequency of misallocated care.3,6-12 These studies provide much evidence that misalloca- tion of respiratory care occurs frequently. Such misallocation has led to the use of respiratory care protocols that are imple- mented by RTs (as described in the section on Methods for Enhancing the Quality of Respiratory Care).

Respiratory Therapists

In addition to competent medical direction and using well- constructed respiratory care protocols (see Fig. 2-1), capable RTs are an indispensable element in delivering high-quality respi ratory care. The quality of RTs depends primarily on their training, education, experience, and professionalism. Training teaches students to perform tasks at a competent level, whereas clinical education provides students with the knowledge they can use in evaluating a situation for making appropriate deci- sions.13 Both adequate training and clinical education are required to produce qualified RTs for assessing patients and implementing respiratory care protocols.14

Designations and Credentials of Respiratory Therapists

The two levels of general practice credentialing in respiratory care are (1) certified respiratory therapists (CRTs) and (2) registered respiratory therapists (RRTs). Students eligible to become CRTs and RRTs are trained and educated in colleges and universities. After completion of an approved respiratory care educational program, a graduate may become credentialed by taking the entry-level examination to become a CRT. A CRT may be eligible to sit for the registry examinations to become a credentialed RRT. Students who complete a 2-year program graduate with an associate degree, and students who complete a 4-year program receive a baccalaureate degree. Some RTs go on to complete a graduate degree (e.g., master or doctorate) with additional study in the areas of respiratory care, education, management, or health sciences. The further development of graduate education in respiratory care has been encouraged by the American Association for Respiratory Care (AARC), and several masters-level RT programs are currently available.15

Respiratory care education programs are reviewed by the Committee on Accreditation for Respiratory Care (CoARC). This committee is sponsored by four organizations: the AARC, the American College of Chest Physicians (ACCP), the Ameri- can Society of Anesthesiologists (ASA), and the American Tho- racic Society (ATS). The CoARC is responsible for ensuring that respiratory therapy educational programs follow accrediting standards or essentials as endorsed by the American Medical Association (AMA). Members of the CoARC visit respiratory therapy educational programs to judge applications for accredi- tation and make periodic reviews. The mission of the CoARC, in collaboration with the Association of Specialized and Profes- sional Accreditors, is to promote high-quality respiratory therapy education through accreditation services. An annual listing of accredited respiratory therapy programs is published.

to deliver high-quality respiratory care. Finally, we review the concept of evidence-based medicine as it applies to the practice of respiratory care. Other aspects of measuring and monitoring quality and patient safety are discussed in Chapter 3.

ELEMENTS OF A HOSPITAL-BASED RESPIRATORY CARE PROGRAM: ROLES SUPPORTING QUALITY CARE

Medical Direction

The medical director of respiratory care is professionally responsible for the clinical function of the department and provides oversight of the clinical care that is delivered (Box 2-1). Medical direction for respiratory care is usually provided by a pulmonary/critical care physician or an anesthesiologist. Whether the role of a respiratory care service medical director is designated as a full-time or part-time position, it is a full-time responsibility; the medical director must be available on a 24-hour basis for consultation with and to give advice to other physicians and the respiratory care staff. The current philoso- phy of cost containment and cost-effectiveness, dictated by medical care market forces, poses a challenge to the medical and technical leadership of respiratory care services to provide increasingly high-quality patient care at low cost. A medical director must possess administrative, leadership, and medical skills.1

Perhaps the most essential aspect of providing high-quality respiratory care is to ensure that the care being provided is appropriate (i.e., is clinically indicated) and that it is delivered competently. Traditionally, the physician has evaluated patients for respiratory care and has written the specific respiratory therapy orders for the respiratory therapist (RT) to follow. However, such traditional practices often have been associated with what has been called “misallocation of respiratory care.”2-4 Such misallocation may consist of ordering therapy that is not indicated, ordering therapy to be delivered by an inappropriate

Box 2-1 Responsibilities of a Medical Director of Respiratory Care

• Medical supervision of respiratory therapist in the following areas: • General medical, surgical, and respiratory nursing wards • Intensive care units • Ambulatory care (including rehabilitation) • Pulmonary function laboratory

• Development and approval of department clinical policies and procedures

• Supervision of ongoing quality assurance activities • Medical direction for respiratory care in-service and training

programs • Education of medical and nursing staffs regarding respiratory

therapy • Participation in the selection and promotion of technical staff • Participation in preparing the department budget

20 SECTION I • Foundations of Respiratory Care

TABLE 2-1

Frequency of Misallocation of Respiratory Care Services in Selected Series

Type of Service Author Date Patient Type No. Patients Frequency of Overordering Frequency of Underordering

Supplemental oxygen

Zibrak et al6 1986 Adults NS 55% reduction in incentive spirometry after therapist supervision began

Brougher et al7 1986 Adult, non-ICU inpatients

77 38% ordered to receive O2 despite adequate oxygenation

Small et al8 1992 Adult, non-ICU inpatients

47 72% of patients checked had PaO2 > 60 mm Hg or SaO2 > 90% but were prescribed O2

Kester and Stoller3

1992 Adult, non-ICU inpatients

230 28% for supplemental O2 8% for supplemental O2

Albin et al9 1992 Adult, non-ICU inpatients

274 61% ordered to receive supplemental O2 despite SaO2 ≥ 92%

21% underordered, including 19% prescribed to receive inadequate O2 flow rates

Shelledy et al12 2004 Adults 75 0 5.3% indicated but not ordered

Bronchial hygiene techniques

Zibrak et al6 1986 Adults NS 55% reduction in incentive spirometry after therapist supervision began

Shapiro et al10 1988 Adult, non-ICU inpatients

3400 evaluations

61% reduction of bronchial hygiene after system implemented

Kester and Stoller3

1992 Adult, non-ICU inpatients

230 32% 8%

Shelledy et al12 2004 Adults 75 37.5% 8% Bronchodilator

therapy Zibrak et al6 1986 Adults NS 50% reduction in incentive

aerosolized medication after therapist supervision began

Kester and Stoller3

1992 Adult, non-ICU inpatients

230 12% 12%

Shelledy et al12 2004 Adults 75 34.4% 5.3% Kester and

Stoller3 1992 Adult, non-ICU

inpatient 230 40% 6.7%

ABGs Browning et al11 1989 Surgical ICU inpatients

724 ABGs 42.7% inappropriately ordered before guidelines implemented

Modified from Stoller JK: The rationale for therapist-driven protocols. Respir Care Clin N Am 2:1, 1996. ABGs, Arterial blood gases; ICU, intensive care unit; NS, Not stated; NA, not assessed.

As of May 2014, there were approximately 453 CoARC-approved respiratory care programs.

Credentialing is a general term that refers to recognizing individuals in particular occupations or professions. Generally, the two major forms of credentialing in the health fields are state licensure and voluntary certification. Licensure is the process in which a government agency gives an individual per- mission to practice an occupation. Typically, a license is granted only after verifying that the applicant has demonstrated the minimum competency necessary to protect the public health, safety, or welfare. Licensure laws are normally made by state legislatures and enforced by specific state agencies, such as medical, nursing, and respiratory care boards. In states where licensure laws govern an occupation, practicing in the field without a license is considered a crime punishable by fines or imprisonment or both. Licensure regulations are based on a practice act that defines (and limits) what activities the profes- sional can perform. Two other forms of state credentialing are less restrictive. States that use title protection simply safeguard

the use of a particular occupational or professional title. Alter- natively, states may request or require practitioners to register with a government agency (registration). Neither title protec- tion nor state registration constitutes a true practice act, and because both title protection and registration are voluntary, neither provides strong protection against unqualified or incompetent practice.

Certification is a voluntary, nongovernment process whereby a private agency grants recognition to an individual who has met certain qualifications. Examples of qualifications are grad- uating from an approved educational program, completing a specific amount of work experience, and performing acceptably on a qualifying examination. The term registration is often used interchangeably with the term certification, but it also may refer to a type of government credentialing. As a voluntary process, certification involves standards that are often higher than the minimum standards specified for entry-level compe- tency. A major difference between certification and licensure is that certification generally does not prevent others from working

Delivering Evidence-Based Respiratory Care • CHAPTER 2 21

Licensure and certification help ensure that only qualified RTs participate in the practice of respiratory care. Many institu- tions conduct annual skills checks or competency evaluations in compliance with The Joint Commission (TJC, formerly the Joint Commission on Accreditation of Healthcare Organiza- tions [JCAHO]) requirements. Beyond TJC-required skills checks, experience with respiratory care protocols suggests the need to develop and monitor additional skills among RTs (Box 2-2). Ensuring and maintaining these skills require ongoing training and quality review programs, which are discussed in Chapter 3 (see section on Monitoring Quality in Respiratory Care).

Professionalism

By definition, professionalism is a key attribute to which all RTs should aspire and that must guide respiratory care practice. Webster’s New Collegiate Dictionary defines a profession as “a calling that requires specialized knowledge and often long and intensive academic preparation.” A professional is characterized as an individual conforming to the technical and ethical stan- dards of a profession. RTs demonstrate their professionalism by maintaining the highest practice standards, engaging in ongoing learning, conducting research to advance the quality of respira- tory care, and participating in organized activities through professional societies such as the AARC and associated state societies. Box 2-3 lists the professional attributes of the RT. We emphasize the importance of these attributes because the con- tinued value and progress of the field depend critically on the professionalism of each practitioner.16

in that occupation, as do most forms of licensure. Both types of credentialing apply in respiratory care.

The primary method of ensuring quality in respiratory care is voluntary certification or registration conducted by the National Board for Respiratory Care (NBRC). The NBRC is an independent national credentialing agency for individuals who work in respiratory care and related services. The NBRC is cooperatively sponsored by the AARC, ACCP, ASA, ATS, and National Society for Pulmonary Technology. Representatives of these organizations make up the governing board of the NBRC, which assumes the responsibility for all examination standards and policies through a standing committee. The NBRC provides the credentialing process for both the entry-level CRT and the advanced-practitioner RRT. As established in January 2006, to be eligible for either the CRT or the RRT examination, all can- didates must have an associate degree or higher. An additional advanced-practitioner credential, the neonatal/pediatric spe- cialist (NPS), has been established for the field of pediatrics. The NBRC also encourages professionals in the field to maintain and upgrade their skills through voluntary recredentialing. Both CRTs and RRTs may demonstrate ongoing professional competence by retaking examinations. Individuals who pass these examinations are issued a certificate recognizing them as “recredentialed” practitioners. In addition to the certification and registration of RTs, the NBRC provides credentialing in the area of pulmonary function testing for certified pulmonary function technologists (CPFTs) and registered pulmonary func- tion technologists (RPFTs). Since its inception, the NBRC has issued more than 350,000 professional credentials to more than 209,000 individuals. According to United States Bureau of Labor Statistics data from 2012, there were approximately 119,300 active RTs, many of whom hold more than one creden- tial. Table 2-2 shows the distribution of these credentialed individuals.

At the time of publication, 48 states, the District of Colum- bia, and Puerto Rico have some form of state licensure. Many states use the NBRC entry-level respiratory care examination for state licensing, whereas others simply verify NBRC creden- tials. Most licensure acts require the RT to attain a specified number of continuing education credits to maintain his or her license. Continuing education helps practitioners keep up to date and aware of the changes and advances that occur in their health care field.

TABLE 2-2

Distribution of Credentialed Practitioners

Credential Type No. Credentialed Practitioners

CRT 219,830 RRT 130,375 CPFT 12,711 RPFT 4279 NPS 11,491

NOTE: As of February 2013. Practitioners may hold more than one credential (i.e., RRTs are also CRTs and NPS are also CRTs or RRTs).

Box 2-2 Additional Respiratory Therapist Skills Required for Implementing Protocols

• Assess and evaluate patients regarding indications for therapy and for the most appropriate delivery method

• Be cognizant of age-related issues and how they affect the patient’s ability to understand and use various treatments

• Adapt hospital policies and procedures to alternative care sites

• Conduct and participate in research activities to ensure a scientific basis for advances in respiratory care technology

• Communicate effectively with all members of the health care team, and advance knowledge in the field of respiratory care

Box 2-3 Professional Characteristics of a Respiratory Therapist

• Completes an accredited respiratory therapy program • Obtains professional credentials • Participates in continuing education activities • Adheres to the code of ethics put forth by the institution or

state licensing board or both • Joins professional organizations

22 SECTION I • Foundations of Respiratory Care

checked and specific maintenance procedures must be per- formed on a regular basis. Because of rapidly changing respira- tory care technology, the job of the technical director poses significant challenges. Circuit boards and computers have replaced simpler mechanical devices. New medications and delivery devices for the treatment of asthma and newer strate- gies for treating other respiratory diseases (e.g., low-stretch ventilatory approaches for acute respiratory distress syndrome [ARDS]) continue to evolve. Individuals responsible for techni- cal direction must ensure that these new devices, methods, and strategies not only are effective but also have value.

Respiratory Care Protocols

In an effort to improve the delivery and allocation of respiratory care services, respiratory care protocols (also known as therapist-driven protocols) have been developed and are in use in many hospitals in the United States, Canada, and other coun- tries. Respiratory care protocols are guidelines for delivering appropriate respiratory care treatments and services (i.e., treat- ments and services that are clinically indicated, delivered by the correct method, and discontinued when no longer needed). Protocols may be written in outline form or may use algo- rithms (an example of which is a branching logic flow diagram [Figures 2-1 and 2-2]).

Gaylin and colleagues17 conducted a telephone survey in 1999 of 371 RT members of the AARC, of whom 51% were practitioners, 26% were clinical supervisors, and 23% were administrators. When asked if their organizations used guide- lines or protocols, 98% of the respondents indicated that they did. Of the 2% who did not, 53% were planning their use. A survey conducted by the AARC in 2005 indicated that of 681 responding hospitals, 73% were providing care by means of at least one protocol.18 More recently, the 2009 AARC Human Resources Survey showed that of 2764 responders, approxi- mately two-thirds (65.7%) indicated that they have delivered respiratory care by protocol.19 Finally, in a survey of 348 RT program directors, more than 95% reported teaching RT stu- dents how to treat using RT protocols.20 The use of respiratory care protocols by qualified RTs is a logical practice because well- trained RTs possess extensive knowledge of respiratory care modalities and have the assessment and communication skills required to implement the protocols effectively.21

The success of a respiratory care protocol program requires several key elements, including active and committed medical direction, capable RTs, collaboration with physicians and nurses, careful monitoring, and a responsive hospital environment (Box 2-5). As further evidence that RT protocols have been widely adopted, the ACCP has identified the elements of an acceptable respiratory care protocol (Box 2-6). This document may serve as a guide for developing protocols. Protocols may be constructed for individual therapies, such as aerosol the- rapy, bronchopulmonary hygiene, bronchodilators, O2 therapy, hyperinflation techniques, suctioning, and pulse oximetry. Pro- tocols also can be written for a specific purpose, such as arterial blood gas (ABG) sampling, weaning from mechanical ventila- tion, decannulating a tracheostomy, and titrating O2 therapy.

In the highly regulated careers of health care, professional- ism also requires compliance with external standards, such as the standards set by TJC and the government. One such stan- dard is defined by the Health Insurance Portability and Account- ability Act (HIPAA) of 1996. HIPAA sets standards regarding the way personal health information is communicated and revealed in the transmission of medical records and in the written and verbal communication in the hospital. Some spe- cific provisions of HIPAA are presented in Box 2-4. As with all hospital and health care personnel, standards of respiratory therapy professionalism require knowledge of HIPAA and com- pliance with its terms.

Technical Direction

Another important element for delivering quality respiratory care is technical direction. Technical direction is often the responsibility of the manager of a respiratory care department, who must ensure the equipment and the associated protocols and procedures have sufficient quality to ensure the safety, health, and welfare of the patient using the equipment. Medical devices are regulated under the Medical Device Amendment Act of 1976, which comes under the authority of the U.S. Food and Drug Administration (FDA). The FDA also regulates the drugs that are delivered by RTs. The purpose of the FDA is to establish safety and effectiveness standards and to ensure that these standards are met by equipment and pharmaceutical manufacturers.

Procedures and protocols related to the use of equipment and medications must be written to provide a guide for the respiratory care staff. In addition, equipment must be safety

Box 2-4 Health Insurance Portability and Accountability Act of 1996

The use and disclosure of protected health information (PHI) by a covered entity are prohibited by the Health Insurance Portability and Accountability Act unless it is a permitted use or disclosure for purposes of treatment, payment, or health care operations or is authorized by the patient. When disclosure or use of PHI is permitted, ensure that only the minimum necessary information is disclosed.

DEFINITION OF TERMS Use: Release of PHI within the institution Disclosure: Release of PHI outside the institution PHI: Individually identifiable health information Covered entity: Health care provider, health plan, health care

clearinghouse Permitted: As long as there are reasonable safeguards in place

regarding the Privacy Rule and the information given is the “minimum necessary”

Treatment: Necessary information can be disclosed to all involved in treatment (physicians, nurses, allied health personnel)

Payment: To allow for billing, for insurance purposes and third-party payers

Authorized: Patient’s written agreement for permitted use Minimum necessary: Reasonably necessary to accomplish

intended purpose

Delivering Evidence-Based Respiratory Care • CHAPTER 2 23

MINI CLINI A Specific Treatment Protocol: Aerosolized Bronchodilator Therapy

PROBLEM: A 54-year-old woman is admitted to the hospital with an exacerbation of chronic obstructive pulmonary disease (COPD). She has a history of smoking one and one-half pack of cigarettes per day for 32 years. She is alert and oriented, and her respiratory rate is 32 breaths/min. On auscultation, she has bilateral wheezes on inspiration and exhalation. Her vital capacity (1.3 L) is greater than the predicted minimal volume for effective incentive spirometry, but she is unable to take in a slow, deep breath and hold it for longer than 5 seconds, which is the criterion sometimes used for appropriate metered dose inhaler (MDI) use. What should the RT do now?

SOLUTION: Following the aerosol therapy protocol algo- rithm, this patient would receive an aerosolized bronchodilator treatment from a small-volume nebulizer with a mouthpiece. An algorithm for aerosolized bronchodilator therapy is shown in Figure 2-1.

MINI CLINI A Specific Treatment Protocol: Aerosolized Bronchodilator Therapy

PROBLEM: A 70-year-old woman is admitted from the emergency department with an asthma exacerbation. She is a nonsmoker and has advanced dementia. She is alert and calm, and her respiratory rate is 24 breaths/min. She has bilateral wheezes on exhalation. The patient is able to take deep breaths, but she cannot follow simple directions. What would be the bronchodilator device of choice for this patient?

SOLUTION: This patient should receive a small-volume neb- ulizer, because she does not fulfill MDI criteria (because of her advanced dementia). The aerosolized bronchodilator therapy algorithm that guides this decision is shown in Figure 2-1.

Successful implementation of protocols requires acceptance by various stakeholders in the hospital, including the hospital administrators, physicians, nurses, and RTs. Hospital adminis- trators are likely to accept RT protocols if they are convinced that protocols enhance patient care, improve allocation of respi- ratory care services, and reduce costs. Physicians are likely to accept RT protocols if they are convinced that protocols will enhance their patients’ care, preserve the physician’s ability to specify orders if desired, and maintain the physician’s awareness of changes in a patient’s condition and changes in the respira- tory care plan. Physicians’ acceptance also requires their having trust in the quality, professionalism, and competence of the respiratory therapy staff. Nurses are likely to accept protocols if they are persuaded that protocols will enhance the efficiency of care, help relieve sometimes excessive nursing workloads, and preserve communication with the bedside nurse regarding the patient’s plan of treatment. Finally, successful implementation and acceptance of protocols by RTs requires a desire to be progressive, confidence in their own assessment and communi- cation skills, “ownership” of the protocol process (e.g., by par- ticipating in drafting the protocol policies and strategies by which protocols are put in place), and willingness to change and to abandon outdated task-driven practices in respiratory care.

Features of RT departments that are ready for and embrace change have been studied22 and are presented in Box 2-7. Steps and tactics to ensure successful implementation of respiratory care protocols are described in Box 2-8. Selecting a planning team with broad membership that includes physicians, nurses, and administrators is a key element in developing a protocol implementation process that avoids potential barriers and satis- fies the institution’s specific and unique requirements. Once

MINI CLINI A Specific Purpose Protocol: Oxygen Therapy Titration

PROBLEM: A 42-year-old man has returned to a medical- surgical nursing unit from the recovery room after a cholecys- tectomy. He has no history of lung disease and is wearing a nasal cannula at 2 L/min. He is alert and oriented; his respira- tory rate is 18 breaths/min and heart rate is 82 beats/min. When the RT arrives to check his oxygen setup and pulse oximeter reading, his SpO2 (pulse oximeter reading) is 97% on the 2 L/ min nasal cannula. What should the RT do next?

SOLUTION: Following the O2 therapy titration protocol algo- rithm, the RT removes the nasal cannula and returns in 15 minutes to recheck the patient’s SpO2 reading, which is now 93% on room air. The RT discontinues the O2 therapy. An O2 therapy titration algorithm is shown in Figure 2-2.

Box 2-6 Elements of an Acceptable Respiratory Care Protocol as Described by the American College of Chest Physicians

• Clearly stated objectives • Outline that includes an algorithm • Description of alternative choices at decision and action

points • Description of potential complications and corrections • Description of end points and decision points at which the

physician must be contacted • Protocol program

Box 2-5 Key Elements of a Respiratory Care Protocol Program

• Strong and committed medical direction • Capable respiratory therapists (RTs) • Active quality monitoring • Collaborative environment among RTs, physicians, and

nurses • Responsiveness of all participants to address and correct

problems

24 SECTION I • Foundations of Respiratory Care

Aerosol Therapy

Indications: Current, or history, of bronchospasm

Type of medication: Bronchodilator

Patient alert?

Shallow breathing?

Can patient take a deep breath?

Small-volume nebulizer with

mask

PAP* device with mask

PAP* device with mouthpiece

VC � minimal

predicted?

MDI criteria met?

Small-volume nebulizer with mouthpiece

MDI with a spacer

*Appropriate PAP (positive airway pressure) device.

• PEP (i.e., Thera PEP) • Measured PEP (i.e., EZ PAP) • Oscillatory device (i.e., Acapella) • Intermittent CPAP

NoNo

Yes

YesYes

Yes

FIGURE 2-1 Respiratory care protocol. Aerosolized bronchodilator therapy algorithm for current or history of bronchospasm. CPAP, Continuous positive airway pressure; MDI, metered dose inhaler; PAP, positive airway pressure; PEP, positive expiratory pressure; VC, vital capacity.

Box 2-7 “Highly Desired” Features of a Change-Avid Respiratory Therapy Department

From Stoller JK, Kester L, Roberts VT, et al: An analysis of features of respiratory therapy departments that are avid for change. Respir Care 53:871, 2008.

1. Having a close and collegial working relationship between the medical director and the respiratory therapists (RTs)

2. Having a strong and supportive champion for change in the hospital administrative structure (e.g., hospital leaders, medical director)

3. Using data and other evidence to define problems and measure the effectiveness of proposed solutions

4. Using multiple and redundant types of communication to cascade information throughout the respiratory therapy department

5. Being attentive to the forces of resistance and obstacles to change and being able to navigate within institutional systems and people to achieve change

6. Being willing to confront, engage, and gain closure on tough issues

7. Having and maintaining a culture of internal, self-imposed, systematic, ongoing education and knowledge acquisition

8. Consistently rewarding and recognizing change-avid behavior among respiratory therapy department members

9. Fostering ownership for change rather than just complying with external policies and demands and, as part of this ownership, taking the time to identify and involve stakeholders (e.g., physicians, nurses, hospital thought leaders and decision makers) in change

10. Paying attention to leadership development and succession planning in the RTs

11. Having and communicating a vision in the department

protocols have been designed, it is often advisable to do pilot studies, either of each protocol individually or of a group of protocols on a single hospital floor or unit. By using this staged rollout with an initial pilot trial, unexpected problems can be worked out and helpful feedback can be gathered from protocol users before the protocols are implemented on a hospital-wide basis.

A comprehensive approach for using protocols is to combine specific protocols to form a respiratory therapy consult service

or an evaluate-and-treat program, which is used in institutions such as the Cleveland Clinic and the University of California at San Diego. With the use of a respiratory therapy consult service, the sequence of events for a respiratory therapy consult may occur as shown in Box 2-9.

A carefully structured assessment tool and care plan form (Figures 2-3 and 2-4) are essential elements for a comprehensive protocol program. These tools help ensure consistency among therapist evaluators. The following Mini Clini on Writing a

Delivering Evidence-Based Respiratory Care • CHAPTER 2 25

FIGURE 2-2 Respiratory care protocol to determine when oxygen concentration should be increased or decreased or when the therapy should be discontinued. (1) Shortness of breath, tachycardia, diaphoresis, confusion. (2) O2 saturation measured by pulse oximeter (SpO2) criteria may be modified with documented evidence of preexisting chronic hypoxemia. (3) Appropriate time lapse for recheck: 10 minutes for patients without pulmonary history; 20 minutes for patients with pulmonary history. NOTE: O2 concentration should not be decreased more than once per shift. D/C, Discontinue.

Yes

Yes No

No Yes

Yes No

No Yes

Delay O2 titration, see O2 algorithm

Does patient require O2 to

maintain SpO2 ≥ 92%?

Restart O2 maintain SpO2

≥ 92% Recheck (3)

Does patient have clinical signs of hypoxemia? (1)

Is SpO2 ≥ 92%

on room air?

Is SpO2 ≥ 92% on room air?

Is SpO2 < 92%?

D/C O2

Check SpO2 on next shift

(while awake)

Recheck on next shift

(while awake)

Is patient’s SpO2 or O2 sat

≥ 92%? (2)

O2 to achieve an

SpO2 ≥ 92% Recheck (3)

Continue present O2

therapy

O2 to maintain SpO2 ≥ 92% Recheck (3)

26 SECTION I • Foundations of Respiratory Care

Respiratory Care Plan shows how an assessment tool and care plan document, used along with corresponding algorithms, can guide therapists in developing an appropriate respiratory care plan. Other essential elements of a respiratory care protocol service include ensuring the respiratory therapist’s competence to deliver the care as part of a quality control program (see Figure 2-5) and assessing the accuracy of audits (see Figure 2-6).

Demonstrated advantages of respiratory care protocols include better allocation of respiratory care services without an increased frequency of respiratory care treatments and cost savings (Tables 2-3 and 2-4). Other advantages include more responsive respiratory care with more adjustment of respiratory care services to keep pace with patients’ changing clinical status and more versatile use of respiratory care services (Table 2-5).12,23-26

Box 2-9 Sequence of Events for a Respiratory Care Consult

1. A physician writes an order for a respiratory care protocol or consult.

2. A physician order entry system or the nursing unit secretary notifies a respiratory therapist (RT) evaluator.

3. The evaluator assesses the patient using specific guidelines. 4. The evaluator writes a care plan using designated indications

and algorithms and documents the care plan in the patient’s chart for review by the physician.

5. The RT covering the nursing unit delivers the care. 6. The patient is assessed on a shift-by-shift basis for changes

in status and indicated modifications for the care plan, which are also documented.

7. The physician is notified of any deterioration in the patient’s status.

8. When indications for respiratory care no longer exist, respiratory care treatment is discontinued, and notification is placed in the patient’s chart.

Box 2-8 Tactics for Implementing Respiratory Care Protocols

1. Select a planning team with diverse membership. 2. Conduct an audit to assess the occurrence of misallocation

of therapy to justify departure from usual care. 3. Identify sources of resistance (e.g., physicians, nurses,

administrators, respiratory therapists [RTs]). 4. Design a protocol program that fits the individual hospital. 5. Develop a training program for RTs. 6. Develop an evaluation and quality monitoring system.

MINI CLINI Writing a Respiratory Care Plan

PROBLEM: A 40-year-old woman with a history of asthma was admitted to the hospital for gastrointestinal dysmotility with abdominal distention. Her chest radiograph showed an elevated diaphragm with accompanying atelectasis in the bases of the lung fields. Her laboratory test results were as follows: white blood cell count 10,200 cells/mcl, hemoglobin 11.6 g/dl, and platelet count 260,000/mm3. Her pulse oximetry reading was 96% on room air; no ABGs were drawn. Her heart rate was 84 beats/min, blood pressure was 110/78 mm Hg, respiratory rate was 20 breaths/min, and temperature was 36.8° C. She was alert and oriented, and her vital capacity was 1.35 L. She is 5 feet 7 inches tall and has a predicted minimal vital capacity of 0.927 L (15 ml/kg of ideal body weight). On auscultation, her breath sounds were decreased bilaterally and she had slight inspiratory wheezes in the apices of her lung fields. She had a weak, nonproductive cough and was able to ambulate on her own. A respiratory care evaluation should be performed for this patient.

SOLUTIONS: The patient’s assessment score sheet and her respiratory therapy care plan, using the respiratory therapy consult protocol and treatment algorithms currently in use at the Cleveland Clinic, are shown (see Figures 2-3 and 2-4).

TABLE 2-3

Cost Savings Associated With Respiratory Care Protocols

Author Date Duration of Study Cost Savings

Hart et al36

1989 3 mo $4316 (decrease in actual costs)

Walton et al37

1990 6 yr 9.7% (decrease in charges)

Orens38 1993 1 yr $81,826 (decrease in costs for one nursing unit)

Ford39 1994 1 yr $150,000 (decrease in costs)

Komara and Stoller40

1995 40 postsurgical patients; oxygen use up to 6 days

53.3% (decrease in costs)

Shrake et al41

1996 2 years, 4420 patients; cost comparisons: 3 months after protocol

$15,337 for 3 study months, annualized to $61,348/year

Stoller et al25

1998 1 year, 145 patients $20 (decrease in true costs/patient)

Kollef et al26

2000 9 months, 694 patients $186 (decrease in charges/patient)

Shelledy et al12

2004 3 months, 75 patients $75,395 (estimated annual decrease)

Modified from Haney DJ: Therapist-driven protocols for adult non-intensive care unit patients: availability and efficacy. Respir Care Clin N Am 2:93, 1996.

RULE OF THUMB

Respiratory care protocols have been shown to help ensure that the correct respiratory care treatments are delivered to the patients who are likely to benefit from the therapy (i.e., improved allocation of respiratory care).

Delivering Evidence-Based Respiratory Care • CHAPTER 2 27

FIGURE 2-3 Evaluation form for guiding a standardized patient assessment and assigning a severity of respiratory illness score. The score for the greatest degree of dysfunction for each assessment category is written in the right-hand column and tallied to determine the severity of respiratory illness (triage) score. RR, Respiratory rate; VC, vital capacity. (Courtesy Cleveland Clinic Respiratory Institute, Cleveland, Ohio.)

Total points

The Cleveland Clinic Foundation

Department of Pulmonary Disease

Respiratory Therapy Evaluation

Date: / / Age: Time: Ht: Diagnosis:

Respiratory therapist

40 5’ 7’’

Inpatient ID label

Chart Assessment

Clinical findings 0 X X X

X1 2 3 4 Points

Pulmonary status

(�) History

(�) Smoking

Smoking history

�1 pk a day

Smoking history

�1 pk a day

Pulmonary impairment

(acute or chronic)

Severe or chronic with exacerbation 3

20110/7084

96% RA

10.2 11.6 260k

0.927L

1.35L

Surgical status

No surgery

General surgery

Lower abdominal

Thoracic or upper

abdominal

Thoracic with pulmonary

disease Chest x-ray

Clear or not indicated

Chronic changes or

x-ray pending

Infiltrates, atelectasis or pleural effusions

Infiltrations in more than

one lobe

Infiltrate � atelectasis �pleural effusion

Patient Assessment

Clinical findings

X X

Respiratory pattern

Regular pattern

RR 12-20

Increased RR 21-25

Dyspnea on exertion, irregular pattern

RR 26-30

Decreased vital capacity* RR 31-35

Severe SOB, use of

accessory muscles RR � 35

Mental status

Alert, oriented,

cooperative

Lethargic, follows

commands

Confused, does not follow

commands

Obtunded Comatose

Breath sounds

Clear to auscultation

Decreased unilaterally

Decreased bilaterally

Crackles in the bases

Wheezing and/or rhonchi

X 2 Cough

effectiveness Strong,

spontaneous, nonproductive

Strong, productive

Weak, nonproductive

Weak, productive or

weak with rhonchi

No spontan- eous cough or may require suctioning

0 Level of activity

Ambulatory Ambulatory with

assistance

Temporarily nonambulatory

Bed rest, able to position self

Bed rest, unable to

position self

Oxygen required for

SpO2 � 92%

No oxygen 1-3 liters 4-6 liters �50% �100%

100%

Lab test: Date: / / pH PaCO2 PaO2 HCO3 Sat/FIO2

WBC Hb Plts

Pulmonary function test:

Minimal pred. VC

VC Peak flow

SpO2/FIO2 Vital signs:

Temperature (24 hr max)

HR BP RR

Date: / /

*VC � 10 minimal predicted: Predicted ideal body weight (males: 50 � 2.54 x inches �60)

(females: 45 � 2.54 � inches �60) Multiply above ideal body wt. � 15 cc for min. pred. VC

Triage 1 �20

Triage 2 (16-20)

Triage 3 (11-15)

Triage 4 (6-10)

Triage 5 (0-5)

Triage #

FIGURE 2-4 Care plan form for recording a patient’s indications for therapy and the therapeutic modalities for treating the indications. ABGs, Arterial blood gases; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; GI, gastrointestinal; Hx, history; IPPB, intermittent positive pressure breathing; Incen. spiro., incentive spirometer; PEP, positive expiratory pressure; RA, room air. (Courtesy Cleveland Clinic Respiratory Institute, Cleveland, Ohio.)

Aerosol Therapy

Post Thoracic Surgery Protocol

Aerosol Therapy

Triage Number 3

Albuterol X

QID and prn

at night

To be used q1hr

96%/RA 1.35 l

Time of Evaluation

Date of Evaluation

Your patient has been evaluated by the Respiratory Therapy Consult Service. Based on the patient’s clinical indicators, the Care Plan designated below will be implemented.

Diagnosis(es) GI dysmotility

Hx asthma

Care plan modifications, made in response to changes in the patient’s condition, are available for your review through the Phamis Last Word computer system.

Signature: Respiratory Therapy Evaluator

Print Name: /Beeper:

bph

Hyperinflation

Oxygen Therapy

Monitoring

Suctioning

Comments Patient needs encouragement to cough effectively.

FrequencyNeb.DPI MDI

Clinical Indications

Respiratory Therapy Consult/Evaluation

Care Plan

Bronchospasm

History of bronchospasm

Inflammation/ mucosal edema

Proteinaceous secretions

Home regimen

Productive cough

Rhonchi on auscultation

History of mucous prod. disease

Atelectasis

Pos. drainage

Incen. spiro.

FIO2 %

Pulse oximetry

Nasal-tracheal

Percussion/vibration

CPAP/PEP

Liters/minute

ABGs

Tracheal

Coughing techniques

IPPB

Resp. mechanics

Upper abdominal or thoracic surgery, or COPD & surgery

Restrictive disease associated with quadriplegia and/ or dysfunctional diaphragm

SpO2 � 92% on room air

PaO2 � 55 mm Hg on room air

Clinical signs of hypoxemia

O2 titration (pulse ox.)

Unstable resp. status

SpO2 � 92% on room air or 4 Lpm O2 (ABGs)

Oximetry sat/FIO2 Vital capacity

Presence of secretions

Unable to cough effectively

Altered consciousness

Patient unable to deep breathe and cough spontaneously

Broncho/Pulm Hygiene Hyperinflation

Oxygen Therapy

Respiratory Monitoring

IMPRINT/LABEL

Suctioning

Physician order

Delivering Evidence-Based Respiratory Care • CHAPTER 2 29

FIGURE 2-5 Example of a skills checklist for suctioning. DOB, Date of birth; MRN, medical record number.

Suctioning

Date First name Last name Employee number Use your employee number only, Do NOT use any letters.mm/dd/yyyy

Supervisor Observed by

Patient or simulation? � Patient � Simulation

Last 4 digits of patient MRN Unit

Age (If applicable) � Neonate/infant (0-18 mos.) � Child (19 mos.-8 yrs.) � Adolescent (9-18 yrs.)

� Adult (19-69 yrs.) � Geriatric (70�yrs.)

Did the RT interact appropriately with the patient with regard to the specific age category listed above? (If applicable)

� Yes � No

Observe OSHA standards for universal precautions

Pre-assesses patient 1. Heart rate 2. Respiratory rate 3. Breath sounds 4. Pulse oximetry

Perform suctioning procedure 1. Maintain sterile technique 2. Pre-oxygenate 3. Hyper-inflate at least 5-6 times with artificial airways 4. Suction 5. Lubricate catheter for nasotracheal route 6. Insert catheter smoothly as far as possible, careful to stop on encountering resistance 7. Apply suction intermittently as catheter is withdrawn 8. Suction period should not exceed 15 seconds 9. Oxygenate and hyper-inflate after each pass with the catheter 10. Lavage as needed 11. Repeat until airways are clear or as the patient tolerates 12. Note amount, color, and consistency of any secretions

Post treatment assessment 1. Heart rate 2. Respiratory rate 3. Breath sounds 4. Cough 5. Sputum 6. Mental status 7. Activity

Assures patient safety and clean environment 1. Removes all other trash from bed and area 2. Verifies medical support systems are intact (ex. oxygen) 3. Ensures patient safety (ex. bedrails are up)

Charts appropriately 1. Charts correctly in Mediserve in a timely manner 2. Includes any complications and/or adverse events and informs physician

Comments

Skills Checklist

According to section standards

Prepare equipment and assess patient 1. Verify order, verifies patient using at least 2 patient identifiers (Name, MRN, DOB) 2. Introduce self and explains procedure (If applicable) 3. Correctly assemble the equipment per procedure manual, suction kit, manual resuscitator, oxygen, saline for lavage, suction source (wall outlet: 80-120 mm Hg portable: 3-5 inches Hg), lubricating jelly for nasotracheal route

(Last name, first name)

(Enter as unit-bed number ex. H81-15 or G111-09)(If applicable)

30 SECTION I • Foundations of Respiratory Care

FIGURE 2-6 Form for providing feedback to therapist evaluators on their patient assessment and care plan writing performance. Agreement is indicated by an A (auditor) and a T (therapist) in the same triage scoring box or therapeutic category. (Courtesy Cleveland Clinic Respiratory Institute, Cleveland, Ohio.)

A � Auditor T � Therapist

Pulmonary Status

0 1 2

Triage Score

Care Plan

3 4

Surgical Status

Chest X-Ray

Respiratory Pattern

Mental Status

Breath Sounds

Cough

Level of Activity Oxygen Requirement

The triage score was ___________% correct.*

*“% Correct” defined as the percent of auditor’s scores (for each of the eight axes) with which the therapist’s score agrees.

The care plan was ______% correct.*

*“% Correct” defined as (number of agreements)/six (total items for therapy).

Care plan complete?

Evaluation on time?

Frequencies correct?

Yes

Comments:

Total A____ T____

Aerosol bph Hyperinflation Oxygen Pulse Ox Suctioning

A � Auditor

T � Therapist

Therapist: Auditor: Date:

Diagnosis:

Care Plan Audit

Stamp Here

EVIDENCE-BASED MEDICINE

Another important concept regarding high-quality care is evidence-based medicine. Evidence-based medicine refers to an approach to determining optimal clinical management based on several practices, as follows28-32: (1) a rigorous and systematic review of available evidence, (2) a critical analysis of available evidence to determine which conclusions are most sound and applicable, and (3) a disciplined approach to incorporating the

literature with personal practice and experience. In a broader context, evidence-based medicine can be thought of as under- standing and using the best quality evidence available (i.e., the best-designed, most rigorous clinical trials) to support the most appropriate and correct possible clinical decisions.

In rating the quality of scientific evidence, it is important to recognize the various designs and types of study designs from which scientific evidence comes.32 This section reviews these designs. The simplest and least rigorous design is a single case

Delivering Evidence-Based Respiratory Care • CHAPTER 2 31

report, in which a new clinical issue or problem is described in a single patient. A description of the favorable outcome of using a new mode of mechanical ventilation in one patient with refractory hypoxemia is an example of a single case report. Although single case reports have value in pointing out new insights and new possibilities for treatment, disease associa- tions, or disease causation, they cannot prove the effectiveness of a treatment or the causality of a risk factor because, by nature, they lack a control or comparison group (i.e., a group that is similar to the patient or patients described, differing only in whether the risk factor of interest was present or the treat- ment of interest was applied). Collecting a group of patients with similar clinical features is called a case series and may have greater impact than a single case report because it suggests that the issue is more general than in a single patient alone. However, like a single case report, a case series cannot prove the efficacy of a treatment or the causality of a risk factor because no com- parison or control group is included.

Cohort studies, which compare the clinical outcomes in two compared groups (or cohorts), generally have greater scientific rigor than case studies or case series and consist of two broad types of study designs: observational cohort studies and ran- domized controlled trials. In trying to establish whether a treat- ment works (i.e., has efficacy), an observational cohort study compares the outcomes between two groups of patients when the treatment is allocated to one group but not the other. More

specifically, an observational cohort study of a new mode of mechanical ventilation would compare the outcomes between two groups of similar patients (i.e., especially similar with regard to their risk for developing the outcome measure that is being studied) when the mode of mechanical ventilation is determined either by physician choice (i.e., the physician decided to use this treatment in this patient) or by patient choice. In contrast to an observational cohort study, in a ran- domized controlled trial, sometimes regarded as the most methodologically rigorous study design (when well conducted), the outcomes of two similar groups of patients are compared when the use of the new mode of mechanical ventilation is determined not by patient or physician choice but rather by chance alone (randomization). When ideally designed and con- ducted, a randomized controlled treatment trial eliminates all sources of bias that would prevent attributing differences in outcomes between the compared groups to anything other than the treatment that is being studied. In this way, randomization can “isolate” the effect of the treatment. Said differently, at its best, a randomized controlled treatment trial provides rigorous evidence about the efficacy of the treatment because all other potential biases and confounding variables (e.g., features of the compared patient groups, other medications, or other treat- ments that the study participants are receiving) are eliminated from consideration. This allows the investigators and the readers of the clinical trial results to confidently attribute outcome

TABLE 2-4

Summary of Available Randomized Trials on the Effectiveness of Respiratory Care Protocols

Clinical Activity Author Date No. Patients Findings

Weaning from mechanical ventilation Kollef et al43 1997 357 Use of protocols was associated with shorter duration of mechanical ventilation

Ely et al44 1996 300 Routine daily trials of spontaneous breathing trials were associated with shorter duration of mechanical ventilation

Marelich et al45 2000 253 Use of protocols shortened duration of mechanical ventilation Respiratory care protocol service Stoller et al25 1998 145 Use of respiratory therapy consult service was associated

with improved allocation of respiratory care service with lower costs and no adverse events

Kollef et al26 2000 694 Use of respiratory protocol service was associated with fewer orders discordant with guidelines and lower charges

From Stoller JK: Are respiratory therapists effective? Assessing the evidence. Respir Care 46:56, 2001.

TABLE 2-5

Changes in Modalities After Protocol Implementation

Author Date Observed Reductions in Misallocated Therapy After Implementation of Protocols (%)

Change from Before Protocol to Current Status

Hart et al36 1989 37 (aerosol, hyperinflation) 48%-11% Walton et al37 1990 49.1 (aerosol, chest physiotherapy) Beasley et al46 1992 11.9% (blood gas use) 42.7%-30.8% Ford,39 1994 57% (aerosol, chest physiotherapy) 7000-4000 treatments Orens,38 1993 35% (aerosol, bronchopulmonary, hygiene, hyperinflation oxygen, oximetry)

From Haney DJ: Therapist-driven protocols for adult non-intensive care unit patients: availability and efficacy. Respir Care Clin N Am 2:93, 1996.

32 SECTION I • Foundations of Respiratory Care

FIGURE 2-7 Study design of the two types of randomized controlled trial: parallel-control and crossover. In a parallel-control trial, after randomization (R), one group receives the study treatment, while the control group receives the comparison treatment (possibly a placebo). At the end of the subsequent observation period, study outcomes are measured, and the trial is over. In a crossover trial, one group initially receives the study treatment and the other group receives the comparison treatment; outcomes are measured; and after a washout period (see text), each group receives the alternative treatment for another period, after which outcomes are measured again.

Parallel Control Randomized Trial

Measure outcomes Study treatment

Baseline state

Crossover Randomized Trial

Washout

Control treatment

Study treatment

Crossover

Control treatment

R Measureoutcomes

Study treatment

Baseline state Control

treatment

tered to the first study group can wear off completely (or so-called washout), allowing the study group to return to its baseline state before the alternative treatment is administered. When the effects of treatment are permanent (e.g., surgery, radiation therapy), a crossover trial involving that treatment cannot be done because washout of the treatment effect is not possible.

Evidence-based medicine requires knowledge of how to analyze carefully the results of clinical trials (e.g., randomized controlled trials and observational cohort studies) and how to apply the results of such research to high-quality clinical prac- tice. Other tools of evidence-based medicine include system- atically reviewing the available literature, or what is called meta-analysis of the literature.29,30 A meta-analysis of a clinical question (e.g., does a low-stretch mechanical ventilation strat- egy improve survival in ARDS?)33 identifies, analyzes, and sum- marizes the body of literature about this topic by assessing the quality of the available evidence and giving greater weight to better designed, more rigorous studies. Sometimes, meta- analyses pool the actual data from different trials together when pooling is scientifically and statistically permissible. In other instances (called narrative analyses), the meta-analysis simply evaluates the quality of the data from each available trial (based on explicit methodologic criteria) to offer a conclusion about the clinical issue.

A meta-analysis performed as part of an evidence-based approach to determining the optimal ventilatory approach for ARDS might weigh the results of large randomized clinical trials of low-stretch versus conventional tidal volume approach mechanical ventilation more heavily than the results of small observational studies. As an example of a narrative meta- analysis, a 2003 evidence-based review of the management of individuals with alpha-1 antitrypsin deficiency issued graded recommendations for testing for this genetic cause of COPD.34

differences between the compared groups to the treatment that is being studied.

Different types of the randomized controlled trials exist and include the parallel-control study and the crossover study (Figure 2-7). Parallel-control treatment studies compare two groups: one receives the treatment being studied, and the other receives the control treatment. Sometime after the end of the treatment, outcomes in the two groups are assessed and com- pared, especially regarding the main outcome of interest in the study. For example, a parallel-control randomized trial of low- stretch ventilation for ARDS would compare one group of patients receiving low-stretch ventilation with another (other- wise similar) group receiving higher stretch ventilator settings, and the two groups would be compared after a prespecified period with regard to key outcomes, such as survival, discharge from the intensive care unit, and organ system failures. This very design was used in the ARDSNet parallel-control random- ized controlled trial that showed the superiority of using a tidal volume of 6 ml/kg (ideal body weight) in managing patients with acute lung injury or ARDS.33

In the other type of randomized controlled trial—the cross- over trial—the study treatment is first administered to one group of study subjects while the other group receives the control or comparison treatment, and then, after measuring outcomes and a subsequent “washout period” (in which the effects of the initial treatment decay and wear off fully), the group initially given the study treatment receives the control treatment and the group initially given the control treatment receives the study treatment. The crossover study design offers a statistical advantage of greater power to detect a differ- ence between the compared groups, which means that fewer study participants are required to find a statistically significant difference, if one exists. However, crossover studies can be per- formed only when the effects of the initial treatment adminis-

Delivering Evidence-Based Respiratory Care • CHAPTER 2 33

SUMMARY CHECKLIST

◗ High-quality respiratory care can be defined as the competent delivery of indicated respiratory care services. ◗ Essential elements for delivering quality respiratory care

include: ◗ Energetic and competent medical direction ◗ Methods for providing indicated and appropriate

respiratory care ◗ Educated, competent respiratory care personnel

◗ Adequate, well-maintained equipment ◗ Intelligent system for monitoring performance

improvement ◗ Delivery of high-quality respiratory care requires the

combined activities of a qualified and committed medical director and capable RTs and can be enhanced by well-constructed respiratory care protocols.

◗ Respiratory care protocols are guidelines for delivering appropriate respiratory care services and are widely used in current respiratory care practice.

◗ Available evidence suggests that use of respiratory care protocols can improve allocation of respiratory care services. In doing so, the use of respiratory care protocols lessens misallocation of respiratory care. ◗ Misallocation of respiratory care services, which hinders

the delivery of high-quality respiratory care, can be defined as overordering or underordering of respiratory care services and is common in current practice.

◗ Practitioner credentialing is important in respiratory care; the RRT represents the highest credential and is based on successful completion of the NBRC examination.

◗ Maintaining and improving quality requires ongoing monitoring, as may be accomplished by quality audits and repeated competence testing of RTs.

◗ Evidence-based medicine is an approach to determining the best possible patient management based on critically assessing the available evidence. It is recommended that RTs use this approach as they assess the information that is available regarding respiratory care management strategies.

References

1. Stoller JK: Medical direction of respiratory care: past and present. Respir Care 43:217, 1998.

2. Stoller JK: Misallocation of respiratory care services: time for a change (editorial). Respir Care 38:263, 1993.

3. Kester L, Stoller JK: Ordering respiratory care services for hospitalized patients: practices of overuse and underuse. Cleve Clin J Med 59:581, 1992.

4. Kallam A, Meyerink A, Modrykamien A: Physician-order aerosol therapy versus respiratory therapy-driven protocol: the effect on resource utiliza- tion. Respir Care 58:431, 2013.

5. Stoller JK: Why therapist-driven protocols? A balanced view (editorial). Respir Care 39:706, 1994.

6. Zibrak JD, Rossetti P, Wood E: Effect of reductions in respiratory therapy on patient outcomes. N Engl J Med 315:292, 1986.

7. Brougher LI, Blackwelder AK, Grossman GD, et al: Effectiveness of medical necessity guidelines in reducing cost of oxygen therapy. Chest 39:646, 1986.

8. Small D, Duha A, Weiskopf B, et al: Uses and misuses of oxygen in hospital- ized patients. Am J Med 92:591, 1992.

9. Albin RJ, Criner GJ, Thomas S, et al: Pattern of non-ICU inpatient supple- mental oxygen utilization in a university hospital. Chest 102:1992, 1672.

10. Shapiro BA, Cane RD, Peterson J, et al: Authoritative medical direction can assure cost-beneficial bronchial hygiene therapy. Chest 93:1038, 1988.

11. Browning JA, Kaiser DL, Durbin CG: The effect of guidelines on the appro- priate use of arterial blood gas analysis in the intensive care unit. Respir Care 34:269, 1989.

12. Shelledy DC, LeGrand TS, Peters JI: An assessment of the appropriateness of respiratory care delivered at a 450 bed acute care Veterans Affairs hospi- tal. Respir Care 49:907–916, 2004.

13. Kester L, Stoller JK: Respiratory care education: current issues and future challenges (editorial). Respir Care 41:98, 1996.

RULE OF THUMB

The randomized controlled clinical trial is often considered to be the most rigorous type of study design to prove the efficacy of a treatment. The optimal randomized controlled clinical trial is designed to be free from bias that can confuse the study results and is well-conducted.

A level A recommendation (i.e., that testing should be per- formed) was issued to test all symptomatic adults with airflow obstruction on pulmonary function tests (whether carrying the diagnosis of emphysema, COPD, or asthma in which airflow obstruction fails to reverse completely with bronchodilators), asymptomatic individuals with persistent airflow obstruction on pulmonary function tests with identifiable risk factors (e.g., cigarette smoking, occupational exposure), individuals with unexplained liver disease, and adults with the skin condition necrotizing panniculitis.34 Although the hope is that issuing such evidence-based guidelines will improve the care that such individuals receive by allowing clinicians to access efficiently the best available information, experience suggests that clinicians may sometimes be slow to adopt the best available evidence in caring for their patients.35

Although some authors point out that evidence-based medi- cine does not differ from prior practice in which clinicians were always called on to analyze carefully available data and make clinical judgments based on the best quality information avail- able, evidence-based medicine does specify precise methods for analyzing available information and allowing the clinician to judge best the available evidence. As a measure of the impor- tance of evidence-based medicine in respiratory care, several articles in Respiratory Care considered the effectiveness of RTs and of various respiratory care treatment modalities using an evidence-based approach.28-30 The Clinical Practice Guidelines of the AARC are being systematically reviewed to reflect the rigorous techniques of evidence-based medicine and to ensure that guidelines for respiratory care management reflect the best available evidence.30 The proof that low-stretch ventilation is associated with improved survival in patients with ARDS and the methods used to enhance awareness of this best practice are further examples of evidence-based medical practice.

34 SECTION I • Foundations of Respiratory Care

31. Hess DR: Evidence-based clinical practice guidelines: where’s the evidence and what do I do with it? Respir Care 48:838, 2003.

32. Feinstein AR: Randomized clinical trials. In Feinstein AR, editor: Clinical epidemiology: the architecture of clinical research, Philadelphia, 1985, Saunders, pp 683–718.

33. The ARDS Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the ARDS. N Engl J Med 342:1301, 2000.

34. American Thoracic Society/European Respiratory Society: Standards for the diagnosis and management of individuals with alpha-1 antitrypsin deficiency. Am J Respir Crit Care Med 168:816, 2003.

35. Carlbom DJ, Rubenfeld GD: Barriers to implementing protocol-based sepsis resuscitation in the emergency department: results of a national survey. Crit Care Med 35:2525, 2007.

36. Hart SK, Dubbs W, Gil A, et al: The effects of therapist-evaluation of orders and interaction with physicians on the appropriateness of respiratory care. Respir Care 34(3):185–190, 1989.

37. Walton JR, Shapiro BA, Harrison EH: Review of a bronchial hygiene evalu- ation program. Respir Care 35:1214, 1990.

38. Orens DK: A manager’s perspective on a respiratory therapy consult service (editorial). Respir Care 38:884, 1993.

39. Ford R: The University of California San Diego experience with patient- driven protocols. Presented at AARC State-of-the-Art Conference: therapist- driven protocols, Dallas, May 1994.

40. Komara JJ, Stoller JK: The impact of a postoperative oxygen therapy proto- col on use of pulse oximetry and oxygen therapy. Respir Care 40:1125, 1995.

41. Shrake KL, Scaggs JE, England KR, et al: A respiratory care assessment- treatment program: results of a retrospective study. Respir Care 41:703, 1996.

42. Epstein RS, Sharwood LM: From outcomes research to disease manage- ment: a guide for the perplexed. Ann Intern Med 124:832, 1996.

43. Kollef MH, Shapiro SD, Silver P, et al: A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ven- tilation. Crit Care Med 25(4):567–574, 1997.

44. Ely EW, Baker AM, Dunagan DP, et al: Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335(25):1864–1869, 1996.

45. Marelich GP, Murin S, Battistella F, et al: Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest 118(2):459–467, 2000.

46. Beasley K, Darin J, Durbin C: The effect of respiratory care department management of a blood gas analyzer on the appropriateness of arterial blood gas utilization. Respir Care 37:343, 1992.

14. Stoller JK: Are respiratory therapists effective? Assessing the evidence. Respir Care 46:56, 2001.

15. Stoller JK: The future of respiratory therapy (RT) research and scholarship: when you’re finished changing, you’re finished. Can J Respir Therapy 46:8, 2010.

16. Beachey WD: A comparison of problem-based learning and traditional curricula in baccalaureate respiratory therapy education. Respir Care 52: 1497, 2007.

17. Gaylin DS, Shapiro JR, Mendelson DN, et al: The role of respiratory care practitioners in a managed healthcare system: emerging areas of clinical practice. Am J Manag Care 5:749, 1999.

18. Dubbs W: By the numbers: results from the AARC’s 2005 human resources study. AARC Times 30:37, 2005.

19. American Association for Respiratory Care: 2009 human resources survey of respiratory therapists. American Association for Respiratory Care, 2009. <http://www.aarc.org>. Accessed May 1, 2015.

20. Barnes TA, Kacmarek RM, Durbin CG, Jr: Survey of respiratory therapy education program directors in the United States. Respir Care 56:2011, 1906.

21. Stoller JK: The rationale for therapist-driven protocols. Respir Care Clin N Am 2:1, 1996.

22. Stoller JK, Kester L, Roberts VT, et al: An analysis of features of respiratory therapy departments that are avid for change. Respir Care 53:871, 2008.

23. Stoller JK, Haney D, Burkhart J, et al: Physician-ordered respiratory care vs. physician-ordered use of a respiratory therapy consult service: early experi- ence at the Cleveland Clinic Foundation. Respir Care 38:1143, 1993.

24. Stoller JK, Skibinski C, Giles D, et al: Physician-ordered respiratory care vs. physician-ordered use of a respiratory therapy consult service: results of a prospective observational study. Chest 110:422, 1996.

25. Stoller JK, Mascha EJ, Kester L, et al: Randomized controlled trial of physician-directed versus respiratory therapy consult service-directed respiratory care to adult non-ICU inpatients. Am J Respir Crit Care Med 158:1068, 1998.

26. Kollef MH, Shapiro SD, Clinkscale D, et al: The effect of respiratory therapist-initiated treatment protocols on patient outcomes and resource utilization. Chest 117:467, 2000.

27. Elrodt G, Cook DJ, Lee J, et al: Evidence-based disease management. JAMA 278:1997, 1687.

28. Stoller JK: Donald F. Egan Scientific Lecture: are respiratory therapists effective? Assessing the evidence. Respir Care 46(56):2001, 2000.

29. Respiratory Care Special Issue: Evidence-based medicine in respiratory care, Part I. Respir Care 46:11, 2001.

30. Respiratory Care Special Issue: Evidence-based medicine in respiratory care, Part II. Respir Care 46:12, 2001.

http://www.aarc.org

C H A P T E R 3

Quality, Patient Safety, Communication, and Recordkeeping

SCOTT P. MARLOW AND UMUR HATIPOĞLU

CHAPTER OBJECTIVES

After reading this chapter you will be able to: ◆ Define the meaning of quality in health care services. ◆ Understand the basic tools used in quality improvement projects. ◆ Describe established methods of quality improvement such as Six Sigma and Lean Management. ◆ Understand the importance of monitoring quality to promote better patient outcomes. ◆ Identify impediments to care and risk in the direct patient environment. ◆ State how communication can affect patient care. ◆ Describe the two-patient identifier system. ◆ List the factors associated with the communication process. ◆ Describe how to improve your communication effectiveness. ◆ Describe how to recognize and help resolve interpersonal or organizational sources of conflict. ◆ List the common components of a medical record. ◆ State the legal and practical obligations involved in recordkeeping. ◆ Describe how to maintain a problem-oriented medical record. ◆ Describe how to apply good body mechanics and posture to moving patients. ◆ Describe how to ambulate a patient and the potential benefits of ambulation. ◆ Write definitions of key terms associated with electricity, including voltage, current, and resistance. ◆ Identify the potential physiologic effects that electrical current can have on the body. ◆ State how to reduce the risk for electrical shock to patients and yourself. ◆ Identify key statistics related to the incidence and origin of hospital fires. ◆ List the conditions needed for fire and how to minimize fire hazards.

CHAPTER OUTLINE

Quality Considerations What Is Quality? The Methods of Quality Improvement Plan-Do-Study-Act Cycle Six Sigma Lean Management What Is Quality in Health Care? Monitoring Quality in Respiratory Care Peer Review Organizations

Safety Considerations Patient Movement and Ambulation Electrical Safety Fire Hazards General Safety Concerns

Communication Communication in Health Care Factors Affecting Communication Improving Communication Skills

Conflict and Conflict Resolution Sources of Conflict Conflict Resolution

Recordkeeping Components of a Traditional Medical Record Legal Aspects of Recordkeeping Practical Aspects of Recordkeeping Problem-Oriented Medical Record

36 SECTION I • Foundations of Respiratory Care

resolution, and recordkeeping that comprise essential compo- nents of high-quality patient care.

QUALITY CONSIDERATIONS

What Is Quality?

The quality of a service or product refers to the sum of its properties that serve to satisfy the needs of its consumer. High- quality services get high demand and also become a source of pride and financial success for the producer.

The Methods of Quality Improvement

Methods of attaining and ensuring quality were born in the automobile manufacturing industry in Japan, led by American engineers and scientists. These principles were only later adopted in the United States. William Edwards Deming (1900- 1993), an electrical engineer and statistician, is credited for laying the foundations of quality control and management. Working first with the Japanese automobile industry and later with Ford Motor Company, Deming believed that high quality can be obtained only by a major culture change promoting a continuous improvement cycle in an organization. In essence, Deming suggested that the purpose of an organization is to constantly seek improvement of its product or service aligned with customer needs.1 Rather than relying on constant inspec- tion, quality should be built into the product from the begin- ning by design of the process or structure. Emphasis must be placed on the quality of the product and pride in the workman- ship rather than on sheer quantitative productivity. Quality improvement must be everyone’s job, starting from executive management to the front-line worker. Deming heavily relied on statistical quality control techniques, established by Walter A. Shewhart (1891-1967), another American engineer and scien- tist. Through statistical process control charts (SPCs), Shewhart pointed out that in every process associated with production, there was a variability, which he termed common cause varia- tion. Common cause variation in a process can be quantitated by monitoring over time. Using sound statistical principles, an upper confidence limit (UCL) and a lower confidence limit (LCL) could be determined that define the range of common cause variation. A continuous monitoring of the process is pos- sible by taking a small but representative sample and charting

P rovision of high-quality care in a safe environment is the focus of today’s health care industry. Achieving this goal requires the integration of multiple disciplines, including respiratory therapy. Consequently, respiratory thera- pists (RTs) should be familiar with the concepts of quality improvement as it relates to health care.

This chapter will define quality and how it relates to health care. Through a narrative review, we will outline how quality is measured, monitored, and adapted to our health care environ- ment. Discussions regarding quality in health care will demon- strate how RTs share the general responsibilities for providing a safe and effective health care environment with nurses and other members of the health care team. RTs are also required to have specific technical knowledge of the environment of direct patient care. In addition to technical skills, all health care pro- fessionals must be able to communicate effectively with each other and with patients and patients’ families and to document pertinent information. Figure 3-1 shows this relationship for patient safety. This chapter aims to provide the foundational knowledge needed to understand the general aspects of patient safety considerations, communication in health care, conflict

FIGURE 3-1 Patient safety continuum.

Respiratory therapist and

health care team

Communication and

recordkeeping

Safety considerations

KEY TERMS

ambulation ampere attending auditory channel competencies cross-training current disease management

feedback ground macroshock microshock ohm performance improvement problem-oriented medical record

(POMR)

process control quality assurance quality improvement resistance SOAP voltage

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 37

Do Phase In the Do phase, the intervention is begun and observations are recorded. On occasion, observations may need to be made on a limited sample that is representative of the entire process. The size of that sample should be determined by statistical methods that may require the help of a quality improvement professional or biostatistician. The observations are plotted on a statistical process chart or its simpler version, a so-called run chart, for analysis (Figure 3-4).

Run charts are graphic representations of data over a period of observation. In contrast to SPCs, there are no defined upper and lower limits. Rather, movement of the data points around the median value (the gray line) is visualized and interpreted. Rules of interpretation are based on statistical principles. A consistent change in the placement of data points on either side of the median indicates special cause variation. The run chart in Figure 3-4 displays the percentage of patients who have

numerical values on the SPC. Should the sample for any given time interval reveal values outside of the range—for example, higher or lower than UCL and LCL, respectively—then special cause variation is suspected (Figure 3-2). This unnatural pattern will then need to be investigated for a cause. Shewhart’s SPCs continue to form the backbone of continuous quality improve- ment. Another important contribution to the practice of quality improvement by this brilliant engineer is the Plan-Do-Study- Act (or Plan-Do-Check-Act) cycle, also known as the Shewhart cycle.

Plan-Do-Study-Act Cycle

The Plan-Do-Study-Act Cycle (PDSA) can be seen visualized as the wheels of the car that is continuous quality improvement. As the wheels of PDSA turn, one gets closer to that difficult-to- achieve “perfect” product or service.

Plan Phase In the Plan phase, clear goals are set for the quality improve- ment process. These goals are best stated in the form of hard numbers such as “a 20% increase in referrals to pulmonary rehabilitation on discharge for patients with chronic obstructive pulmonary disease (COPD.” The planned intervention should be stated clearly. For instance, “respiratory therapist stationed on the nursing floor will distribute pulmonary rehabilitation program pamphlets to clinical team and remind clinicians to place the order for patients with COPD.” A time limit should be specified, for example “a 20% increase in referrals to pulmo- nary rehabilitation on discharge over the next 3 months.” During the planning phase, it is also helpful to create a diagram or a flow chart of the process that needs to be improved. The project team may choose to use tools such as the fishbone (or Ishikawa) diagram to systematically evaluate the different factors that affect the process and contribute to the problem, that is, people, technology, environment, materials, equipment, and methods (see Mini Clini and Figure 3-3).

FIGURE 3-2 Statistical process control chart showing proportion of patients having to be readmitted to the hospital after discharge. Upper (UCL) and lower (LCL) control limits are marked with gray lines. At approximately September 2011, there appears to be a spike in readmissions to the hospital outside of the UCL that may require investigation.

0.4

0.3

0.2

0.1

0.5

0.0

JanOctJulAprJanOctJulAprJan Apr

2010 2011 2012 Month

P ro

po rt

io n

UCL = 0.4173

LCL = 0.0038

P = 0.2106

FIGURE 3-4 Run chart showing percentage of patients who received pneumonia vaccination over time.

100

0 FebAugFebAugFeb

2011 2012 2013

P er

ce nt

o f p

at ie

nt s

Project begins

Feb–Jun 11

FIGURE 3-3 Fishbone diagram.

There is a 15-minute delay in treatments that causes significant patient and provider dissatisfaction.

Problem statement

Staff not attentive enough

Not enough staff

People

Bulky nebulizer

Tubing stored separately

Machine

Tubing not available consistently on the floor

Nebulizer solution not consistently available

on the floor

Materials

Time spent assembling nebulizer

Need to wait in the room after start treatment

Need to return to the room for collection of supplies

Process / Methods

38 SECTION I • Foundations of Respiratory Care

Measure: Identify metrics, develop data collection plan, collect baseline data.

Analyze: Evaluate collected data in the measure phase, deter- mine root causes for the problem and estimate the relative impact of each.

Improve: Discuss, develop, and implement solutions to the root cause(s), and confirm that the intervention is well targeted.

Control: Continue to implement solutions and follow metrics to ensure maintenance and adoption.

Origin of the Term Six Sigma Sigma (σ) is a Greek letter that is used to note standard devia- tion in a normally distributed population. Accordingly, one standard deviation from the mean in each direction, that is, ± 1 σ, contains approximately 68% of the population. Similarly, 2 times σ contains 95% and 3 times σ contains 99%. If one considers a process to operate at 1 σ, then one would have to accept a 68% rate of successful product (or a failure rate of 32%). At the 2 σ level of acceptance, the failure rate would be 5% and at 3 σ, it would be 1%. At 6 Sigma, the rate of failure would be 3 in 1 million (or 0.000003). Thus, the Six Sigma process has a goal of a very, very small error rate (Figure 3-5).

Lean Management

Lean management is a business management philosophy that focuses on eliminating waste or non–value added activities. The origins of lean management are in the Japanese automobile maker, Toyota Motor Company. Lean management is analogous to ergonomics; eliminating waste of time, excess work, and unevenness of product are the goals. This goal is achieved by broadly using the principles of “just in time” (i.e., having equip- ment, personnel, supplies at the right place at the right time, Figures 3-6 and 3-7) and “Jidoka” (a joining of automation and human intelligence that results in a higher level of quality control). According to the Jidoka principle, any person involved in a service or manufacturing of product can stop the process if he or she sees a defect.

Lean management uses tools similar to those in PDSA and Six Sigma, with emphasis on waste elimination. These have been collectively termed the lean toolbox. The main instrument is value stream mapping, which is essentially a flow chart with emphasis on identifying value-added activities versus those that are not.

received pneumonia vaccination before discharge from the hos- pital before and after the onset of a quality improvement project. In this instance, six data points are observed above the median value after the project starts. Five or more points on one side of the median indicates special cause variation (an interpretation rule), in this case, the consequence of an effective project.

Study (or Check) Phase In the Study phase, the observations are analyzed, usually by examination of the process charts. The barriers to achieving the set goals are considered and discussed.

Act Phase In the Act phase, based on the analysis performed in the Study phase, modifications to the intervention are made.

The Plan-Do-Study-Act Cycle Starts Over The paradigm of the PDSA cycle has served as the foundation for modern quality management systems such as the lean man- agement system and Six Sigma, which are discussed in the fol- lowing section.

FIGURE 3-5 Normal (Gaussian) distribution. LSL, Lower specific limit; USL, upper specific limit.

USLLSL

-2-3-4-5-6 -1 2 3 4 5 61

RULE OF THUMB

The crucial components of a quality improvement project are summarized in the PDSA cycle: Plan: Determine the specific aim, duration, data

collection strategy, and team that will run the quality improvement project.

Do: Collect data and record the observations. Study: Analyze results and derive conclusions. Act: Change the process for improvement, plan the

next cycle.

Six Sigma

By the mid-twentieth century, it had become obvious to the leading industrial companies that the rate of defective products had to be lowered to maintain market competitiveness and customer loyalty. Developed by the American telecommunica- tions company Motorola, the Six Sigma method for quality improvement recognizes that there is a natural variation in process output that can be measured and monitored over time. Controlling and reducing this variation are the keys to business success. Statistical methods are used to calculate acceptable variation. There has to be a strong commitment on the part of management, from top to bottom, to these princi- ples. The Six Sigma method also is based on the belief that improvement to existing processes is always possible and has to be achieved systematically. Analogous to the PDSA cycle, Six Sigma adopts the (Define-Measure-Analyze-Improve-Control (DMAIC) cycle for continuous quality improvement. Define: Describe and validate the problem, create solutions,

create a process map, and create a timeline for completion of the project.

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 39

MINI CLINI Case Study

Michael Breathewell, an RRT, is the respiratory therapy manager in the respiratory care department of a 300-bed unit in Our Lady of Sacred Lungs Hospital. Over the past 6 months, he has been made aware, through the newly implemented serious event reporting system (SERS), of the time delay in delivery of sched- uled inhaled bronchodilator treatments to patients. There is increasing pressure from physicians, nursing, and administration to fix this problem. After careful review of the cases, Michael determines that the problem occurs throughout all shifts and with different RTs and services involved. He believes that the problem may be due to a system issue and not special cause variation.

There are over 200 scheduled treatments given per day at the hospital. Tracking each treatment delay on a daily basis would be a huge job. Therefore, Michael has to select a sample that repre- sents the time delay for the entire population. He asks the hospital biostatistician for help. Based on several assumptions, the biostat- istician determined that 16 randomly sampled events were needed to have a fair idea of the average time delay between scheduled treatments and actual delivery.

Next, Michael asks for the help of a quality improvement professional in choosing the appropriate statistical process control chart for studying and monitoring the process of bronchodilator administration. He then begins collecting and graphing the data.

After a 3-month period of observation, he determines that there is an average of 15 minutes of delay between scheduled time and delivery time per patient see (Figure 3-6).

Michael decides to apply the Plan-Do-Study-Act cycle (PDSA) to tackle the issue.

PLAN: Michael calls a brainstorming session with floor respira- tory managers and the medical director of respiratory care at this hospital. During the meeting, Michael and the group identify and analyze the problem and map the process. To facilitate the discus- sion, he uses an Ishikawa fishbone diagram to explore potential causes. Figure 3-6 shows the completed fishbone diagram. The fishbone allows a systematic discussion of possible contributors to the problem by considering factors related to machines, people, material, and process. The attendees overwhelmingly feel that the bulk of the time is spent getting the nebulizer and tubing, setting up the patient, and then returning back to the room. They also research best practices and conduct a literature review to under- stand reasons for delay in delivering nebulized treatments.

An attendee points out that administration of bronchodilators via metered dose inhalers (MDIs) has been found to be equivalent in efficacy across different diseases and disease severity.2-4

After some deliberation, weighing the balancing measures such as cost difference, the group decides to switch to broncho- dilator administration via MDIs with a spacer and to follow time delay between scheduled time of bronchodilator delivery and actual time of delivery. The group decides that a 3-month obser- vation should be enough to determine the effect of the interven- tion and meet monthly to review results. Michael and the team also identify the measures of success, including monitoring time delay between order entry and administration of the medication and employee satisfaction. Michael meets with hospital adminis- tration and with the chief financial officer, getting their support and ensuring financial feasibility of the switch.

DO: The group begins to administer scheduled short-acting bronchodilators by MDI with a spacer throughout the hospital floors. At least 16 observations of bronchodilator administration are made randomly throughout the day and recorded on the statistical process chart. Although the literature provides strong support for this intervention, Michael carefully reviews patient outcomes (e.g., treatment failure that results in a higher level of care or intensive care unit admission) to ensure that the switch to MDIs does not have unintended consequences.

STUDY: Michael measures the effect of the intervention and sees a trend toward reduction in delay times after 1 month and is pleased. However, some RTs suggest that further reduction in delays might be possible if patients’ MDIs and spacers are kept at the bedside.

ACT: The suggestion to switch to delivery by MDI is discussed with the committee for pharmacy and therapeutics and is approved. MDIs with the patient’s name stamp and spacer are kept at the bedside.

At the end of 3 months, Michael studies the process chart (Figure 3-7) and notes that delays have been consistently below the LCL of the original process. He congratulates the entire team and continues to monitor progress. Michael and colleagues plan to refine the intervention through iterative cycles, going back to the plan phase if future results are not as expected or yield unin- tended consequences.

What Is Quality in Health Care?

As the reader can see, there are common themes in all quality improvement approaches: Identification of process compo- nents, increasing efficiency (reducing waste), standardization (reducing common variation), and a teamwork approach in implementing solutions. Broadly speaking, health care delivery systems were slow to adopt these principles, with the possible exception of laboratory medicine. Rising health care costs, however, have brought about a revolution in how health care is delivered in the United States. In line with the Patient Protection

and Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) began the Hospital Value-Based Purchasing Program, which rewarded or penalized hospitals based on their performance in the domains of process measures (also called core measure compliance), outcomes, patient experience, and efficiency. The Hospital Value-Based Purchasing Program is budget neutral, meaning that superior performance is rewarded and poor performers have to pay a penalty. Funds from the penalties provide the money for the rewards to hospitals that perform well. The federal government also enacted the Hospital Readmissions Reduction Program, which is strictly a penalty

40 SECTION I • Foundations of Respiratory Care

FIGURE 3-7 Time delay between scheduled and delivered nebulization. LCL, Lower control limit; PDSA, Plan-Do-Study-Act; UCL, upper control limit.

1 2220181614121086421 24

Week of observation

Ti m

e de

la y

Time delay between scheduled and delivered nebulization (min)

UCL

LCL

Beginning of intervention

2nd cycle PDSA

program that withholds a certain percentage of entire CMS reimbursements if the hospital has excess readmissions within 30 days of index discharge, compared to the national mean. With these incentives and threats of penalties, the health care industry is now adopting principles of quality improvement quickly.

The National Academy of Medicine (formerly the Institute of Medicine), the health arm of the National Academy of Sci- ences, suggests the following dimensions in health care quality: Safety, Timeliness, Effectiveness, Efficiency, Equity, Patient- centeredness (STEEP). These elements also define the starting points for quality improvement projects in health care.

Adoption of clinical guidelines and protocols are also impor- tant steps toward standardizing care and thereby driving im- provement and reducing variation in outcomes (see Chapter 2).

This satisfies the effectiveness and efficiency dimensions of health care quality. The patient safety dimension is addressed by adopting the “Jidoka” principle—stopping the process when any team member sees a defect in delivery of the care. Com- prehensive and effective handoffs, as discussed later, between RTs are also critical for patient safety. RT-run education pro- grams fulfill the patient centeredness principle. RTs also play a vital role in implementation of the guideline-based RT protocols and disease management programs, which represent a holistic approach to patient care across the continuum of health care settings. Disease management is discussed in the following section, and protocols are discussed in more detail in Chapter 2.

Disease Management Disease management refers to an organized strategy of deliver- ing care to a large group of individuals with chronic disease to improve outcomes and reduce cost. Disease management has been defined as a systematic population-based approach to identify persons at risk, intervene with specific programs of care, and measure clinical and other outcomes.5,6 Disease man- agement programs comprise four essential components: (1) an integrated health care system that can provide coordinated care across the full range of patient needs; (2) a comprehensive knowledge base regarding the prevention, diagnosis, and treat- ment of disease that guides the plan of care; (3) sophisticated clinical and administrative information systems that can help assess patterns of clinical practice; and (4) a commitment to continuous quality improvement. Disease management pro- grams may be developed for chronic conditions such as asthma, diabetes, COPD, and congestive heart failure.

A disease management program for COPD might be adopted by a health care provider, insurance company, or health main- tenance organization in defining its practice approach to indi- viduals with COPD. The disease management program might contain algorithms addressing when to suspect COPD, tests to perform (e.g., spirometry, alpha1-antitrypsin level, diffusing capacity), medications to prescribe based on disease severity, management of exacerbations, and indications for rehabilita- tion. Disease management programs are often outlined in doc- uments containing branched logic algorithms that specify care, similar to respiratory care protocols (see Chapter 2); however, disease management protocols often address large groups and are based on an underlying diagnosis rather than on individual signs and symptoms. Other dimensions of the COPD manage- ment program include a data collection activity regarding the number of patients served, the outcomes of care, and, perhaps, the associated costs. In addition, as with quality monitoring in general, ongoing review and periodic updating and revision of the care algorithms are important dimensions of the program.

Monitoring Quality in Respiratory Care

Beyond ensuring that all elements of a high-quality respiratory care program are in place, quality must be monitored to ensure that it is being maintained. Strategies to monitor quality include intrainstitutional monitoring practices, centralized government

5 1110987654321 12

Week of observation

Ti m

e de

la y

Time delay between scheduled and delivered nebulization

UCL

Mean

LCL

21.8

14.8

7.8

FIGURE 3-6 Time delay between scheduled and delivered nebulization. LCL, Lower control limit; UCL, upper control limit.

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 41

remains the first goal of hospitals and respiratory care services. Performance improvement, also commonly called continuous quality improvement, is an ongoing process designed to detect and correct factors hindering the provision of quality and cost- effective health care. This process crosses department boundar- ies and follows the continuum of the patient’s care. In 2009, TJC set forth three standards for monitoring performance improve- ment along with associated elements of performance detailing how the monitoring is to be conducted. These standards are listed in Box 3-2. Meeting quality goals is increasingly being tied to reimbursement rates by the CMS and insurers to hospitals; this phenomenon has been called “pay for performance.”9 Beyond general monitoring goals for respiratory therapy, use of respiratory care protocols creates the need for additional quality monitoring benchmarks regarding correctness, consistency, efficacy, and effectiveness (Box 3-3, Chapter 2).

At the present time, specific methods to monitor the quality of respiratory care protocol programs include conducting care plan audits in real time and ensuring practitioner training by using case study exercises. Evolving innovations include using simulation exercises to enhance and to measure the perfor- mance of RTs.

Monitoring correctness of respiratory care plans can be accomplished by using a care plan audit system. Care plan audi- tors must be therapists who are experienced in providing respi- ratory care and patient assessment. The auditors must also be practiced in using the institution’s protocol system and in writing care plans. With an auditing system, the auditor writes a care plan for a patient and compares it with the care plan written by the therapist evaluator to determine correctness. A specified number of audits should be performed monthly, with results tabulated and reported monthly or quarterly, depending on the size of the hospital. Feedback must be provided to the evaluators whose care plans are being audited to show their proficiency or to indicate areas that require improvement. Figure 2-6 shows a form used at the Cleveland Clinic to provide feedback to evaluators.

monitoring bodies, such as the Centers for Medicare and Med- icaid Services (CMS), and independent agencies such as The Joint Commission (TJC).

Intrainstitutional quality assurance often uses skills checks or competencies. Competence, or the quality of being compe- tent, can be defined as having suitable or sufficient skill, knowl- edge, and experience for the purposes of a specific task.7 Competence for a specific skill is frequently determined by observation of the practitioner’s performance of the skill according to a prescribed checklist. Annual competency checks are documented for skills and procedures that carry some degree of patient risk (e.g., arterial puncture, aerosol therapy, bilevel positive airway pressure setup). An example of a skills checklist is shown in Figure 2-5.

Although skills checks have traditionally been done in person or with direct supervision of patient care activities, a new dimension of skills training and certification that is being widely implemented is the use of clinical simulation, using either low-fidelity or high-fidelity simulation trainers. Such simulation training, in which RTs use technology that attempts to reproduce reliably a true patient or true patient scenario, is similar to the flight simulator training that commercial airline pilots undergo to achieve certification to fly various airplanes. Uses of simulation training in respiratory therapy involve intu- bation, ventilator management, arterial line placement, and optimizing teamwork in acute resuscitation scenarios.8

Many health care organizations, including hospitals, sub- acute care facilities, and outpatient clinics, seek voluntary accreditation as a way to improve their service and assure the public that they maintain high standards. In health care, TJC is a very important organization. TJC (as the Joint Commission on the Accreditation of Healthcare) was formed in 1951 by the American College of Surgeons, the American Hospital Associa- tion, and the American Medical Association. Accreditation by TJC is based on satisfying specific standards established by pro- fessional and technical advisory committees.

TJC requires a hospital service to have a quality assurance plan to provide a system for controlling quality. Nine generally recognized steps for a quality assurance plan are used as the basis for quality assurance programs (Box 3-1).

Current standards of TJC for accreditation emphasize organization-wide efforts for performance improvement. Despite increased emphasis on cost containment, quality care

Box 3-1 Nine Steps for a Quality Assurance Plan

1. Identify problem 2. Determine cause of problem 3. Rank problem 4. Develop strategy for resolving problem 5. Develop appropriate measurement techniques 6. Implement problem-resolution strategy 7. Analyze and compile results of intervention 8. Report results to appropriate personnel 9. Evaluate intervention outcome

Box 3-3 Quality Monitoring Benchmarks

• Monitoring the correctness of respiratory care plans • Monitoring the consistency of formulating respiratory care

plans among therapist evaluators • Evaluating the efficacy of algorithms or protocols • Evaluating the overall effectiveness of the protocol program

Box 3-2 The Joint Commission Standards for Performance Improvement

• The hospital collects data to monitor its performance. • The hospital compiles and analyzes data. • The hospital improves performance on an ongoing basis.

Compiled from The Joint Commission, Oakbrook Terrace, IL.

42 SECTION I • Foundations of Respiratory Care

the responsibilities of equipment purchase and maintenance, continuing education, and quality improvement may be as- signed to nursing personnel. Some experience suggests that nurses may be uncomfortable with these additional burdens,13 so careful planning and stakeholder assessment is needed before decentralization could be implemented.

Although less commonly practiced, another aspect of restructuring and redesign is cross-training personnel and using assistive staff. Cross-training among professional health care workers can be attempted by teaching activities normally performed by a specific discipline but not restricted by licensing to personnel of another discipline. Nurses might cross-train RTs to perform phlebotomy, whereas RTs might cross-train nurses to perform metered dose inhaler (MDI) therapy. Although theoretically appealing, this strategy has fallen into disfavor because of the substantial associated challenges in implementation.

Cross-training assistive personnel involves on-the-job train- ing of unlicensed personnel, who may not have an educational background in health care, to perform basic technical functions. These assistive personnel may learn to perform some nursing functions, such as taking vital signs, measuring intake and output, and inserting urinary catheters; laboratory technician activities, such as phlebotomy and simple urinalysis; and respi- ratory therapy activities, such as incentive spirometry follow-up and O2 checks. The intent of using cross-trained assistive per- sonnel, whose compensation is lower than that of licensed health care workers, is to enable an institution to reduce the number of nurses, laboratory technicians, and RTs they employ, thereby reducing costs. Although some aspects of hospital restructuring and redesign have been implemented and persist, others (e.g., cross-training and decentralization) have been abandoned.

SAFETY CONSIDERATIONS

Safety is a very important part of ensuring high-quality care. Importantly, patient safety must always be the first consider- ation in respiratory care. Although the RT usually does not have full control over the patient’s environment, efforts must be made to minimize potential hazards associated with respiratory care. The key areas of potential risk for patients, RTs, and co-workers are patient movement and ambulation, electrical hazards, fire hazards, and general safety concerns. Each of these will be discussed as part of attention to providing high-quality, safe care.

Patient Movement and Ambulation

Basic Body Mechanics Posture involves the relationship of the body parts to each other. A person needs good posture to reduce the risk for injury when lifting patients or heavy equipment. Poor posture may place inappropriate stress on joints and related muscles and tendons. Figure 3-8 illustrates the correct body mechanics for lifting a heavy object. The correct technique calls for a straight spine and use of the leg muscles to lift the object.

Another monitoring method found useful for respiratory therapy consult services is the case study exercise (or simulated patient scenario exercise). Simulated patient exercises can help determine the consistency of respiratory care plans among ther- apist evaluators. The scores of individual RTs may be tracked over time to identify problems and assess improvement.

Simulated patient exercises may consist of a set of three or four patient scenarios. All RTs working under the protocol system, whether or not they are evaluators, complete an assess- ment sheet and, following the associated algorithms, write a care plan for each scenario. The assessment sheets and the care plans are compared with the gold standard, or correct assess- ments and care plans, as determined by the consensus of the education coordinator and the supervisors. Scores are tabulated for the individual RTs, and the number of errors for each therapy is examined. If a particular therapy consistently has a large number of associated errors, the algorithm is reviewed for errors or vagueness. To facilitate administering and grading patient simulation exercise results, a computer-based system that scores the assessments and care plans and provides feed- back to the RT has been used.10 Performance data of individual RTs are maintained in a database to calculate and track aggre- gate performance statistics.

Peer Review Organizations

In addition to the voluntary accreditation process that health care organizations use to help ensure patients are receiving quality care, the federal government has established an elabo- rate system of peer review organizations (PROs) to evaluate the quality and appropriateness of care given to Medicare beneficiaries. PROs evaluate care provided to individual patients in real time to assess and ensure compliance with federal guidelines.

In recent years, health care organizations have attempted to improve the quality of patient care while reducing costs by implementing several innovative health care models. Histori- cally, models that were commonly implemented were hospital restructuring and redesign and patient-focused care. Protocols and disease management represent continuing solutions. Accountable care organizations (ACOs)11 have been proposed as a solution to enhance quality and lessen cost. An ACO can be broadly thought of as an emerging model in which a group of health care providers aligns and agrees together to try to meet quality and care targets and to receive payments as a collective entity, from which individual payments then can be disbursed. The ACO can benefit as a group from its success and can absorb losses as a group related to its failure to meet the targets.

Restructuring and redesign involved changing the basic organization of health care services in an attempt to do more with less, thereby increasing value. Approaches for restructuring have commonly included cross-training employees, using unli- censed assistive staff, and decentralizing services.12 In one of these approaches, when respiratory therapy departments are decentralized and respiratory care management is eliminated, RTs are deployed to individual nursing units and report to nursing supervisors. When complete decentralization occurs,

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 43

Moving the Patient in Bed Conscious people assume positions that are the most comfort- able. Bedridden patients with acute or chronic respiratory dys- function often assume an upright position, with their arms flexed and their thorax leaning forward. This position helps decrease their work of breathing. In other cases, patients may have to assume certain positions for therapeutic reasons such as when postural drainage is applied.

Figure 3-9 shows the correct technique for lateral movement of a bed-bound patient. Figure 3-10 illustrates the ideal method for moving a conscious patient toward the head of a bed. Figure 3-11 shows the proper technique for assisting a patient to the bedside position for dangling his or her legs or transfer to a chair.

Ambulation Ambulation (walking) helps maintain normal body function. Extended bed rest can cause numerous problems, including bed sores and atelectasis (low lung volumes). Ambulation should begin as soon as the patient is physiologically stable and free of severe pain. Ambulation has been shown to reduce the length of hospital stay after hip surgery and in patients recovering from community-acquired pneumonia.13,14 RTs may assist to ambu- late patients while they are on a mechanical ventilator or while on O2. Safe patient movement includes the following steps:

1. Place the bed in a low position and lock its wheels. 2. Place all equipment (e.g., intravenous [IV] equipment,

nasogastric tube, surgical drainage tubes) close to the patient to prevent dislodgment during ambulation.

3. Move the patient toward the nearest side of bed. 4. Assist the patient to sit up in bed (i.e., arm under nearest

shoulder and one under farthest armpit). 5. Place one hand under the patient’s farthest knee, and grad-

ually rotate the patient so that his or her legs are dangling off the bed.

6. Let the patient remain in this position until dizziness or lightheadedness lessens (encouraging the patient to look forward rather than at the floor may help).

FIGURE 3-8 Body mechanics for lifting and carrying objects.

FIGURE 3-9 A, Method to pull a bed-bound patient. B, Method to push a bed-bound patient.

7. Assist the patient to a standing position. 8. Encourage the patient to breathe easily and unhurriedly

during this initial change to a standing posture. 9. Walk with the patient using no, minimal, or moderate

support (moderate support requires the assistance of two practitioners, one on each side of the patient).

10. Limit walking to 5 to 10 minutes for the first exercise. Monitor the patient during ambulation. Note the patient’s

level of consciousness, color, breathing, strength or weakness, and complaints such as pain or shortness of breath throughout the activity. Ask the patient about his or her comfort level fre- quently during the ambulation period. Ensure that chairs are present so emergency seats are available if the patient becomes distressed. Ambulation is increased gradually until the patient is ready to be discharged. Each ambulation session is docu- mented in the patient chart and includes the date and time of ambulation, length of ambulation, and degree of patient tolerance.

44 SECTION I • Foundations of Respiratory Care

MINI CLINI “Tingling” Equipment

PROBLEM: An RT is caring for a patient on a mechanical ventilator that requires both electrical and pneumatic power for operation. When the RT touches the metal housing of the ventilator, a shock is felt. How should the RT handle the situ- ation based on this observation?

DISCUSSION: All therapeutic instruments used in patient care, including mechanical ventilators, should be connected to grounded outlets (three-wire). Because the ground wire is a protection device only and not part of the main circuit, equip- ment may continue to operate without the clinician being aware that a problem exists. Because the RT felt a tingling sensation when touching the ventilator, this could represent an improper ground and possible serious current leakage. In this situation, the RT should immediately take the equipment out of service and get it replaced (while providing backup ventila- tion). All electrical equipment used in patient care should be routinely checked for appropriate grounding.

FIGURE 3-10 Method to move a patient up in bed with the patient’s assistance.

FIGURE 3-11 Method to assist a patient in dangling the legs at the side of the bed.

Electrical Safety

The potential for accidental shocks of patients or personnel in the hospital exists because of the frequent use of electrical equipment. The presence of invasive devices, such as internal catheters and pacemakers, may add to the risk for serious harm from electrical shock. Although this risk is present, it has been significantly reduced in recent years through a combination of education and more rigid standards for wiring, especially in patient care areas. RTs must understand the fundamentals of electrical safety because respiratory care often involves the use of electrical devices.

Fundamentals of Electricity The ability of humans to create and harness electricity is one of the most important developments in modern times. Because controlled electricity is available on a 24-hour-a-day basis, we can depend on it to power the equipment and appliances that make modern life comfortable and productive. Despite the fact that electricity is one of the most popular sources of power, most people who use it have a poor understanding of it. This lack of knowledge is often a major factor in cases of electrocution.

Electricity moves from point A to point B because of differ- ences in voltage. Voltage is the power potential behind the electrical energy. Low-voltage batteries (e.g., 9 V) are sufficient to power a small flashlight but inadequate to power a major appliance such as a microwave oven. Most homes and hospitals are powered with 120-V power sources. Power sources that have high voltage have the potential to generate large amounts of electrical current. The current that moves through an object is directly related to the voltage difference between point A and

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 45

For example, as long as a person is insulated by normal clothing and shoes and is in a dry environment, a 120-V shock may hardly be felt because the resistance is high in this situation (10,000 Ω). Current can be calculated as:

Current A V A or mA( ) , .= =120 10 000 0 012 12Ω

Currents of 12 mA would cause a tingling sensation but no physical damage.

However, if the same person is standing without shoes on a wet floor, a much higher current occurs because the resistance is much lower (1000 Ω). The current is then calculated as:

Current A V A or mA( ) .= =120 1000 0 12 120Ω

Because the heart is susceptible to any current level greater than 100 mA, 120 mA represents a potentially fatal shock; this is in sharp contrast to the first example, in which the same voltage caused only a tingling sensation.

A shock hazard exists only if the electrical “circuit” through the body is complete, meaning that two electrical connections to the body are required for a shock to occur. In the previous example, the person standing in water with no shoes has “grounded” himself. The finger touching the hot wire provides the input source while the feet standing in water provide the exit to ground. If the same person is wearing rubber boots, the connection to ground does not exist and the current cannot flow through the individual.

In electrical devices, these two connections typically consist of a “hot” wire and a “neutral” wire. The neutral wire completes the circuit by taking the electrical current to a ground. A ground is simply a low-resistance pathway to a point of zero voltage, such as the earth (hence the term ground).

Figure 3-12 shows how current can flow through the body. In this case, a piece of electrical equipment is connected to an AC line power via a standard three-prong plug. However, unknown to the practitioner, the cord has a broken ground wire. Normally, current leakage from the equipment would flow back to the ground through the ground wire. However, this pathway is unavailable. Instead, the leakage current finds a path of low resistance through the practitioner to the damp floor (an ideal ground).

Current can readily flow into the body, causing damage to vital organs when the skin is bypassed via conductors such as pacemaker wires or saline-filled intravascular catheters (Figures 3-13 and 3-14). Even urinary catheters can provide a path for current flow. The heart is particularly sensitive to electrical shock. Ventricular fibrillation can occur when currents of 20 µA (20 microamperes, or 20 millionths of 1 ampere) are applied directly to the heart.

Electrical shocks are classified into two types: macroshock and microshock. A macroshock exists when a high current (usually >1 mA) is applied externally to the skin. A microshock exists when a small, usually imperceptible current (<1 mA) bypasses the skin and follows a direct, low-resistance path into the body. Patients susceptible to microshock hazards are termed electrically sensitive or electrically susceptible. Table 3-1 summa- rizes the different effects of these two types of electrical shock.

point B and inversely related to the resistance offered by the makeup of the object. Objects with low resistance (e.g., copper wires) allow maximum current to flow through the object. Objects with high resistance (e.g., rubber tubing) allow minimal or no current to flow through the object despite higher levels of voltage.

The simple analogy of water flowing through a piping system is useful to understand electricity. The water pressure level at the source is equivalent to the voltage. Higher water pressure provides the potential for greater water flow or current. The friction (resistance) offered by the pipe across the length of the pipe influences the flow exiting the other end. Pipes with lots of friction reduce the water flow (current) greatly. If the friction (resistance) is minimal, the water flow (current) is maximal. Similarly, when voltage is high and resistance is low, electrical current flows easily through the object.

The difference in resistance between two people or two objects explains why the same voltage applied to both can seri- ously damage one and cause no effect to the other. Two people accidentally touching a “hot” wire with 120 V can experience two completely different sensations. A person with wet skin offers little resistance, and the 120 V passes through the person with high current and can cause serious injury or death. A person with dry skin, which offers high resistance, may not even feel a shock and experiences no injury. The degree of resistance offered by the skin varies from person to person based on the chemistry of the person’s skin, the cleanliness of the skin, and the amount of moisture on the surface. For this reason, it is never wise to touch a potentially hot wire even though your skin is dry.

As stated before, voltage is the energy potential from an electrical source, and it is measured with a voltmeter. Current is the flow of electricity from a point of higher voltage to one of lower voltage and is reported in amperes (amps). Current is measured with an ampmeter. The resistance to electrical current is reported in ohms. We can determine the resistance to current for any object by the following equation:

Resistance ohms Voltage V Current amps A( [ ]) ( ) ( [ ])Ω =

Current represents the greatest danger to you or your patients when electrical shorts occur. Voltage and resistance are impor- tant only because they determine how much current potentially can pass through the body. High voltage provides greater poten- tial for high currents, but if resistance is also very high, current would be minimal or nonexistent. Current represents the potential danger to the patient. The harmful effects of current depend on: (1) the amount of current flowing through the body, (2) the path it takes, and (3) the duration the current is applied. Higher currents (>100 milliamps [mA]) that pass through the chest can cause ventricular fibrillation, diaphragm dysfunction (owing to severe, persistent contraction), and death.

Because current is most important, you should be familiar with the equation used to calculate it:

Current A Voltage V Resistance( ) ( ) ( )= Ω

46 SECTION I • Foundations of Respiratory Care

FIGURE 3-14 Possible hazard through use of certain cardiac monitors and a pacemaker.

Practitioner Pacer wire to heart

Patient

Ground

Instrument with defective ground or other undergrounded metal surface

Monitor that grounds right leg of patient

Pacemaker

FIGURE 3-12 Hazard created by broken ground wire.

Hot

Neutral

Grounded Instrument case

Practitioner

Broken ground

wire

Damp floor

FIGURE 3-13 Possible microshock hazard caused by patient grounding.

Hot

Broken ground

wire Ground

Transducer

Saline-filled tube or catheter

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 47

Hospital fires can be very serious, especially when they occur in patient care areas and when supplemental O2 is in use. Fires in O2-enriched atmospheres (OEAs) are larger, more intense, faster burning, and more difficult to extinguish. In addition, some material that would not burn in room air would burn in O2-enriched air. Hospital fires are also more serious because evacuation of critically ill patients is difficult and slow. For these reasons, hospital fires often cause more injuries and deaths per fire than do residential fires. For a fire to start, three conditions must exist: (1) flammable material must be present, (2) O2 must be present, and (3) the flammable material must be heated to or above its ignition temperature. When all three conditions are present, a fire starts. Conversely, removing any one of the condi- tions can stop a fire from starting or extinguish it after it has begun. Fire is a serious hazard around respiratory care patients using supplemental O2. Although O2 is nonflammable, it greatly accelerates the rate of combustion. Burning speed increases with an increase in either the concentration or the partial pres- sure of O2.

Flammable material should be removed from the vicinity of O2 use to minimize fire hazards. Flammable materials include cotton, wool, polyester fabrics, bed clothing, paper materials, plastics, and certain lotions or salves such as petro- leum jelly. Removal of flammable material is particularly important whenever O2 enclosures, such as O2 tents or crou- pettes, are used.

Ignition sources, such as cigarette lighters, should not be allowed in rooms where O2 is in use. In addition, the use of electrical equipment capable of generating high-energy sparks, such as exposed switches, must be avoided. All appliances that transmit house current should be kept out of O2 enclosures. Children should not play with toys that may create a spark when O2 is in use. RTs must be diligent in educating patients and visitors about the dangers associated with spark-producing items, open flames, and burning cigarettes in the hospital envi- ronment, especially in areas with O2-enriched air.

A frequent source of concern is the presence of static electri- cal sparks generated by friction. Even in the presence of high O2 concentrations, the overall hazard from static sparks with the materials in common use is very low. Solitary static sparks

Preventing Shock Hazards Most shock hazards are caused by inappropriate or inadequate grounding. Shock hazards can be eliminated or minimized if wiring in patient care areas is appropriate and if all equipment brought into the patient care area has been Underwriters Labo- ratories (UL) approved and checked on a regular basis by a qualified person.

Ground Electrical Equipment Near the Patient All electrical equipment (e.g., lights, electrical beds, ventilators, monitoring or therapeutic equipment) should be connected to grounded outlets with three-wire cords. In these cases, the third (ground) wire prevents the dangerous buildup of voltage that can occur on the metal frames of some electrical equipment.

Modern electrical devices used in hospitals are designed so their frames are grounded, but their connections to the patient are not. In this manner, all electrical devices in reach of the patient are grounded, but the patient remains isolated from ground. Because the ground wire is simply a protection device and not part of the main circuit, equipment continues to operate normally even if the ground wire is broken. All electri- cal equipment, particularly devices used with electrically sus- ceptible patients, must be checked for appropriate grounding on a regular basis by a qualified electrical expert.

Fire Hazards

In 1980, approximately 12,000 health care facility fires were officially reported in the United States.15 During the period of 2006 to 2010, the average annual number of fires in health care facilities was 6240.14 These health care facilities include hospi- tals, hospice facilities, nursing homes, mental health facilities, and doctors’ offices or clinics. This significant reduction in health care facility fires is primarily due to education and enforcement of strict fire codes.

Approximately 23% of fires in health care facilities occur in hospitals or hospice, and 46% occur in nursing homes; the most common site of origin of the fire is the kitchen.15 Medical facil- ity fires cause an annual average of 6 civilian deaths, 171 civilian injuries, and approximately $52.1 million in damage.15

TABLE 3-1

Effects of Electrical Shock*

Amperes (A) Milliamperes (mA) Microamperes (µA) Effects Applied to Skin (Macroshock) ≥6 >6000 >6,000,000 Sustained myocardial contraction followed by normal rhythm; temporary respiratory

paralysis; burns, if small area of contact 0.1-3 100-3000 100,000 Ventricular fibrillation; respiratory center intact 0.050 50 50,000 Pain; fainting; exhaustion; mechanical injury; heart and respiratory function intact 0.016 16 16,000 “Let go” current; muscle contraction 0.001 1 1000 Threshold of perception; tingling

Applied to Myocardium (Microshock) 0.001 0.1 100 Ventricular fibrillation

Duration of exposure and current pathway are major determinants of human response to electrical shock. *Physiologic effects of AC shocks applied for 1 second to the trunk or directly to the myocardium.

48 SECTION I • Foundations of Respiratory Care

treatments in a way that does not impede access to care and that reduces risk for falls. In addition, when care is completed, the RT should ensure that the patient has easy access to the patient call system.

Disaster Preparedness A key component of disaster preparedness involves learning to transport and transfer critically ill patients safely. Another component includes preparing for a loss of electricity, whether it is due to an internal or external disaster. In these emergen- cies, hospitals have backup generators to power essential equip- ment. All electrical outlets may not function on the backup generator. Some hospitals designate emergency outlets with a red outlet or red dot on an outlet, whereas others may power an entire wing, such as a medical intensive care unit, with the backup generator power. It is important for the RT to know the specific hospital policy for power failures and other potential disasters.

Magnetic Resonance Imaging Safety MRI exposes the body to powerful magnetic fields and a small amount of radiofrequency. This powerful magnetic field can create a risk to patients, health care workers, and equipment if metal objects are brought within specified proximity to the field. There are safe proximity areas referred to as safety zones or Gauss lines. Metal objects can be so forcefully attracted to the magnetic field that they can mimic a missile, causing physical harm. Reports of accidents associated with MRI have involved O2 cylinders, stethoscopes, scissors, and IV poles. Deaths have been described when O2 cylinders were pulled into the magnetic area where a patient was lying to undergo an MRI examination. RTs need to become familiar with MRI-compatible ventilators, O2 supplies, and ancillary equipment. Each radiology depart- ment has specific rules and safety precautions that need to be communicated to all patients, caregivers, and health care personnel.

Medical Gas Cylinders Use of compressed gas cylinders by RTs requires special han- dling. The physical hazards resulting from improper storage or handling of cylinders include increased risk for fire, explosive release of high-pressure cylinders, and the toxic effect of some gases. It is important to store and transport cylinders in appro- priate racks or chained containers. Compressed gas cylinders should never be stored without support.

Storage of medical-grade gases is regulated by National Fire Protection Association Standards 99 Healthcare Facilities Code (2014 edition) and monitored by TJC. Quantities of O2 or nitrous oxide of 300 cubic feet or less (about 12 E-cylinders) in a patient care area not to exceed 2100 m2 are required to be secured properly but do not have special storage room require- ments.16 Storing 300 to 3000 cubic feet of O2 or N2O requires noncombustible or limited combustible storage rooms with self-closing doors and at least a 30-minute fire rating.16 Cylin- ders must be stored 20 feet from any combustibles (5 feet if room is equipped with a sprinkler system).16 Follow your

generally do not have sufficient heat energy to raise common materials to their flash points. The minimal risk that may be present can be reduced further by maintaining high relative humidity (>60%).

If you identify a fire in a patient care area, you must know what to do. Each hospital must have a core fire plan that identi- fies the responsibilities of hospital personnel. The plan should be taught to all hospital personnel and practiced with fire drills to reinforce the education. Requirements may include routinely walking the fire exits and reviewing proper fire extinguisher training. Fire extinguisher training includes following the acronym PASS:

Pull the pin. There may be an inspection tag attached. Aim the nozzle. Aim low at the bottom of the fire. Squeeze the handle. The extinguisher has less than 30 seconds

of spray time. Sweep the nozzle across the base of the fire. The core fire plan follows the acronym RACE: Rescue patients in the immediate area of the fire. The person

discovering the fire should perform the rescue. Alert other personnel about the fire so they can assist in the

rescue and can relay the location of the fire to officials. This step also involves pulling the fire alarm.

Contain the fire. After rescuing patients, shut doors to prevent the spread of the fire and the smoke. In patient care areas, follow your hospital policy regarding turning off O2 zone valves.

Evacuate other patients and personnel in the areas around the fire who may be in danger if the fire spreads.

RTs are frequently key participants in successful handling of hospital fires. First, they know where the O2 zone valves are located and how to shut them off. Second, they have the knowl- edge and skills needed to evacuate patients receiving mechani- cal ventilation or supplemental O2 to sustain life. Third, they know how to treat and resuscitate victims of smoke inhalation. For these reasons, RTs should be included in all hospital evacu- ation planning and practices.

General Safety Concerns

In addition to electrical and fire safety, RTs need to be aware of general safety concerns, including the direct patient environ- ment, disaster preparedness, magnetic resonance imaging (MRI) safety, and medical gas safety. Medical gas safety is dis- cussed in more detail in Chapter 40.

Direct Patient Environment The immediate environment around the patient can create risk for patient safety. Because RTs use medical equipment and par- ticipate in direct patient care, it is necessary for RTs to be cog- nizant of the patient’s immediate environment.

To reduce the risk for patient falls and allow easy access to care, the patient care environment should be as free of impediments to care as possible. Use of respiratory supplies and medical equipment by the RT creates an environment that could impede access to care and create a fall risk. It is the responsibility of the RT to position equipment, tubing, and

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 49

sender to measure communication success and provide addi- tional information when needed.

Communication in Health Care

Effective communication is the most important aspect of pro- viding safe patient care. The first two 2010 National Patient Safety Goals of TJC are to improve accuracy of patient identi- fication and effectiveness of communicating critical test values among caregivers.17 All health care personnel must correctly identify patients before initiating care using a two–patient iden- tifier system. The patient identifiers can include any two of the following: name, birth date, and medical record number. Effec- tively communicating critical test values should include a “read back” scenario verifying the reporter and the receiver of the information and accurate reporting and recording of test values. Each institution may have specific values as critical test values; for example, RTs may be expected to report blood gas values of a pH less than 7.2 or a PaO2 less than 50 mm Hg. The process of the read back scenario is described in Box 3-4.

hospital policies and procedures when handling, transporting, or storing medical gas cylinders.

COMMUNICATION

Because the delivery of safe, high-quality health care requires interactions among many contributors from different disci- plines (e.g., physicians, RTs, nurses, etc.), communication is essential to the quality mission of a health care organization. Strategies to enhance communication are critical to organiza- tional success.

Communication is a dynamic human process involving sharing of information, meanings, and rules. Communication has five basic components: sender, message, channel, receiver, and feedback (Figure 3-15).

The sender is the individual or group who transmits the message. The message is the information or attitude that is communicated by the sender. Messages may be verbal or non- verbal. Verbal messages are voiced or written. Examples of dif- ferent kinds of messages are lectures, letters, and e-mail memos. Nonverbal communication is any communication that is not voiced or written. Nonverbal communication includes gestures, facial expressions, eye movements and contact, voice tone, space, and touch.

The channel of communication is the method used to trans- mit messages. The most common channels involve sight and hearing, such as written and oral messages. However, other sensory input, such as touch, may be used with visual or audi- tory communication. In addition, communication channels may be formal (memos or letters) or informal (conversation).

The receiver is the target of the communication and can be an individual or a group. One-on-one communication is often more effective because both parties can respond to each other. Communication with a group can be more challenging but is a more efficient way to get information to numerous individuals.

The last essential part of communication is feedback. Human communication is a two-way process in which the receiver serves an active role. Feedback from the receiver allows the

FIGURE 3-15 Elements of human communication. (See text on pp. 49 to 50.)

Sender Message Channel Receiver

• Communication skills • Attitudes • Experience • Culture • Self-concept

• Elements • Structure • Content • Treatment • Coding

• Seeing • Hearing • Touching • Smelling • Tasting

Feedback

Box 3-4 “Read Back” Process to Ensure Accurate Communication of Information

PRESCRIBER/REPORTER • Orders or critical test results are read and clearly enunciated,

using two patient identifiers. • Avoid abbreviations. • Ask receiver to “read back” the information if this is not done

voluntarily. • Verify with the receiver that the information is correct.

RECEIVER • Record the order or value. • Ask “prescriber/reporter” to repeat if information is not

understood. • “Read back” the information, including two patient identifiers. • Receive confirmation from the “prescriber/reporter” that the

information is correct; if incorrect, repeat the process.

50 SECTION I • Foundations of Respiratory Care

FIGURE 3-16 Factors influencing communication. (Modified from Wilkins RL, Sheldon RL, Krider SJ: Clinical assessment in respiratory care, ed 6, St. Louis, 2010, Mosby.)

INTERNAL FACTORS

SENSORY/EMOTIONAL FACTORS

INTERNAL FACTORS

ENVIRONMENTAL FACTORS

VERBAL EXPRESSION NONVERBAL EXPRESSION

Previous experiences Attitudes, values Cultural heritage Religious beliefs

Self-concept Listening habits

Preoccupations, feelings

Fear Stress, anxiety

Pain Mental acuity, brain damage, hypoxia

Sight, hearing, speech impairment

Previous experiences Attitudes, values Cultural heritage Religious beliefs

Self-concept Listening habits

Preoccupations, feelings Illnes

Lighting Noise

Privacy Distance

Temperature

Language barrier Jargon

Choice of words/questions Feedback, voice tone

Body movement Facial expression

Dress, professionalism Warmth, interest

state. The RT who considers all of these factors will become a better communicator. One example of this would the RT who combines a compassionate-toned verbal message such as, “You’re going to be all right now,” with a confirming touch of the hand is sending a much stronger message to an anxious patient than the message provided by either component alone. Several key purposes of communication are summarized in Box 3-5.

Improving Communication Skills

To enhance your ability to communicate effectively, focus on improving sending, receiving, and feedback skills. In addi- tion, identify and overcome common barriers to effective communication.

Another setting for improving communication between RTs regards transitions of care or “hand-off” of care; that is, when one RT is telling a colleague about the care of a patient who will be passed to the incoming RT for care. An effective communica- tion tool in this instance may be an SBAR (Situation, Back- ground, Assessment, and Recommendation).18 An example of this would be an RT discussing a patient’s intolerance to non- invasive ventilation. The situation is the patient is prescribed noninvasive ventilation but is not tolerating the device. The background is the patient has COPD and was admitted with a high PaCO2 and would benefit from the noninvasive ventila- tion. The assessment is the patient feels “claustrophobic” in the current full-face mask. Finally, the recommendation would be to try a smaller, less-confining mask to improve patient comfort.

As an RT, you will have many opportunities to communicate with patients, other RTs, nurses, physicians, and other members of the health care team. Success as an RT depends on your ability to communicate with these key people. Poor communi- cation skills can limit your ability to treat patients, work well with others, and find satisfaction in your employment.

Factors Affecting Communication

Many factors affect communication in the health care setting (Figure 3-16). The uniquely human or “internal” qualities of sender and receiver (including their prior experiences, attitudes, values, cultural backgrounds, and self-concepts and feelings) play a large role in the communication process.

Generally, the verbal and nonverbal components of com- munication should enhance and reinforce each other. Other factors that can affect communication include the patient’s direct health care environment and their sensory or emotional

Box 3-5 Purposes of Communication in the Health Care Setting

• To establish rapport with another individual, such as a colleague, a patient, or a member of the patient’s family

• To comfort an anxious patient by explaining the unknown • To obtain information, such as during a patient interview • To relay pertinent information, as when charting the results

of a patient’s treatment • To give instructions, as when teaching a patient how to

perform a lung function test • To persuade others to take action, as when attempting to

convince a patient to quit smoking • To educate and confirm understanding as in a “teach back”

scenario

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 51

MINI CLINI Patient Communication

PROBLEM: A 73-year-old man with COPD is admitted to the emergency department for acute shortness of breath that is not relieved with rest. The patient has been admitted more than eight times during the past year for various respiratory problems. The patient’s physician thinks that this episode may reflect a worsen- ing of his disease process and orders an inhaled bronchodilator via an MDI. After the RT enters the room and introduces herself, the patient becomes quite defensive, stating that he does not need any assistance with treatments and that she should just leave the medication in the room. The RT has not treated the patient in the past and has to decide how to respond to the patient’s request.

DISCUSSION: Although this patient exhibited reluctance in allowing the RT to administer the therapy, enough verbal and perhaps nonverbal communication (message) was expressed by the patient (sender) for the RT (receiver) to determine a plan of action. Because human communication is a two-way process, the RT serves an active role for further messages and interaction. This

is a key concept for RTs to master because it helps in identifying a patient’s problems, evaluating progress, and recommending further respiratory care. The RT must recognize that when an individual verbalizes disagreement with a treatment order and exhibits defensive behavior, the RT must attempt to understand what the patient is saying and must not overreact. The RT could try to put the patient at ease by making eye contact, gesturing effectively, and maintaining a safe distance from the patient when talking. The RT should seek feedback from the patient to ensure that the message was understood as it was intended. In this situ- ation, it may be appropriate for the RT to review and demonstrate MDI use, ask the patient to “teach back” proper inhaler use, and observe the patient self-administer the medication. This process (message) can be repeated until the patient can demonstrate proper technique. Allowing the patient to participate actively in medical care when feasible may serve to help him maintain a sense of control over his disease process.

Practitioner as Sender Your effectiveness as a sender of messages can be improved in several ways. These suggestions may be applied to the clinical setting as follows: • Share information rather than telling. Health professionals

often provide information in an authoritative manner by telling colleagues or patients what to do or say. This approach can cause defensiveness and lead to uncooperative behavior. Conversely, sharing information creates an atmosphere of cooperation and trust.

• Seek to relate to people rather than control them. This is of particular significance during communication with patients. Health care professionals often attempt to control patients. Few people like to be controlled. Patients feel much more important if they are treated as an equal partner in the rela- tionship. Explaining procedures to patients and asking their permission to proceed is a way to make them feel a part of the decision making regarding their care.

• Value disagreement as much as agreement. When individu- als express disagreement, make an attempt to understand what they are saying and do not become defensive. Be prepared for disagreement and be open to the input of others.

• Use effective nonverbal communication techniques. The non- verbal communication that you use is just as important as what you say. Nonverbal techniques may include eye contact, effective gesturing, facial expressions, and voice tone. It is important that your nonverbal communication matches what you are saying. It is also important to be cognizant of cultural differences in nonverbal contact. Some cultures may view direct eye contact as inappropriate, whereas in our country most find it an effective communication tool.

Practitioner as Receiver and Listener Receiver skills are just as important as sender skills. Messages sent are of no value unless they are received as intended. Active listening on the part of the receiver is required. Learning to listen requires a strong commitment and great effort. A few simple principles can help improve your listening skills, as follows: • Work at listening. Listening is often a difficult process. It takes

effort to hear what others are saying. Focus your attention on the speaker and on the message.

• Stop talking. Practice silent listening and avoid interrupting the speaker during an interaction. Interrupting the patient is a sure way to diminish effective communication.

• Resist distractions. It is easy to be distracted by surrounding noises and conversations. This is particularly true in a busy environment such as a hospital. When you are listening, try to tune out other distractions and give your full attention to the person who is speaking.

• Keep your mind open; be objective. Being open-minded is often difficult. All people have their own opinions that may influence what they hear. Try to be objective in your listening so that you treat everyone fairly.

• Hear the speaker out before making an evaluation. Do not just listen to the first few words of the speaker. This is a common mistake made by listeners. Often, listeners hear the first sen- tence and tune out the rest, assuming they know what is being said. It is important to listen to the entire message; otherwise, you may miss important information.

• Maintain composure; control emotions. Allowing emotions, such as anger or anxiety, to distort your understanding or drawing conclusions before a speaker completes his or her thoughts or arguments is a common error in listening.

52 SECTION I • Foundations of Respiratory Care

mean different things to different people. These differences in meaning derive from differences in the background or culture between the sender and receiver and the context of the communication. For example, RTs often use the letters COPD to refer to patients with chronic obstructive pulmo- nary disease caused by long-term smoking. Patients may hear COPD used in reference to them and be confused about the meaning and interpret COPD to mean a fatal lung disease. Never assume that the patient has the same under- standing as you in the interpretation of commonly used symbols or phrases.

• Different value systems. Everyone has his or her own value system, and many people do not recognize the values held by others. A large difference among the values held by individuals can interfere with communication. A clinical supervisor may inform students of the penalties for being late with clinical assignments. If a student does not value timeliness, he or she may not take seriously what is being said.

• Emphasis on status. A hierarchy of positions and power exists in most health care organizations. If superiority is empha- sized by individuals of higher status, communication can be stifled. Everyone has experienced interactions with profes- sionals who make it clear who is in charge. Emphasis on status can be a barrier to communication not only among health care professionals but also between health care profes- sionals and patients.

• Conflict of interest. Many people are affected by decisions made in health care organizations. If people are afraid that a decision will take away their advantage or invade their ter- ritory, they may try to block communication. An example might be a staff member who is unwilling to share expertise with students. This person may feel that a student is invading his or her territory.

• Lack of acceptance of differences in points of view, feelings, values, or purposes. Most of us are aware that people have different opinions, feelings, and values. These differences can thwart effective communication. To overcome this barrier, an effective communicator allows others to express their dif- ferences. Encouraging individuals to communicate their feelings and points of view benefits everyone. Most of us think we are always correct. Accepting input from others promotes growth and cooperation.

• Feelings of personal insecurity. It is difficult for people to admit feelings of inadequacy. Individuals who are insecure do not offer information for fear they appear ignorant or they may be defensive when criticized, blocking clear com- munication. Many of us have worked with individuals who are insecure, realizing the difficulty in communicating with them. To become an effective communicator, identify the purpose

of each communication interaction and your role in it. Use specific sending, receiving, and feedback skills in each interac- tion. Finally, minimize any identified barriers to communica- tion with patients or peers, to ensure that messages are received as intended.

• Active listening is a key component in health care commu- nication. Many of the messages being sent are vital to patient care. If you do not listen effectively, important information may be lost and the care of your patients may be jeopardized.

Providing Feedback To enhance communication with others, effective feedback needs to be provided. Examples of effective feedback mecha- nisms in oral communication with patients include attending, paraphrasing, requesting clarification, perception checking, and reflecting feelings: • Attending. Attending involves the use of gestures and pos-

ture that communicates one’s attentiveness. Attending also involves confirming remarks, such as, “I see what you mean.”

• Paraphrasing. Paraphrasing, or repeating the other’s response in one’s own words, is a technique that is useful in confirm- ing that understanding is occurring between the parties involved in the interaction. However, overuse of paraphras- ing can be irritating.

• Requesting clarification. Requesting clarification begins with an admission of misunderstanding on the part of the listener, with the intent being to understand the message better through restating or using alternative examples or illustra- tions. Overuse of this technique, as with paraphrasing, can hamper effective communication, especially if it is used in a condescending or patronizing manner. Requests for clarifi- cation should be used only when truly necessary and always should be nonjudgmental in nature.

• Perception checking. Perception checking involves confirm- ing or disproving the more subtle components of a com- munication interaction, such as messages that are implied but not stated. For example, the RT might sense that a patient is unsure of the need for a treatment. In this case, the RT might check this perception by saying, “You don’t seem to be sure that you need this treatment. Is that correct?” By verifying or disproving this perception, both the health care professional and the patient understand each other better.

• Reflecting feelings. Reflecting feelings involves the use of statements to determine better the emotions of the other party. Nonjudgmental statements, such as, “You seem to be anxious about (this situation),” provide the opportunity for patients to express and reflect on their emotions and can help them confirm or deny their true feelings.

Minimizing Barriers to Communication There are many potential barriers to effective communication. A skillful communicator tries to identify and eliminate or mini- mize the influence of these barriers in all interactions. By mini- mizing the influence of these barriers, the sender can help ensure that the message will be received as intended. Key bar- riers to effective communication are the following: • Use of symbols or words that have different meanings. Words

and symbols (including nonverbal communication) can

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 53

1. Competing 2. Accommodating 3. Avoiding 4. Collaborating 5. Compromising

Competing Competing is an assertive and uncooperative conflict resolution strategy. Competing is a power-oriented method of resolving conflict. A supervisor who uses rank or other forces to attempt to win is using the competing strategy. This strategy may be useful when an unpopular decision must be made or when one must stand up for his or her rights. However, because it often causes others to be quiet and feel inferior, competing should be used cautiously.

Accommodating Accommodating is the opposite of competing. Accommodat- ing is being unassertive and cooperative. When people accom- modate others involved in conflict, they neglect their own needs to meet the needs of the other party. Accommodation is a useful strategy when it is essential to maintain harmony in the environment. Accommodation is also appropriate when an issue is much more important to one party or the other in a dispute.

Avoiding Avoiding is both an unassertive and an uncooperative conflict resolution strategy. In avoiding conflict, one or both parties decide not to pursue their concerns. Avoidance may be appropriate if there is no possibility of meeting one’s goals. In addition, if one or both of the parties are hostile, avoid- ance may be a good strategy, at least initially. However, too much avoidance can leave important issues unattended or unresolved.

Collaborating As a conflict resolution strategy, collaborating is the opposite of avoiding. Collaborating is assertive and cooperative. In collabo- ration, the involved parties try to find mutually satisfying solu- tions to their conflict. Collaboration usually takes more time than other methods of conflict management and cannot be applied when the involved parties harbor strong negative feel- ings about each other.

Compromising Compromising is a middle-ground strategy that combines assertiveness and cooperation. People who compromise give up more than individuals who compete but give up less than indi- viduals who accommodate. Compromise is best used when a quick resolution is needed that both parties can accept. However, because both parties often feel they are losing, compromise should not be used exclusively.

Deciding which type of conflict resolution strategy to use requires knowledge of the context, the specific underlying problem, and the desires of the involved parties.

CONFLICT AND CONFLICT RESOLUTION

Conflict is sharp disagreement or opposition among people over interests, ideas, or values. Because no two people are exactly alike in their backgrounds or attitudes, conflict can be found in every organization. Health care professionals experience a great deal of conflict in their jobs. Rapid changes occurring in health care have made everyone’s jobs more complex and often more stressful. Because conflict is inevitable, all health care profes- sionals must be able to recognize its sources and help resolve or manage its effect on people and on the organization.

Sources of Conflict

The first step in conflict management is to identify its potential sources. The four primary sources of conflict in organizations are (1) poor communication, (2) structural problems, (3) per- sonal behavior, and (4) role conflict.

Poor Communication Poor communication is the primary source of conflict in orga- nizations. The previously discussed barriers to communication all are potential sources of conflict. If a supervisor is unwilling to accept different points of view for dealing with a difficult patient, an argument may occur. The importance of good com- munication cannot be overemphasized.

Structural Problems The structure of the organization itself can increase the likeli- hood of conflict. Conflict tends to grow as the size of an orga- nization increases. Conflict is also greater in organizations whose employees are given less control over their work and in organizations in which certain individuals or groups have excessive power. Structural sources of conflict are the most rigid and are often difficult to control.

Personal Behavior Personal behavior factors are a major source of conflict in orga- nizations. Different personalities, attitudes, and behavioral traits create the possibility of great disagreement among health care professionals and between health care professionals and patients.

Role Conflict Role conflict is the experience of being pulled in several direc- tions by individuals who have different expectations of a per- son’s job functions. A clinical supervisor is often expected to function both as a staff member and as a student supervisor. Trying to fill both roles simultaneously can cause stress and create interpersonal conflict.

Conflict Resolution

Conflict resolution or management is the process by which people control and channel disagreements within an organi- zation. The following are five basic strategies for handling conflict:

54 SECTION I • Foundations of Respiratory Care

Because the law requires that a record be kept of the patient’s care, a patient’s chart is also a legal document. For this reason, charting or recordkeeping must be done so that it is meaningful for days, months, or years.

Components of a Traditional Medical Record

Each health care facility has its own specification for the medical records it keeps. Although the forms themselves vary among institutions, most acute care medical records share common sections (Box 3-6). Documentation sheets are designed to report data briefly and to decrease time spent in documenta- tion. Entries can include many measurements, and review of a sequence of entries can reveal trends in patient status.

Legal Aspects of Recordkeeping

Legally, documentation of the care given to a patient means that care was given; no documentation means that care was not given. Hospital accreditation agencies critically evaluate the medical records of patients. If the RT does not document care given (i.e., patient assessment data, interventions, and evalua- tion of care rendered), the practitioner and the hospital may be accused of patient neglect.

Adequate documentation of care is valuable only in refer- ence to standards and criteria of care. Similar to all departments in health care facilities, respiratory care departments must gen- erate their own standards of patient care. For each standard, criteria must be outlined so that the adequacy of patient care can be measured. Documentation must reflect these standards.

Practical Aspects of Recordkeeping

Recordkeeping is one of the most significant duties that a health care professional performs. Documentation is required for each medication, treatment, or procedure. Accounts of the patient’s condition and activities must be charted accurately and in clear terms. Brevity is essential, although a complete account of each patient encounter is needed. The use of standardized terms and abbreviations is acceptable; however, TJC had published a “Do Not Use” abbreviation list developed to reduce potential errors (Table 3-2).19 Documentation of consultations with the attend- ing physician that include the date and time of the conversation is recommended.

Accounts of care and the patient’s condition can be hand- written, but with increasing frequency, EMRs facilitate data entry by selection from menus of choices or direct typing (see section on EMR in Chapter 7). In either case, you must docu- ment only what is—not an interpretation or a judgment. Assessments of data must be clearly within one’s professional domain. When a practitioner cannot interpret the data obtained, he or she should state so in the record and contact another health care professional for advice or referral and document the referral in the patient’s medical record. Other general rules for medical recordkeeping are listed in Box 3-7. In addition to these general rules, each institution has its own policies governing medical recordkeeping.

RECORDKEEPING

By 2015, the U.S. government would like all medical record- keeping to be done electronically. The electronic medical record (EMR) is changing the way health care practitioners document care, but the overall content and concept of what we record remains the same (see Chapter 7 for a full discus- sion of the EMR). A medical record or chart presents a written picture of occurrences and situations pertaining to a patient throughout his or her stay in a health care institution. Medical records are the property of the institution and are strictly con- fidential. This information is protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The content of a patient’s medical records, health insurance, or billing are not to be read or discussed by anyone except for the individuals directly caring for the patient in a hospital or medical care facility. In addition, the medical record is a legal document.

MINI CLINI Legal Aspects of Recordkeeping

PROBLEM: A patient was given a respiratory treatment by a respiratory care student, who forgot to chart that the therapy was given. The student reasoned that because he did not observe any adverse effects during or immediately after the treatment and he knew that the treatment was given, not docu- menting the treatment in the medical record this one time would be acceptable. What are the problems associated with this student’s judgment and subsequent actions?

DISCUSSION: The medical record is a legal document intended to identify types of care given to a patient and serve as a source of information to the physician, RT (including the student), and other health care providers in developing an indi- vidualized plan of care. It further serves as a tool for evaluating the effectiveness in reaching the goals of therapy. Hospitals and other health care agencies critically evaluate the medical records of patients to maintain high-quality patient care. Failure to document care rendered, such as a respiratory treatment, hinders the process of providing high-quality care in several ways.

First, information that is important to the physician and other caregivers interested in the patient’s respiratory status is missing from the medical record. In this situation, although the student observed a lack of response by the patient during and immediately after the treatment, a delayed effect still could have occurred. Consequently, the physician or RT would have dif- ficulty in establishing the cause of a condition change in the patient related to the respiratory treatment. From a legal per- spective, patient care not documented may be viewed as care not rendered, making the hospital or institution vulnerable to charges of patient neglect, which would be difficult to defend in a court of law.

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 55

TABLE 3-2

The Joint Commission “Do Not Use” List*

Do Not Use Potential Problem Use Instead

U (unit) Mistaken for 0 (zero), the number 4 (four) or cc Write “unit” IU (international unit) Mistaken for IV (intravenous) or the number 10 (ten) Write “international unit” Q.E., QD, q.d., qd (daily); Q.O.D.,

POD, q.o.d, qod (every other day) Mistaken for each other; period after the Q mistaken for I and

the O mistaken for I Write “daily” or “every other day”

Trailing zero (X.0 mg)†; lack of leading zero (.X mg)

Decimal point is missed Write “X mg” or “0.X mg”

MS Can mean morphine sulfate or magnesium sulfate Write “morphine sulfate” MSO4, MgSO4 Confused for one another Write “magnesium sulfate”

Additional Abbreviations, Acronyms, and Symbols for Possible Future Inclusion in the Official “Do Not Use” List > (greater than); < (less than) Misinterpreted as the number 7 (seven) or the letter L; confused

for one another Write “greater than” or “less

than” Abbreviations for drug names Misinterpreted owing to similar abbreviations for multiple drugs Write drug names in full Apothecary units Unfamiliar to many practitioners; confused with metric units Use metric units @ Mistaken for the number “2” (two) Write “at” cc Mistaken for U (units) when poorly written Write “mL” or “ml” or “milliliters”

(“mL” is preferred) µg Mistaken for mg (milligrams) resulting in 1000-fold overdose Write “mcg” or “micrograms”

From Joint Commission on Accreditation of Healthcare Organizations: 2010 JCAHO “Do Not Use” list. http://www.jointcommission.org/hospitals. Accessed September 17, 2014. *Applies to all orders and all medication-related documentation that is hand-written (including free-text computer entry) or on preprinted forms. †Exception: A “trailing zero” may be used only where required to show the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

Box 3-6 General Sections Found in a Patient Medical Record

ADMISSION DATA Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, and admission diagnosis

HISTORY AND PHYSICAL EXAMINATION Records the patient’s admitting history and physical examination, as performed by the attending physician or resident

HEALTH MAINTENANCE AND IMMUNIZATIONS Records the dates of administration

PHYSICIAN’S ORDERS Records the physician’s orders and prescriptions

PROGRESS NOTES Keeps a continuing account of the patient’s progress for the physician

NURSES’ NOTES Describes the nursing care given to the patient, including the patient’s complaints (subjective symptoms), the nurses’ observations (objective signs), and the patient’s response to therapy

MEDICATION RECORD Notes drugs and IV fluids that are given to the patient

ALLERGIES Notes reaction, severity, type, and date

VITAL SIGNS FLOWSHEET Records the patient’s temperature, pulse, respirations, and blood pressure over time

I/O SHEET Records patient’s fluid intake (I) and output (O) over time

LABORATORY RESULTS Summarizes the results of laboratory tests

CONSULTATION NOTE Records notes by physicians who are called in to examine a patient to make a diagnosis

SURGICAL OR TREATMENT CONSENT Records the patient’s authorization for surgery or treatment

ANESTHESIA AND SURGICAL RECORD Notes key events before, during, and immediately after surgery

SPECIALIZED THERAPY RECORDS AND PROGRESS NOTES Records specialized treatments or treatment plans and patient progress for various specialized therapeutic services (e.g., respiratory care, physical therapy)

SPECIALIZED FLOW DATA Records measurement made over time during specialized procedures (e.g., mechanical ventilation, kidney dialysis)

ADVANCED DIRECTIVES Records wishes and documents regarding living wills, power of attorney, and do-not-resuscitate orders

http://www.jointcommission.org/hospitals

56 SECTION I • Foundations of Respiratory Care

TABLE 3-3

Examples of Objective Data, Assessments, and Plans Typical for Documentation Using SOAP Notes

Objective Data Assessment Plan

Sputum Production Thick, purulent Respiratory infection Humidity therapy, antibiotics

Auscultation Expiratory wheezing Bronchospasm Bronchodilator Stridor Upper airway obstruction Racemic epinephrine, possible intubation Late-inspiratory crackles Atelectasis Lung expansion therapy

Breathing Pattern Prolonged expiratory time Bronchospasm Bronchodilators Prolonged inspiratory time Upper airway obstruction Racemic epinephrine; consider need for intubation Rapid and shallow Restrictive lung disease Notify physician, perform additional assessment, consider lung expansion

therapy

Vital Signs Acute tachycardia/tachypnea Acute respiratory failure Obtain ABGs, chest x-ray films; call physician Abnormal sensorium Acute hypoxia Assess patient further; oxygen therapy

ABGs PaO2 40-60 mm Hg Moderate hypoxemia Give O2 via cannula or mask PaO2 < 40 mm Hg Severe hypoxemia Give high concentration O2 as needed and consider positive pressure

ventilation with PEEP or CPAP

Chest Radiograph Low lung volumes or infiltrates Atelectasis Lung expansion therapy Air in pleural space Pneumothorax Insert chest tube

ABGs, Arterial blood gas analysis; CPAP, continuous positive airway pressure; PEEP, positive end-expiratory pressure.

Problem-Oriented Medical Record

The problem-oriented medical record (POMR) is an alterna- tive documentation format used by some health care institu- tions. The POMR contains four parts: (1) the database, (2) the problem list, (3) the plan, and (4) the progress notes. Whether electronic or written, the precise forms these records take vary among institutions but will share common information.

The database contains routine information about the patient. A general health history, physical examination results, and results of diagnostic tests are included.

In the POMR, a problem is something that interferes with a patient’s physical or psychologic health or ability to function. The patient’s problems are identified and listed on the basis of the information provided by the database. The list of problems is dynamic; new problems are added as they develop, and prob- lems are removed as they are resolved.

The POMR progress notes contain the findings (subjective and objective data), assessment, plans, and orders of the physi- cians, nurses, and other practitioners involved in the care of the patient. The format used is often referred to as SOAP (S = sub- jective information, O = objective information, A = assessment, P = plan of care). Figure 3-17 shows a representative SOAP form for respiratory care progress notes. Box 3-8 provides a hand- written example of a SOAP entry. Table 3-3 lists common objec- tive data gathered by RTs and examples of applicable assessments and plans. In many institutions, all caregivers chart on the same form, using the SOAP format.

Box 3-7 General Rules for Medical Recordkeeping

• Entries on the patient’s chart should be printed or handwritten unless the institution is using an electronic medical record. After completing the account in the handwritten record, sign the chart with one initial and your last name and your title (CRT, RRT, Resp Care Student; e.g., S. Smith, CRT). Institutional policy may require that supervisory personnel countersign student entries in the hand-written record.

• Do not use ditto marks. • Do not erase. Erasures provide reason for question if the

chart is used later in a court of law. If a mistake is made, a single line should be drawn through the mistake and the word error printed above it. Then continue your charting in a normal manner.

• Record after completing each task for the patient, and sign your name correctly after each entry.

• Be exact in noting the time, effect, and results of all treatments and procedures.

• Chart patient complaints and general behavior. Describe the type, location, onset, and duration of pain. Describe clearly and concisely the character and amount of secretions.

• Leave no blank lines in the charting. Draw a line through the center of an empty line or part of a line. This prevents charting by someone else in an area signed by you.

• Use standard abbreviations. (Follow the “Do Not Use” list.18) • Use the present tense. Never use the future tense, as in

“Patient to receive treatment after lunch.” • Spell correctly. If you are unsure about the spelling of a

word, look it up in a dictionary. • Document conversations with the patient or other health

care providers that you think are important (e.g., you informed the patient’s physician or nurse that the patient seems confused or more short of breath).

Quality, Patient Safety, Communication, and Recordkeeping • CHAPTER 3 57

FIGURE 3-17 Example of a SOAP form for respiratory care progress notes. (From Des Jardins T, Burton GG: Clinical manifestations and assessment of respiratory disease, ed 6, St. Louis, 2011, Mosby.)

PRESENT PLAN

PLAN MODIFICATIONS

Re sp

ira to

ry A

ss es

sm en

t F lo

w C

ha rt

Subjective Objective Assessment Plan

Other:

Neg. O2 transport factors SpO2SaO2PaO2

PaCO2pH HCO3 �ABG:

Cough: Sputum production: Sputum char.

Strong Weak

Yes No

Bedside spir.: PEFR a� p� Tx SVC FVC NIF

Radiography

Palp. Perc. Ausc.

Insp. Chest assessment:

Vital signs: RR HR BP Temp. On antipyretic agent?

Pt. name

Age Male Female

Date Time

Admitting diagnosis

Therapist

Hospital

Posterior

RULE OF THUMB

Charting Progress Notes Using the SOAP Format SOAP stands for Subjective, Objective, Assessment, Plan. • Subjective information obtained from the patient, his

or her family members, or a similar source • Objective information based on caregivers’

observations of the patient, the physical examination, or diagnostic or laboratory tests such as arterial blood gases or pulmonary function tests

• Assessment, which refers to the analysis of the patient’s problem

• Plan of action to be taken to resolve the problem

Box 3-8 Example of SOAP Entry

PROBLEM 1 Difficult breathing.

SUBJECTIVE “I can’t catch my breath.”

OBJECTIVE Awake; alert; oriented to time, place, and person; sitting upright in bed with arms leaning over the bedside stand; pale, dry skin; respirations 26 breaths/min and shallow; pulse 98 beats/min, regular and faint to palpation; blood pressure 112/68 mm Hg, left arm, sitting position; body temperature 101° F; bronchial breath sounds in lower posterior lung fields; occasionally expectorating small volumes of mucopurulent sputum. Chest x-ray film shows left lower lung infiltrate.

ASSESSMENT Retained mucus and possible infection.

PLAN Therapeutic: Assist with coughing and deep breathing at least

every 2 hours; postural drainage and percussion every 4 hours; assist with ambulation as per physician orders and patient tolerance.

Diagnostic: Continue to monitor lung sounds before and after each treatment.

Education: Teach patient to cough and deep breathe and evaluate return demonstration.

58 SECTION I • Foundations of Respiratory Care

SUMMARY CHECKLIST

◗ The quality of a service or product refers to the sum of its properties that serve to satisfy the needs of its consumer.

◗ Quality improvement is everyone’s job. ◗ Statistical process control and run charts are tools that

allow continuous monitoring of quality of service. ◗ Quality improvement projects involve different phases:

Planning the project, implementing the project, analyzing the results, and changing course of action based on analysis.

◗ Competency is defined as having suitable or sufficient skills, knowledge, and experience for the purposes of the specific task.

◗ Annual competency checks need to be documented for skills and procedures that pose potential risk to patient safety.

◗ The Joint Commission (TJC) is an independent, non-for- profit organization that strives to continuously improve quality and safety of health care services by setting high standards and evaluating health care organizations for adherence.

◗ TJC requires hospitals to have quality assurance plans and encourages performance improvement efforts.

◗ Hospital accreditation by TJC is based on satisfying specific standards established by professional and technical advisory committees.

◗ Good posture is needed when lifting patients or heavy equipment to avoid injury.

◗ Electrical current (flow) is the dangerous element of electricity. Current is directly related to voltage and inversely related to resistance.

◗ A microshock is a small, imperceptible current (<1 mA) that enters the body through external wires or catheters; microshocks can cause ventricular fibrillation.

◗ To avoid electrical hazards, always ground equipment and use only equipment that has been checked for proper wiring.

◗ Fires in health care facilities most often start in the kitchen, but when they occur in patient care areas, loss of life and serious injuries are likely.

◗ Maintain a safe and clutter-free direct patient care environment.

◗ Store and transport medical grade gases in a safe and effective manner.

◗ Communication skills play a key role in the ability to identify a patient’s problems, to evaluate the patient’s progress, to make recommendations for respiratory care, and to achieve desired patient outcomes.

◗ Individuals’ prior experiences, attitudes, values, cultural backgrounds, self-concepts, and feelings play a large role in the communication process.

◗ To enhance communication ability, focus on improving sending, receiving, and feedback skills; in addition, be able to identify and overcome common barriers to effective communication.

◗ Choose the best strategy for handling conflict considering knowledge of the context, the specific underlying problem, and the desires of the involved parties.

◗ The EMR is transforming the way we document care but not the concept and content of what is documented.

◗ A medical record is a confidential document that summarizes the care received by a patient; legally, a failure to document care means that care was not given.

◗ Following accepted standards, each medication, treatment, or procedure provided to the patient, including his or her condition and response to therapy, must be documented in accurate and clear terms.

◗ When entering notes in a POMR, use a SOAP format.

References

1. Deming WE: Out of the crisis, Cambridge, MA, 2009, Massachusetts Insti- tute of Technology Center for Advanced Engineering Study.

2. Turner MO, Patel A, Ginsburg S, et al: Bronchodilator delivery in acute airflow obstruction: a meta-analysis. Arch Intern Med 157:1736, 1997.

3. Cates C: Spacers and nebulisers for the delivery of beta-agonists in non- life-threatening acute asthma. Respir Med 97:762, 2003.

4. Cates CC, Welsh EJ, Rowe BH: Holding chambers versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev (9): CD000052, 2013.

5. Epstein RS, Sharwood LM: From outcomes research to disease manage- ment: a guide for the perplexed. Ann Intern Med 124:832, 1996.

6. Elrodt G, Cook DJ, Lee J, et al: Evidence-based disease management. JAMA 78:1997, 1687.

7. Mish FC, Gilman WW, editors: Webster’s ninth new collegiate dictionary, Springfield, MA, 1985, Merriam-Webster.

8. Harder BN: Use of simulation in teaching and learning in health sciences: a systematic review. J Nurs Educ 49:23, 2010.

9. Van Herck P, De Smedt D, Annemans L, et al: Systematic review: effects, design choices, and context of pay-for- performance in healthcare. BMC Health Serv Res 10:247, 2010.

10. Kester EL, Stoller JK: A computer-aided audit system for respiratory therapy consult evaluations: description of a method and early results. Respir Care 58:790, 2013.

11. Lowell KH, Bertko J: The accountable care organization (ACO) model: building blocks for success. J Ambul Care Manage 33:81, 2010.

12. Kester L, Stoller JK: Respiratory care in the adult non-ICU setting. Respir Care 42:101, 1997.

13. Siu AL, Penrod JD, Boockvar KS, et al: Early ambulation after hip fracture: effects on function and mortality. Arch Intern Med 166:766, 2006.

14. Mundy LM, Leet TL, Darst K, et al: Early mobilization of patients hospital- ized with community-acquired pneumonia. Chest 124:883, 2003.

15. Ahrens M: U.S. Fires in healthcare facilities, Quincy, MA, 2012, National Fire Protection Association. <http://www.nfpa.org>. Accessed May 15, 2015.

16. National Fire Protection Association: Healthcare facilities 99, standard for healthcare facilities, ed 2015, Quincy, MA, 2014, National Fire Protection Association.

17. Joint Commission: National Patient Safety Goals 2014. http://www .jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf. Accessed September 17, 2014.

18. Haig K, Sutton S, Whittington J: SBAR: a shared mental model for improv- ing communication between clinicians. Jt Comm J Qual Patient Saf 32:171, 2006.

19. Joint Commission on Accreditation of Healthcare Organizations: 2010 JCAHO “Do Not Use” list. http://www.jointcommission.org/hospitals. Accessed September 17, 2014.

http://www.nfpa.org

http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf

http://www.jointcommission.org/hospitals

C H A P T E R 4

Principles of Infection Prevention and Control

MICHELE MESSAM AND THOMAS G. FRASER

CHAPTER OBJECTIVES

After reading this chapter you will be able to: ◆ Define health care–associated infections and state how often they occur. ◆ Describe why infection prevention is important in respiratory care. ◆ Identify and describe the three elements that must be present for transmission of infection within a health care

setting. ◆ List the factors associated with an increased risk for a patient acquiring a hospital-acquired infection. ◆ State the three major routes for transmission of human sources of pathogens in the health care environment. ◆ Describe strategies to control the spread of infection in the hospital. ◆ Describe how to select and apply chemical disinfectants for processing respiratory care equipment. ◆ Describe equipment-handling procedures that help prevent the spread of pathogens. ◆ State when to use personal protective equipment during patient care. ◆ Describe surveillance with regard to infection control.

CHAPTER OUTLINE

Spread of Infection Sources of Infectious Agents Susceptible Hosts Modes of Transmission

Infection Prevention Strategies Creating a Safe Culture Maintaining a Healthy Workforce Eliminating the Source of Pathogens Interrupting Transmission Standard Precautions Hand Hygiene Gloves Mouth, Nose, Eye, and Face Protection Respiratory Protection Gowns, Aprons, and Protective Apparel Cough Etiquette Transmission-Based Precautions

Protective Environment Transport of Infected Patients Medical Devices and Bundles

Disinfection and Sterilization Spaulding Approach to Disinfection and Sterilization

of Patient Care Equipment Cleaning Disinfection Sterilization

Equipment Handling Procedures Maintenance of In-Use Equipment Processing Reusable Equipment Disposable Equipment Fluids and Medications Precautions Handling Contaminated Articles and Equipment Handling Laboratory Specimens

Surveillance for Hospital-Acquired Infections

KEY TERMS

antiseptic bactericidal bacteriostatic cohorting

contact precautions disinfection droplet nuclei droplet precautions

fomites health care–associated infection Healthcare Infection Control

Practices Advisory Committee

60 SECTION I • Foundations of Respiratory Care

gens, (2) a susceptible host, and (3) a route of transmission for the pathogen (Figure 4-1).2

Sources of Infectious Agents

Humans (patients, personnel, or visitors) are the primary source for infectious agents in the health care setting, but inani- mate objects (e.g., contaminated medical equipment, linen, medications) also have been implicated in transmission. Patients quickly contaminate their local hospital environment, particu- larly high-touch surfaces, such as call lights, bed rails, tray tables, and bathrooms. People also may serve as their own source of infection, via endogenous flora. This latter process is called autogenous infection.

Susceptible Hosts

Susceptibility and resistance to infection vary greatly. Host factors in the acute setting that predispose to HAI can be considered modifiable and nonmodifiable. Host factors, such as poorly controlled diabetes mellitus, extremes of age, and underlying acquired (human immunodeficiency virus [HIV] infection) or iatrogenic (through chemotherapy or anti–tumor necrosis factor inhibitors) immunodeficiency, can enhance sus- ceptibility to infection and are not readily modifiable in the acute setting. Surgical incisions and radiation therapy impair defenses of the skin and organ space. Medical devices, such as urinary tract catheters, central venous catheters, and endotra- cheal tubes, increase the risk for infection by impeding local host defenses and providing a surface for the development of biofilms. The need for the medical device may be unavoidable. However, the risk for infection associated with it can be modi- fied by employing appropriate techniques for insertion, main- tenance, and removal.

Modes of Transmission

The three major routes for transmission of human pathogens in the health care environment are contact (direct and indirect), respiratory droplets, and airborne droplet nuclei (respirable par- ticles <5 µm). Table 4-1 provides examples of the common transmission routes for selected microorganisms.3

P atients are at risk for developing infections during their hospital stay. A recent study estimated that 4% of hos-pitalized patients in the United States develop a health care–associated infection.1 To help better understand preventive measures, infections can be categorized by where they originate. Those that develop outside the hospital are called community onset. Those that develop in the hospital are called hospital- onset or nosocomial infections. However, in the current era, patients can receive care in many different settings—the home, the hospital, a skilled nursing facility, or an outpatient treat- ment center. Patients who are at home but getting care in a nonhospital setting can develop community-onset infections that are related to health care and are not community acquired. The term health care–associated infection (HAI) refers to infections that develop in a patient during the course of medical treatment. This classification system is not arbitrary, because there are unique risks for HAIs such as the presence of an endo- tracheal tube or a central venous catheter. HAIs also can be related to certain pathogens that are more likely to be resistant to one or more classes of antimicrobial agents. For example, Pseudomonas aeruginosa is commonly seen as a cause of HAI pneumonia; however, it is not routinely seen as a cause of community-acquired disease.

Efforts to decrease hospital-acquired infection and HAIs are commonly organized and coordinated by a hospital’s Infec- tion Prevention (IP) program. IP programs are charged with reducing the risk for HAIs and thereby protecting patients, employees, and visitors. They do this by providing guidance to their organizations so that they can break the chain of events leading to HAIs. Guidance and prevention efforts are directed at overall organizational structure and systems (“this is what we do as an institution to prevent infection”) and at the individual caregiver level (“this is what I do to prevent infection”).

Protecting patients and health care professionals against HAIs requires strict adherence to IP procedures. These proce- dures aim to eliminate the sources of infectious agents, create barriers to their transmission, and monitor and evaluate the effectiveness of control. IP departments coordinate activities and provide guidance to their institutions. Decreasing the risk for HAIs is a major and ongoing responsibility of all health care workers, including respiratory therapists (RTs). To fulfill this responsibility, RTs must be able to select and consistently apply a full spectrum of daily competencies. This chapter provides the foundation needed to assume this important responsibility.

SPREAD OF INFECTION

Three elements must be present for transmission of infection within a health care setting: (1) a source (or reservoir) of patho-

FIGURE 4-1 Elements that must be present for infection to spread.

Source Route

Host

high-efficiency particulate air/ aerosol filters

hospital-acquired infections Occupational Safety and Health

Administration

respiratory hygiene/cough etiquette sporicidal standard precautions

sterilization surveillance virucidal

Principles of Infection Prevention and Control • CHAPTER 4 61

pathogens from one person to another are called fomites. Indi- rect contact transmission involving fomites can occur when instruments have been inadequately cleaned between patients before disinfection or sterilization.

Droplet Transmission Droplet transmission is a form of contact transmission, but the mechanism of transfer of the pathogen is distinct and addi- tional prevention measures are required. Organisms that are transmitted by respiratory droplets include influenza and Neis- seria meningitidis. Respiratory droplets are generated when an infected individual discharges large contaminated liquid drop- lets into the air by coughing, sneezing, or talking. Respiratory droplets are also generated during procedures such as suction- ing, bronchoscopy, and cough induction. Transmission occurs when infectious droplets are propelled (usually ≤3 feet through the air) and are deposited on another person’s mouth or nose. Using the distance of 3 feet or less as a minimum threshold for donning a mask has been effective in preventing transmission of infectious agents. However, experimental studies with small- pox and investigations of outbreaks of severe acute respiratory syndrome (SARS) suggest that droplets from infected patients rarely are able to reach a person 6 feet away.4 A distance of 3 feet or less around the patient is considered a short distance and is not used as a criterion for deciding when a mask should be donned to protect from exposure. Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines state it may be prudent to don a mask when within 6 to 10 feet of a patient or on entry into the room of a patient who is on droplet isolation.3

Airborne Transmission Airborne transmission occurs via the spread of airborne droplet nuclei. These are small particles (≤5 µm) of evaporated drop- lets containing infectious microorganisms that can remain sus- pended in air for long periods. Microorganisms carried in this manner may be dispersed widely by air currents because of their small size and inhaled by susceptible hosts over a longer dis- tance from the source patient compared with droplet trans- mission. Examples of pathogens transmitted via the airborne route include Mycobacterium tuberculosis, varicella-zoster virus (chickenpox), and rubeola virus (measles).4

Special air handling and ventilation and respiratory protec- tion are required to prevent airborne transmission because microorganisms may remain suspended in air and be widely dispersed by air currents before contacting a susceptible host. In addition to airborne infection isolation rooms, personal respiratory protection with National Institute for Occupational Safety and Health (NIOSH)–approved N-95 or higher respira- tors is required to prevent airborne transmission.3 A surgical mask, used for droplet precautions, is insufficient.

Miscellaneous Types of Aerosol Transmission The separation of organisms that are transmitted by aerosols into the categories of droplet and airborne is based on the usual

TABLE 4-1

Routes of Infectious Disease Transmission

Mode Type Examples

Contact Direct Hepatitis A HIV Staphylococcus Enteric bacteria

Indirect Pseudomonas aeruginosa Enteric bacteria Hepatitis B and C HIV

Droplet Haemophilus influenzae (type B) pneumonia and epiglottitis

Neisseria meningitidis pneumonia Diphtheria Pertussis Streptococcal pneumonia Influenza Mumps Rubella Adenovirus Rhinovirus

Vehicle Water-borne Shigellosis Cholera

Food-borne Salmonellosis Hepatitis A

Airborne Aerosols Legionellosis Droplet nuclei Tuberculosis

Varicella Measles Smallpox

Vector-borne Ticks and mites Rickettsia Lyme disease

Mosquitoes Malaria Fleas Bubonic plague

HIV, Human immunodeficiency virus.

Contact Transmission Contact transmission is the most common route of transmis- sion and is divided into two subgroups: direct and indirect. Direct contact transmission occurs when a pathogen is trans- ferred directly from one person to another. Direct contact trans- mission occurs less frequently than indirect contact in the health care environment but is more efficient. An example of direct contact transmission would be development of respira- tory syncytial virus bronchiolitis in a bone marrow transplant recipient owing to transmission of the virus from an ill health care worker who did not perform appropriate hand hygiene before providing care.

Indirect contact transmission is the most frequent mode of transmission in the health care environment and involves trans- fer of a pathogen through a contaminated intermediate object or person. The most common indirect contact transmission in health care involves unwashed hands of health care personnel that touch an infected or a colonized body site on one patient, or a contaminated inanimate object, and subsequently touch another patient. Inanimate objects that may serve to transfer

62 SECTION I • Foundations of Respiratory Care

ate time, equipment, and training to provide the best possible care. Competent health care workers execute appropriate prac- tice, such as attention to hand hygiene and adherence to infec- tion prevention bundles of care on a daily basis with every patient. Failure to perform these basics is a deviation from good practice and cannot be tolerated. The presence of appropriate systems to deliver care and a committed workforce consistently executing best practice are necessary for an organization to reli- ably prevent infections.6

Maintaining a Healthy Workforce

The day-to-day care of hospitalized patients relies on people. A sick health care worker not only has difficulty executing assign- ments but could also serve as a source of infection for vulner- able patients. There are multiple different components to maintaining a healthy workforce. The standard and transmission- based precautions described later not only prevent transmission of pathogens from patient to patient but also protect health care workers. Other efforts employed to protect health care workers are employee immunization and chemoprophylaxis. Certain immunizations are recommended for susceptible health care personnel to decrease the risk for infection and the potential for transmission to patients and co-workers within the health care facility.5 The Occupational Safety and Health Administration (OSHA) mandates that employers offer hepatitis B vaccination. Vaccinations of health care workers in the absence of evidence of immunity against varicella, rubella, and measles should be strongly encouraged. In addition, health care personnel should receive the adult acellular pertussis vaccine, particularly those who care for young infants and children. Health care personnel without medical contraindications should receive an annual influenza vaccination.5 Health care worker influenza vaccina- tion is the single most effective way to prevent health care– associated influenza. A vaccinated population decreases the risk for presenteeism (health care workers being at work when sick). The importance of receiving an influenza vaccine is reflected in the recent requirement that health care facilities publicly report vaccination rates of their employees, licensed independent practitioners, volunteers, and adult students.7 To improve health care worker vaccination adherence, many organizations have made receiving a flu vaccine mandatory.

Uncommonly, health care workers are recommended to take antibiotics in addition to standard and transmission- based precautions and vaccination, to prevent disease. Exam- ples of these situations include postexposure prophylaxis after close contact with a patient with meningococcal meningitis or exposure to blood or body fluid of a patient with HIV. One specific situation in which vaccination and chemoprophylaxis are combined is exposure to a patient with Bordetella pertussis (whooping cough). Infants can develop severe complications from whooping cough, including death. If health care workers have had close contact with an active case of whooping cough, and have contact with infants younger than 1 year of age or women in the third trimester of pregnancy, they should receive prophylaxis in addition to having their vaccination status updated.3,5

manner in which disease is transmitted. In-depth investigations of outbreaks have demonstrated that the line between these two categories of transmission is sometimes blurry. In certain circumstances, such as during endotracheal intubation and aerosol-generating procedures, there is some evidence that organisms such as influenza and SARS can be transmitted via droplet nuclei. Similarly, norovirus, the most common cause of infectious diarrhea transmitted mainly by contact, probably also can be transmitted by swallowing aerosolized virus from vomitus. Based on these examples, aerosol transmission of droplet nuclei can be further refined as follows3: • Obligate transmission: Under natural conditions, disease

occurs after transmission of the microorganism only through airborne (droplet nuclei) aerosols. An example of obligate transmission is tuberculosis.

• Preferential transmission: Natural infection results from transmission through multiple routes, but airborne trans- mission predominates. Measles is an example of preferential airborne transmission.

• Opportunistic transmission: Microorganisms that cause dis- ease through other routes—droplet or contact—but under certain environmental conditions may be transmitted via airborne transmission. An example of this is SARS transmis- sion via an aerosol plume that originated from sewage in the Amoy Gardens housing complex in the Kowloon section of Hong Kong in 2003.4

Awareness of these nuances of transmission informs health care workers to wear the appropriate personal protective equip- ment depending on the clinical circumstances. For example, during a bronchoscopy for a patient infected with influenza, the possibility of opportunistic airborne transmission of the virus would cause one to consider wearing an N95 mask as opposed to a regular surgical mask.

Other Sources of Infection Not Involving Person-to-Person Transmission Common vehicle transmission occurs via exposure to patho- gens in contaminated food, water, or medications (e.g., heparin solution). Vector-borne transmission of infectious diseases from insects and rats and other vermin occurs but is of less significance in U.S. health care facilities.

INFECTION PREVENTION STRATEGIES

Creating a Safe Culture

From an organizational perspective, a crucial first step to decrease the risk for HAIs is the creation by leadership, at all levels, of a culture of safety in which there is a shared commit- ment to patient and health care worker safety. Creating a culture of safety is also the responsibility of each individual health care worker. It is important that each person is empowered and willing to speak up and “stop the line” if the person has a concern that a patient or employee is in an unsafe situation.

Organizations also endorse best practices for infection pre- vention by ensuring that the bedside caregiver has the appropri-

Principles of Infection Prevention and Control • CHAPTER 4 63

The application of standard precautions by health care per- sonnel during patient care depends on the nature of the interac- tion and the potential for blood, body fluid, or pathogen contact. For some patient care situations, only gloves are required. In other cases, gloves, gowns, and face shield may be required. Box 4-1 describes standard precautions, including hand hygiene; use of gloves, masks, and eye protection; equip- ment handling; and patient placement.

Hand Hygiene

The importance of hand hygiene to reduce the transmission of infectious agents cannot be overemphasized and is an essential element of standard precautions.8 Hand hygiene includes hand- washing with either plain or antiseptic-containing soap and water for at least 15 seconds or the use of alcohol-based prod- ucts (gels, rinses, and foams). In the absence of visible soiling of hands, approved alcohol-based products are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of skin, and convenience. The quality of performing hand hygiene can be affected by the type and length of fingernails and by wearing jewelry. Artificial fingernails and extenders should not be worn by health care workers because of their association with infections.8 Figure 4-2 illustrates the proper technique for handwashing.

Gloves

Gloves protect both patients and health care workers. Gloves protect patients from exposure to pathogens that may be carried on the hands of health care workers. Gloves protect caregivers from contamination when contacting blood, body fluids, secretions, excretions, mucous membranes, and nonin- tact skin of patients and when handling or touching visibly or potentially contaminated patient care equipment and environ- mental surfaces.8

Caregivers should wear sterile gloves whenever performing invasive procedures. A single pair of nonsterile disposable gloves (e.g., latex, vinyl, nitrile) may be used for routine patient care. Hand hygiene always should be performed before donning gloves. Gloves should be changed between each patient contact and after any direct contact with infectious material, even if in the middle of a procedure. After removing the gloves, caregivers always must clean their hands. Gloves may have small, invisible defects or may be torn during use. The hands also can be con- taminated during removal of the gloves. For these reasons, the wearing of gloves should never be used as a substitute for hand hygiene.

Mouth, Nose, Eye, and Face Protection

Face protection is an important component of standard precau- tions because the mucous membranes of the eyes, nose, and mouth are particularly vulnerable to some types of pathogens. Masks protect mucosal surfaces against splashes or sprays, but should not be confused with particulate respirators that are recommended for protection from small particles (as described subsequently for airborne isolation [AI]). The wearing of masks,

RULE OF THUMB

All health care workers with patient contact should undergo immunization for hepatitis B and varicella (if not immune), pertussis booster, and annual influenza vaccination.

Eliminating the Source of Pathogens

Elimination of all pathogens from any working environment is impossible. Nonetheless, standard infection prevention proce- dures always include efforts to eliminate pathogens, and recom- mended practices for cleaning and disinfecting noncritical surfaces in patient care areas should be followed. Procedures designed to remove environmental pathogens fall into two major categories: general sanitation measures and specialized equipment processing.

General sanitation measures help keep the overall environ- ment clean. General sanitation aims to reduce the number of pathogens to a safe level. This reduction is achieved through sanitary laundry management, food preparation, and house- keeping. Environmental control of the air (using specialized ventilation systems) and water complements these efforts.

The goal of specialized equipment processing is to decon- taminate equipment capable of spreading infection. Equipment processing involves cleaning, disinfection, and sterilization (when necessary). Methods that kill bacteria are bactericidal, whereas methods and techniques that inhibit the growth of bacteria are bacteriostatic. Methods that destroy spores are sporicidal, and methods that destroy viruses are virucidal.

Interrupting Transmission

General sanitation measures and equipment processing have limits. To prevent the spread of infections between patients and to keep themselves healthy, health care personnel must take measures to stop infection. Best practices to limit transmission of pathogens in the hospital have been put forth by HICPAC and the Centers for Disease Control and Prevention (CDC). These recommendations include standard precautions and transmission-based precautions.3

Standard Precautions

The term standard precautions refers to the simplest level of infection control based on the recognition that all blood, body fluids, secretions, and excretions (with the exception of sweat) may contain transmissible infectious agents. Standard precau- tions are intended to be applied to the care of all patients in all health care settings all the time. This is the primary strategy for the prevention of health care–associated transmission of infec- tions among patients and health care personnel. To reduce risk for infection, a health care worker should employ personal pro- tective equipment (PPE). PPE refers to various barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. Gloves, gowns, masks, eye protection, and face shields should be employed depending on the anticipated exposure.

64 SECTION I • Foundations of Respiratory Care

Box 4-1 Standard Precautions

HAND HYGIENE • Perform hand hygiene before and after patient contacts,

immediately after removing gloves, and when otherwise indicated to avoid cross contamination.

• Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, even if wearing gloves.

• Perform hand hygiene between tasks and procedures on the same patient if cross contamination of different body sites is possible (e.g., tracheostomy care after assistance with a bedpan).

• Use an approved alcohol-based product for routine hand hygiene. If hands are visibly soiled, use soap and water.

GLOVES • Perform hand hygiene before and after removing gloves. • Wear clean gloves when touching blood, body fluids,

secretions, excretions, and contaminated items. • Don clean gloves just before touching mucous membranes

and nonintact skin. • Change gloves between tasks and procedures on the same

patient after contact with infectious material. • Remove gloves promptly after use, before touching

noncontaminated items and environmental surfaces, and before going to another patient.

MASKS, EYE PROTECTION, FACE SHIELDS • Wear a mask and eye protection or a face shield to protect

mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.

GOWNS • Wear a clean gown to protect skin and prevent soiling of

clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.

• Remove a soiled gown as promptly as possible and perform hand hygiene to avoid transfer of microorganisms to other patients or environments.

PATIENT CARE EQUIPMENT • Handle used patient care equipment soiled with blood, body

fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments.

• Do not use reusable equipment to care for another patient unless it has been cleaned and reprocessed appropriately.

• Discard single-use items properly.

OCCUPATIONAL HEALTH AND BLOOD-BORNE PATHOGENS • Exercise extreme caution when handling needles, scalpels,

and other sharp instruments or devices; when cleaning used instruments; and when disposing of used needles.

• Never recap used needles, handle them using both hands, or point toward any part of the body.

• Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand.

• Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers; place reusable syringes and needles in a puncture- resistant container for transport to the reprocessing area.

• Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.

PATIENT PLACEMENT • Place patients who contaminate the environment or who do

not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in a private room.

• If a private room is unavailable, consult with infection preventionist regarding patient placement.

eye protection, and face shields in specified circumstances when exposures are likely to occur (e.g., bronchoscopy suite) is man- dated by the OSHA Bloodborne Pathogen Standard.

Respiratory Protection

Respiratory protection (use of NIOSH-approved N-95 or higher level respirator) is intended for diseases (e.g., M. tuber- culosis) that could be transmitted through the airborne route.3 The term respiratory protection has a regulatory context that includes components of a program required by OSHA to protect workers: (1) medical clearance to wear a respirator, (2) provision and use of appropriate NIOSH-approved fit-tested respirators, and (3) education in respirator use.

Gowns, Aprons, and Protective Apparel

Isolation gowns and other apparel (aprons, leg coverings, boots, or shoe covers) also provide barrier protection and can prevent

the contamination of clothing and exposed body areas from blood and body fluid contact and transmissible pathogens (e.g., respiratory syncytial virus and Clostridium difficile). Selection of protective apparel is dictated by the nature of the interaction of the health care worker with the patient, including anticipated degree of body contact with infectious material.3 In most instances, gowns are worn only if contact with blood and body fluid is likely. Clinical coats and jackets worn over clothing are not considered protective apparel. Isolation gowns always should be donned with gloves and other protective equipment as indicated. As with gloves and masks, a gown should be worn only once and then discarded. In most situations, aseptically clean, freshly laundered, or disposable gowns are satisfactory.

Cough Etiquette

The emergence of novel respiratory viruses such as SARS and Middle East respiratory syndrome (MERS) along with pan- demic H1N1 influenza have reinforced the need for a strategy

Principles of Infection Prevention and Control • CHAPTER 4 65

FIGURE 4-2 Steps for handwashing. A, Thorough wetting of hands. B, Washing around wrist and forearm. C, Scrubbing palm of hand. D, Washing between digits on back of hand.

Continued

for preventing transmission of respiratory infections at the first point of contact within a health care setting (e.g., physician’s office), termed respiratory hygiene/cough etiquette. This concept is a component of standard precautions.3 The elements of respiratory hygiene/cough etiquette include (1) education of health care personnel, patients, and visitors; (2) posted signs in language appropriate to the population served with instructions for patients and accompanying family members or friends; (3) source control measures (covering the mouth and nose with a tissue when coughing or placing a surgical mask on a coughing

person when possible); (4) hand hygiene after contact with respiratory secretions; and (5) spatial separation (≥3 feet from persons with respiratory infections in common waiting areas).

Transmission-Based Precautions

Transmission-based precautions are for patients who are known or suspected to be infected with pathogens that require addi- tional control measures to prevent transmission. There are three categories of transmission-based precautions based on the pre- dominant manner in which the pathogen is transmitted: contact

66 SECTION I • Foundations of Respiratory Care

precautions, droplet precautions, and airborne infection isola- tion (see earlier section on Modes of Transmission). Whether used singularly or in combination, these precautions are always used in addition to standard precautions.3

Contact precautions are intended to reduce the risk for transmission by direct or indirect contact with the patient or the patient’s environment. Contact precautions require health care personnel and visitors to wear gowns and gloves for all interactions that may involve contact with the patient or the patient’s environment. Contact precautions are most com- monly employed to decrease the spread of multidrug-resistant organisms such as C. difficile. Contact precautions are described in Box 4-2.

Droplet precautions are used to prevent a form of contact transmission that occurs when droplets are propelled short dis- tances (≤3 feet through the air). Droplets are often generated with coughing, sneezing, suctioning, bronchoscopy, and cough induction. Health care personnel and visitors should don a mask during all interactions that may involve contact with such patients. Droplet precautions are employed for patients with

Box 4-2 Contact Precautions (Used in Addition to Standard Precautions)

• Place the patient in a private room; if a private room is unavailable, cohorting is acceptable.

• Perform hand hygiene and don gown and gloves to enter room whether or not direct patient contact is anticipated. Wear clean gloves when entering the room.

• Remove gown and gloves before leaving the patient’s environment and perform hand hygiene.

• After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room.

• Limit transport of the patient from the room to essential purposes only.

• When possible, dedicate the use of noncritical patient care equipment to a single patient or patient cohort.

• If use of common equipment or items cannot be avoided, ensure that it is adequately cleaned and disinfected before use on another patient.

E, Washing around the cuticle. F, Drying hands with clean towel. G, Using towel to turn off faucet. FIGURE 4-2, cont’d

Principles of Infection Prevention and Control • CHAPTER 4 67

minimum of two outdoor air changes per hour, minimum of 12 total air changes per hour for new construction or 6 air changes per hour for existing buildings, and air exhausted directly to the outside).9 In settings where AII cannot be imple- mented because of limited resources, physical separation, mask patients, and respiratory protection for health care personnel should be implemented to reduce the likelihood of airborne transmission. Box 4-5 describes airborne precautions that should be used in addition to standard precautions.

Box 4-4 Guidelines for Cough-Inducing and Aerosol-Generating Procedures

• Cough-inducing procedures include endotracheal intubation and suctioning, diagnostic sputum induction, aerosol treatments (e.g., pentamidine therapy), and bronchoscopy.

• Cough-inducing procedures should not be performed on patients who may have infectious tuberculosis, unless the procedures are essential and can be performed with appropriate precautions.

• All cough-inducing procedures performed on patients who may have infectious tuberculosis should be performed using booths or special enclosures; if this is not feasible, a room that meets the ventilation requirements for airborne infection isolation can be used.

• After completion of cough-inducing procedures, patients who may have infectious tuberculosis should remain in their isolation rooms or enclosures until coughing subsides. They should be required to cover their mouths and noses with tissues when coughing.

• Before the enclosure or room is used for another patient, enough time should be allowed to pass for at least 99% of airborne contaminants to be removed (this time varies according to the efficiency of the ventilation or filtration system).

Box 4-3 Droplet Precautions (Used in Addition to Standard Precautions)

• Place the patient in a private room; if a private room is unavailable, cohorting is acceptable.

• Special air handling and ventilation are unnecessary, and the door may remain open.

MASK • Perform hand hygiene and put on a surgical mask before

entering the room. • Remove mask before exiting the room and perform hand

hygiene. • Limit movement and transport of the patient from the room

to essential purposes only. • If transport or movement is necessary, minimize droplet

transmission by having the patient wear a surgical mask.

MINI CLINI Isolation Methods

PROBLEM: A serious influenza outbreak occurs in a local long-term care facility. You are called to the emergency depart- ment (ED) because four of the sickest patients are being admit- ted together to your hospital for treatment. Currently, no private rooms are available for these patients. Outline the key isolation methods you would apply to help prevent the spread of influenza in your institution.

DISCUSSION: Influenza spreads via the droplet route. Both standard and droplet precautions must be applied for these patients. When transporting these patients out of the ED, you must be sure they wear surgical masks. Because private rooms are unavailable, these patients need to be grouped together. If this is not feasible, the patients must be separated from other patients by at least 3 feet. Special air handling and ventilation are unnecessary, and the door may remain open. In addition to following standard precautions, all caregivers and visitors should wear surgical masks when within 3 feet of these patients (or entering the room). All remaining patients at the long-term care facility should be immunized with the flu vaccine (if not already) and be given antiviral prophylaxis.

presumed or confirmed infection with organisms known to be transmitted by respiratory droplets such as influenza. Droplet precautions are described in Box 4-3. Precautions for use when performing cough-inducing and aerosol-producing procedures are described in Box 4-4. Airborne infection isolation (AII) refers to isolation techniques intended to reduce the risk for selected infectious agents transmitted by “small droplets” of aerosol particles (e.g., M. tuberculosis).5 Persons who enter an AII room must wear respiratory protection (an NIOSH- approved N-95 or higher respirator). Patients should be placed in a single-patient AII room that is equipped with special air handling and ventilation capacity that meets the American Institute of Architects/Facility Guidelines Institute standards (monitored negative pressure relative to surrounding area,

Box 4-5 Airborne Precautions (Used in Addition to Standard Precautions)

• Place the patient in a private negative-pressure room that has 6 to 12 air changes per hour and either safe external air discharge or HEPA filtration of recirculated air.

• Keep the room door closed and the patient in the room. • If a private room is unavailable, cohorting is acceptable. • Perform hand hygiene and don respiratory protection when

entering the room of a patient with known or suspected infectious pulmonary tuberculosis.

• Remove respiratory protection and perform hand hygiene after leaving the room.

• Susceptible persons should not enter the room of patients known or suspected to have measles (rubeola) or varicella (chickenpox) if other immune caregivers are available; individuals who are immune to measles or varicella need not wear respiratory protection.

• Limit transport of the patient from the room to essential purposes only.

• If transport or movement is necessary, minimize patient dispersal of droplet nuclei by having the patient wear a surgical mask.

68 SECTION I • Foundations of Respiratory Care

different permutations of VAP bundles described. Common components to most include maintaining the head of the bed above 30 degrees, routine mouth care with chlorhexidine, and minimizing sedation (daily sedation vacation).11 Other prac- tices commonly included in VAP bundles are venous thrombo- embolism prophylaxis and stress ulcer prophylaxis, even though these practices do not have a direct effect on the risk for pneu- monia. Institutions should be committed to these processes of care, and individual health care workers should be familiar with these practices and execute them on a routine basis.11–13 Com- pliance with bundles can be tracked over time as part of process improvement projects. Each individual component can be tracked, or all components can be tracked in an all or none, total appropriateness of care manner.

DISINFECTION AND STERILIZATION

Medical instruments are used in tens of millions of procedures in the United States every year. When properly performed, cleaning, disinfection, and sterilization procedures can reduce the risk for infection associated with the use of invasive and noninvasive medical instruments. Although a detailed review of disinfection and sterilization is beyond the scope of this chapter, overall principles are discussed, particularly as they pertain to the use of bronchoscopes. The interested reader is referred to detailed guidance available from the CDC.14 Table 4-2 lists defi- nitions of the steps involved in equipment reprocessing.

Spaulding Approach to Disinfection and Sterilization of Patient Care Equipment

In 1968, Spaulding published his approach to disinfection and sterilization, which was based on the degree of risk for infection

MINI CLINI Spread of Infection

PROBLEM: You work in the neonatal intensive care unit (NICU) of a large urban hospital. Over the last 2 days, many infants in the unit have developed serious Staphylococcus aureus infections. Identify the most likely source and route of trans- mission and suggest ways to prevent spread of this serious infection.

DISCUSSION: In hospitals, S. aureus commonly colonizes the skin of both health care professionals and visitors. Neonates are very susceptible hosts because of their poor immunity. Staphy- lococcus infections spread mainly via direct contact transmis- sion (see Table 4-1). To help prevent the spread of this infection to the newborn infants, you should try to disrupt the transmis- sion route. Meticulous attention to hand hygiene and use of gloves would help. In addition, you could isolate the infected neonates from uninfected infants (cohorting) and, in an effort to identify patients who may be colonized, begin S. aureus screening of the umbilicus and nares of all infants in the NICU and all new admissions.

RULE OF THUMB

Apply standard precautions when caring for all patients. 1. Wash your hands after touching blood, body fluids,

or contaminated items (even if gloves were worn). 2. Wear fresh, clean gloves for all tasks and

procedures involving potential contact with blood, body fluids, or contaminated items.

3. Exercise extreme caution when handling “sharps.” 4. Handle soiled equipment in a manner that prevents

skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments.5

Protective Environment

A specialized engineering approach to protect highly immuno- compromised patients is a protective environment. A protective environment is used for patients with allogeneic hematologic stem cell transplants to minimize fungal spore counts in the air.3 The rationale for such controls has been studies showing out- breaks of aspergillosis associated with construction. Air quality for patients with hematologic stem cell transplants is improved through a combination of environmental controls that include (1) high efficiency particulate air (HEPA) filtration of incoming air, (2) directed room airflow, (3) positive room air pressure relative to the corridor, (4) well-sealed rooms to prevent infil- tration of outside air, (5) ventilation to provide 12 or more air changes per hour, (6) strategies to reduce dust, and (7) prohibi- tion of dried and fresh flowers and potted plants in rooms.

Transport of Infected Patients

By limiting the transport of patients with contagious disease, the risk for cross infection can be reduced. However, infected patients sometimes do need to be transported and, when that occurs, the patient needs to wear appropriate barrier protection (mask, gown, impervious dressings) consistent with the route and risk for transmission.3 Health care personnel receiving the patient need to be notified of the patient’s impending arrival and what infection control measures are required.

Medical Devices and Bundles

A large percentage of HAIs are device-related infections, includ- ing ventilator-associated pneumonia (VAP), catheter-related bloodstream infection, and catheter-associated urinary tract infection. The best way to decrease host susceptibility to a device-related infection is first to limit device use and second to ensure that devices are placed and maintained appro- priately. Prevention bundles—defined as the use of multiple different evidence-based best practices to prevent device-related infection—have been shown to decrease the incidence of HAIs significantly.10,11 Exactly how much each component of a bundle contributes to a reduction in infection is often difficult to deter- mine. There are bundles for placement of central vascular cath- eters, placement and maintenance of urinary catheters, and for the management of patients on ventilators. There are several

Principles of Infection Prevention and Control • CHAPTER 4 69

TABLE 4-2

Equipment Processing Definitions

Term Definition

Cleaning Removal of all foreign material (e.g., soil, organic material) from objects

Disinfection (general term)

Inactivation of most pathogenic organisms, excluding spores

Disinfection, low level

Inactivation of most bacteria, some viruses, and fungi, without destruction of resistant microorganisms such as Mycobacterium tuberculosis or bacterial spores

Disinfection, intermediate level

Inactivation of all vegetative bacteria, most viruses, most fungi, and M. tuberculosis, without destruction of bacterial spores

Disinfection, high level

Inactivation of all microorganisms except bacterial spores (with sufficient exposure times, spores may also be destroyed)

Sterilization Complete destruction of all forms of microbial life

TABLE 4-3

Processing of Medical Equipment According to Infection Risk Categories

Category Description Examples Processing

Critical Devices introduced into the bloodstream or other parts of the body

Surgical devices Sterilization Intravascular catheters Implants Heart-lung bypass components Dialysis components Bronchoscope forceps/brushes

Semicritical Devices that directly or indirectly contact mucous membranes

Bronchoscopes Oral, nasal, and tracheal airways

High-level disinfection

Ventilator circuits/humidifiers Pulmonary function testing mouthpieces and tubing Nebulizers and their reservoirs Resuscitation bags Laryngoscope blades/stylets Pressure, gas, or temperature probes

Noncritical Devices that touch only intact skin or do not contact patient

Face masks Detergent washing Blood pressure cuffs Low- to intermediate-level

disinfectionVentilators

Modified from Chatburn RL, Kallstrom TJ, Bajasouzian S: A comparison of acetic acid with a quaternary ammonium compound for disinfection of hand-held nebulizers. Respir Care 34:98–109, 1989.

involved in the use of the item in patient care.15 The three cat- egories he described were critical, semicritical, and noncritical (Table 4-3). Critical items are categorized based on the high risk for infection if such an item is contaminated with pathogens, including bacterial spores (e.g., items that enter sterile tissue or the vascular system). Critical devices enter normally sterile tissues. Most of these items should be purchased sterile or be sterilized with steam if possible. Semicritical items come into contact with mucous membranes or nonintact skin; this includes most respiratory equipment. These items should be free of all microorganisms before use (bacterial spores may be present). Semicritical items require at least high-level disinfec- tion using chemical disinfectants. Noncritical items come into

contact with intact skin (an effective barrier to most microbes) but not mucous membranes. Most noncritical reusable devices may be decontaminated where they are used (e.g., bedpans, patient bed rails).

Bronchoscopes routinely become contaminated with high levels of organisms during a procedure because of the body cavities in which they are used. The benefits of these medical devices are numerous; however, proper reprocessing is crucial because numerous outbreaks and pseudo-outbreaks owing to improper procedures have been described. Individuals respon- sible for bronchoscope reprocessing should receive initial and annual training, and their competency should be ensured. The five key components to bronchoscope reprocessing are cleaning, disinfecting, rinsing, drying, and storage (Box 4-6).14 Auto- mated bronchoscope reprocessors (ABRs) offer many advan- tages over manual disinfection because they automate several of these steps. Regardless of whether disinfection is done manu- ally or with an ABR, personnel responsible for this task need to ensure reprocessing is done per device manufacturer and repro- cessor guidelines with products registered with U.S. Environ- mental Protection Agency (EPA) or cleared by the U.S. Food and Drug Administration (FDA). Health care workers should wear appropriate PPE while cleaning, disinfecting, or sterilizing medical equipment to protect themselves from potentially infectious material and chemical products used in the process.

Cleaning

Medical equipment must be cleaned and maintained according to the manufacturer’s instructions. Cleaning is the first step in all equipment processing, including those undergoing low- level or high-level disinfection and sterilization. Cleaning involves removing all dirt and organic material from equip- ment, usually by washing (see Table 4-3).14 Failure to clean

70 SECTION I • Foundations of Respiratory Care

Chemical Disinfection Chemical disinfection involves the application of chemical solu- tions to contaminated surfaces or equipment. The EPA groups disinfectants based on whether the product label claims “limited,” “general,” or “hospital” disinfection.14 Numerous dis- infectants are used alone or in combination in the health care setting, including alcohol, chlorine and chlorine products, glutaraldehyde, iodophors, phenolics, quaternary ammonium compounds, peracetic acid, and hydrogen peroxide. In most cases, a given product is designed for a specific purpose and should be used in a certain manner; the label should be read carefully. Table 4-4, excerpted from the CDC guideline for ster- ilization and disinfection, summarizes common chemical dis- infectants and their activity against various pathogens.14 Health care facilities should select disinfectant agents that best meet their overall needs. Product manufacturer’s recommendations for the amount, dilution, and contact time of disinfectants should be followed. A comprehensive overview of disinfectants in the hospital can be found in the updated CDC guidelines for disinfection and sterilization in health care facilities.14

For high-level disinfection to be effective, cleaned equipment must be completely immersed in the disinfectant solution. The FDA provides a list of cleared chemical disinfectants that can be used for high-level disinfection of medical devices. Cleared agents include 2.4% or greater glutaraldehyde, 0.55% orthoph- thaldehyde (OPA), 0.95% glutaraldehyde with 1.64% phenyl- phenate, 7.35% hydrogen peroxide with 0.23% peracetic acid, 1.0% hydrogen peroxide with 0.08% peracetic acid, and 7.5% hydrogen peroxide.16 The choice of agent used in high-level disinfection is dictated by the device manufacturer.

After a set “contact” time, the equipment is removed, rinsed in sterile water (to remove toxic residues), and thoroughly dried. Equipment must be handled and stored carefully, to prevent recontamination during subsequent reassembly, pack- aging, and storage.

Sterilization

Sterilization destroys all microorganisms on the surface of an article or in a fluid, which prevents transmission of patho- gens associated with the use of that item. Both physical and chemical means can achieve sterilization. Physical methods include various forms of heat (steam) and ionizing radiation. Chemical methods of sterilization include low-temperature sterilization technologies such as ethylene oxide (EtO) gas. Table 4-5, excerpted from the CDC guideline for sterilization and disinfection, compares and contrasts the major methods of sterilization.14

Medical devices that have contact with sterile body tissues or fluids are critical items and should be sterile before use. If the object is heat resistant, steam sterilization is usually recom- mended. However, increases in the use of medical devices that are heat and moisture sensitive have necessitated the develop- ment of low-temperature sterilization technology. These include, but are not limited to, EtO, hydrogen peroxide gas plasma, and peracetic acid. A review of the commonly used sterilization technologies with a summary of advantages and

equipment properly can render all subsequent processing efforts ineffective. Cleaning should occur in a designated facility with separate dirty and clean areas. Before being cleaned, the equip- ment should be disassembled per manufacturer’s recommenda- tions and examined for worn parts. Disassembly helps ensure good exposure to the cleaning agent.

Because water alone cannot dissolve organic matter, deter- gents or enzymatic cleaners and brushes should be used to clean all internal and external surfaces of equipment. Enzymatic cleaners are neutral detergents with enzymes added that help remove organic (proteinaceous) material from equipment. Some EPA-registered products combine a germicide with a detergent, providing the dual action of cleaning and dis- infection. This product type is generally appropriate for use on noncritical items. Noncritical items, such as stethoscopes, intra- venous pumps, and ventilator surfaces, must be cleaned and low-level disinfected using an appropriate EPA-registered product before use on another patient.

Although careful cleaning removes most pathogens from the equipment, it cannot eliminate the risk for infection. For this reason, semicritical and critical medical equipment must then undergo either high-level disinfection or sterilization.

Disinfection

Disinfection describes a process used on medical equipment that destroys the vegetative form of all pathogenic organisms on an inanimate object, except bacterial spores. By definition, disinfection differs from sterilization by its lack of sporicidal activity.14 However, a few disinfectants kill spores with pro- longed exposure times (hours) and are called chemical sterilants. Disinfection can involve either physical or chemical methods. The most common physical method of disinfection is pasteuri- zation. Many chemical methods are used to disinfect respiratory care equipment.

Box 4-6 Key Components of Bronchoscope Sterilization or Disinfection

Clean: Mechanically clean external surfaces, including brushing internal channels and flushing each internal channel with water and a detergent or enzymatic cleaner. 1. Disinfect: Immerse bronchoscope in high-level disinfectant

and perfuse disinfectant into the suction/biopsy channel and air/water channel and expose for at least 20 minutes (or FDA-cleared exposure time).

2. Rinse: The bronchoscope and all channels should be rinsed with sterile water, filtered water, or tap water.

3. Dry: Rinse insertion tube and inner channels with alcohol, and dry with forced air after disinfection and before storage.

4. Store: The bronchoscope should be stored in a way that prevents recontamination (e.g., hung vertically in an enclosed cabinet, the bronchoscope should not touch any surface of the cabinet).

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Principles of Infection Prevention and Control • CHAPTER 4 71

disadvantages can be found in the updated CDC guidelines for disinfection and sterilization in health care facilities.14 Follow- ing is an overview of a few of these technologies.

Steam Sterilization Moist heat in the form of steam under pressure is the most common, most efficient, and easiest sterilization method. Steam sterilization is the application of steam under pressure. Steam sterilization is efficient, quick, cheap, clean, and reliable. Equip- ment always must be thoroughly cleaned before sterilization because materials that remain on the surfaces of equipment interfere with the effectiveness of the sterilization process. Clean equipment is wrapped in muslin, linen, or paper or placed in specially designed rigid containers, all of which are easily pen- etrated by steam. Items must be properly packed in the auto- clave to ensure exposure. The higher the temperature and pressure of the sterilizer, the shorter is the time needed for sterilization. The combination most commonly used for auto- claving is 15 psi at 121° C for a minimum of 30 minutes. After sterilization, the packaging prevents recontamination during handling and storage. Numerous quality control monitors (mechanical, chemical, and biological) are employed to ensure adequate sterilization has taken place.

TABLE 4-4

Comparison of the Characteristics of Selected Chemicals Used as High-Level Disinfectants or Chemical Sterilants

HP (7.5%) PA (0.2%) Glut (≥2.0%) OPA (0.55%) HP/PA (7.35%/0.23%)

HLD claim 30 min at 20° C NA 20-90 min at 20°-25° C

12 min at 20° C, 5 min at 25° C in AER

15 min at 20° C

Sterilization claim 6 hr at 20° C 12 min at 50°-56° C 10 hr at 20°-25° C None 3 hr at 20° C Activation No No Yes (alkaline glut) No No Reuse lifea 21 days Single use 14-30 days 14 days 14 days Shelf life stabilityb 2 yr 6 mo 2 yr 2 yr 2 yr Disposable restrictions None None Localc Localc None Materials compatibility Good Good Excellent Excellent No data Monitor MECd Yes (6%) No Yes (≥1.5%) Yes (0.3% OPA) No Safety Serious eye damage

(safety glasses) Serious eye and skin

damage (conc soln)e Respiratory Eye irritant, stains skin Eye damage

Processing Manual or automated Automated Manual or automated Manual or automated Manual Organic material

resistance Yes Yes Yes Yes Yes

OSHA exposure limit 1 ppm TWA None Nonef None HP-1 ppm TWA Cost profile (per

cycle)g + (manual), ++

(automated) ++++ (automated) + (manual), ++

(automated) ++ (manual) ++ (manual)

Data from Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Disease Control and Prevention: Guidelines for sterilization and disinfection in healthcare facilities, Atlanta, 2008, http://www.edu.gov./hicpac/.pdf/guidelines. glut, Glutaraldehyde; HLD, high level-disinfectant; HP, hydrogen peroxide; NA, not applicable; OPA, orthophthalaldehyde (FDA cleared as a high-level disinfectant, included for comparison with other chemical agents used for high-level disinfection); PA, peracetic acid; PA/HP, peracetic acid and hydrogen peroxide; TWA, time-weighted average for a conventional 8-hour workday. aNumber of days a product can be reused as determined by reuse protocol. bTime a product can remain in storage (unused). cNo U.S. Environmental Protection Agency regulations, but some states and local authorities have additional restrictions. dMinimum effective concentration is the lowest concentration of active ingredients at which the product is still effective. eConc soln, concentrated solution. fThe ceiling limit recommended by the American Conference of Governmental Industrial Hygienists is 0.05 ppm. gPer cycle cost profile considers cost of the processing solution (suggested list price to health care facilities in August 2001) and assumes maximum use life (e.g., 21 days for hydrogen peroxide, 14 days for glutaraldehyde), five reprocessing cycles per day, 1-gallon basin for manual processing, and 4-gallon tank for automated processing. +, Least expensive; ++++, most expensive.

MINI CLINI Selection of a Disinfectant

PROBLEM: You work in the pulmonary function laboratory of a community hospital. Immediately after performing spi- rometry on a patient, you learn that he has been admitted and tests positive for pulmonary tuberculosis. You also remember him coughing into the spirometry tubing. You have four more patients scheduled for spirometry testing, beginning in 45 minutes. How should you process the spirometry tubing to prevent transmission of the tuberculosis?

DISCUSSION: Ideally, you would have a backup set of tubing to deal with this type of problem. If not, you need to disinfect or sterilize the tubing quickly. Because permanent spirometry tubing is made from heat-labile plastics, you cannot use steam (damage). Ethylene oxide (EtO) gas is an option, but aeration would take too long. Instead, you should select a broad- spectrum, quick-acting disinfectant solution that works well in the presence of organic matter and does not damage rubber or plastic. Glutaraldehyde is a good choice, with a minimum exposure time of 20 minutes. A stabilized hydrogen peroxide– based compound or a 1 : 50 sodium hypochlorite solution also might be considered.

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72 SECTION I • Foundations of Respiratory Care

Immediate Use Sterilization Immediate-use (previously referred to as flash sterilization) “steam sterilization” is a modification of conventional steam sterilization in which the item is placed in an open tray or a specially designed container to allow for rapid penetration of steam.14 It is considered an acceptable practice for processing cleaned patient care items that cannot be packaged, sterilized, and stored before use. Its use only for reasons of convenience (e.g., to save time) should be discouraged.

Low-Temperature Sterilization Technologies Low-temperature (<60° C) sterilants are needed for sterilizing temperature-sensitive and moisture-sensitive medical devices and equipment. Low-temperature sterilant technology includes

TABLE 4-5

Advantages and Disadvantages of Accepted Methods for Equipment Sterilization

Sterilization Method Advantages Disadvantages

Steam Nontoxic to patient, staff, environment Cycle easy to control and monitor Rapidly microbial Least affected by organic/inorganic soils

among sterilization processes listed Rapid cycle time Penetrates medical packing, device lumens

Deleterious for heat-sensitive instruments Microsurgical instruments damaged by repeated exposure May leave instruments wet, causing them to rust Potential for burns

Hydrogen peroxide gas plasma

Safe for the environment Leaves no toxic residuals Cycle time is 28-75 min (varies with model

type) and no aeration necessary Used for heat- and moisture-sensitive items

because process temperature <50° C Simple to operate, install (208 V outlet), and

monitor Compatible with most medical devices Requires electrical outlet only

Cellulose (paper), linens, and liquids cannot be processed Sterilization chamber size from 1.8-9.4 ft3 total volume (varies with

model type) Some endoscopes or medical devices with long or narrow lumens

cannot be processed at this time in the United States (see manufacturer’s recommendations for internal diameter and length restrictions)

Requires synthetic packaging (polypropylene wraps, polyolefin pouches) and special container tray

Hydrogen peroxide may be toxic at levels >1 ppm TWA 100% Ethylene

oxide (EtO) Penetrates packaging materials, device

lumens Single-dose cartridge and negative pressure

chamber minimizes potential for gas leak and EtO exposure

Simple to operate and monitor Compatible with most medical materials

Requires aeration time to remove EtO residue Sterilization chamber size 4.0-7.9 ft3 total volume (varies with

model type) EtO is toxic, a carcinogen, and flammable EtO emission regulation by states but catalytic cell removes 99.9%

of EtO and converts it to CO2 and H2O EtO cartridges should be stored in flammable liquid storage cabinet Lengthy cycle/aeration time

EtO mixtures: 8.6% EtO/91.4% HCFC; 10% EtO/90% HCFC; 8.5% EtO/91.5% CO2

Penetrates medical packaging and many plastics

Compatible with most medical materials Cycle easy to control and monitor

Some states (e.g., California, New York, Michigan) require EtO emission reduction of 90%-99.9%

CFC (inert gas that eliminates explosive hazard) banned in 1995 Potential hazards to staff and patients Lengthy cycle/alteration time EtO is toxic, a carcinogen, and flammable

Peracetic acid Rapid cycle time (30-45 min) Low temperature (50°-55° C) liquid

immersion sterilization Environmentally friendly by-products Sterilant flows through endoscope, which

facilitates salt, protein, and microbe removal

Point-of-use system, no sterile storage Biologic indicator may be unsuitable for routine monitoring Used for immersible instruments only Some material incompatibility (e.g., aluminum anodized coating

becomes dull) One scope or a small number of instruments processed in a cycle Potential for serious eye and skin damage (concentrated solution)

with contact

EtO, hydrogen peroxide gas plasma, ozone, vaporized hydrogen peroxide, and peracetic acid.14 We review the most commonly used process—EtO.

EtO is a colorless, toxic gas and potent sterilizing agent. Because it is active at ambient temperatures and is harmless to rubber and plastics, EtO is a good sterilant for items that cannot be autoclaved. Similar to steam, EtO penetrates most packaging materials, permitting prewrapping. Were it not for its many hazards, EtO would be the ideal sterilant.16 Acute exposure to EtO gas can cause airway inflammation, nausea, diarrhea, head- ache, dizziness, and seizures. Chronic exposure to the gas is associated with respiratory infections, anemia, and altered behavior. Residual EtO left on processed equipment can cause tissue inflammation and hemolysis. When combined with

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Principles of Infection Prevention and Control • CHAPTER 4 73

pathogens, sterile water should still be used to fill bubble-type humidifiers.

The primary problem stems from contaminated condensate in the inspiratory limb of the ventilator circuit. Most often, the source of this contamination is the patient. Spillage of contami- nated condensate into the patient circuit and the patient occurs when moving the tubing or the patient, increasing the risk for self-infection. In addition, microorganisms in this condensate can be transmitted to other patients via the hands of the health care worker handling the fluid, if he or she is negligent. This is another reason why it is crucial for RTs to practice hand hygiene before and after contact with every ventilated patient. Contact with the patient’s ventilator is considered contact with the patient’s body.

One way to address this problem is by reducing or eliminat- ing circuit condensation. This reduction or elimination is easily achieved using heated wire circuits or a heat-and-moisture exchanger (HME). Available guidance does not recommend daily changing of HMEs. These devices should be inspected daily and replaced if contaminated with patient secretions or if flow resistance has increased. HMEs can be used safely for 48 hours, and with some patient populations they may be able to be used for up to 7 days.17

Based on current knowledge, both the CDC and the Ameri- can Association for Respiratory Care (AARC) have developed guidelines addressing ventilator-associated infection control. Box 4-8 provides general procedures for minimizing HAIs

water, EtO forms ethylene glycol, which also can irritate tissues. Other potential problems include carcinogenic, mutagenic, and teratogenic effects. EtO concentrations greater than 3% are explosive.

EtO requires special attention to general safety precautions, equipment preparation, and sterilization cycle parameters. In addition, because of its toxicity, residual EtO must be removed from equipment after sterilization via a process called aeration. EtO is used to sterilize critical (and sometimes semicritical) items that cannot be steam sterilized.

EQUIPMENT HANDLING PROCEDURES

Equipment handling procedures that help prevent the spread of pathogens include maintenance of in-use equipment, process- ing of reusable equipment, application of one-patient-use dis- posables, and fluid and medication precautions.

Maintenance of In-Use Equipment

In-use respiratory care equipment that can spread pathogens includes nebulizers, ventilator circuits, bag-valve-mask devices (manual resuscitators), and suction equipment. Oxygen therapy and pulmonary function equipment are also implicated as potential sources of HAIs.

Nebulizers Small-volume medication nebulizers (SVNs) also can produce bacterial aerosols. SVNs have been associated with health care–associated pneumonia, including Legionnaires disease, resulting from either contaminated medications or contami- nated tap water used to rinse the reservoir. Procedures designed to prevent nebulizers from spreading pathogens are presented in Box 4-7.

Ventilators and Ventilator Circuits The internal workings of ventilators are uncommon sources for infection; this is partly a result of the widespread use of high- efficiency particulate air/aerosol (HEPA) filters, which have an efficiency rate of 99.97%, and the use of sheathed suction cath- eters, which help reduce endotracheal tube contamination. An inspiratory HEPA filter (placed between the machinery and the external circuit, proximal to any humidifier) can eliminate bac- teria from the driving gas and prevent retrograde contamina- tion back into the machine. An expiratory filter using a heated thermistor to prevent condensation performs the same function and still protects the internal ventilator components. Expiratory filters also prevent pathogens from being expelled into the sur- roundings from the patient’s expired air.

The external ventilator circuitry poses the most significant contamination risk, particularly in systems using heated humid- ifiers. The humidifiers themselves are rarely the problem. Bubble or wick designs produce little or no aerosol and pose minimal infection risk. In addition, heating the humidifier reduces or eliminates growth of most bacterial pathogens. However, because tap water or distilled water may harbor heat-resistant

Box 4-7 Procedures to Minimize Infection Risk With Nebulizers

LARGE-VOLUME NEBULIZERS AND MIST TENTS • Always fill nebulizers with sterile distilled water. • Fill fluid reservoirs immediately before use; do not add fluid

to replenish partially filled reservoirs. If fluid is to be added, discard the remaining old fluid first.

• Drain tubing condensate away from the patient and discard as contaminated waste; do not allow condensate to drain back into reservoir.

• Sterilize or high-level disinfect large-volume nebulizers between patients and after every 24 hours of use on the same patient.

• Use mist tent nebulizer and reservoirs that have undergone sterilization or high-level disinfection, and replace them between patients.

• Do not use large-volume room air humidifiers that create aerosols unless they can be sterilized or subjected to high-level disinfection at least daily and filled only with sterile water.

SMALL-VOLUME NEBULIZERS • Between treatments on the same patient, disinfect, rinse

with sterile water, and air dry small-volume nebulizers. • Between patients, replace small-volume nebulizers with

sterile or high-level disinfected units. • Use only sterile fluids for nebulization, and dispense these

fluids aseptically. • When possible, use single-use medication vials; if using

multidose vials, handle, dispense, and store them according to manufacturer’s instructions and checking expiration dates.

74 SECTION I • Foundations of Respiratory Care

posable O2 humidifiers have a contamination rate of 33%. Conversely, prefilled, sterile disposable humidifiers present a negligible infection risk.20 On the basis of this knowledge, procedures that can help prevent O2 therapy apparatus from spreading pathogens are outlined in Box 4-9.

Pulmonary Function Equipment The inner parts of pulmonary function testing equipment are not a major source for spread of infection. However, contami- nation of external tubing, connectors, rebreathing valves, and mouthpieces can occur during testing. These components should be cleaned and subjected to high-level disinfection or sterilization between patients.21,22 The common practice of using HEPA filters to isolate the spirometer from the patient makes sense logically but has yet to be proved either effective or necessary in preventing HAI.

Other Respiratory Care Devices Use of other respiratory care equipment, including O2 analyz- ers, the hand-held bedside spirometer, and circuit probes, has been linked with hospital outbreaks of gram-negative bacterial infections.21 The most likely transmission route is direct patient- to-patient contact via either the device itself or the contami- nated hands of caregivers. The best way to control this problem is with proper hand hygiene and sterilization or high-level dis- infection of the devices between patients.

Processing Reusable Equipment

Improperly processed reusable equipment is another potential source for pathogens. General principles for cleaning, disinfec- tion, and sterilization were provided previously. This section presents specific guidelines for processing reusable respiratory care equipment and a special section on bronchoscope disinfection.

Respiratory Care Equipment Several factors must be considered in selecting a processing method for reusable respiratory care equipment (Box 4-10).

Box 4-8 Procedures to Minimize Infection Risk With Mechanical Ventilators

• Do not routinely sterilize or disinfect the internal workings of ventilators.

• Do not routinely change ventilator circuit more often than every 48 to 72 hours with HME.

• Sterilize or high-level disinfect reusable breathing circuits and humidifiers.

• Periodically drain tubing condensate away from patient and discard.

• Wash hands after draining tubing condensate or handling the fluid.

• Do not place bacterial filters distal to humidifier reservoirs. • Use sterile water to fill bubble humidifiers. • Use sterile, distilled water to fill wick humidifiers. • Change HMEs according to manufacturer’s recommendation

and when you observe evidence of gross contamination or mechanical dysfunction.

• Do not routinely change HME breathing circuits while in use.

HME, Heat-and-moisture exchanger.

associated with ventilator use. Mechanical ventilation exposes the patient to the risk for VAP, and the frequency of circuit changes and the relationship to VAP have been investigated.11 Current guidelines suggest that ventilator circuits should not be changed routinely for infection control purposes; however, they should be changed when visibly soiled or malfunctioning.18

Bag-Mask Devices Bag-mask devices are a source for colonizing both the airways of intubated patients and the hands of medical personnel.19 Nondisposable bag-mask devices should be sterilized or high- level disinfected between patients. In addition, the exterior surface of any bag-mask device should be cleaned of visible debris and disinfected at least once a day.

Suction Systems Tracheal suctioning increases the risk for infection. Proper hand hygiene and gloving help minimize this risk. Although much has been made of the infection prevention advantages of sheathed suction systems over open tracheal suction systems, evidence is mixed as to whether it is clearly superior. However, guidance recommends in-line suctioning as part of VAP reduc- tion program.18 There is no need to change a closed system suction catheter daily. To minimize the risk for cross contami- nation during suctioning with an open system, a fresh, sterile, single-use catheter should be used on each patient. In addition, only sterile fluid should be used to remove secretions from the catheter. Last, both the suction collection tubing and collection canister should be changed between patients except in short- term care units, where only the collection tubing needs to be changed.

Oxygen Therapy Apparatus O2 therapy devices pose much less risk than other in-use equip- ment but are still a potential infection hazard. In-use nondis-

Box 4-9 Procedures to Minimize Infection Risk With Oxygen Therapy Apparatus

• Humidifiers are not needed with flows less than 4 L/min. • When needed and whenever possible, prefilled, sterile

disposable humidifiers should be used. • With reusable humidifiers, fluid reservoirs should be filled

immediately before use with sterile distilled water. • Fluid must not be added to replenish partially filled

reservoirs. If fluid is to be added, discard the remaining old fluid first, then clean and dry reservoir before refilling.

• The tubing and oxygen delivery device should be changed between patients; prefilled, sterile, disposable humidifiers do not need to be changed between patients in high-use areas such as the recovery room.

• Prefilled, disposable humidifiers can be used safely for 30 days.

Principles of Infection Prevention and Control • CHAPTER 4 75

4-1 Care of the Ventilator Circuit and Its Relationship to Ventilator-Associated Pneumonia

AARC Clinical Practice Guideline (Excerpts)*

■ INTRODUCTION A concern related to the care of a mechanically ventilated patient is the development of VAP. For many years, this concern focused on the ventilator circuit and humidifier. The circuit and humidifier have been changed on a regular basis in an attempt to decrease the VAP rate. However, as the evidence evolved, it became apparent that the origin of VAP is more likely from sites other than the ventilator circuit, and the prevailing practice has become one of changing circuits less frequently. If this practice is safe, it would offer substantial cost savings. Other issues related to the components of the circuit and VAP also have become more important. Humidification systems can be either active or passive. Increasingly, in-line suction is used and this becomes part of the ventilator circuit.

■ QUESTIONS A systematic review of the literature was conducted with the intention of making recommendations for change frequency of the ventilator circuit and additional components of the circuit. Specifically, the Writing Committee wrote these evidence- based clinical practice guidelines to address the following questions: 1. Do ventilator circuits need to be changed at regular

intervals? 2. What is the economic impact of decreasing the frequency

of ventilator circuit changes? 3. What are the issues related to circuit type? 4. Does the choice of active versus passive humidification

affect ventilator circuit change frequency? 5. Do passive humidifiers need to be changed at regular

intervals? 6. Do in-line suction catheters need to be changed at regular

intervals? 7. Are there specific populations for which the

recommendations should be altered?

■ RECOMMENDATIONS Recommendation #1 Ventilator circuits should not be changed routinely for infection control purposes. The available evidence suggests no patient harm and considerable cost savings associated with extended ventilator circuit change intervals. The maximum duration of time that circuits can be used safely is unknown. (Evidence Grade A)

Recommendation #2 Evidence is lacking related to VAP and issues of heated versus unheated circuits, type of heated humidifier, method for filling the humidifier, and technique for clearing condensate from the ventilator circuit. It is prudent to avoid excessive accumulation of condensate in the circuit. Care should be

taken to avoid accidental drainage of condensate into the patient’s airway and to avoid contamination of caregivers during ventilator disconnection or during disposal of condensate. Care should be taken to avoid breaking the ventilator circuit, which could contaminate the interior of the circuit. (Evidence Grade D)

Recommendation #3 Although the available evidence suggests a lower VAP rate with passive humidification than with active humidification, other issues related to the use of passive humidifiers (e.g., resistance, dead space volume, airway occlusion risk) preclude a recommendation for the general use of these devices. The decision to use a passive humidifier should not be based solely on infection control considerations. (Evidence Grade A)

Recommendation #4 Passive humidifiers do not need to be changed daily for reasons of infection control or technical performance. They can be safely used for at least 48 hours, and with some patient populations, some devices may be able to be used for up to 1 week. (Evidence Grade A)

Recommendation #5 The use of closed suction catheters should be considered part of a VAP prevention strategy. When closed suction catheters are used, they do not need to be changed daily for infection control purposes. The maximum time that closed suction catheters can be used safely is unknown. (Evidence Grade A)

Recommendation #6 Clinicians (e.g., respiratory therapists, nurses, and physicians) caring for mechanically ventilated patients should be aware of risk factors for VAP (e.g., nebulizer therapy, manual ventilation, and patient transport). (Evidence Grade B)

■ EVIDENCE GRADES Grade A: Scientific evidence provided by randomized,

well-designed, well-conducted, controlled trials with statistically significant results that consistently support the guideline recommendation; supported by Level 1 or 2 evidence

Grade B: Scientific evidence provided by well-designed, well-conducted observational studies with statistically significant results that consistently support the guideline recommendation; supported by Level 3 or 4 evidence

Grade C: Scientific evidence from bench studies, animal studies, and case studies; supported by Level 5 evidence

Grade D: Expert opinion provides the basis for the guideline recommendation, but scientific evidence either provided inconsistent results or was lacking

*For the complete guidelines, see AARC Clinical Practice Guidelines, Care of the ventilator circuit and its relation to ventilator-associated pneumonia. Respir Care 48:569–879, 2003.

76 SECTION I • Foundations of Respiratory Care

particularly difficult to disinfect, and meticulous cleaning must precede any sterilization or high-level disinfection process.

Disposable Equipment

An important alternative to reprocessing equipment continu- ally is employing single-patient-use disposable devices. In the past, only O2 therapy devices (i.e., masks, cannulas), suction apparatus (i.e., catheters, tubing), and some supplies were disposable. Today, manufacturers provide a range of dispos- able devices, including humidifiers, nebulizers, incentive spi- rometers, ventilator circuits, bag-valve-masks, and monitoring transducers.

Three major issues are involved in using disposable devices: cost, quality, and reuse. Cost issues boil down to straightforward dollar comparisons between purchasing and processing reus- able devices versus stocking and distributing disposable devices. Good comparisons take into account direct and indirect costs (e.g., personnel, inventory, maintenance) and risk factors. Most recent findings support the cost-effectiveness of disposable devices over reusable devices in respiratory care.

Cost savings notwithstanding, many quality issues persist. Although disposable devices generally perform well, poor quality control remains a problem.20 Respiratory care managers need to evaluate carefully disposable devices being considered for bulk purchase before actual clinical use. To ensure reliability, this evaluation should include physical testing of multiple units of each model being assessed. Finally, bedside clinicians need to inspect carefully and confirm the operation of any disposable device before use.

Reusing high-cost, high-volume disposable equipment saves hospitals money. The practice of reusing devices labeled by the manufacturer for “single-use only” raises significant safety con- cerns and issues of negligence. The FDA provides stringent regulations for reprocessing and reusing single-use devices.23 A reused single-use device must comply with the same regulatory requirements of the original manufactured device, including, but not limited to, submitting documents for premarket noti- fication or approval, submitting adverse event reports, and meeting manufacturing and labeling requirements. The U.S. Centers for Medicare and Medicaid Services recommends that the reprocessing of single-use devices be performed by an FDA- approved third-party reprocessor and not by hospitals.

Fluids and Medications Precautions

Unit dosing has decreased but has not eliminated the infection hazard associated with medications. Box 4-11 outlines several simple procedures designed to help prevent cross contamina- tion while using fluids and medications.

Handling Contaminated Articles and Equipment

Contaminated items, whether reusable or disposable, should be enclosed in an impervious bag before removal from a patient’s room. Bagging helps prevent accidental exposure of both per- sonnel and the environment to contaminated articles. A single bag is satisfactory if (1) the bag is strong and impervious, and

When a device’s risk category is known, its composition must be matched to the resources available for hospital disinfection and sterilization. In this manner, each reusable device under- goes the most effective and least costly processing approach available.

MINI CLINI Selection of Equipment Processing Methods

PROBLEM: A patient is discharged from the intensive care unit after extubation from mechanical ventilatory support. The following contaminated nondisposable items are returned to the respiratory care department for processing: the ventilator, the ventilator circuit and humidifier, a resuscitation bag, a mechanical (vane-type) respirometer, and a laryngoscope with blades. Outline what processing you would select for each item and why.

DISCUSSION: First, the circuit, humidifier, and resuscitation bag should be disassembled and cleaned using a detergent or enzymatic cleaner combined with a low-level or intermediate- level disinfectant. Because the ventilator, respirometer, and laryngoscope and blades cannot be immersed in water, they should immediately undergo surface disinfection, using an appropriate EPA-registered product.

Box 4-10 Factors to Consider in Processing Reusable Equipment

• Infection risk (critical, semicritical, noncritical) • Material and equipment configuration • Available hospital disinfection resources • Relative cost (labor and materials)

After cleaning and initial disinfection, you should sort the items according to risk category and heat sensitivity. No items from this patient pose a critical infection risk. The ventilator circuit, humidifier, resuscitation bag, respirometer, and laryn- goscope are semicritical items, whereas the ventilator itself is a noncritical item. The ventilator circuit, humidifier, and resusci- tation bag are also plastic and probably heat labile. The respi- rometer and laryngoscope are heat stable.

When possible, semicritical items should be sterilized between patients; the heat-stable items should be autoclaved, and heat-labile items should undergo EtO sterilization. The ventilator (a noncritical item) need undergo only low-level to intermediate-level surface disinfection. The inner parts of the ventilator need not be sterilized or disinfected between patients.

HAIs associated with bronchoscopes have been most com- monly reported with M. tuberculosis, nontuberculosis mycobac- teria, and P. aeruginosa.22 The most common reasons for transmission include failure to adhere to recommended clean- ing and disinfection procedures, failure of automated endo- scope reprocessors, and flaws in design. Flexible endoscopes are

Principles of Infection Prevention and Control • CHAPTER 4 77

centralized or decentralized (to the various service depart- ments). The following principles should be a part of any infec- tion prevention surveillance program2: (1) use of standard definitions for HAIs; (2) use of microbiology-based data (when available), including resistance patterns for pathogens of signifi- cance (e.g., S. aureus); (3) establishment of risk stratification for infection risk when available (e.g., ventilator days, device days); (4) monitoring of results prospectively and identifying trends that indicate unusual rates of infection or transmission within the facility; and (5) provision of feedback to stakeholders within the institution (e.g., surgical site infection rates reported back to individual surgeons). It is also common for infection preven- tion programs to oversee hand hygiene and standard precau- tions adherence observations.

Most hospitals perform surveillance for device-related infec- tions: central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and VAPs. It is also commonplace to track certain organisms, including C. difficile infection and methicillin-resistant S. aureus infec- tion. Surveillance is performed by applying National Healthcare Safety Network (NHSN) definitions. Increasingly, there are regulatory mandates for the public reporting of surveillance results.

Traditionally, VAP was tracked and a standardized definition was employed. The VAP surveillance definition has significant limitations, including a lack of sensitivity and specificity that limits its usefulness.11 Recently, a new construct for evaluating the development of complications in ventilated adult patients has been developed and publicized by NHSN.24 Instead of fol- lowing patients only for the development of VAP, surveillance is performed to look for ventilator-associated events (VAE). VAEs are broken down into three tiers: ventilator-associated conditions (VAC), infection-related ventilator-associated con- ditions (IVAC), and possible and probable VAP (Figure 4-3). VAE surveillance starts with the identification of a VAC defined as an increase in the daily minimum positive end expiratory pressure (PEEP) or daily minimum fraction of inspired oxygen (FiO2) for 2 calendar days or longer after a period of stability. An IVAC is considered present if a VAC has been identified and there is an elevated temperature or white blood cell count and new antibiotics have been started and administered for 4 or more days. Possible VAP is identified in a patient with an IVAC who has purulent sputum by Gram stain or a positive sputum culture. Probable VAP is an IVAC in a patient with purulent sputum by Gram stain and a positive semiquantitative or quan- titative sputum culture. The cultures need to be positive for a known respiratory pathogen. VAE surveillance is a new para- digm in surveillance in that it tries to examine the overall safety of ventilator therapy and not focus just on infection-related outcomes. Conduct of this surveillance requires a partnership among infection prevention, critical care physicians, and respi- ratory therapists.

The surveillance activities of an infection prevention program are most effective when they generate actionable data that are communicated to the bedside caregiver in a timely fashion. These data can become the springboard for continuous

(2) the contaminated items can be bagged without contaminat- ing the outer surface of the bag. Otherwise, the contaminated items should be double-bagged. Bags used for contaminated articles or waste materials should be clearly labeled or color- coded for this purpose.

After bagging, reusable patient care equipment must be returned to the applicable processing area. Contaminated reus- able equipment should remain bagged until ready for decon- tamination or sterilization. When contaminated waste is being discarded, both OSHA procedures and any applicable local, state, or federal regulations must be followed.

Handling Laboratory Specimens

When gathering laboratory specimens (e.g., sputum), extreme care needs to be taken to prevent contamination of the external surface of the container. If the outside of the container is con- taminated, the caregiver must either disinfect it or place it in an impervious bag. To minimize the likelihood of laboratory speci- mens leaking during transport, they always should be placed in a sturdy container with a secure lid. When gathering a specimen from a patient on isolation precautions, the container must be placed in an appropriately labeled, impervious bag before it is removed from the room.

SURVEILLANCE FOR HOSPITAL-ACQUIRED INFECTIONS

Surveillance is an ongoing process of monitoring patients and health care personnel for acquisition of infection, colonization of pathogens, or both. It is one of the five key recommended components of an infection prevention program; the others are investigation, prevention, control, and reporting.2 Surveillance is a tool to provide HAI data on patients to provide outcome measurements either to ensure there is no ongoing problem or detect problems and intervene to prevent transmission of pathogens in the health care environment.

Generally, an infection prevention committee establishes surveillance policies and an infection preventionist or epidemi- ologist administers them. The surveillance program may be

Box 4-11 Fluids and Medications Precautions

• Sterile fluids should always be used for tracheal suctioning and to fill nebulizers and bubble humidifiers. These fluids should be dispensed aseptically.

• Sterile water should be used when rinsing equipment. If tap water must be used, either an alcohol rinse must follow or the equipment must thoroughly air dry before use.

• If a large stock bottle of sterile fluid must be reused, the container must be resealed and dated after opening. Remaining fluid should be discarded within 24 hours.

• When multidose medication vials are being used, they must be handled, dispensed, and stored according to manufacturer’s instructions (on the label or package insert). Medication must not be used after its expiration date.

78 SECTION I • Foundations of Respiratory Care

FIGURE 4-3 Ventilator-associated events (VAE) surveillance algorithm.

January 2015

*According to Centers for Disease Control (CDC).

Device-associated Module VAE

(Modified April 2015) 10-18

Figure 1: Ventilator-Associated Events (VAE) Surveillance Algorithm*

Ven�lator-Associated Condi�on (VAC)

A�er a period of stability or improvement on the ven�lator, the pa�ent has at least one of the following indicators of worsening oxygena�on: 1) Increase in daily minimum* FiO2 of ≥0.20 (20 points) over the daily minimum FiO2 in the baseline period, sustained for ≥2 calendar days. 2) Increase in daily minimum* PEEP values of ≥3 cmH2O over the daily minimum PEEP in the baseline period

†, sustained for ≥2 calendar days. *Daily minimum defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour. †Daily minimum PEEP values of 0-5 cmH2O are considered equivalent for the purposes of VAE surveillance.

On or a�er calendar day 3 of mechanical ven�la�on and within 2 calendar days before or a�er the onset of worsening oxygena�on, the pa�ent meets both of the following criteria:

1) Temperature >38 °C or <36°C, OR white blood cell count ≥12,000 cells/mm3 or ≤4,000 cells/mm3. AND 2) A new an�microbial agent(s) (see Appendix for eligible an�microbial agents) is started, and is con�nued for ≥4 calendar days.

Infec�on-Related Ven�lator-Associated Complica�on (IVAC)

On or a�er calendar day 3 of mechanical ven�la�on and within 2 calendar days before or a�er the onset of worsening oxygena�on, ONE of the following criteria is met (taking into account organism exclusions specified in the protocol):

1) Criterion 1: Posi�ve culture of one of the following specimens, mee�ng quan�ta�ve or semi-quan�ta�ve thresholds as outlined in protocol, without requirement for purulent respiratory secre�ons:

• Endotracheal aspirate, ≥10 5 CFU/ml or corresponding semi-quan�ta�ve result • Bronchoalveolar lavage, ≥104 CFU/ml or corresponding semi-quan�ta�ve result • Lung �ssue, ≥104 CFU/g or corresponding semi-quan�ta�ve result • Protected specimen brush, ≥103 CFU/ml or corresponding semi-quan�ta�ve result

2) Criterion 2: Purulent respiratory secre�ons (defined as secre�ons from the lungs, bronchi, or trachea that contain >25 neutrophils and <10 squamous epithelial cells per low power field [lpf, x100])† plus a posi�ve culture of one of the following specimens (qualita�ve culture, or quan�ta�ve/semi-quan�ta�ve culture without sufficient growth to meet criterion #1):

• Sputum • Endotracheal aspirate • Bronchoalveolar lavage • Lung �ssue • Protected specimen brush † If the laboratory reports semi-quan�ta�ve results, those results must correspond to the above quan�ta�ve thresholds. See addi�onal instruc�ons for using the purulent respiratory secre�ons criterion in the VAE Protocol.

3) Criterion 3: One of the following posi�ve tests:

• Pleural fluid culture (where specimen was obtained during thoracentesis or ini�al placement of chest tube and NOT from an indwelling chest tube)

• Lung histopathology, defined as: 1) abscess forma�on or foci of consolida�on with intense neutrophil accumula�on in bronchioles and alveoli; 2) evidence of lung parenchyma invasion by fungi (hyphae, pseudohyphae or yeast forms); 3) evidence of infec�on with the viral pathogens listed below based on results of immunohistochemical assays, cytology, or microscopy performed on lung �ssue

• Diagnos�c test for Legionella species • Diagnos�c test on respiratory secre�ons for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus,

Possible Ven�lator-Associated Pneumonia (PVAP)

Pa�ent has a baseline period of stability or improvement on the ven�lator, defined by ≥2 calendar days of stable or decreasing daily minimum* FiO2 or PEEP values. The baseline period is defined as the 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2. *Daily minimum defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour.

rhinovirus human metapneumovirus coronavirus

Principles of Infection Prevention and Control • CHAPTER 4 79

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improvement in the delivery of care. Infection preventionists must communicate the results of surveillance activities to bedside caregivers in a meaningful way so that continuous improvements in care occur based on local data. Health care workers need to be willing to accept surveillance data in the way it is intended, not as a punitive grade, but as a tool to encourage reflection on current processes for delivering care. All health care workers should be aware of the rates of adherence in their area to bundles, hand hygiene, and HAI and should seek out their infection preventionist with any questions, observations, and suggestions on how care could be improved.

SUMMARY CHECKLIST

◗ The five major routes for transmission of pathogens are contact, droplet, airborne, common vehicle, and vector-borne.

◗ Infection prevention procedures involve (1) eliminating the sources of infectious agents, (2) creating barriers to their transmission, and (3) monitoring and evaluating the effectiveness of control.

◗ Failure to clean equipment properly can render all subsequent processing efforts ineffective.

◗ Physical or chemical disinfection destroys the vegetative form of pathogenic organisms but cannot kill bacterial spores.

◗ Glutaraldehyde (20 minutes) is the most common option for high-level disinfection of semicritical respiratory care equipment.

◗ EtO is best suited for sterilization of critical moisture- sensitive or heat-sensitive items; heat-stable critical items should be steam-sterilized.

◗ Among respiratory care equipment, large-volume nebulizers have the greatest potential to spread infection.

◗ Ventilator circuits should be changed when visibly soiled or malfunctioning.

◗ HMEs may be used up to 96 hours before they need to be changed.

◗ Single-use items should be reused only if there is hard documented evidence that reprocessing poses no threat to the patient, it does not alter the function of the device, and FDA guidelines are followed. The use of a third-party reprocessor is recommended.

◗ Sterile fluids always must be used for tracheal suctioning and filling nebulizers and humidifiers.

◗ Hands need to be thoroughly cleaned after any patient contact, even when gloves are used.

◗ Standard precautions must be used in caring for all patients, regardless of their diagnosis or infection status.

◗ The use of gloves is part of routine basic care when there is skin contact with a patient.

◗ Masks, goggles, or a face shield must be worn during any procedure that can generate splashes or sprays of blood, body fluids, secretions, or excretions.

◗ RTs must be familiar with the overall infection prevention program, including surveillance policies and procedures.

http://www.cdc.gov/ncidod/dhap/pdf/isolation2007pdf

80 SECTION I • Foundations of Respiratory Care

23. U.S. Food and Drug Administration: Reprocessing of single-use devices. <http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/ ReprocessingofSingle-UseDevices/default.htm>. Accessed August 19, 2015.

24. National Health and Safety Network, Device associated module: ventila- tor associated event. <http://www.cdc.gov/nhsn/acute-care-hospital/index .html>. Accessed December 1, 2014.

20. Kallstrom TJ: American Association for Respiratory Care: AARC guideline: oxygen therapy for adults in acute care facilities. Respir Care 47:717–720, 2002.

21. Centers for Disease Control and Prevention: Guideline for preventing health-care associated pneumonia, 2003. MMWR Morb Mortal Wkly Rep 53(RR03):1–36, 2003.

22. Miller MR, Crapo R, Hankinson J, et al: General considerations for lung function testing. Eur Respir J 26:153–161, 2005.

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/ReprocessingofSingle-UseDevices/default.htm

http://www.cdc.gov/nhsn/acute-care-hospital/index.html

C H A P T E R 5

Ethical and Legal Implications of Practice

ANTHONY L. DEWITT

CHAPTER OBJECTIVES

After reading this chapter you will be able to: ◆ Summarize the philosophical foundations of ethics. ◆ Explain what constitutes an ethical dilemma and how such dilemmas arise in health care. ◆ Describe how professional codes of ethics apply to ethical decision making. ◆ Explain how traditional ethical principles are useful in resolving ethical dilemmas. ◆ Describe the information that should be gathered before making an ethical decision. ◆ Explain how the systems of civil and criminal law differ. ◆ Describe what constitutes professional malpractice and negligence. ◆ Explain how a respiratory therapist can become liable for wrongful acts. ◆ List the elements that constitute a practice act. ◆ Explain how licensing affects legal responsibility and liability. ◆ Describe how changes in health care delivery have shaped the ethical and legal aspects of practice. ◆ Summarize the basic elements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). ◆ Describe the role of advance directives and living wills in health care.

CHAPTER OUTLINE

Philosophical Foundations of Ethics Ethical Dilemmas of Practice Codes of Ethics Ethical Theories and Principles

Autonomy Veracity Nonmaleficence Beneficence Confidentiality Justice Role Duty

Ethical Viewpoints and Decision Making Formalism Consequentialism Mixed Approaches Virtue Ethics Intuitionism Comprehensive Decision-Making Models

Legal Issues Affecting Respiratory Care Systems of Law Health Insurance Portability and Accountability Act

of 1996 Medical Supervision

Interaction of Ethics and the Law Professional Licensure Issues

Licensure Statute Understanding the Causes of Discipline Engaging Counsel

Respiratory Therapists Who Speak Out About Wrongdoing Patient Protection and Affordable Care Act National Labor Relations Act False Claims Act

Health Care and Change Health Care Advance Directives

82 SECTION I • Foundations of Respiratory Care

ethical and legal, unethical but legal, ethical but illegal, or unethical and illegal.

For example, a therapist who spends 30 minutes after clock- ing out visiting with a patient because the patient has no family is performing an act that is both ethical and legal. If the purpose of the visit, however, is to encourage the patient to offer her monetary gratuities for this extra visitation, the act would be legal but unethical because it seeks to exploit the emotional vulnerability of a patient. If the same patient, however, was a prisoner subject to a restriction on their right to visitation by the state, and the therapist knowingly violated the prohibition against visitation in violation of a state statute, the act would not be unethical (because the act does not violate the standards of the profession) but may well be illegal under state law. Finally, if the purpose of the visit was to rummage through a demented patient’s valuables for the purpose of taking their credit card and checkbook, the act would be both unethical (because it would be exploiting the patient’s mental vulnerabilities in viola- tion of professional norms) and illegal (because it would be theft in violation of state criminal laws).

This chapter provides a foundation of principles related to the ethical and legal practice of respiratory care.

PHILOSOPHICAL FOUNDATIONS OF ETHICS

Although an in-depth discussion of philosophy is beyond the scope of this chapter, you should realize that ethics has its origins in philosophy. Philosophy may be defined as the love of wisdom and the pursuit of knowledge concerning humankind, nature, and reality.1 Ethics is one of the disciplines of philoso- phy, which include ontology (the nature of reality), metaphys- ics (the nature of the universe), epistemology (the nature of knowledge), axiology (the nature, types, and criteria of values), logic, and aesthetics. Ethics is primarily concerned with the question of how we should act. Although ethics may share common origins with the disciplines of law, theology, and eco- nomics, as an applied practice, ethics is clearly different from these disciplines.1 Ethics can be described philosophically as a moral principle that supplements the golden rule and can be

A n effective respiratory therapist (RT) must possess excellent clinical skills and an understanding of the business of health care. The health care industry, similar to all industries, must deliver services in an atmosphere in which ethical and legal considerations are an integral part of the organizational culture. RTs regularly encounter circum- stances that require them to make choices or take actions that have ethical and legal implications. In society, ethics and law help maintain order, stability, and accountability. In profes- sional practices, ethics guide RTs in carrying out their duties in a morally defensible way. Law establishes the minimum legal standards to which practitioners must adhere. Although not always the case, ethical practice may require a standard above that of legal practice. The tension between these two competing values can sometimes be problematic.

The force behind law is threefold: (1) state statutes regulate individual conduct by imposing criminal and sometimes civil penalties on those whose actions are considered to be against public policy by the legislative branch of government. The sanctions range from reparations and fines to imprisonment; (2) state statutes and professional boards regulate the practice of therapists and set minimum standards for competent prac- tice as well as requirements for continuing education. Violation of licensing statutes and regulations can result in fines or disci- pline or revoking of the individual practitioner’s license; and (3) the common law of civil liability for negligent and inten- tional acts imposes a duty to pay compensation to individuals who are injured. Civil judgments are usually monetary—they do not affect personal liberty.

Sanctions for ethical misconduct range from a loss of profes- sional standing to expulsion from the profession or professional societies. In some cases, ethical misconduct and legal misbehav- ior may result from the same incident. The distinction between illegal acts and unethical behavior is not always obvious but is straightforward. An illegal act violates the standards of conduct set down for all citizens (e.g., domestic assault), whereas ethical misconduct usually relates to violations of professional and ethical norms established by the profession as a whole. A given act may fit any one of the following categories, depending on the cir- cumstances and the ethical orientation of the person involved:

KEY TERMS

advance directives assault autonomy axiology battery beneficence benevolent deception breach of contract compensatory justice confidentiality consequentialism

defendant distributive justice double effect formalism informed consent intuitionism justice libel living will malpractice negligence

nonmaleficence plaintiff res ipsa loquitur respondeat superior rule utilitarianism slander strict liability tort veracity virtue ethics

Ethical and Legal Implications of Practice • CHAPTER 5 83

procedures. When the hospital admission or procedure is approved, specific requirements or limitations are usually asso- ciated with the patient’s care. As a result, health care workers, including RTs, may find themselves engaged in clinical processes that are dictated more by the third-party payers than by patient needs. Under these circumstances, health care workers may feel frustrated and helpless if they believe a patient needs care beyond that approved by the third-party payer. Ethics may impose a duty on professionals to interact with and press for change with the third party.

The rationing of care continues to be a side effect of staffing patterns created by managed care. Although all businesses must carefully balance staffing patterns against productivity, managed care has brought this concept home in a major way to health care facilities. An RT working in an understaffed department may decide that Patient A can really forego therapy because the department is short staffed and Patient A is really not going to get better anyway. Although this may sound at first like a case of simple neglect of duty, it is also an ethical dilemma. Unless this behavior is endorsed by a treatment protocol approved by the medical director and medical staff, it may violate profes- sional norms and be unethical to effectively prefer one patient over another on the basis of factors beyond the patient’s control.

The approaches used to address ethical issues in health care range from the specific to the general. Specific guidance in resolving ethical dilemmas is usually provided by a professional code of ethics. General approaches involve the use of ethical theories and principles to reach a decision.3

CODES OF ETHICS

A code of ethics is an essential part of any profession that claims to be self-regulating. The adoption of a code of ethics is one way in which an occupational group establishes itself as a pro- fession. A code may try to limit competition, restrict advertise- ment, or promote a particular image in addition to setting forth rules for conduct.4

The first American medical code of ethics (established in 1847) was as much concerned with separating orthodox prac- titioners from nontraditional ones as it was with regulating behavior. Even modern codes tend to be vague regarding what is prescribed and what is to be avoided.

The American Association for Respiratory Care (AARC) has adopted a Statement of Ethics and Professional Conduct. The current code appears in Box 5-1. This code represents a set of general principles and rules that have been developed to help ensure that the health needs of the public are provided in a safe, effective, and caring manner. Codes for different professions might differ from the code governing respiratory care because they may seek different goals. However, all codes of ethics seek to establish parameters of behavior for members of the chosen profession. Professional codes of ethics often represent overly simplistic or prohibitive notions of how to deal with open mis- behavior or flagrant abuses of authority.

The most difficult ethical decisions arise from situations in which two or more right choices are incompatible, in which the

summed up by a commitment to “respect the humanity in persons.”2

ETHICAL DILEMMAS OF PRACTICE

The growth of respiratory care has paralleled the development of advanced medical technology and treatment protocols. At the same time, during the 1970s and through the 1990s, the medical community has experienced rising expectations about acceptable standards of care. This is due to an ever-growing and sophisticated patient population fueled by medical benefit packages from the government and employers. In the latter part of the 1990s, managed care strategies and other cost-containment methods adopted by most third-party payers slowed the growth of the health care industry. The ethical and legal issues faced by practitioners, although changed in many cases, continued to grow. In the earlier period, RTs faced ethical dilemmas and legal issues associated with patient expectations, staffing, and quality of care, among others. RTs continue to face ethical dilemmas and legal issues; however, such dilemmas may now include the rationing of care, dealing with conflicts associated with third party–imposed standards of care, and delivery of the appropri- ate standard of care in the face of cost constraints and corporate influence. Staffing issues continue to be a problem and are at the root of many of the ethical and legal concerns faced by RTs. As respiratory care continues to mature as a profession, these challenges are likely to increase. The twenty-first century has brought one particular challenge, although not new to health care or to RTs: a heightened awareness of the patient’s right to privacy. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), discussed later in this chapter, is now a major consideration for RTs as they perform their jobs. It also has brought new opportunities in the form of the Patient Protection and Affordable Care Act of 2010 (PPACA). The PPACA has improved access to health care and increased reimbursement for patient care services, as well as creating disease management opportunities for RTs.

RTs work in complex health care settings. As a result, there is a large range of ethical dilemmas that may face the RT on a regular basis. The clinical aspects and the management aspects of health care are full of possibilities for ethical dilemmas. In addition, the ethical orientation of the RT plays a role in recog- nition and identification of ethical dilemmas. The health care industry continues to be in a period of dynamic change, bring- ing many new challenges. New technologic and management methodologies are continuously being introduced to accom- plish the missions and goals of health care organizations. Over the past decade, there has been an almost complete change from a relatively open fee-for-service system to one in which care is managed in some fashion and the fees are in some form of capitated payment. These changes often pose serious ethical dilemmas.

For example, managed care uses a concept known as “restric- tive gatekeeping.” Restrictive gatekeeping requires patients to obtain prior approval from their third-party payer, usually an insurance company, before hospitalization and before certain

84 SECTION I • Foundations of Respiratory Care

choices represent different priorities, or in which limited resources exist to achieve a desired end. Ethicists readily admit that reducing these issues to simple formulations is not an easy task. The number and complexity of ethical dilemmas continue to grow as the complexity of life and health care increases. For health care, difficult ethical dilemmas continue to involve con- cerns about the practical limits on financial resources, the growing emphasis on individual autonomy, and more research advances such as cloning and stem cell research. Resolution of these more complex problems requires a more general approach than that provided by a code of ethics. This more general per- spective is provided by ethical theories and principles.

In addition to the moral obligations that ethical duties impose on RTs, ethical obligations are often cited in legal pro- ceedings as a tool of cross-examination. If an RT expresses opinions or is accused of actions that would violate the ethical duties of the profession, the RT’s ignorance of ethical standards during cross-examination can have a powerful effect on a jury.

ETHICAL THEORIES AND PRINCIPLES

Ethical theories and principles provide the foundation for all ethical behavior. Contemporary ethical principles have evolved

MINI CLINI Conflicting Obligations

PROBLEM: Mary Smith, a registered RT with 18 years’ expe- rience, has worked for a large regional medical center for the past 10 years. She is generally happy with her work but is con- cerned about the financial stability of the hospital. As a result, she has signed on with a temporary agency to ensure that she will have work if the hospital decides to initiate a reduction in force. On one of her scheduled days off, Mary Smith agrees to work a shift for the temporary agency at another hospital. Two hours before her shift is scheduled to begin, she receives a telephone message from the medical center where she is employed. Her supervisor asks Mary Smith to report to work at the medical center because the only experienced therapist on the shift has been in an automobile accident. Mary Smith is torn between her obligation to the medical center where she has worked for 10 years and the agency.

DISCUSSION: Professionalism and ethics generally require a commitment to one’s duties. In this situation, Mary Smith must consider not only her duty but also the consequences of each decision that she might make. In either case, there is the possibility that her decision will leave a staffing shortage at one of the hospitals.

DISCUSSION QUESTIONS: Should Mary Smith cancel her shift with the agency, although she has agreed to give the agency a 4-hour notice except in an emergency? Should she work the shift at the agency as scheduled, using the rationale that she did not create the staffing problem at the medical center? Should she call her supervisor, explain the situation, and ask for help in making the right decision, realizing that the final decision would still be hers? Should she call her supervisor and tell the supervisor that she is ill and cannot come in and report to the agency job?

GUIDANCE: Generally, a therapist’s loyalty should be to the primary institution that employs her. In this situation the hos- pital has invested time, money, and benefits, as well as training, in the therapist, and the therapist owes the institution a duty of loyalty. Saying “I didn’t create the problem” does not solve the problem; it merely passes the buck. The agency may be annoyed at the change of plans, but likely has others to call. The same does not appear to be true of the hospital. Calling the supervisor makes the problem a shared problem, and that is probably not fair to the supervisor because the supervisor did not seek outside employment. Thus this situation requires the therapist to consider her duty of loyalty to her employer and do the right thing.

Box 5-1 American Association for Respiratory Care Statement of Ethics and Professional Conduct (Revised July, 2004)

In the conduct of professional activities, the respiratory therapist shall be bound by the following ethical and professional principles. Respiratory therapists shall: • Demonstrate behavior that reflects integrity, supports

objectivity, and fosters trust in the profession and its professionals. Actively maintain and continually improve their professional competence and represent it accurately.

• Perform only those procedures or functions in which they are individually competent and that are within the scope of accepted and responsible practice.

• Respect and protect the legal and personal rights of patients they treat, including the right to informed consent and refusal of treatment.

• Divulge no confidential information regarding any patient or family unless disclosure is required for responsible performance of duty or required by law.

• Provide care without discrimination on any basis, with respect for the rights and dignity of all individuals.

• Promote disease prevention and wellness. • Refuse to participate in illegal or unethical acts and refuse to

conceal illegal, unethical, or incompetent acts of others. • Follow sound scientific procedures and ethical principles in

research. • Comply with state or federal laws that govern and relate to

their practice. • Avoid any form of conduct that creates a conflict of interest

and shall follow the principles of ethical business behavior. • Promote health care delivery through improvement of the

access, efficacy, and cost of patient care. • Encourage and promote appropriate stewardship of

resources.

from many sources, including Aristotle’s and Aquinas’ natural law, Judeo-Christian morality, Kant’s universal duties, and the values characterizing modern democracy.5,6 Although contro- versy exists, most ethicists agree that autonomy, veracity, nonmaleficence, beneficence, confidentiality, justice, and role fidelity are the primary guiding principles in contemporary ethical decision making.1,5

Each of these ethical principles, as applied to professional practice, consists of two components: a professional duty and a

Ethical and Legal Implications of Practice • CHAPTER 5 85

tions between health care providers and the patient and has a chilling effect on the rapport that is so necessary for good care. In a poll conducted by the Louis Harris group, 94% of Ameri- cans surveyed indicated that they wanted to know everything about their cases, even the dismal facts. Other than with pedi- atrics and rare cases in which there is evidence that the truth would lead to a harm (e.g., suicide), the truth, provided in as pleasant a manner as possible, is probably the best policy.7

Truth telling also can involve documentation and medical recordkeeping. This type of dilemma is occurring more fre- quently under strict managed care reimbursement protocols.FIGURE 5-1 Reciprocal relationship between professional obligations and patient rights.

Professional obligations

Patient rights

MINI CLINI Patient Rights

PROBLEM: An RT working at a hospital receives a physician order to administer an aerosolized bronchodilator treatment to a 26-year-old female patient with asthma admitted for sus- pected pneumonia. The patient refuses the treatment on enter- ing the room, stating that she is having a “bad day” today and does not want to be bothered by anyone. The patient is regarded as being competent and fully capable of making health care decisions for herself. How should the RT handle this situation?

DISCUSSION: The RT must acknowledge and respect the patient’s right to decide freely whether or not to allow the respiratory care treatment. According to the principles of ethical theory and conduct, health care professionals have an obligation to promote patient autonomy by permitting freedom of will and freedom of action. It is also important that neither coercion nor deceit be used to get a patient to reverse his or her decision to refuse a treatment. According to the American Hos- pital Association statement called “The Patient Care Partner- ship,” the patient has the right to refuse treatment and to be informed of the medical consequences of her action.

The RT could talk to the patient and explore what the term “bad day” meant to her. It might be that she is not feeling well because of breathing problems from her asthma condition and worsening symptoms of possible pneumonia. The RT has an important role in ensuring that the patient understands the benefits of the respiratory treatment and the health conse- quences of refusal so that the patient can make a well-informed decision. If the RT approaches the patient in a professional, nonthreatening manner, she may feel more at ease and be willing to discuss in greater depth why she does not want to take the treatment. It is common for a patient to refuse therapy initially only to change his or her mind after discussion with the RT. Should the patient still refuse the treatment after discus- sion with the RT, the RT should remain nonjudgmental, even if he or she disagrees with the patient’s decision. Appropriate documentation in the medical record and physician notifica- tion should then occur.

patient right (Figure 5-1). The principle of autonomy obliges health care professionals to uphold the freedom of will and freedom of action of others. The principle of beneficence obliges health care professionals to further the interests of others, either by promoting their good or by actively preventing their harm. The principle of justice obliges health care professionals to ensure that others receive what they rightfully deserve or legiti- mately claim.

Expressed in each duty is a reciprocal patient right. Recipro- cal patient rights include the right to autonomous choice, the right not to be harmed, and the right to fair and equitable treat- ment. More specific rules can be generated from these general principles of rights and obligations, such as those included in a code of ethics.

Autonomy

The principle of autonomy acknowledges the personal liberty of patients and their right to decide their own course of treat- ment and follow through on a plan on which they freely agree. It is from this principle that rules about informed consent are derived. Under the principle of autonomy, the use by an RT of deceit or coercion to get a patient to reverse the decision to refuse a treatment is considered unethical. Likewise, it is unethi- cal and illegal to threaten a patient who is unwilling to sign a consent form.

Veracity

The principle of veracity (accuracy or truthfulness) is often linked to autonomy, especially in the area of informed consent. Generally, veracity binds the health care provider and the patient to tell the whole truth about the choices inherent in medical care. This means providing not only information about the benefits of a particular course of action but also what might go wrong and what kinds of frequent complications occur. The nature of the health care delivery process is such that both parties involved are best served in an environment of trust and mutual sharing of all information. Problems with the veracity principle revolve around such issues as benevolent deception. In actions of benevolent deception, the truth is withheld from the patient for, supposedly, his or her own good.

When the physician decides to withhold the truth from a conscious, well-oriented adult, the decision affects the interac-

Nonmaleficence

The principle of nonmaleficence requires that health care pro- viders avoid harming patients and prevent harm actively where

86 SECTION I • Foundations of Respiratory Care

MINI CLINI Veracity

PROBLEM: Jon performs pulmonary function testing, in- cluding blood gases, for his hospital. Many of the patients he sees are attempting to qualify or requalify for continuous reim- bursement for home oxygen use. To qualify, the patient’s PaO2 must be less than 60 mm Hg on room air at rest. Patient A, who has home O2 therapy, is attempting to requalify, although her condition has improved from what it was 1 year earlier. Her blood gas results show a PaO2 of 63 mm Hg. The patient’s husband asks Jon if there is anything he can do, while relating how greatly his wife benefits from the O2. Jon tells the husband that there is nothing he can do and assists the husband in taking the patient out to her car. At the car, the husband pulls out his wallet, shows it to Jon, and repeats the question.

DISCUSSION POINTS: RTs have an obligation to carry out their duties in the most competent and professional manner possible. Failure to do so may constitute both an ethical dilemma and a legal issue. Similarly, RTs have a duty to be truthful with third parties who may rely on their clinical results.

DISCUSSION QUESTIONS: What is the potential ethical dilemma in this situation? What ethical principles are involved here? What other ways could Jon have chosen to handle this situation?

GUIDANCE: The ethical dilemma here is whether to accept cash to change a blood gas result, and there should be no ques- tion about the right answer. It is never okay to accept money from patients for doing your job. It creates a situation in which a clinician feels obligated to perform additional or, in this case, unlawful acts for the patient. That is a slippery slope, and once a therapist starts down that path, there is frequently no turning back. Falsification of medical records can result in both civil and criminal liability. Accepting money to change the test result could be viewed as receiving a kickback under the federal Anti- Kickback statute, which carries criminal penalties. It could be viewed as an unlawful and unethical act by the state board, and result in license discipline. Worse, it erodes the trust of other professionals—including physicians and nurses—in the scien- tific objectivity and professional status of all the other thera- pists who will be tarred with the same brush.

This Mini Clini involves the ethical principles of veracity and the duty of candor to third parties. Therapists have fought hard for professional recognition, and selling test results under- mines the entire profession. The ethical principle of veracity is among the most important of the ethical principles because it has the potential to do the most damage if it is violated.

possible. It is sometimes difficult to uphold this principle in modern medicine because in many cases, drugs and procedures have secondary effects that may be harmful in varying degrees. Procedures carry risks for complications, not all of which can be predicted. For example, an RT might ask whether it is ethical to give a high dose of steroids to an asthmatic patient, knowing the many harmful consequences of these drugs. One solution to these dilemmas is based on the understanding that many helping actions inevitably have both a good and a bad effect, or double effect. The key is the first intent. If the first intent is good, the harmful effect is viewed as an unintended result. The double effect brings us to the essence of the definition of the word dilemma. The word comes from the Greek terms di, meaning “two,” and lemma, meaning “assumption” or “proposition.”8

Consideration of intent alone, however, does not settle the issue. Nonmaleficience and veracity cannot always be separated; effects must be explained, even if this may lead the patient to pass up the intended benefits of the treatment.

Beneficence

The principle of beneficence raises the “do no harm” require- ment to an even higher level. Beneficence requires that health care providers go beyond doing no harm and contribute actively to the health and well-being of their patients. Many quality-of- life issues are included within this dictum. Practitioners of medicine today possess the technology to keep some individuals alive well beyond any likelihood of meaningful recovery. This technology presents dilemmas for practitioners who have the ability to prolong life but not the ability to restore any uniquely human qualities.

One approach in this situation is for the RT to tell the patient that the physician will interpret the studies and provide a full report at the next office visit. All final discussion of results must ultimately go through the physician.

Some individuals interpret the principle of beneficence to mean that they must do everything to promote a patient’s life, regardless of how useful the life might be to that individual. Other professionals in the same situation might believe they are allowing the principle to be better served by doing nothing and allowing death to occur without taking heroic measures to prevent it. In an attempt to allow patients to participate in resolving this dilemma, legal avenues, called advance directives, have been developed.9 Advance directives allow a patient to give direction to health care providers about treatment choices in circumstances in which the patient may no longer be able to provide that direction. The two types of advance directives available at the present time and widely used are the living will and the durable power of attorney for health care. A durable power of attorney for health care allows the patient to identify another person to carry out his or her wishes with respect to health care, whereas a living will states a patient’s health care preferences in writing. As a result of the Patient Self- Determination Act of 1990, most states require that all health care agencies receiving federal reimbursement under Medicare/ Medicaid legislation provide adult clients with information on advance directives.9,10

Confidentiality

The principle of confidentiality is founded in the Hippocratic Oath; it was later reiterated by the World Medical Association in 1949. It obliges health care providers to “respect the secrets which are confided even after the patient has died.”11 Confi- dentiality, as with the other axioms of ethics, often must be balanced against other principles, such as beneficence. Notably, state laws require a breach of confidence under certain

Ethical and Legal Implications of Practice • CHAPTER 5 87

health care providers. The widespread use of these data systems also threatens patient confidentiality. In an attempt to reduce this threat, most clinical databases are restricted to use by only the health care workers who have a need to know. In addition to being unethical, an RT who reads the file of a patient whom he or she is not treating would likely be in violation of institu- tional policy. The accompanying Mini Clini below provides an example.

MINI CLINI Confidentiality

PROBLEM: Mary, an RT, is working the evening shift at a large urban medical center when she receives a telephone call from a friend telling her that her next door neighbor has been admitted to the medical center. Mary’s first thought is to check the neighbor’s file on the computer system to see why her neighbor has been hospitalized.

DISCUSSION POINT: Mary knows that the medical center has a policy that employees are to access only the charts for which they have a reason to do so.

DISCUSSION QUESTIONS: Should Mary access this chart via the computer system? If she does, what kind of violation will she be committing—ethical, legal, or both? What ethical principles, if any, would apply here? What is the harm in simply checking the computer on this patient? Is anyone likely to know if Mary accesses this patient’s information?

GUIDANCE: The answer here is straightforward. She should absolutely not access the computer. The policy is there to keep the facility compliant with HIPPA and with state laws regarding privacy. Mary runs the risk for being fired because this action violates hospital policy. What harm does looking at the com- puter do? It erodes the confidentiality that patients expect. The far greater harm will be to Mary’s reputation and future employability. If Mary does this, she will certainly be found out because the electronic medical record system has an “audit trail” that indicates who accessed the record and when. Mary will face hospital discipline for the policy violation (likely ter- mination) and she may face criminal charges or civil adminis- trative penalties under state and federal law for breaches of patient confidentiality. This action also places Mary at risk for a civil lawsuit for invasion of privacy.

The only exception to the rule of confidentiality regarding Mary’s neighbor is if Mary is assigned to provide care to her as a treating RT. Only then does she have a need to know what is in the chart and what is wrong with her neighbor. But even then, the wiser course, because of the close relationship, would be for Mary to ask that she be excused from this case and that someone else handle the clinical duties for the patient.

Why? If the patient has an illness that carries any stigma with it (human immunodeficiency virus [HIV] infection, pediculosis capitis, etc.), the patient will likely be very embar- rassed if her neighbor knows about it. And, if the patient’s other neighbors learn about the condition from another source, Mary will be suspected. This will have consequences at work. For this reason, Mary should steer clear of this patient’s medical record.

RULE OF THUMB

Patient information should be discussed only in private and with persons who have a legitimate reason and need to know.

conditions (e.g., reporting gunshot wounds or child abuse) in which risk to other parties may result from not disclosing events or results.

The main ethical issue surrounding confidentiality is whether more harm is done by occasionally violating its mandate or by always upholding it regardless of the consequences. This limita- tion to confidentiality is known as the harm principle. This principle requires that practitioners refrain from acts or omis- sions in which foreseeable harm to others could result, espe- cially when the others are vulnerable to risk. This principle would require that confidentiality be maintained for a patient with acquired immunodeficiency syndrome (AIDS) in matters involving his or her landlord. In this case, confidentiality is justified because the landlord is not particularly vulnerable. However, if the patient was planning to marry, the harm prin- ciple would require that confidentiality be broken because of the special vulnerability of the future spouse.

Confidentiality is usually considered a qualified, rather than an absolute, ethical principle in most health care provider– patient relationships. These qualifications are often written into codes of ethics. The American Medical Association Code of Ethics, Section 9, provides the following guidelines: “A physician may not reveal the confidences entrusted to him in the course of medical attendance or the deficiencies he may observe in the character of patients, unless he is required to do so by law or unless it becomes necessary in order to protect the welfare of the community or a vulnerable individual.” Under the require- ments of public health and community welfare, there is often a legal requirement to report such things as child abuse, poison- ings, industrial accidents, communicable diseases, blood trans- fusion reactions, narcotic use, and injuries caused with knives or guns.12 In many states, child abuse statutes protect the health care practitioner from liability in reporting even if the report should prove false as long as the report was made in good faith. Failure to report a case of child abuse can leave the practitioner legally liable for additional injuries that the child may sustain after being returned to the hostile environment.

Breaches of confidentiality more often result from careless slips of the tongue than from decision making or purposeful actions. Trading gossip about patients is unprofessional, unethi- cal, and, in certain cases, illegal. Risks for inadvertent disclosure increase markedly when RTs may exchange information on social networks such as Facebook and LinkedIn. Such informa- tion should never be placed in such social media networks, because doing so violates the rights of individual patients.

Because of the widespread use of computerized databases, confidential information, previously highly protected, is now relatively easy to obtain. Clinical data are available for close scrutiny by the clerical staff, laboratory personnel, and other

88 SECTION I • Foundations of Respiratory Care

Despite medical and sociologic advances, potential viola- tions of the individual’s right to privacy in certain populations, such as patients with AIDS, pose a special risk because disclo- sure may result in economic, psychologic, or physical harm to the patient. RTs should adhere to the dictum found in the Hip- pocratic Oath: “What I may see or hear in the course of the treatment or even outside of treatment of the patient in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things to be shameful to be spoken about.”13

Justice

The principle of justice involves the fair distribution of care. Rising health care expectations, coupled with the decreased availability of care because of cost, is making this principle an important one for health care workers. Population trends and the financial shortfalls in programs such as Medicaid and Medi- care will contribute to the continuing importance of this principle.

The United States is rapidly approaching the point at which a balance must be found between health care expenses and the revenue available to pay for them. Efforts to achieve this balance may lead to some form of rationing of the delivery of health care services. This type of justice is properly referred to as dis- tributive justice.

A second form of justice seen in health care is compensatory justice. This form of justice calls for the recovery for damages that were incurred as a result of the action of others. Damage awards in civil cases of medical malpractice or negligence are examples of compensatory justice. Compensatory justice often has been cited as playing a major role in increasing the cost of health care. However, the Congressional Budget Office esti- mates that less than 2% of the cost of health care is related to medical malpractice. Studies by Zurich Insurance Company,14 Harvard University, and Dartmouth College showed little to no impact on the cost of health care and generally debunk the myth that physicians always practice defensive medicine. The Harvard study showed that patients were not compensated in the pres- ence of actual malpractice more frequently than physicians were held accountable in the absence of actual malpractice. Other studies generally confirm that the civil justice system does a good job of protecting the rights of health care workers and patients in negligence litigation. There is a general bias, fueled in part by media reports, against medical liability. Nationally, 75% of medical negligence cases that go to trial are won by the medical provider.

Role Duty

Because no single individual can be solely responsible for pro- viding all of a patient’s health care needs, modern health care is necessarily a team effort. There are more than 100 allied health professions, and allied health workers (excluding nursing and physicians) provide approximately 60% of all patient care. Each of the allied health professions has its own practice niche, defined by tradition or by licensure law. Practitioners have a duty to understand the limits of their role and to practice with

fidelity. For example, because of differences in role duty, an RT might be ethically obliged not to tell a patient’s family how critical the situation is, instead having the attending physician do so.3 The previous Mini Clinis addressed role duty, and the accompanying Mini Clini presents another example of the ethics of role duty.

ETHICAL VIEWPOINTS AND DECISION MAKING

In deciding ethical issues, some practitioners try to strictly interpret one or more of the aforementioned ethical principles. Other practitioners seek to decide the issue solely on a case-by- case basis, considering only the potential good (or bad) conse- quences. Still other practitioners would appeal to the image of a “good practitioner,” asking themselves what a virtuous person would do in a similar circumstance. Finally, many practitioners acknowledge that they largely follow their intuition for making ethical decisions. These different viewpoints represent the four dominant theories underlying modern ethics.5,15 The viewpoint that relies on rules and principles is called formalism, or duty- oriented reasoning. The viewpoint in which decisions are based on the assessment of consequences is called consequentialism. The viewpoint that asks what a virtuous person would do in a similar circumstance is called virtue ethics. When intuition is involved in the decision-making process, the approach is called intuitionism.

Formalism

Formalist thought asserts that certain features of an act deter- mine its moral rightness. In this framework, ethical standards of right and wrong are described in terms of rules or principles. These rules function apart from the consequences of a particu- lar act. An act is considered morally justifiable only if it upholds the rules or principles that apply.

The major objection to this duty-oriented approach lies in its potential for inconsistency. Critics of formalist reasoning insist that no principle or rule can be framed that does not have exceptions. These critics claim that no principle or rule can be framed that does not conflict with other rules.

Consequentialism

For the consequentialist, an act is judged to be right or wrong based on its consequences. Each possible act is assessed in terms of the relative amount of good (over evil) that it would cause. The most common application of consequentialism judges acts according to the principle of utility. The principle of utility, in its simplest form, aims to promote the greatest general good for most people.

Critics of this approach claim that it has two fundamental flaws. First, the analyzing and weighing the amount of good over evil that might occur is not always possible. Second, reli- ance on the principle of utility to the exclusion of all else can result in actions that are incompatible with ordinary judg- ments about right and wrong. A classic example of this problem can be seen in the true World War II case of the battle for

Ethical and Legal Implications of Practice • CHAPTER 5 89

MINI CLINI Role Duty

PROBLEM: Sue, an RT, receives a request to perform a blood gas analysis for a patient on a ventilator because, as reported by the nurse, the patient’s oxygen saturation is only 61%. The patient has an order to obtain blood gas values as needed. As the nurse and RT look at the blood gas results, they both are surprised because the saturation is now 93%. The nurse suggests repeating the blood gas examination. The RT is about to comply until she notes the oximeter display on which the nurse is relying shows the patient with an O2 saturation of 93% and a pulse rate of 61 beats/min.

DISCUSSION POINT: Teamwork and role delineation are both essential components of good patient care. Each practitioner also has an obligation to perform his or her duties in the most com- petent and professional manner possible.

DISCUSSION QUESTIONS: What kind of issue or dilemma exists here—legal, ethical, or both? What should the RT do at this point? Should an incident report be written and, if so, by whom?

GUIDANCE: The dilemma here is to explain the nurse’s mistake in a way that does not jeopardize the working relationship with the nurse, while at the same time protecting the patient and the facility. Clearly a second blood gas value should not be obtained. Placement of the oximeter should be checked, and, if the oximeter is functioning properly, then it should be believed.

There are both legal and ethical components to the problem. The nurse had a good-faith belief that blood gas levels were required based on her understanding of the pulse oximeter. Her belief was wrong but reasonable. It is easily corrected with some training, and it is far better to discover this problem with an error that does not harm a patient as opposed to an error in which patient harm might have resulted.

The first issue is to explain the way the oximeter works and the meaning of the readings. Many nurses fail to understand the oxyhemoglobin dissociation curve, and as a result, interpret data from oximeters incorrectly. A therapist’s job is to educate both

patients and other caregivers and to do so in a professional and nonjudgmental manner.

The second issue is to evaluate the level of risk. There is very limited legal risk in this situation because the patient simply was not harmed by the error. The ethical duty of veracity and the duty of loyalty to the employer create a tension, however, regarding the filing of an incident report. Incident reports are necessary to protect the institution.

The nurse may be very reluctant to write an incident report about this event because it makes her look bad. Sadly, in some institutions incident reports are used incorrectly as a disciplinary tool instead of as a method of reporting errors from which systems can be improved. So the nurse may not wish to write an incident report, but the therapist must insist in this case. In the current era ensuring high-quality care is so important that hos- pitals must establish a culture in which reporting errors is encouraged and, in fact, expected as every caregiver’s obligation to use the experience of errors and “near miss” errors to improve care.

Why must a report be filed regarding the current event? First, the incident carried with it a strong presumption that risk to patients was present because the nurse did not understand the limits of the technology. Second, although a bad outcome was averted, at least one unnecessary blood gas level was obtained and a second was advocated. Third, the therapist is involved because she should have checked the oximeter before doing the first blood gas measurement to determine that the equipment was operating within specifications. So there is error on both sides of the issue. Even if the nurse does not write an incident report, the incident report should be written by the therapist and the mistake dis- closed to the physician. Teamwork and a commitment to high- quality care for patients requires honesty and full disclosure. Hospitals must ensure that reporting such events causes a focus on the process of care and opportunities to improve rather than on punishing the caregivers involved.

North Africa. In this scenario, there were two groups of sol- diers but only enough antibiotics for one group. One group required the medication for syphilis contracted in the local brothels; the other group needed antibiotics for wounds sus- tained in battle. The dilemma arose as to who should receive the antibiotics. Formalist or duty-oriented reasoning would base the decision about who should receive the antibiotics on some concept of justice, such as giving priority to the sickest or to the individuals most in need. However, the actual decision in this case was a consequentialist one, based not on the desire to distribute the drug justly but rather on the need to obtain a quick victory with as few casualties as possible. The scarce medication was given to the soldiers who were “wounded” in the brothels rather than in battle because these soldiers could be restored quickly and returned to the frontlines to aid the war effort.

Mixed Approaches

Mixed approaches to moral reasoning try to capitalize on the strengths of two major lines of ethical thought. One approach, called rule utilitarianism, is a variation of consequentialism. Under this framework, the question is not which act has the greatest utility but which rule would promote the greatest good if it were generally followed.

The rule utilitarian would agree with the formalist that truth telling is a necessary ethical principle but for a different reason. To the rule utilitarian, truth telling is a needed principle not because it has any underlying moral rightness but because it promotes the greatest good in professional-patient relation- ships. Specifically, if truth telling were not followed consistently, trusting relationships between patients and health care profes- sionals would be impossible.

90 SECTION I • Foundations of Respiratory Care

The rule utilitarian approach is probably the most appealing and useful to health care professionals. This approach is appeal- ing because it addresses both human rights and obligations and the consequences of actions. Rule utilitarianism seems best able to account for the modern realities of human experience that so often affect the day-to-day practice of health care. However, although it has some value as an ethical framework, it has the disadvantage of being quite variable among caregivers. Where caregivers have different values and different educational levels, ethical decision making using this tool frequently is inconsistent.

Virtue Ethics

A theory of virtue ethics has evolved based in part on the limits of both formalism and consequentialism. Virtue ethics is founded not in rules or consequences but in personal attributes of character or virtue. Under this formulation, the first question is not, “How do I act in this situation?” but rather, “How should I carry out my life if I am to live well?” or “How would the good RT act?”

Virtue-oriented theory holds that professions have historical traditions. Individuals entering a profession enter into a rela- tionship not only with current practitioners but also with the practitioners who have come before them. With these tradi- tions comes a history of character standards set by the indi- viduals who have previously distinguished themselves in that profession.

According to this perspective, the established practices of a profession can give guidance, without an appeal to either the specific moral principles or the consequences of an act.3 When the professional is faced with an ethical dilemma, he or she need only envision what the “good practitioner” would do in a similar circumstance. It is hard to imagine the good RT stealing from the patient, charging for services not provided, or smothering a patient with a pillow.

Rapidly changing fields such as respiratory care pose some problems for virtue ethics. What might be considered good ethical conduct at one time might be deemed wrong the next time. An example of this change over time is an RT who is asked not only to disconnect a brain-dead patient from a ventilator but also to remove the feeding tubes and intravenous lines.

In addition to the difficulty with changing values in virtue ethics, it provides no specific directions to aid decision making. The heavy reliance of virtue ethics on experience rather than on reason makes creative solutions less likely. Finally, practitio- ners often find themselves in conflicting role situations for which virtue ethics has no answers. A good example is an RT who practices the virtue of being a good team player but is confronted with the need to “blow the whistle” on a negligent or incompetent team member.3 Despite these limitations, virtue ethics is probably the way most practitioners make their ethical decisions.

Intuitionism

Intuitionism is an ethical viewpoint that holds that there are certain self-evident truths, usually based on moral maxims such

MINI CLINI Role Duty

PROBLEM: Courtney is the lone RT on duty on the midnight shift in a small, 65-bed rural hospital. She likes working at the small hospital and knows most of the patients and their condi- tions by memory. The night is quiet and uneventful until 2:00 am, when a code is called for a patient in the intensive care unit (ICU). Courtney immediately heads for the ICU while men- tally noting the condition of the patient on whom the code has been called. She remembers that the patient is 78 years old and has COPD. Just as she nears the ICU, a second code is called for a patient in a room just outside of the ICU. Courtney quickly jogs her memory and remembers that this patient is a 25-year-old woman with diabetes who has just given birth to a baby girl.

DISCUSSION POINT: The lone RT can attend to only one code, although she has an obligation to provide the best care possible to all patients. There is no protocol of which the RT is aware that would provide guidance about which patient she should help first. At the time the second code is called, she is at an equal distance from both patients.

DISCUSSION QUESTIONS: Is this RT facing an ethical dilemma? If so, what guiding principle or principles should be relied on to determine the best course of action? Which patient should the RT help first?

GUIDANCE: The ethical dilemma here is one that arises more frequently than most clinicians realize. Fortunately, however, because it is not new there are certain principles that can be used to help guide decision making.

First of all, there is no “right” answer. The life of a 78-year- old man is no less valuable than the life of a 25-year-old woman. They are both equal under the law and from an ethical point of view. But the therapist cannot be in two places at once. So, irrespective of whether it is fair, a choice must be made. Triage is the principle that guides the approach to these situations. According to the 2014 Unabridged Webster’s Third New Inter- national Dictionary, the term triage comes from the French verb trier, meaning to separate, sift, or select. In this situation, the therapist has to sift through two choices. Triage originated from the need to treat multiple wounded soldiers with limited resources. Wounded soldiers were initially assigned into three categories: (1) those who would likely live without medical aid, (2) those who would likely die no matter what was done, and (3) those for whom immediate treatment would likely be lifesaving.

Between the two patients, there is a strong likelihood that no matter what is done for the 78- year-old patient, that patient will expire given his diagnosis and comorbidities. The young woman likely has the greatest chance for survival, so that life- saving care will likely benefit her more than the 78-year-old patient. These are the factors that could be used to make the decision, but ultimately, the decision belongs to the therapist. No one can say whether one choice is better than the other. Ethics rarely involves the choice between good and evil, it usually involves a choice between good and better, or better and best. Because the lines are so gray, it is easy to cross them.

Ethical and Legal Implications of Practice • CHAPTER 5 91

performed on me?” The initial decision is considered ethical if, and only if, it passes this test of human values. A simpler but nonetheless comprehensive model is used by many ethicists. The model uses eight key steps (Box 5-2).

With or without these models, RTs are often at a double disadvantage in ethical decision making because RTs not only must live with their own decisions but also must support (and act on) the decisions of their physician colleagues. Unless excel- lent communication exists, misunderstandings can occur. Such misunderstandings may be an essential factor in the high job stress, burnout, and attrition in respiratory care.

Classes in ethics, decision making, and communication skills are crucial components of the preparation of RTs for the often confusing and frustrating practice in today’s medical settings. The specialty requires practitioners who can go beyond simple assertions of right or wrong and provide justifications that are both right and reasoned. Many hospitals have ethics boards or committees to review and set policy and to assist in making informed ethical decisions. In addition to administrators and medical staff members, these committees may include a member of the lay public, a chaplain, and one or more experts in bioethics.

A major factor in the disciplinary decisions of professional boards is frequently whether the acts of the RT conformed to the ethical standards of the profession. Nearly every respiratory care practice act has ethical principles embedded in the statute and codified in state regulations. Every RT should be aware of what the particular state dictates in terms of ethical practice.

FIGURE 5-2 Comprehensive ethical decision-making model. (Redrawn from Brody H: Ethical decisions in medicine, ed 2, Boston, 1981, Little, Brown.)

List consequences 1. Immediate 2. Long-range

1. Conditions 2. Who 3. What

Problem Perception

List alternatives

Make choice

Frame ethical statement

For each consequence: • Scan list of personal values • Compare to consequences

CONSISTENT

Consider ALL consequences

ETHICAL STATEMENT IS VALID

INCONSISTENT

Reconsider and restate

RULE OF THUMB

Never attempt to make ethical decisions for others. You can only make them for yourself.

Box 5-2 Ethical Decision-Making Model

1. Identify the problem or issue. 2. Identify the individuals involved. 3. Identify the ethical principle or principles that apply. 4. Identify who should make the decision. 5. Identify the role of the practitioner. 6. Consider the alternatives (long-term and short-term

consequences). 7. Make the decision (including the decision not to act). 8. Follow the decision to observe its consequences.

as “treat others fairly.” The easiest way to understand intuition- ism is to think of as many timeless maxims as you can, which form the basis for intuitionism. These maxims may range from “do not kill” to “look before you cross the street.”6 As a decision- making tool, intuitionism is not helpful, mostly because it depends on the intuitional abilities of the specific caregiver.

Comprehensive Decision-Making Models

To aid in the process of decision making in bioethics, several comprehensive models have been developed. Figure 5-2 depicts one example of a comprehensive decision-making model that combines the best elements of formalism, consequentialism, and virtue ethics. As is evident in this approach, the ethical problem is framed in terms of the conditions and who is affected. Initially, an action is chosen based on its predicted consequences. The potential consequences of this decision are compared with the human values underlying the problem. The short test of this comparison is a simple restatement of the golden rule, that is, “Would I be satisfied to have this action

LEGAL ISSUES AFFECTING RESPIRATORY CARE

Not all decisions can be made in the confines of the medical community. The patient comes from outside this community of professionals, and with expectations different from those of the professionals who will care for her. Sometimes there is a conflict in the expectations and the results. Other times, there

92 SECTION I • Foundations of Respiratory Care

Public (Criminal and Administrative) Law The two major divisions of public law are criminal law and administrative law. Criminal law deals with acts or offenses against the welfare or safety of the public. Offenses against criminal law are punishable by fines, imprisonment, or both. In these cases, the accuser is the state, and the person prosecuted is the defendant.

Administrative law is the second major branch of public law. Administrative law consists of the countless regulations set by government agencies. Health care facilities face a large number of administrative and agency rules that affect almost every aspect of operation. RTs are obligated to abide by these rules and regulations.

Civil Law Private or civil law protects private citizens and organizations from others who might seek to take unfair and unlawful advan- tage of them. If an individual believes that his or her rights have been compromised, the individual can seek redress in the civil courts. In these cases, the individual bringing the complaint is known as the plaintiff, and the individual accused of wrong is the defendant. Civil courts, usually in the form of juries, decide between the two parties with regard to the degree of wrong and the level of reparation required. The category of civil law best related to respiratory care is tort law.

Tort Law. A tort is a civil wrong, other than a breach of contract, committed against an individual or property, for which a court provides a remedy in the form of an action for damages. Causes for the complaints may range from assault and battery to invasion of privacy. The basic functions of torts are to keep the peace between individuals and to substitute a com- pensatory remedy for personal injury instead of allowing indi- viduals to seek vengeance.

There are three basic forms of torts: negligent torts, inten- tional torts, and torts in which liability is assessed regardless of fault (as in the case of manufacturers of defective products). The basic difference between negligent and intentional torts is the element of intent. An intentional tort always involves a willful act that violates another’s interest. A negligent tort does not have to involve any action at all. Instead, a negligent tort can consist of an omission of an action or a failure to carry out a professional duty.

Professional Negligence. Negligence, in its simplest terms, is the failure to perform one’s duties competently. For example, to clarify negligence to juries in Missouri, the state’s jury instruc- tions state:

The term negligent or negligence as used in this [these] instruction[s] means the failure to use that degree of skill and learning ordinarily used under the same or similar circum- stances by the members of defendant’s profession.‡

Negligence may involve acts of commission or omission. The tort of negligence is concerned with the compensation of an individual for loss or damages arising from the unreasonable behavior of another. The normal standard for the claim, for

are medical errors or acts by professionals that fail to meet professional standards. When the result of those errors is patient injury or death, the possibility of professional liability results.

Recently, some hospitals and health care organizations have adopted a model that attempts to subvert the medical liability process. It involves the rapid investigation of sentinel events, and, where errors are made, the disclosure of those errors to the patient followed by an immediate apology. In those instances where there is compensable injury, immediate compensation is offered. This process has reduced medical liability costs for some providers.*

Unfortunately for professionals, in the absence of a system designed to address errors within the professional community, these problems often go to the courts. The problem of profes- sional liability in the delivery of health care is significant. Pro- fessional liability may contribute to increasing health care costs. Limits on medical liability have been key factors in recent leg- islation; however, these limits often suffer from constitutional flaws.†

Practitioners are caught in the middle. On one hand, they are required to keep costs down by avoiding overuse of technol- ogy and therapeutics. On the other hand, they are faced with a level of consumerism that holds them accountable when medical errors result from scarcity of resources. The costs, losses, frustration, and distraction brought about by the current level of legal intervention in health care practice are a concern, but a manageable one. Very few cases actually wind up going to court, and most therapists will practice their entire career without ever seeing the inside of a courtroom.

Systems of Law

Under our legal system, the law is divided into two broad classes: public law and civil law. Public law deals with the relationships of private parties and the government. Civil law is concerned with the recognition and enforcement of the rights and duties of private individuals and organizations.

‡Missouri Approved Instruction 11.06 (1990 Revision).

†See, for example, S. Okeson, Missouri Supreme Court overturns 2005 cap on liability lawsuits, Springfield News-Leader, August 1, 2012; available online at http://archive.news-leader.com/article/20120801/NEWS12/308010053/Missouri -Supreme-Court-liability-lawsuits-Springfield-Cox.

*See, for example, Health Affairs, January 2014—Communication-and- resolution programs: the challenges and lessons learned from six early adopters; American Journal of Gastroenterology, November 2013—Effect of a health system’s medical error disclosure program on gastroenterology-related claims rates and costs; Bulletin of the American College of Surgeons, March 2013— The University of Michigan’s Early Disclosure & Offer Program; Milbank Quar- terly, December 2012—Disclosure, apology, and offer programs: stakeholders’ views of barriers to and strategies for broad implementation; Press release: Doing the right thing when things go wrong; Frontiers in Health Services Management, April 2012—Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: lessons learned and future directions; Press release: Honesty is the best policy: UMHS approach to medical error & malpractice spreads beyond Michigan; Annals of Internal Medicine, August 2010—liability claims and costs before and after implementation of a medical error disclosure program; Press release: U-M’s efforts to encourage disclosure of medical errors decreased claims; Journal of Health and Life Sciences Law, January 2009—A better approach to medical malpractice claims? The Univer- sity of Michigan experience.

http://archive.news-leader.com/article/20120801/NEWS12/308010053/Missouri-Supreme-Court-liability-lawsuits-Springfield-Cox

Ethical and Legal Implications of Practice • CHAPTER 5 93

privileges. The claim must be established by a preponderance of the evidence to prevail. Essentially this means that a jury must be convinced that it is more likely than not that negligence occurred.

For the tort of negligence to cause liability, the breach of duty must be shown to be the cause of the injury. Causation revolves around whether the acts of negligence were the cause in fact and the legal cause of the damages. Causation in fact means simply that the negligent act of the caregiver caused the damages. Proximate causation or legal causation usually turns on foreseeability and whether it is fair to impose damages on a defendant.

Factual causation usually is a question for the jury. It is best illustrated in the context of a motor vehicle accident. If a car runs a stop sign but does not hit anyone, the driver may well be negligent, but no one could sue because the driver did not cause any harm. If there is a collision, there is harm flowing directly from the failure to stop. For that reason, the mere failure to provide the appropriate standard of care is insufficient to neces- sitate payment of damages unless injury occurs as a result of the action or omission. In most states, the act of negligence does not have to be the only cause; it only has to be one cause. Some- times this is referred to in jury instructions as a requirement that the defendant’s actions “caused or contributed to cause” the injury. Ordering O2 turned off on a severely hypoxemic patient might be the direct cause of the patient’s injury, but the thera- pist’s acting on that order instead of questioning it could be thought of as a contributing cause.

Proximate causation turns on foreseeability. It tends to be a retrospective analysis. If an RT fails to check a ventilator as required, it is foreseeable that the patient could develop a com- promised airway and sustain brain damage or die. The RT’s failure would be both the factual and the legal cause of the injury. Proximate causation also comes into play, however, when there are multiple wrongdoers. For example, a nurse requests a therapist’s help to place a patient on the bedside commode. The therapist is unaware that the patient’s systolic blood pressure is 60 mm Hg by Doppler. The patient bears down, experiences a cardiac arrest, and dies. Although the actions of the therapist in helping to move the patient to the commode are the cause in fact, the therapist might escape liability because it was not fore- seeable that helping the nurse move the patient would result in the patient’s death.

Most medical negligence lawsuits are defended by claiming that no matter what the medical error was, it was not the cause in fact of the patient’s death. This is frequently possible because only a very limited number of patients actually get autopsies. There may be no demonstrative evidence or pathology report detailing what caused the patient’s death.

For example, in a situation in which the leads were reversed in a patient receiving a dual-chamber pacemaker, the heart, on autopsy, showed focal areas of inflammation. The defendant had a pathologist testify that the most likely cause of death was not the failure to place the pacemaker leads in the correct position, but rather, a particularly virulent virus (never identi- fied) that caused rhythm disturbances and death. In nearly

example, in an automobile accident, is the duty imposed on individuals not to cause risk or harm to others, the standard being what a reasonable and prudent person should have fore- seen and avoided. Professional negligence is different because the duty is defined by other professionals, and for that reason, requires expert testimony to establish.

In negligence cases, the breach of duty often involves the matter of foreseeability. Cases in which the patient falls, is burned, is given the wrong medication, or is harmed by defects in an apparatus often revolve around the duty of the health care provider to anticipate the harm. Duty is imposed by law. Courts tell us the following about duty:

For purposes of determining whether a duty exists, this Court has defined foreseeability as the presence of some probability or likelihood of harm sufficiently serious that ordinary persons would take precautions to avoid it. [citation omitted] The existence of a mere possibility is insufficient. Id. The test is not the balance of probabilities, but of the existence of some probability of sufficient moment to induce the reasonable mind to take the precautions which would avoid it.

Lopez v. Three Rivers Elec. Co-op., 26 S.W.3d 151, 156 (Mo. 2000)

For the tort of negligence to be a valid claim, the four condi- tions listed in Box 5-3 must be met.

The assessment of what is reasonable and prudent for an RT can be determined by guidelines established by a professional group (e.g., the AARC), by direct expert testimony, or by cir- cumstantial evidence. The legal principle res ipsa loquitur (the thing speaks for itself) may apply where a court determines under the facts that the circumstantial evidence rises to a level to permit its assertion. Res ipsa loquitur is sometimes invoked to show that the harm would not ordinarily have happened if the individuals in control had used appropriate care. In these cases, negligence is established by inference.

For a claim of res ipsa loquitur to be supported, three basic conditions must be met: (1) The harm was such that it would not normally occur without someone’s negligence. (2) The action responsible for the injury was under the control of the defendant. (3) The injury did not result from any contributing negligence or voluntarily assumed risk on the part of the injured party. An example of res ipsa loquitur might be the failure to recognize that a patient’s right main stem bronchus had been intubated with a resultant pneumothorax. For negligence to occur, the breach in duty also must cause damage or injury to the individual. The injured party must file the lawsuit within the time frame set by the statute of limitations. The term injury, in this sense, may include not only physical harm but also mental anguish and other invasions of the patient’s rights and

Box 5-3 Elements of Negligence

• The practitioner owes a duty to the patient. • The practitioner breaches that duty. • The breach of duty was the cause of damages. • Damage or harm came to the patient.

94 SECTION I • Foundations of Respiratory Care

the practitioner directed such remarks only to the individual involved, it would not be slanderous; if the remark was made in the presence of a third party, it might constitute slander. Torts involving defamation are subject to short statutes of limitation and are generally disfavored in the law. The First Amendment to the Constitution may even provide a shield against slander or libel in many cases.

Caution to avoid unauthorized disclosure of patient infor- mation is especially critical in cases involving diseases such as AIDS, which often carries a high degree of medical and social stigma. Patients have the legal right to expect that all informa- tion about their illness will be held in strict confidence. Several states now have civil liability and criminal penalties for the release of confidential HIV test results in which the breach of confidence results in economic, psychologic, or bodily harm to the patient.

An assault is an intentional act that places another person in fear of immediate bodily harm. Threatening to injure someone through some overt act (e.g., swinging a bat at a person, even if it misses) is considered an act of assault. Battery represents unprivileged, nonconsensual physical contact with another person. In the classic act of assault and battery, one individual threatens injury through some overt act (throws a punch) and injures another through an overt act (connects with the punch).

Although battery is an unusual charge against a clinician (because of the nature of the work), it creates special problems. The major element of battery is physical contact without consent. When a practitioner performs a procedure without the patient’s consent, this contact may be considered battery. In most instances, there is an implied consent, created when the patient seeks care from the physician. This implied consent allows the performance of ordinary procedures without written consent. In all cases of unusual, difficult, or dangerous proce- dures, such as surgery, the courts require written consent. For this reason, to avoid being accused of battery, RTs should always explain all procedures involving physical contact to their patients before they proceed. If a patient refuses something like a blood gas test, in the absence of some other factor that makes it unreasonable to do so, the patient’s refusal should be honored.

There are two general defenses against intentional torts. The first defense is that there was a lack of intent to harm and that only clinicians who engage in intentional conduct are liable. For example, if a practitioner fainted during a procedure and caused the patient injury, he or she would not be liable because the action was involuntary. The second defense is that the patient gave consent for the procedure. If the patient consented to the action, knowing the risks involved, the practitioner would not be liable. Consent by the patient for both nonroutine and routine procedures should be obtained in writing before care is rendered.

Strict Liability. Strict liability is a theory in tort law that can be used to impose liability without fault, even in situations in which injury occurs under conditions of reasonable care. The most common cases of strict liability are cases involving the use of dangerous products or techniques. Courts have imposed this

every case, one of the primary defenses will always be a lack of medical causation.

Damages are another factor in negligence lawsuits. There are three kinds of damages: economic, noneconomic, and punitive. Economic damages are awarded for economic loss. For example, a working wife and mother killed in a vehicular accident leaves a family without a caregiver for the children and without the $45,000 a year salary she earned. Her economic damages include both the salary figure (adjusted for inflation and wage increases over her work life) and the cost of replacing the home care she rendered to her family.

Noneconomic damages include pain, suffering, disability, disfigurement, and loss of the enjoyment of life. Although eco- nomic damages can be guided by hard numbers, juries are often left to decide the value of a person’s pain or suffering. Many states have limited the amounts that can be awarded for these elements of damage, as noted earlier, but in some states those caps have been overturned.

Punitive damages are damages that are awarded to punish wrongful conduct and discourage future unlawful conduct. Punitive damages are quite rare in medical negligence cases except where alcohol or drug use by caregivers is involved or where there is overwhelming negligence that is equivalent to intentional conduct. Some states also limit these damages.

Malpractice. Malpractice, as a form of negligence, can involve professional misconduct, unreasonable lack of skill or fidelity in professional duties, evil practice, or unethical conduct. There are three classifications of malpractice: (1) Criminal mal- practice includes crimes such as assault and battery or eutha- nasia (handled in criminal court). (2) Civil malpractice includes negligence or practice below a reasonable standard (handled in civil court). (3) Ethical malpractice includes violations of pro- fessional ethics and may result in censure or disciplinary actions by licensure boards.

Intentional Torts. An intentional tort is a wrong perpe- trated by someone who intends to do the act and, possibly, intends to do the harm. In contrast, in negligence, the profes- sional fails to exercise adequate care in doing what is otherwise permissible. The acts must be intentionally performed to produce the harm or must be performed with the belief that the result was likely to follow. These torts are more serious than the tort of negligence, in that the defendant intended to commit the wrong. Consequently, punitive and actual damages may be awarded. Examples of intentional torts are acts that involve fraud, defamation of character, invasion of privacy, deceit, infliction of mental distress, and assault and battery.

In the hospital, the unwarranted discussion of the patient’s condition, diagnosis, or treatment for purposes other than the exchange of information is always deemed suspect in regard to defamation of character. Under the general title of defamation of character are the torts of libel and slander. Slander is the verbal defamation of an individual by false words by which his or her reputation is damaged. Libel is printed defamation by written words, cartoons, and such representations to cause the individual to be avoided or held in contempt. Libel and slander do not exist unless they are seen or heard by a third person. If

Ethical and Legal Implications of Practice • CHAPTER 5 95

protects the RT not only from the plaintiff but also from any settling defendant who attempts to point the finger at the RT. It is crucial that the RT adhere to professional legal advice and not try to “go it alone” in a malpractice case. Sometimes well- meaning but poorly informed risk professionals tell therapists that having their own insurance is likely to get them sued. This is simply untrue.

There is no central registry or online resource where an attorney can look up an individual and determine if she has malpractice insurance. As therapists exercise greater discretion about what treatments to give and under what circumstances, that discretion is likely to increase rather than decrease their malpractice liability risk. It is the negligent act that determines who will be sued, not the insurance status of that individual. Decisions about whom to sue are made early, before any oppor- tunity is developed for discovery, and the presence or absence of insurance is unlikely to have any impact on the person suing. Whether the person being sued has malpractice insurance can have a huge impact, because the defendant may stand to risk losing her home and everything she has worked for in the event of an unsuccessful defense. For this reason, malpractice insur- ance is an essential element of every RT’s professional respon- sibility. No therapist should practice without it.

Avoiding Lawsuits There is no foolproof formula for avoiding lawsuits; the right to bring suit is protected by the United States Constitution and guarded by the U.S. legal system. But the simplest and most effective way of avoiding lawsuits is both providing excellent care that meets professional standards and documenting that care carefully. Documenting the care that was given is a skill that every RT should develop, because it is what prevents, in most cases, lawsuits for professional negligence.

Practitioners should always deliver care in a professional manner and document care in a way that proves professional standards were met. For example, in the case of routine ventila- tor care, frequent documentation of tube position and suction- ing is vital to show that the patient’s airway was protected and that therapists were aware of the patient’s condition. Documen- tation of an Allen’s test before an arterial blood gas measure- ment shows attention to detail and documents that the patient’s circulation was assessed. Knowing both what to do and how to document it are critical to avoiding litigation.

A key step to avoid litigation is being aware of and conform- ing to all professional standards regarding the care that is being delivered. All professionals should adhere to the legal require- ments of professional licensure, and institutions should have policies and procedures that require the licensure status be veri- fied upon employment and regularly thereafter.

Being aware of professional standards also includes keeping pace with institutional practice policies and procedures and the facility’s own internal standards of care.

Moreover, risk management is a job requirement for every clinician. It should be an ongoing component of departmental operation and professional development and should always address documentation standards and risk management.

principle on medical equipment manufacturers and on hospi- tals. However, strict liability generally has not been extended to professional services.

Breach of Contract. Breach of contract is a more unusual legal claim than negligence. This claim is based on the theory that when a health care professional renders care, an implicit or explicit professional-patient “contract” is established. Essen- tially, the contract binds the health care professional to place the patient’s welfare as the foremost concern, to act only in the patient’s behalf, to protect the patient’s life, to preserve the patient’s health, to relieve suffering, and to protect privacy. When the patient is injured as a result of the services rendered under this contract, the patient may claim that the failure of the health care professional to perform the service competently is a breach of the contract. Most state laws do not permit this kind of action, and those that do require high standards for proof.

RTs are responsible for their actions, as are members of all other professions. When these actions result in the injury of another, the injured party may turn to the courts for redress. If the RT, while acting for the physician, injures the patient through some negligent act, the patient may sue both the RT and the physician.

Civil Suits. Civil action can be brought for many reasons, such as to challenge a law or to prevent an activity. However, as in the case of malpractice suits, most civil suits seek monetary damages. The following scenario is an example of a situation that might involve the RT. The physician intends to order 0.5 ml of a bronchodilator for a 3-year-old asthmatic patient but inad- vertently prescribes 5.0 ml of the drug. Because of the overdose given by the RT, the child dies.

A clearly articulated legal principle in negligence is that the duty owed to the patient is commensurate with the patient’s needs. In short, the more vulnerable the patient, the greater is the caregiver’s duty to protect. When the order is unclear or seems inappropriate under this principle, clinicians have an obligation to clarify rather than risk harm.

The suit could be brought against the physician for negli- gence for ordering the overdose, against the nurses and RT for failing to recognize that the dose was incorrect for the child, and, possibly, against the pharmacist for failing to gain adequate information as to the nature of the patient so that an appropri- ate dosage could be calculated. The plaintiff would base the secondary charges against the nurses and allied health practi- tioners on the theory that liability would be incurred by the individuals who missed an opportunity to correct the first wrongdoer’s mistake. The hospital’s risk management depart- ment and legal counsel can sometimes provide direction and counsel to the RT in the case of a civil suit. If the hospital in which the RT works does not provide malpractice insurance for the RT, then he or she should carry his or her own policy of malpractice insurance.

Professional liability insurance is available through the AARC’s preferred provider, and it provides RTs with an attorney not only to represent them in the case of a malpractice lawsuit but also in those rare instances in which a professional board questions the conduct of the RT. Should a judgment result, it

96 SECTION I • Foundations of Respiratory Care

beyond the scope of this chapter. The practitioner in clinical practice need not be concerned with particular exceptions because, in most cases, basic patient confidentially requires a standard at least equal to the strictest interpretation of the Privacy Rule.16

The basic goal of the Privacy Rule is to protect all “individu- ally identifiable health information,” commonly referred to as protected health information. Protected information includes any record or information that would or could identify or reveal (1) an individual’s past, present, or future physical or mental health or condition; (2) the provision of health care to the individual; or (3) the past, present, or future payment for the provision of health care to the individual. Protected health information includes information in any format, which may include patient charts (electronic or paper), faxes, e-mails, or other records. The Privacy Rule provides avenues for the normal and appropriate conduct of health care treatment and business for all “covered entities,” individuals, and organizations that have a legitimate need to access and use the information. Consent of the individual is not required for these covered entities.16

Medical Supervision

RTs are required by their scope of practice to work under com- petent medical supervision. This requirement creates not only a professional relationship but also a legal one. If the RT is employed by the physician, the physician is liable for the RT’s actions. If the RT is employed by the hospital, the hospital is liable for the RT’s actions. Under the laws of some states, the supervising physician may still be liable even if the RT is employed by the hospital where the legal theory involves a failure to supervise. The legal basis for this liability is rooted in centuries-old common law. When tradesmen had apprentices and masters had servants, the negligence of the apprentice or servant was applied to the master who controlled the action of the servants. Under modern law, an employer is deemed a master, and an employee is deemed a servant. This principle, sometimes called vicarious liability, is premised on this centuries- old concept expressed in Latin as respondeat superior (“let the master answer”).

Under the doctrine of medical supervision, the physician assumes responsibility for the wrongful actions of the RT as long as such negligence occurred in the course of the employer- employee relationship. For this liability to apply, two conditions must be met: (1) the act must be within the scope of employ- ment, and (2) the injury caused must be the result of an act of negligence. If the RT acted outside of his or her scope of prac- tice, as outlined by licensure laws or by institutional regulations, the court would have to decide whether the physician would still be liable. If the RT, while in the patient’s room to deliver an aerosol treatment, went beyond the normal scope of practice and adjusted cervical traction, causing injury, it is doubtful that the physician could be held fully responsible. However, under the principle of respondeat superior, the hospital, as a corporate entity, could be held responsible for the actions of its employees.

Even if everyone does every possible thing right, there is no guarantee that the plaintiff or her attorney will understand this if the patient meets an untimely or unexpected death because of things outside the control of the clinicians. Just as there are “professionals” with medical degrees who will testify that every- thing was done properly when standards of care were violated, so too are there people who are willing to say anything on behalf of a plaintiff in a lawsuit. Once a professional meets the baseline requirements of an expert witness (skill and expertise in the field and exposure to the facts of the case sufficient to form an opinion), in most cases his or her opinion will become evidence in the case. For this reason, malpractice insurance as well as having a good legal team to defend the case are the best safe- guards a clinician has to protect against liability.

Not all cases wind up in court. Sometimes, when the parties are willing, a lawsuit can be avoided with mediation. However, when any potential legal claim or lawsuit surfaces, decisions about how to proceed should be made only with full input of institutional risk management and legal counsel experienced in professional negligence defense.

In recent years, the experience of several large hospital systems has suggested that active risk management practices and appropriate guest relations policies are two of the most effective tools to prevent malpractice litigation. Unhappy patients are identified quickly, and corrective action is imple- mented immediately. Good guest relations programs encourage listening that often results in better clinical decision making, preventing the malpractice that is at the heart of every medical malpractice lawsuit. The best way to avoid a malpractice suit is to develop a good, sound relationship with the patient that communicates to the patient that he or she is important and valued.

Health Insurance Portability and Accountability Act of 1996

In August 1996, the U.S. Congress enacted HIPAA, which required, among other things, the establishment of Standards for Privacy of Individually Identifiable Health Information. These standards, which have become known as simply the Privacy Rule, added a major dimension to the need to treat medical records and information as confidential. The Privacy Rule was developed, with public comment and input, in the years after enactment of HIPAA. The final rule was issued in March 2002. Updates to the Privacy Rule are likely to continue, making it imperative that the practitioner remain up to date with the latest requirements of the rule. The primary goal of the rule was to strike a balance between protecting individuals’ health information and not impeding the exchange of informa- tion needed to provide quality health care and protect the pub- lic’s health and well-being.16

The Privacy Rule applies to all health care providers, health plan providers (with some exceptions, such as small employer plans with fewer than 50 participants administered solely by the employer), and health care clearinghouses. An example of a health care clearinghouse is an entity that processes insurance claims for payment. Some of the exceptions are complex and

Ethical and Legal Implications of Practice • CHAPTER 5 97

MINI CLINI Health Insurance Portability and Accountability Act

PROBLEM: You, the RT, are in Ms. Smith’s room tending to her respiratory equipment when the telephone rings. Ms. Smith and some of her family members are well known to you because of her many previous hospitalizations. During this hospitaliza- tion, Ms. Smith’s condition has progressively worsened and today has been a particularly bad day for her. At this point, she is having serious difficulty moving and even talking. As the telephone rings, she looks at you and in a barely audible voice asks you to please answer the telephone. You do so, and the person on the other end identifies herself as Ms. Smith’s grand- daughter. You tell Ms. Smith that her granddaughter is on the telephone, but Ms. Smith simply looks away. You tell the grand- daughter that Ms. Smith cannot talk right now and to call back later. The granddaughter asks you why Ms. Smith cannot talk, along with a series of specific questions about her condition.

DISCUSSION: As the RT, how should you handle this situation? 1. What HIPAA guidelines, if any, are applicable in this case? 2. Because you know Ms. Smith and her family, is it permis-

sible to answer the granddaughter’s questions? 3. To avoid alarming the granddaughter, should you say Ms.

Smith is asleep or in the bathroom?

GUIDANCE: The first question is whether HIPAA applies. HIPAA pertains to “the individual’s past, present or future physical or mental health or condition.”* HIPAA requires that protected health care information never be disclosed to those who are not authorized to receive it, and the rule requires a written authorization of who can receive protected health information by the patient. Until you verify that the person on the other end of the phone is authorized in writing to receive information, you cannot disclose anything. You also may have no way of knowing whether this really is the daughter of the patient, even if you think you recognize the voice. The hospital has specific policies regarding the release of information, and you must follow those to protect yourself from any allegation of wrongdoing.

Simply because you know Mrs. Smith and her family, it is not sufficient to disclose information. Information must be given only to those on the written authorization. Verbal autho- rizations are not permitted because (1) you have no way to prove that it happened and (2) the patient may later change his or her mind or forget who was authorized. Thus, until you know that the person is authorized in writing to receive the information, you may not disclose protected health

information.* Even though it may be difficult to tell a family member of

a patient that you cannot share information over the phone, that is the answer that you must give. You may not say that Mrs. Smith is in the bathroom because it is not true. There is no ethical exception that permits lying to family members. Lying erodes trust in the health care system.

*See, for example, “What information is protected” on the Department of Health and Human Services website: http://www.hhs.gov/ocr/privacy/ hipaa/understanding/summary/index.html.

Historically, RTs have not been named individually as defen- dants in malpractice cases because the law generally has not focused on their role as specialized health care providers sepa- rate from the health care facility. Either the hospital or the physician is usually named as the defendant for the acts of the practitioner. RTs in these cases have been viewed simply as employees, merely carrying out the orders of a superior. However, with the increased application of state licensure regu- lations governing respiratory care, and especially with the devel- opment of respiratory care protocols giving RTs more autonomy, this relative protection from liability is changing rapidly. As RTs are given more discretion and are permitted to exercise inde- pendent judgment, their decision making is likely to be more frequently called into question in court.

Scope of Practice One measure of professionalism is the extent to which the group is willing to direct its own development and regulate its own activities. This self-direction is carried out mainly through professional associations and state licensure boards, which attempt to ensure that professionals exhibit minimum levels of competence.

Basic Elements of a Practice Act. Some practice acts emphasize one area over another, but most acts address the following elements: • Scope of professional practice • Requirements and qualifications for licensure • Exemptions • Grounds for administrative action • Creation of examination board and processes • Penalties and sanctions for unauthorized practice

Licensure Laws and Regulations. In licensure legislation, there is always a clause specifying a scope of practice. The scope- of-practice statutes give general guidelines and parameters for the clinician’s practice. Deviation from these statutes could be a source of legal problems as the specialty seeks to add new duties. Practitioners must know the limits of their scope of care and seek amendments to the licensure regulations as they expand their practice. Ideally, the original language of a licen- sure law should be broad enough to account for changes in practice without requiring continual amendment. Continuing education and regular review of the practice act are essential to ensure compliance with both the statute and evolving rules of the practice act.

Providing Emergency Care Without Physician Direc- tion. One unique area that allows practice without the direc- tion of a competent physician is that of rendering emergency medical care to injured persons. Good Samaritan laws protect citizens from civil liability for any errors they make while attempting to give emergency aid. Most states have legislated Good Samaritan statutes to encourage individuals to give needed emergency medical assistance. It is necessary for this aid to be given in good faith and free of gross negligence or willful misconduct. However, it is unlikely that the RT would be pro- tected for giving aid that went beyond the expected skills of the individual or aid that went beyond that which could be defined

http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

98 SECTION I • Foundations of Respiratory Care

ciplined for various offenses related to the practice of respiratory care. Most RTs serve their entire professional careers and never have a problem with their professional boards. There are four significant things that RTs can be aware of now that would help prevent problems with their professional boards later.

Licensure Statute

All RTs should know in detail the requirements of their respira- tory care practice act. They should know what is expected of them in terms of obtaining licensure and in the requirements to remain licensed. After receiving licenses, many professionals never look at their statute and never evaluate what actions are mandated by the rules and regulations enacted by their board. Some states by statute require that RTs report certain behavior.

Section 3758.5. Reporting Violations If a licensee has knowledge that another person may be in viola- tion of, or has violated, any of the statutes or regulations admin- istered by the board, the licensee shall report this information to the board in writing and shall cooperate with the board in furnishing information or assistance as may be required.

California Respiratory Care Practice Act Some states also require that employers make reports not only on individuals terminated for cause but also on the supervisors of the RTs.

Section 3758.6. Report on Supervisor 1. In addition to the reporting required under Section 3758, an

employer shall also report to the board the name, profes- sional licensure type and number, and title of the person supervising the licensee who has been suspended or termi- nated for cause, as defined in subdivision (b) of Section 3758. If the supervisor is a licensee under this chapter, the board shall investigate whether due care was exercised by that supervisor in accordance with this chapter. If the super- visor is a health professional, licensed by another licensing board under this division, the employer shall report the name of that supervisor and any and all information per- taining to the suspension or termination for cause of the person licensed under this chapter to the appropriate licens- ing board.

2. The failure of an employer to make a report required by this section is punishable by an administrative fine not to exceed $10,000 per violation. The second thing all RTs should do to protect themselves

against licensure issues is to purchase an insurance policy that covers professional discipline. Most policies available for pur- chase by RTs provide for coverage of both malpractice liability and professional discipline.

Understanding the Causes of Discipline

A review of professional discipline cases available from publicly available sources, including the California Board for

as first aid, such as performing a tracheostomy. Good Samaritan rules generally apply only to roadside accidents and emergency situations outside the hospital, although this is not always the case. The doctrine has sometimes been used by physicians inside a health care organization who respond to an emergency on a patient who is not their own. However, in California, the statute for RTs specifically extends protection only where the acts of the RT are “outside both the place and the course of employment.”||

INTERACTION OF ETHICS AND THE LAW

A good example of the interaction of ethics and the law in respiratory care is the diversification of the field into home care and durable medical equipment supply. This diversification has led to new relationships between these elements of the health care system and has created the potential for unethical and unlawful activity. If a practitioner accepts some payment, such as a finder’s fee or percentage of the total lease costs for referring patients to a particular home care company or equipment service, he or she should be prepared to face charges of unethi- cal and perhaps illegal practice.

Several federal and many state statutes address the legality of these types of transactions. Generally, these statutes say that anyone who knowingly or willfully solicits, receives, offers, or pays directly or indirectly any payment in return for Medicare business is guilty of a criminal offense. Violation of these stat- utes carries the potential for prison, a substantial fine, or both. In addition, violation of the statutes by an organization can result in exclusion from Medicare and other federal health care programs.

In recent years, hospitals have been encouraged to appoint a corporate compliance officer (CCO) to oversee the hospital’s business practices and ensure that the hospital conforms to the law. In most hospitals with a working compliance plan, the CCO is freely available to discuss legal or ethical issues arising in the course of care. Appointed by the board of directors and reporting both to the hospital administration and to the board, the CCO often can address legal issues quickly and competently. Most hospitals use a toll-free anonymous number to allow employees who wish to remain anonymous to report wrongful activity. If the practitioner is aware of others who are engaged in these practices, he or she should report these activities to the appropriate state or federal health care agency. To aid the clini- cian in maintaining an ethical stance on these new issues, the AARC has established a position statement about ethical per- formance of respiratory home care.

PROFESSIONAL LICENSURE ISSUES

Because nearly every state has now passed some form of licen- sure for respiratory care practitioners, more RTs are being dis-

||Cal. Bus. & Prof. Code § 3706.

Ethical and Legal Implications of Practice • CHAPTER 5 99

identifies a problem still faces retaliation. Several federal laws protect RTs who, because of their respect for ethical issues, speak out about wrongdoing.

Patient Protection and Affordable Care Act

In 2010, Congress passed the PPACA in an attempt to reform health care. Challenges to the PPACA are still finding their way through the state and federal courts, and results to date have been mixed. One thing that the statute did was improve whistle- blower protections for hospital workers. Section 1558 of the PPACA amends the Fair Labor Standards Act of 1938 (FLSA) by adding Section 18C, which provides that an employer cannot discriminate “against any employee with respect to his or her compensation, terms, conditions, or other privileges of employ- ment” because the employee, among other things: 1. Provided, caused to be provided, or is about to provide or

cause to be provided to the employer, the Federal Govern- ment, or the attorney general of a State information relating to the violation of, or any act or omission the employee reasonably believes to be a violation of, any provision of this title;

2. Actually did or is about to assist, participate, or testify in a proceeding about such violation; or

3. Objected to or refused to participate in any activity or task that the employee “reasonably believed” to be in violation of the statute or any rule or regulation promulgated under the statute. Any employee who believes that he or she has been dis-

charged or discriminated against in violation of Section 18C of the FLSA is entitled to seek relief using the same procedures provided in 15 U.S.C. §2087(b), which contains the extensive whistleblower protections contained in the Consumer Product Safety Improvement Act of 2008. These procedures include filing a complaint concerning discrimination or retaliation with the Department of Labor, going through an administrative process to determine whether the employee’s conduct protected by Section 18C was “a contributing factor in the unfavorable per- sonnel action” alleged by the employee, and providing for the filing of a civil action in federal court after exhaustion of the administrative remedies provided by the statute.

Section 1558 explicitly limits application of Section 18C only to violations of the statute’s central provisions related to medical care in hospital and clinic settings. Employees who report fraud, waste, or violations in traditional health care settings fall under the protections afforded by Section 1558. In most cases, an employee needs legal advice to pursue remedies under this section of the FLSA.

National Labor Relations Act

Although the National Labor Relations Act (NLRA) is usually thought of as a “union” statute, the NLRA provides protections to hospital workers whether they are organized into a union or not. Specifically, the NLRA provides for protection where a worker engages in actions for the benefit of all employees. For example, when an RT approaches the supervisor on behalf of

Respiratory Care, reveals that the most frequent causes of pro- fessional discipline are as follows: • Substance abuse • Domestic violence • Sexual abuse • Gross incompetence

Even in cases in which the cause of discipline is rooted in domestic violence or sexual abuse of another person, some form of substance abuse is often a contributing factor. Alcohol violations (driving while intoxicated, driving while impaired) are often the most frequent violation that brings an RT face to face with his or her professional board. RTs with alcoholism or a significant drug habit are almost certain to come before their professional board. Sometimes employers and supervisors take the position that as long as such a problem does not affect a person’s work at the facility, they should not address it. However, even in cases in which an RT does not use drugs or alcohol at work, the disease process is affecting their judgment and deci- sion making and should be addressed. A supervisor who fails to report a substance abuser of any kind is asking for legal trouble, in the form of either a damages lawsuit or a visit from the professional board. Academic RTs should be especially vigi- lant with students and should insist on substance abuse coun- seling for any student who appears to have such a problem.

Sometimes human resources personnel and administrators do not see the value in addressing these kinds of problems and may counsel against discipline for impaired workers. Some- times supervisors ignore the behaviors that should be red flags. Sometimes the human resources department may have made exceptions for other workers and fears that these exceptions may permit an inference of discrimination. None of these excuses sounds good to a jury.

Any good attorney will tell you that it is far better to defend a wrongful termination lawsuit than a wrongful death lawsuit. If you are wrong about the termination, the employee can be rehired. There is no remedy for the patient when an employee’s substance abuse leads to that patient’s death.

Engaging Counsel

If approached by the professional board, an RT should never talk to investigators without an attorney present. Every investi- gation is by its nature oppressive and burdensome, and an attor- ney ensures that the RT’s rights are respected and protected. Often in cases in which an RT has violated the professional code or engaged in conduct that merits discipline, an attorney can help negotiate a better resolution than the RT could without the help of a professional.

RESPIRATORY THERAPISTS WHO SPEAK OUT ABOUT WRONGDOING

RTs are in a unique position to help protect patients from mul- tiple harms. Sometimes they have a duty to speak out about problems or issues in the department. Usually working with a CCO is the most effective way to effect change inside an orga- nization. However, sometimes the person who speaks out and

100 SECTION I • Foundations of Respiratory Care

in the health care system. Specific considerations include (1) factual premises and beliefs, such as the definition of death; (2) legal concepts, such as tort laws; (3) externally imposed mandates or expectations, such as hospital accreditation stan- dards; and (4) the best managed care outcome. In many instances, such considerations uphold our moral convictions and provide support for a given action. The real challenge to RTs arises when moral principles dictate one course of action and factual knowledge, legal concepts, or external expectations dictate another.

Socrates demanded that professionals acknowledge the social context of their activities and recognize their obligations toward the segment of society that they profess to serve. As our analysis of ethical reasoning and the law has made clear, only by identifying, justifying, and prioritizing basic principles of human values can the RT resolve the difficult questions of pro- fessional behavior consistently. To the extent that clearly articu- lated principles guide our choices and actions, all involved will be well served.

all the workers on the second shift to request that shift differ- entials be increased, that RT—who is engaged in what is called “protected concerted activity”—cannot be discharged for acting on behalf of the other RTs in the department. When an RT is discharged for such an offense, the RT has 180 days in which to make a complaint to the local office of the National Labor Relations Board. No attorney is necessary to make such a complaint.

False Claims Act

Buried in the banking section of the United States Code is a little-known statute called the False Claims Act (FCA) (31 USC §3729). The statute forbids making false claims against the gov- ernment and provides for severe sanctions for people who do. Someone making a false claim against a government health care program can be made to repay three times the amount of the false claim plus a civil penalty of $5500 to $11,000 per false claim. Similar to the whistleblower protections built into the PPACA, the FCA contains language that prevents retaliation against an employee who gathers information or supports a government case against his or her employer. Remedies may include reinstatement and back pay.

Perhaps the most powerful part of the statute is the part that permits an employee with knowledge of fraud or false billing to file a lawsuit against the company or organization engaging in fraud. For example, when an emergency medical technician (EMT) knows that his employer is giving away free ambulance services to nursing homes in exchange for the Medicare busi- ness of the nursing homes, the EMT could file an FCA case against the employer.

The government investigates such lawsuits and frequently intervenes in them. Where the government intervenes, the employee who blows the whistle stands to receive an award of up to 25% of the amount the government recovers. In recent years, the United States has recovered greater than $3 billion in fraudulently paid claims, most of which came from employees who blew the whistle on the fraud of their employers or competitors.

HEALTH CARE AND CHANGE

The health care industry is experiencing rapid change relating to how services are funded and how patients and health care workers interact. These changes are occurring at the same time that ethical considerations are reemerging as significant com- ponents of how health care should be structured and delivered. Managed care affects the ethical decision-making process. Although the effect is not negative, it forces health care workers to take a new look at ethical dilemmas to arrive at both the best ethical outcome and the best managed care outcome. Patients no longer freely choose who will deliver health care services to them. Health care practitioners must consider not only the best services to deliver to patients but also the best managed care outcome.

If ethical reasoning is to be of any value, it must account for the reality of human experience and take into account changes

RULE OF THUMB

The letters RCP are used to indicate respiratory care practitioner. They also suggest three important characteristics of the RT when confronted with ethical dilemmas: Respect Compassion Professionalism

Health Care Advance Directives

In recognition of the right of competent adults to exercise choices concerning their health care, all 50 states and the Dis- trict of Columbia have adopted some form of health care advance directives. Although the federal government acknowl- edged the need for advance directives with the 1991 Patient Self-Determination Act by requiring that all hospitals receiving Medicaid or Medicare funds ascertain whether patients have or wish to have advance directives, the advance directive instru- ments are state regulated.

SUMMARY CHECKLIST

◗ Ethical dilemmas occur when there are two equally desirable or equally undesirable choices. Ethical dilemmas may involve situations that are either legal or illegal.

◗ Ethical dilemmas in respiratory care involve scope of practice, confidentiality, working within levels of professional responsibility, professional development issues, staffing patterns, or recordkeeping.

◗ Professional codes of ethics are general guidelines established to identify ideal behavioral parameters by members of a professional group. These codes are often simplistic and tend to deal with behavior over which there is little disagreement.

◗ Traditional ethical principles are rooted in philosophical thought and include autonomy, beneficence,

Ethical and Legal Implications of Practice • CHAPTER 5 101

References

1. Brincat CA, Wike VS: Morality and the professional life: values at work, Upper Saddle River, NJ, 2000, Prentice Hall.

2. Bowie NE: Respecting the humanity in a person. In Ciulla JB, et al, editors: Honest work: a business ethics reader, New York, 2007, Oxford University Press.

3. Carroll C: Legal issues and ethical dilemmas in respiratory care, Philadelphia, 1996, FA Davis.

4. Edge R, Groves R: The ethics of health care: a guide for practice, Albany, NY, 1994, Delmar.

5. Beauchamp TL, Childress JF: Principles of biomedical ethics, ed 4, New York, 1994, Oxford University Press.

6. Boylan M: Business ethics: basic ethics in action, Upper Saddle River, NJ, 2001, Prentice Hall.

7. Husted GL, Husted JH: Ethical decision-making in nursing, St Louis, 1991, Mosby.

8. Pickett JP, et al: The American heritage dictionary of the English language, ed 4, Boston, 2000, Houghton Mifflin.

9. Logue B: Rights: death control and the elderly in America, New York, 1993, Macmillan.

10. Hill TP, Shirley D: A good death: taking more control at the end of your life, Reading, MA, 1992, Addison-Wesley.

11. World Medical Association: Code of medical ethics, <http://www.wma.net/ en/30publications/10policies/c8/index.html>. Accessed June 22, 2015.

12. Pozgar G: Legal aspects of health care administration, Gaithersburg, MD, 1990, Aspen.

13. Hippocrates: The oath. In Jones WHS, translator: The Loeb classical library: Hippocrates, no. 147–150, Cambridge, MA, 1948, Harvard University Press.

14. Sernick TH, Knight AP: An integrated and forward-looking approach to risk management in healthcare, published in The Risk Management Quarterly, Spring 2010 Edition, p 7.

15. Ross WD: The right and the good, Oxford, 1930, Clarendon Press. 16. U.S. Department of Health and Human Services: Summary of the HIPAA

privacy rule. Revised 2003. <http://www.hhs.gov/ocr/privacysummary.pdf>. Accessed June 22, 2015.

confidentiality, role fidelity, justice, nonmaleficence, and veracity. These principles are used in the ethical decision- making process.

◗ There are two basic ethical theories: formalism and consequentialism. The most commonly used ethical decision-making model is the mixed approach. The mixed approach combines components of formalism, consequentialism, and modern decision-making theory.

◗ The basic information that must be identified before a reasoned ethical decision is made includes the problem or issue, the individuals involved, and the ethical principle or principles that apply; a determination of who should make the decision; and the role of the practitioner.

◗ Public law deals with the relationships of private parties and the government. Civil law is concerned with the recognition and enforcement of the rights and duties of private individuals and organizations.

◗ Professional malpractice is negligence in which a professional has failed to provide the care expected, resulting in harm to someone. Examples of situations that RTs might encounter include attempting procedures beyond the practitioner’s skill level, failure to perform a duty as assigned, or failure to perform the duty correctly.

◗ Like members of other professions, RTs are responsible for their actions. If their actions result in injury to others, the injured party or parties are entitled to seek redress in the courts.

◗ A professional license provides a framework under which a licensee carries out his or her duties. Because licensure acts define who can perform specified duties, it is expected that the duties will be performed in a responsible manner and the professional will be responsible for his or her actions. The purpose of licensure is to provide for the public’s safety. Practitioners must carry out their duties with an eye toward defending themselves in the case of legal action.

◗ Patients today are better educated and hold higher expectations from health care practitioners. Many patients are assuming responsibility for their own health care, placing the health care practitioner into the role of consultant.

http://www.wma.net/en/30publications/10policies/c8/index.html

http://www.hhs.gov/ocr/privacysummary.pdf

102

C H A P T E R 6

Physical Principles of Respiratory Care

DANIEL F. FISHER

CHAPTER OBJECTIVES

After reading this chapter you will be able to: ◆ Describe the properties that characterize the three states of matter. ◆ Describe how heat transfer occurs among substances. ◆ Identify the three common temperature scales and explain how to use them. ◆ Describe how substances undergo change of state. ◆ Describe how water vapor capacity, absolute humidity, and relative humidity are related. ◆ Describe how to predict gas behavior under changing conditions, including at extremes of temperature and

pressure. ◆ Describe the principles that govern the flow of fluids.

CHAPTER OUTLINE

States of Matter Internal Energy of Matter Laws of Thermodynamics

Change of State Liquid-Solid Phase Changes (Melting and Freezing) Properties of Liquids Liquid-Vapor Phase Changes Properties of Gases

Gas Behavior Under Changing Conditions Gas Laws Effect of Water Vapor

Properties of Gases at Extremes of Temperature and Pressure

Critical Temperature and Pressure Fluid Dynamics

Pressures in Flowing Fluids Patterns of Flow Flow, Velocity, and Cross-Sectional Area Bernoulli Principle Fluid Entrainment Fluidics and the Coanda Effect

KEY TERMS

absolute humidity adhesion ATPS Avogadro’s law BTPS Coanda effect cohesion condensation conduction convection critical temperature Dalton’s law dew point evaporation

flow resistance Graham’s law Henry’s law jet entrainment kinetic energy laminar flow Laplace’s law latent heat of fusion latent heat of vaporization law of continuity laws of thermodynamics melting point Pascal’s principle Poiseuille’s law

potential energy radiation relative humidity (RH) solubility coefficient specific gravity STPD strain-gauge pressure transducers surface tension thermal conductivity thermodynamics turbulent flow vaporization viscosity water vapor pressure

Physical Principles of Respiratory Care • CHAPTER 6 103

both liquids and gases are considered fluids. Gases have no fixed volume or shape. Both of these qualities depend on local condi- tions for the gas.

Plasma has been referred to as a fourth state of matter. Plasma is a combination of neutral atoms, free electrons, and atomic nuclei. Plasmas can react to electromagnetic forces and flow freely similar to a liquid or a gas (see Figure 6-1, D). Although mentioned here for the sake of completeness, plasmas are not discussed further because at this time they are not known to be relevant to the practice of respiratory care.

Internal Energy of Matter

The atoms that make up all matter are in constant motion at normal temperature.2 This motion is resulting from internal energy. There are two major types of internal energy: (1) poten- tial energy, and (2) kinetic energy. Potential energy is referred to as the energy of position—that is, object balanced on a shelf. Potential energy is a result of the strong attractive forces between molecules. These intermolecular forces are why solids are rigid and liquids have viscosity and cohesiveness. These same inter- molecular forces are not as strong in gases. Kinetic energy is the energy of motion, such as a falling object. Most internal energy in gases is in the form of kinetic energy.

Laws of Thermodynamics

The term thermodynamics can refer to either the science studying the properties of matter at various temperatures or the kinetics (speed) of reactions of matter at various temperatures. From the study of physics, we take special notice of the laws of thermodynamics. The laws describe how fundamental physical quantities (temperature, energy, and entropy) behave under various circumstances and forbid certain phenomena (such as perpetual motion). A basic knowledge of these principles is helpful in understanding many aspects of respiratory care. Of particular interest is the first law of thermodynamics, one version of which states that an increase in the internal energy of a closed system can be the result only of work performed on the system. Work can be viewed as the process of transferring energy to or from a system. The increase in internal energy of a system can be observed as an increase in heat (as with a humidifier) or pressure (as during mechanical ventilation).

Heat Transfer When two objects exist at different temperatures, the first law of thermodynamics tells us that heat will move from the hotter object to the cooler object until the objects’ temperatures are equal. This is an example of transitioning from a higher state of energy to a lower state. Two objects with the same tempera- ture exist in thermal equilibrium. Heat can be transferred in four ways: (1) conduction, (2) convection, (3) radiation, and (4) evaporation and condensation.

Conduction Heat transfer in solids occurs mainly via conduction. Conduc- tion is the transfer of energy by direct contact between hot and cold molecules. How well heat transfers by conduction depends

STATES OF MATTER

There are three primary states of matter: solid, liquid, and gas. Figure 6-1, A to C depicts simplified models of these states of matter.

Solids have a fixed volume and shape. The molecules that make up the solid have the shortest distance to travel until they collide with one another. This motion has been referred to as a “jiggle.” Solids have a high degree of internal order; their atoms or molecules are limited to back-and-forth motion about a central position, as if held together by springs (see Figure 6-1, A). Solids maintain their shape because their atoms are kept in place by strong mutual attractive forces, called van der Waals forces.1

Liquids have a fixed volume, but adapt to the shape of their container. If a liquid is not held within a container, the shape is determined by numerous internal and external forces. Liquid molecules exhibit mutual attraction. However, because these forces are much weaker in liquids than in solids, liquid mole- cules can move about freely (see Figure 6-1, B). This freedom of motion explains why liquids take the shape of their contain- ers and are capable of flow. However, similar to solids, liquids are dense and cannot be compressed easily.

In a gas, molecular attractive forces are very weak. Gas mol- ecules, which lack restriction to their movement, exhibit rapid, random motion with frequent collisions (see Figure 6-1, C). Gases have no inherent boundaries and are easily compressed and expanded. Similar to liquids, gases can flow. For this reason,

FIGURE 6-1 Simplified models of the four states of matter. A, Solid (rigid network of interconnected springs). B, Liquid (freely moving spheres with no space among them). C, Gas (small rapidly moving particles with a lot of space among them). D, Plasma (small rapidly moving charged particles with a lot of space among them).

A B

�

��

�

C D

104 SECTION I • Foundations of Respiratory Care

eye. Objects such as an electrical stove burner or a kerosene heater radiate some of their energy as visible light. In the clinical setting, radiant heat energy is commonly used to keep newborn infants warm.

Evaporation and Condensation Vaporization is the change of state from liquid to gas. Vaporiza- tion requires heat energy. According to the first law of thermo- dynamics, this heat energy must come from the surroundings. In one form of vaporization, called evaporation, heat is taken from the air surrounding the liquid, cooling the air. In warm weather or during strenuous exercise, the body takes advantage of this principle of evaporative cooling by producing sweat. The liquid sweat evaporates and cools the skin.

Condensation is the opposite of evaporation. In condensa- tion, gases become liquids. Because vaporization takes heat from the air around a liquid (cooling), condensation must give heat back to the surroundings (warming). A refrigerator (or air conditioner) works on the principle of repeated vaporization cycles. The food cools as it passes energy through the walls of the refrigerator into pipes containing condensed refrigerant. The refrigerant warms, vaporizes, and expands. Then a com- pressor condenses the refrigerant again, releasing heat that is carried away to the atmosphere by a radiator. The condensed refrigerant is then passed by the food and the cycle repeats. The whole system is basically a heat pump transferring thermal energy from the food to the atmosphere. The next section expands on the concept of change of state and provides more detail on the processes of vaporization and condensation.

Temperature Temperature and kinetic energy are closely related.2 Tempera- ture is a measurement of heat. Heat is the result of molecules colliding with one another. The temperature of a gas, with most of its internal energy spent keeping molecules in motion, is directly proportional to its kinetic energy. In contrast, the tem- peratures of solids and liquids represent only part of their total internal energy.

Absolute Zero In concept, absolute zero is the lowest possible temperature that can be achieved. That is the temperature at which there is no kinetic energy. Because there is no energy, the molecules cease to vibrate and the object has no heat that can be measured. This temperature is defined to be absolute zero. Although researchers have come close to attaining absolute zero, no one has actually achieved it; this is due to the third law of thermodynamics, which states absolute zero is impossible to achieve.

Temperature Scales Multiple scales can be used to measure temperature. The Fahr- enheit and Celsius scales are based on properties of water (freez- ing and boiling). A third scale, the Kelvin scale, is based on molecular motion. Absolute zero provides a logical zero point on which to build a temperature scale. The International System of Units (SI) units for temperature is measured in Kelvin (K)

on both the number and the force of molecular collisions between adjoining objects.

Heat transfer between objects is quantified by using a mea- sure called thermal conductivity. Table 6-1 lists the thermal conductivities of selected substances in centimeter-gram- second (cgs) system units. As is evident, solids (especially metals) tend to have high thermal conductivity. This is why metals feel cold to the touch even when at room temperature. In this case, the high thermal conductivity of metal quickly draws heat away from the skin, creating a feeling of “cold.” In contrast, with fewer molecular collisions than in solids and liquids, gases exhibit low thermal conductivity.

Convection Heat transfer in both liquids and gases occurs mainly by con- vection. Convection involves the mixing of fluid molecules at different temperatures. Although air is a poor heat conductor (see Table 6-1), it can efficiently transfer heat by convection. To do so, the air is first warmed in one location and then circulated to carry the heat elsewhere; this is the principle behind forced- air heating in houses and convection heating in infant incuba- tors. Fluid movements carrying heat energy are called convection currents.

Radiation Radiation is another mechanism for heat transfer. Conduction and convection require direct contact between two substances, whereas radiant heat transfer occurs without direct physical contact. Heat transfer by radiation occurs even in a vacuum, such as when the sun warms the earth.

The concept of radiant energy is similar to that of light. Radiant energy given off by objects at room temperature is mainly in the infrared range, which is invisible to the human

TABLE 6-1

Thermal Conductivities in (cal/sec)/(cm2 °C/cm)

Material Thermal Conductivity (k)

Silver 1.01 Copper 0.99 Aluminum 0.50 Iron 0.163 Lead 0.083 Ice 0.005 Glass 0.0025 Concrete 0.002 Water at 20° C 0.0014 Asbestos 0.0004 Hydrogen at 0° C 0.0004 Helium at 0° C 0.0003 Snow (dry) 0.00026 Fiberglass 0.00015 Cork board 0.00011 Wool felt 0.0001 Air at 0° C 0.000057

From Nave CR, Nave BC: Physics for the health sciences, ed 3, Philadelphia, 1985, WB Saunders.

Physical Principles of Respiratory Care • CHAPTER 6 105

To convert degrees Celsius to degrees Fahrenheit, simply reverse this formula:

° = × ° +F C( . )1 8 32

For example:

° =C 100 ° = × +F ( . )1 8 100 32

° =F 212

Figure 6-2 shows the relationship between the kinetic activ- ity of matter and temperature on all three common tempera- ture scales. For ease of reference, four key points are defined: (1) the zero point of each scale, (2) the freezing point of water (0° C), (3) body temperature (37° C), and (4) the boiling point of water (100° C).

CHANGE OF STATE

All matter can change state. Because respiratory therapists work extensively with both liquids and gases, they must have a good understanding of the key characteristics of these states and the basic processes underlying their phase changes.

Liquid-Solid Phase Changes (Melting and Freezing)

When a solid is heated, its molecular kinetic energy increases. This added internal energy increases molecular vibrations. If enough heat is applied, these vibrations eventually weaken the intermolecular attractive forces. At some point, molecules break free of their rigid structure, and the solid changes into a liquid.

Melting The changeover from the solid to liquid state is called melting. The temperature at which this changeover occurs is the melting point.2 The range of melting points is considerable. For example, water (ice) has a melting point of 0° C, carbon has a melting

with a zero point equal to absolute zero (0° K).3-7 Because the Kelvin scale has 100 degrees between the freezing and boiling points of water, it is a centigrade, or 100-step, temperature scale. The Kelvin scale has the unique quality of being based on the triple-point definition for water (the temperature at which all three phases of water exist). This temperature happens to be approximately 273° K (0.0° C).5-7

The cgs temperature system is based on Celsius (C) units. Similar to the Kelvin scale, the Celsius scale is a centigrade scale (100 degrees between the freezing and boiling points of water). However, 0° C is not absolute zero but instead is the freezing point of water.

In Celsius units, kinetic molecular activity stops at approxi- mately −273° C. Therefore 0° K equals −273° C, and 0° C equals 273° K. To convert degrees Celsius to degrees Kelvin, simply add 273:

° = ° +K C 273

For example:

25 25 273 298° = + = °C K

Conversely, to convert degrees Kelvin to Celsius, you simply subtract 273. For example:

310 310 273 37° = − = °K C

The Fahrenheit scale is the primary temperature scale in the foot, pound, and second (fps) or British system of measure- ment. Absolute zero on the Fahrenheit scale equals −460° F.

To convert degrees Fahrenheit to degrees Celsius, use the following formula:

° = ° −C F( ) .32 1 8

For example:

° =F 98 6.

° = −C ( . ) .98 6 32 1 8

° =C 37

FIGURE 6-2 Linear relationship between gas molecular activity, or pressure, and temperature. The graph shows comparable readings on three scales for five temperature points.

–273 0

–460

Celsius Kelvin

Fahrenheit

–17.80 255.2

0 273 32

37 310

100 373 21298.6

Kinetic activity or

pressure

106 SECTION I • Foundations of Respiratory Care

sublimation occurs because the vapor pressure is low enough for the intermediate liquid not to appear.

Properties of Liquids

Liquids exhibit flow and assume the shape of their container. Liquids also exert pressure, which varies with depth and density. Variations in liquid pressure within a container produce an upward supporting force, called buoyancy.

Although melting weakens intermolecular bonding forces, liquid molecules still attract one another. The persistence of these cohesive forces among liquid molecules helps explain the physical properties of viscosity, capillary action, and surface tension.

Pressure in Liquids Liquids exert pressure, which has the dimensions of force per unit area. The pressure exerted by a liquid depends on both its height (depth) and weight density (weight per unit volume), which is shown in equation form:

P h dL w= ×

where PL is the static pressure exerted by the liquid, h is the height of the liquid column, and dw is the liquid’s weight density.

For example, to compute the pressure at the bottom of a 33.9-ft (1034-cm)-high column of water (density = 1 g/cm3), you would use this equation:

P h d

cm g cm

g cm

L w= × = × =

1034 1

1034

( )

The answer (1034 g/cm2) also equals 1 atmosphere of pressure (atm), or approximately 14.7 lb/in2. This figure does not account for the additional atmospheric pressure (PB) acting on the top

point of greater than 3500° C, and helium has a melting point of less than −272° C.

Figure 6-3 depicts the phase change caused by heating water. At the left origin of −50° C, water is solid ice. As the ice is heated, its temperature increases. At its melting point of 0° C, ice begins to change into liquid water. However, the full change to liquid water requires additional heat. This additional heat energy changes the state of water but does not immediately change its temperature.

The extra heat needed to change a solid to a liquid is the latent heat of fusion. In cgs units, the latent heat of fusion is defined as the number of calories required to change 1 g of a solid into a liquid without changing its temperature. The latent heat of fusion of ice is 80 cal/g, whereas the latent heat of fusion of oxygen is 3.3 cal/g. This change of state, compared with simply heating a solid, requires enormous energy.

Freezing Freezing is the opposite of melting. Because melting requires large amounts of externally applied energy, you would expect freezing to return this energy to the surroundings, and this is exactly what occurs. During freezing, heat energy is transferred from a liquid back to the environment, usually by exposure to cold.

As the kinetic energy of a substance decreases, its molecules begin to regain the stable structure of a solid. According to the first law of thermodynamics,4 the energy required to freeze a substance must equal that needed to melt it. The freezing and melting points of a substance are the same.

Sublimation is the term used for the phase transition from a solid to a vapor without becoming a liquid as an intermediary form. An example of sublimation is dry ice (frozen carbon dioxide). Dry ice sublimates from its solid form into gaseous CO2 without first melting and becoming liquid CO2. This

FIGURE 6-3 Temperature as a function of time for 1 g of water heated at the rate of 1 cal/sec. (Modified from Nave CR, Nave BC: Physics for the health sciences, ed 3, Philadelphia, 1985, WB Saunders.)

Water to steam transition100

–50

Ice to water

Time in seconds (or calories added)

Te m

pe ra

tu re

( °

C )

100 200 300 400 500 600 700 8000

Physical Principles of Respiratory Care • CHAPTER 6 107

of the liquid. The total pressure at the bottom of the column equals the sum of the atmospheric and liquid pressures. In this case, the total pressure is 2068 g/cm2, equal to 29.4 lb/in2, or 2 atm.

As shown in Figure 6-4, the pressure of a given liquid is the same at any specific depth (h), regardless of the container’s shape. This is because the pressure of a liquid acts equally in all directions. This concept is called Pascal’s principle.

Buoyancy (Archimedes’ Principle) Thousands of years ago, Archimedes showed that an object submersed in water appeared to weigh less than in air. This effect, called buoyancy, explains why certain objects float in water. Liquids exert buoyant force because the pressure below a submerged object always exceeds the pressure above it. This difference in liquid pressure creates an upward or supporting force. According to Archimedes’ principle, this buoyant force must equal the weight of the fluid displaced by the object. The buoyant force (B) may be calculated as follows:

B d Vw= ×

where dw is weight density (weight/unit volume) and V is volume of displaced fluid. If the weight density of an object is less than that of water (1 g/cm3), it will displace a weight of water greater than its own weight. In this case, the upward buoyant force will overcome gravity, and the object will float. Conversely, if an object’s weight density exceeds the weight of water, the object will sink.

Clinically, Archimedes’ principle is used to measure the spe- cific gravity of certain liquids. The term specific gravity refers to the ratio of the density of one fluid compared with the density of another reference substance, which is typically water. Figure 6-5 shows the use of a hydrometer to measure the spe- cific gravity of urine. The specific gravity of gases also can be measured. In this case, O2 or hydrogen is used as the standard instead of water.

Gases also exert buoyant force, although much less than that provided by liquids. Buoyancy helps keep solid particles sus- pended in gases. These suspensions, called aerosols, play an

FIGURE 6-4 Pascal’s principle. Liquid pressure depends only on the height (h) and not on the shape of the vessel or the total volume of liquid. (Modified from Nave CR, Nave BC: Physics for the health sciences, ed 3, Philadelphia, 1985, WB Saunders.)

FIGURE 6-5 Using a hydrometer to measure the specific gravity of a urine specimen. The scale value of 1.025 indicates that this urine sample has a weight density 1.025 times greater than that of water.

1.025

1.000

1.010

1.020

1.030

1.040

1.050

important role in respiratory care. More detail on the charac- teristics and use of aerosols is provided in Chapters 38 and 39.

Viscosity Viscosity is the force opposing a fluid’s flow and is similar to friction in solids. The viscosity of a fluid is directly proportional to the cohesive forces between its molecules. The stronger these cohesive forces are, the greater the fluid’s viscosity. The greater

108 SECTION I • Foundations of Respiratory Care

the surface adhere to the glass more strongly than they cohere to each other (see Figure 6-7, A). In contrast, a mercury menis- cus is convex (see Figure 6-7, B). In this case, the cohesive forces pulling the mercury atoms together exceed the adhesive forces trying to attract the mercury to the glass.

Surface Tension Surface tension is a force per unit length (equivalent to surface energy density with units of Nm−1 = Jm−2) exerted by like mol- ecules at the surface of a liquid. A small drop of fluid provides a good illustration of this force. As shown in Figure 6-8, cohe- sive forces affect molecules inside the drop equally from all

a fluid’s viscosity, the greater is its resistance to deformation and the greater its opposition to flow.

The understanding of viscosity leads to the concept that fluids move in discrete cylindrical layers, called streamlines. This pattern of motion is called laminar flow. Laminar flow is viewed as concentric layers of fluid flowing parallel to the tube wall at velocities that increase toward the center. As shown in Figure 6-6, frictional forces between the streamlines and the tube wall impede movement of the outer layers of a fluid. Each layer, moving toward the center of the tube, hinders the motion of the next inner layer less and less.

The difference in the velocity among these concentric layers is called the shear rate and is simply a measure of how easily these layers separate. Shear rate depends on two factors: (1) the pressure pushing or driving the fluid, called the shear stress, and (2) the viscosity of the fluid. Shear rate is directly proportional to shear stress and inversely proportional to viscosity.

In uniform fluids such as water or oil, viscosity varies with temperature. Because higher temperatures weaken the cohesive forces between molecules, heating a uniform fluid reduces its viscosity. Conversely, cooling a fluid increases its viscosity. This is why a car’s engine is so hard to start on a cold winter morning. The oil becomes so viscous that it impedes movement of the engine’s parts.

Blood, in contrast to water or oil, is a complex fluid that contains not only liquid (plasma, which is 90% water) but also cells in suspension. For this reason, blood has a viscosity approximately five times greater than the viscosity of water. The greater the viscosity of a fluid, the more energy is needed to make it flow. The heart works harder to pump blood than it would if it were pumping water. The heart must perform even more work when blood viscosity increases, as occurs in polycy- themia (an increase in red blood cell concentration in the blood).

Cohesion and Adhesion The attractive force between like molecules is called cohesion. The attractive force between unlike molecules is called adhe- sion. These forces can be observed at work by placing a liquid in a small-diameter tube. As shown in Figure 6-7, the top of the liquid forms a curved surface, or meniscus. When the liquid is water, the meniscus is concave because the water molecules at

FIGURE 6-6 Effects of shear stress or pressure (P) on shear rate (velocity gradient [v]) in a Newtonian fluid. (Modified from Winters WL, Brest AN, editors: The microcirculation, Springfield, IL, 1969, Charles C Thomas.)

∆v ∆v∆v

FIGURE 6-7 The shape of the meniscus depends on the relative strengths of adhesion and cohesion. A, Water: Adhesion stronger than cohesion. B, Mercury: Cohesion stronger than adhesion.

A B

FIGURE 6-8 The force of surface tension in a drop of liquid. Cohesive force (arrows) attracts molecules inside the drop to one another. Cohesion can pull the outermost molecules inward only, creating a centrally directed force that tends to contract the liquid into a sphere.

Gas Interface

Liquid molecules

Physical Principles of Respiratory Care • CHAPTER 6 109

work, dW = PdV = TdA, where dV is the change in volume and dA is the change in surface area. Because the area of a sphere is 4πR2, dA = d(4πR2). From calculus, the differential of the expression 4πR2 is 8πRdR. The volume of a sphere is 4πR3/3, so dV = d(4πR3/3). Again taking the differential of this expression gives dV = 4πR2dR. Returning to dW, we now see that because PdV = TdA, it follows that P(4πR2dR) = T(8πRdR). Rearranging and solving for P with simple algebra we get the common expression for the law of Laplace:

P T

R =

For a structure such as a soap bubble, which has two liquid-air surfaces (and hence twice the surface tension) the equation is:

P T

R =

Figure 6-9 suggests that if two alveoli of different sizes are connected, the smaller one will tend to empty into the larger one. However, this does not happen because, in reality, the two alveoli would have different surface tensions. This is because of the thin layer of surfactant inside the alveoli that counteracts the surface tension. As the radius of the alveoli decreases, its internal surface area also increases but the volume of surfactant stays the same. Hence the thickness of the layer of surfactant increases, which decreases the surface tension. Therefore all other factors being equal, the two alveoli will reach equilibrium, at which point they have the same radius. Abnormalities in alveolar surface tension occur in certain clinical conditions, such as prematurity. These abnormalities may result in collapse of alveoli secondary to high surface tension.

Capillary Action Capillary action is a phenomenon in which a liquid in a small tube moves upward, against gravity. Capillary action involves both adhesive and surface tension forces. As shown in Figure 6-10, A, the adhesion of water molecules to the walls of a thin tube causes an upward force on the edges of the liquid and produces a concave meniscus.

Because surface tension acts to maintain the smallest possi- ble liquid-gas interface, instead of just the edges of the liquid moving up, the whole surface is pulled upward. The strength of this force depends on the amount of liquid that contacts the tube’s surface. Because a small capillary tube creates a more concave meniscus and a greater area of contact, liquid rises higher in tubes with smaller cross-sectional areas (see Figure 6-10, B).

Capillary action is the basis for blood samples obtained by use of a capillary tube. The absorbent wicks used in some gas humidifiers are also an application of this principle, as are certain types of surgical dressings.

Liquid-Vapor Phase Changes

Only after ice completely melts does additional heat increase the temperature of the newly formed liquid (see Figure 6-3). As

TABLE 6-2

Examples of Surface Tension

Substance Temperature (°C) Surface Tension (dynes/cm)

Water 20 73 Water 37 70 Whole blood 37 58 Plasma 37 73 Ethyl alcohol 20 22 Mercury 17 547

FIGURE 6-9 Laplace relationship. Two bubbles in a liquid matrix (models of alveoli). They have different sizes but the same surface tension. Bubble A, with the smaller radius, has the greater inward or deflating pressure and is more prone to collapse than the larger bubble, B. Because the two bubbles are connected, bubble A would tend to deflate and empty into bubble B. Conversely, because of the greater surface tension of bubble A, it would be harder to inflate than bubble B.

P = 4ST f

P1 > P2

r1 < r2 r2

P1A B

directions. However, only inward forces affect molecules on the surface. This imbalance in forces causes the surface film to contract into the smallest possible surface area, usually a sphere or curve (meniscus). This phenomenon explains why liquid droplets and bubbles retain a spherical shape.

Surface tension is quantified by measurement of the force needed to produce a “tear” in a fluid surface layer. Table 6-2 lists the surface tensions of selected liquids in dynes per centimeter (cgs). For a given liquid, surface tension varies inversely with temperature: The higher the temperature, the lower is the surface tension. Surface tension plays an important role in determining the relative sizes of connected alveoli (Figure 6-9). To understand this, consider a spherical bubble of air in a liquid (analogous to an alveolus). According to Laplace’s law, the pres- sure inside the bubble varies directly with the surface tension of the liquid and inversely with its radius. Internal surface tension (T) will attempt to contract the bubble but is opposed by the resulting pressure inside the bubble (P). To increase the radius by an amount dR, we must perform work, dW (where d represents an infinitesimal change as used in calculus). The

110 SECTION I • Foundations of Respiratory Care

Energy is also needed to vaporize liquids, as with other phase changes. The energy required to vaporize a liquid is the latent heat of vaporization. In cgs units, the latent heat of vaporiza- tion is the number of calories required to vaporize 1 g of a liquid at its normal boiling point.

Melting weakens attractive forces between molecules, whereas vaporization eliminates them. Elimination of these forces converts essentially all of the internal energy of a sub- stance into kinetic energy. For this reason, vaporization requires substantially more energy than melting. As shown in Figure 6-3, almost seven times more energy is needed to convert water to steam (540 cal/g) than is needed to melt ice.

Evaporation, Vapor Pressure, and Humidity Boiling is only one type of vaporization. A liquid also can change into a gas at temperatures lower than its boiling point through a process called evaporation. Water is a good example (Figure 6-11). When at a temperature lower than its boiling point, water enters the atmosphere via evaporation. The liquid

the water temperature reaches 100° C, a new change of state begins—from liquid to vapor. This change of state is called vaporization. There are two different forms of vaporization: boiling and evaporation.

Boiling The boiling point of a liquid is the temperature at which its vapor pressure exceeds atmospheric pressure. When a liquid boils, its molecules must have enough kinetic energy to force themselves into the atmosphere against the opposing pressure. Because the weight of the atmosphere retards the escape of vapor molecules, the greater the ambient pressure, the greater is the boiling point. Conversely, when atmospheric pressure is low, liquid molecules escape more easily and boiling occurs at lower temperatures. This is why cooking times must be increased at higher altitudes.

Although boiling is associated with high temperatures, the boiling points of most liquefied gases are very low. At 1 atm, O2 boils at −183° C.

FIGURE 6-10 Capillary action. A, Adhesion and surface tension contribute to capillary action (capillarity). B, The liquid rises highest in the smallest tube. (Modified from Nave CR, Nave BC: Physics for the health sciences, ed 3, Philadelphia, 1985, WB Saunders.)

Surface tension

Net upward force

Force of adhesion

A B

FIGURE 6-11 Factors influencing vaporization of water. See text for details.

A B C D

Physical Principles of Respiratory Care • CHAPTER 6 111

molecules are in constant motion, as in the gas phase. Although this kinetic energy is less intense than in the gaseous state, it allows some molecules near the surface to escape into the sur- rounding air as water vapor (see Figure 6-11, A).

After water is converted to a vapor, it acts like any gas. Not to be confused with visible particulate water, such as mist or fog, this invisible gaseous form of water is called molecular water. Molecular water obeys the same physical principles as other gases and exerts a pressure called water vapor pressure. This pressure needs to be considered when calculating gas exchange (Chapter 13).

Evaporation requires heat. The heat energy required for evaporation comes from the air next to the water surface. As the surrounding air loses heat energy, it cools. This is the principle of evaporative cooling, which was previously described.

If the container is covered, water vapor molecules continue to enter the air until it can hold no more water (see Figure 6-11, B). At this point, the air over the water is saturated with water vapor. However, vaporization does not stop when saturation occurs. Instead, for every molecule escaping into the air, another returns to the water reservoir. These conditions are referred to as a state of equilibrium.

Influence of Temperature. No other factor influences evaporation more than temperature. Temperature affects evap- oration in two ways. First, the warmer the air, the more vapor it can hold. Specifically, the capacity of air to hold water vapor increases with temperature. The warmer the air contacting a water surface, the faster is the rate of evaporation.

Second, if water is heated, its kinetic energy is increased, and more molecules are helped to escape from its surface (see Figure 6-11, C). Last, if the container of heated water is covered, the air again becomes saturated (see Figure 6-11, D). However, the heated saturated air, compared with the unheated air (see Figure 6-11, B), now contains more vapor molecules and exerts a higher vapor pressure (as shown by the manometer in Figure 6-11, D). The temperature of a gas affects both its capacity to hold molecular water and the water vapor pressure.

The relationship between water vapor pressure and tempera- ture is shown graphically in Figure 6-12. The left vertical axis plots water vapor pressure in both millimeters of mercury (mm Hg) and (kilopascals (kPa). The horizontal axis plots tem- peratures between 0° and 70° C. This graph shows that the greater the temperature, the greater is the saturated water vapor pressure (bold red dots). Table 6-3 lists actual water vapor pres- sures in saturated air in the clinical range of temperatures (20° to 37° C).

Humidity. Water vapor pressure represents the kinetic activity of water molecules in air. For the actual amount or weight of water vapor in a gas to be determined, the water vapor content or absolute humidity must be measured.

Absolute humidity can be measured by weighing the water vapor extracted from air using a drying agent. The common unit of measure for absolute humidity is milligrams of water vapor per liter of gas (mg/L). Absolute humidity values for satu- rated air at various temperatures are plotted against the right vertical axis of Figure 6-12. The middle column of Table 6-3

FIGURE 6-12 Water vapor pressure (PH O2 ) and absolute humidity (mg H2O/L) curves for gas that is fully saturated (relative humidity [RH] = 100%) and gas that is half saturated (RH = 50%).

150

140

130

120

110

100

90 80

2 10

150

140

130

120

110

100

10 20 30 40 50 60 700

Water vapor pressure

Water content

Vapor pressure

mg H2O/L

m g

H 2O

100% RH

50% RH

m m

H g

kP a

Temperature (°C)

TABLE 6-3

Vapor Pressure and Absolute Humidity for Air Saturated with Water Vapor

Temperature (°C)

Vapor Pressure (mm Hg)

Water Vapor Content (mg/L)

ATPS to BTPS Correction Factor*

20 17.50 17.30 1.102 21 18.62 18.35 1.096 22 19.80 19.42 1.091 23 21.10 20.58 1.085 24 22.40 21.78 1.080 25 23.80 23.04 1.075 26 25.20 24.36 1.068 27 26.70 25.75 1.063 28 28.30 27.22 1.057 29 30.00 28.75 1.051 30 31.80 30.35 1.045 31 33.70 32.01 1.039 32 35.70 33.76 1.032 33 37.70 35.61 1.026 34 39.90 37.57 1.020 35 42.20 39.60 1.014 36 44.60 41.70 1.007 37 47.00 43.80 1.000

ATPS, Ambient temperature and pressure saturated; BTPS, body temperature and pressure saturated. *Correction factors are based on 760 mm Hg pressure.

lists these absolute humidity values for saturated air between 20° and 37° C.

A gas does not need to be fully saturated with water vapor. If a gas is only half saturated with water vapor, its water vapor pressure and absolute humidity are only half that in the fully

112 SECTION I • Foundations of Respiratory Care

saturated with water vapor. Under these conditions, even slight cooling of the gas causes its water vapor to turn back into the liquid state, a process called condensation.

Condensed moisture deposits on any available surface, such as on the walls of a container or delivery tubing or on particles suspended in the gas. Condensation returns heat to and warms the surrounding environment, whereas vaporization of water cools the adjacent air.

If air that is at an RH of 90% is cooled, its capacity to hold water vapor decreases. Although the water vapor capacity of the air decreases, its content remains constant. With a lower capac- ity but the same content, the RH of the air must increase. Continued cooling decreases the air’s water vapor capacity until it eventually equals the water vapor content (RH = 100%). When content equals capacity, the air is fully saturated and can hold no more water vapor.

Because RH never exceeds 100%, any further decrease in temperature causes condensation. The temperature at which condensation begins is called the dew point. Cooling a satu- rated gas below its dew point causes increasingly more water vapor to condense into liquid water droplets.

Figure 6-13 provides a useful analogy of the relationship among water vapor content, capacity, and RH. The various- sized glasses represent the capacity of a gas to hold water vapor. The larger the glass, the greater is its capacity. The water in the glasses represents the actual water vapor content. A glass that is half full is at 50% capacity, or 50% RH. A full glass represents the saturated state, which is equivalent to 100% RH.

Figure 6-13, A, shows what happens when a saturated gas is heated. Warming a gas increases its capacity to hold water vapor but does not change its content. This is equivalent to pouring the contents of the full glass on the left in Figure 6-13, A into

saturated state. Air that is fully saturated with water vapor at 37° C, and 760 mm Hg has a water vapor pressure of 47 mm Hg and an absolute humidity of 43.8 mg/L (see Table 6-3). However, if the same volume of air were only 50% saturated with water vapor, its water vapor pressure would be 0.50 × 47 mm Hg, or 23.5 mm Hg and its absolute humidity would be 0.50 × 43.8 mg/L, or 21.9 mg/L.

When a gas is not fully saturated, its water vapor content can be expressed in relative terms using a measure called relative humidity (RH). The RH of a gas is the ratio of its actual water vapor content to its saturated capacity at a given temperature. RH is expressed as a percentage and is derived with the follow- ing simple formula:

RH content

capacity (%) %= ×100

For example, saturated air at a room temperature of 20° C has the capacity to hold 17.3 mg/L of water vapor (see Table 6-3). If the absolute humidity is 12 mg/L, the RH is calculated as follows:

RH mg L mg L

= × = × =

12 17 3 100

0 69 100

. %

Actual water vapor content does not have to be measured for RH to be computed. Instruments called hygrometers allow mea- surement of RH using a wide variety of ingenuous mechanisms based on the effects of humidity on, for example, temperature through evaporation (psychrometers), the length of a human hair, or electrical capacitance and resistance.

When the water vapor content of a volume of gas equals its capacity, the RH is 100%. When the RH is 100%, a gas is fully

FIGURE 6-13 Relative humidity analogy. A, The effect of increasing capacity without changing content, as when heating a saturated gas. B, The effect of decreasing capacity, as when cooling a gas. See text for details.

Full ½ full

² full

full

Full Full½ full ³

² full³ ³A

Physical Principles of Respiratory Care • CHAPTER 6 113

To compute the humidity deficit, simply subtract the actual water vapor content from its capacity at 37° C (43.8 mg/L).

Influence of Pressure. High temperatures increase vapor- ization, whereas high pressures impede this process. Water mol- ecules trying to escape from a liquid surface must push their way out against the opposing air molecules. If the surrounding air pressure is high, there are more opposing air molecules and vaporization decreases. Alternatively, low atmospheric pres- sures increases vaporization.

Influence of Surface Area. The greater the available surface area of the gas in contact with air, the greater is the rate of liquid evaporation. This statement can be easily proved by comparing how quickly equal volumes of water evaporate under dry condi- tions from a flat plate versus from a tall, narrow glass. The water spread over a flat plate evaporates more quickly compared with the same amount of liquid in a tall, narrow glass. This principle is applied to the design of certain humidifiers to increase their ability to put water vapor in the passing gas.

Properties of Gases

Gases share many properties with liquids. Specifically, gases exert pressure, are capable of flow, and exhibit the property of viscosity. However, in contrast to liquids, gases are readily com- pressed and expanded and fill the spaces available to them through diffusion.

Kinetic Activity of Gases Because the intermolecular forces of attraction of a gas are so weak, most of the internal energy of a gas is kinetic energy. Kinetic theory says that gas molecules travel about randomly at very high speeds and with frequent collisions.

The velocity of gas molecules is directly proportional to tem- perature. As a gas is warmed, its kinetic activity increases, its molecular collisions increase, and its pressure increases. Con- versely, when a gas is cooled, molecular activity decreases, par- ticle velocity and collision frequency decrease, and the pressure decreases.

Molar Volume and Gas Density A major principle governing chemistry is Avogadro’s law. This law states that the 1-g atomic weight of any substance contains exactly the same number of atoms, molecules, or ions. This number, 6.023 × 1023, is Avogadro’s constant. In SI units, this quantity of matter equals 1 mole.

Molar Volume. Avogadro’s law states that equal volumes of gases under the same conditions must contain the same number of molecules. At a constant temperature and pressure, 1 mole of a gas should occupy the same volume as 1 mole of any other gas. This ideal volume is termed the molar volume.

At standard temperature (0.0° C) and pressure (760 mm Hg), dry (STPD); the ideal molar volume of any gas is 22.4 L. In reality, there are small deviations from this ideal. For example, although the molar volumes of both O2 and nitrogen are 22.4 L at STPD, the molar volume of CO2 is closer to 22.3 L. These values are used to calculate gas densities and convert dissolved gas volumes into moles per liter.

MINI CLINI Condensation and Evaporation

A good clinical example of condensation and evaporation is the hygroscopic condenser humidifier, a form of artificial nose (Figure 6-14). These devices consist of layers of water-absorbent material encased in plastic. When a patient exhales into an artificial nose, the warm, saturated expired gas cools, causing condensation on the absorbent surfaces. As condensation occurs, heat is generated in the device. When the patient inhales through the device, the inspired gases are warmed and the previously condensed water evaporates, aiding in airway humidification. Chapter 38 provides more detail on humidifi- cation devices, including the artificial nose.

FIGURE 6-14 Hygroscopic condenser humidifier.

Standard connectors

Outer plastic casing

Hygroscopic layers

progressively larger glasses. The amount of water does not change, but as the glasses get larger, they become less full. We started with a full glass (100% RH) but end up with one that is only one-third full (33% RH).

A decrease in capacity would have the opposite effect. In Figure 6-13, B, we start with a large glass, which is half full (50% RH). The capacity of the glass is decreased by pouring the water into progressively smaller glasses (equivalent to decreasing the gas temperature). Eventually, the water volume is enough to fill a smaller glass (100% RH). What happens if we try to empty this full glass into an even smaller one? Because the smaller glass has less capacity, the excess content must spill over. This spill- over is analogous to the condensation occurring when a satu- rated gas cools below its dew point. However, although condensation has removed the excess moisture from the air, the smaller glass is still full (100% RH).

In clinical practice, two additional measures of humidity are used: percent body humidity (BH) and humidity deficit. The BH of a gas is the ratio of its actual water vapor content to the water vapor capacity in saturated gas at body temperature (37° C). The BH is the same as RH except that the capacity (or denomi- nator) is fixed at 43.8 mg/L:

BH content mg L

(%) ( )

. %= ×

43 8 100

The humidity deficit associated with a BH less than 100% represents the amount of water vapor the body must add to the inspired gas to achieve saturation at body temperature (37° C).

114 SECTION I • Foundations of Respiratory Care

physiology, the term tension is often used to refer to the pressure exerted by gases when dissolved in liquids. The pressure or tension of a gas depends mainly on its kinetic activity. In addi- tion, gravity affects gas pressure. Gravity increases gas density, increasing the rate of molecular collisions and gas tension; this explains why atmospheric pressure decreases with altitude.

Pressure is a measure of force per unit area. The SI unit of pressure is the N/m2, or Pascal (Pa). Pressure in the cgs system is measured in dynes/cm2, whereas pounds per square inch (lb/ in2 or psi) is the British foot-pound-second (fps) pressure unit. Pressure can also be measured indirectly as the height of a column of liquid, as is commonly done to determine atmo- spheric pressure.

Measuring Atmospheric Pressure. Atmospheric pressure is measured with a barometer. A barometer consists of an evacu- ated glass tube approximately 1 m long. This tube is closed at the top end, with its lower, open end immersed in a mercury reser- voir (Figure 6-15). The pressure of the atmosphere on the mercury reservoir forces the mercury up the vacuum tube a distance equivalent to the force exerted. In this manner, the height of the mercury column represents the downward force of atmospheric pressure and is measured in either inches (British) or millimeters (metric). Barometer pressure is reported with readings such as 30.4 inches of mercury (Hg) or 772 mm Hg; this means that the atmospheric pressure is great enough to support a column of mercury 30.4 inches or 772 mm in height.

Alternatively, the term torr may be used in pressure readings. Torr is short for Torricelli, the seventeenth-century inventor of the mercury barometer. At sea level, 1 torr equals 1 mm Hg. A pressure reading of 772 torr is the same as 772 mm Hg.

Density. Density is the ratio of the mass of a substance to its volume. A dense substance has heavy (high atomic weight) particles packed closely together. Uranium is a good example of a dense substance. Conversely, a low-density substance has a low concentration of light atomic particles per unit volume. Hydro- gen gas is a good example of a low-density substance.

In clinical practice, weight is often substituted for mass, and weight density (weight per unit volume [dw]) is actually mea- sured. Solid or liquid weight density is commonly measured in grams per cubic centimeter. For gases, the most common unit is grams per liter. Because weight density equals weight divided by volume, the density of any gas at STPD can be computed easily by dividing its molecular weight (gmw) by the universal molar volume of 22.4 L (22.3 for CO2). Box 6-1 provides exam- ples of gas density calculations.

For the density of a gas mixture to be calculated, the percent- age or fraction of each gas in the mixture must be known. To calculate the density of air at STPD, the following equation is used:

d air FN gmw N FO gmw O L

d air

= × + × = × + ×

( ) ( ) .

( . ) ( .

2 2 22 4

0 79 28 0 21 32)) .

22 4

1 29d air g Lw =

FN and FO2 equal the fractional concentrations of N and O2 in air.

Gaseous Diffusion Diffusion is the process whereby molecules move from areas of high concentration to areas of lower concentration. Kinetic energy is the driving force behind diffusion. Because gases have high kinetic energy, they diffuse most rapidly. However, diffu- sion also occurs in liquids and can occur in solids. Gas diffusion rates are quantified using Graham’s law. Mathematically, the rate of diffusion of a gas (D) is inversely proportional to the square root of its gram molecular weight:

D gmw

gas ∝ 1

According to this principle, light gases diffuse rapidly whereas heavy gases diffuse more slowly. Because diffusion is based on kinetic activity, anything that increases molecular activity quickens diffusion. Heating and mechanical agitation speed diffusion.

Gas Pressure Whether free in the atmosphere, enclosed in a container, or dissolved in a liquid such as blood, all gases exert pressure. In

Box 6-1 Examples of Gas Densities dw at Standard Temperature and Pressure, Dry

dw O2 = gmw/22.4 = 32/22.4 = 1.43 g/L dw N2 = gmw/22.4 = 28/22.4 = 1.25 g/L dw He = gmw/22.4 = 4/22.4 = 0.179 g/L dw CO2 = gmw/22.4 = 44/22.4 = 1.97 g/L

FIGURE 6-15 Major components of a mercury barometer.

Pressure of atmosphere

Evacuated glass tube

Scale calibrated in centimeters and inches

Reservoir of mercury

Physical Principles of Respiratory Care • CHAPTER 6 115

The height of a column of mercury is not a true measure of pressure. Height is a linear measure, whereas pressure repre- sents force per unit area. The pressure exerted by a liquid is directly proportional to its depth (or height) times its density:

Pressure Height Density= ×

At sea level, the average atmospheric pressure supports a column of mercury 76 cm (760 mm) or 29.9 inches in height. If we also know that mercury has a density of 13.6 g/cm3 (0.491 lb/in3), the average atmospheric pressure (PB) is calcu- lated as follows:

cgs units P cm g cm g cmB: .= × =76 13 6 10343 2

fps units P in lb in lb inB: . . .= × =29 9 0 491 14 73 2

These two measures, 1034 g/cm2 and 14.7 lb/in2, are considered standards in the cgs and British fps systems, each being equiva- lent to 1 atm.4-7

Similar to any solid material, a barometer’s housing reacts to temperature changes by expanding and contracting. In addi- tion, the mercury column acts like a large thermometer. Both pressure and temperature affect the mercury level of a barom- eter. For accuracy, the reading must be corrected for tempera- ture changes.

Clinical Pressure Measurements. Mercury is the most common fluid used in pressure measurements both in barom- eters and at the bedside. Because of the high density (13.6 g/ cm3) of mercury, it assumes a height that is easy to read for most pressures in the clinical range. Water columns also can be used to measure pressure (in centimeters of water [cm H2O]) but only low pressures. Because water is 13.6 times less dense than mercury, 1 atm would support a water column 33.9 feet high or about as tall as a two-story building.

Both mercury and water columns are still used in clinical practice, especially when vascular pressures are being measured. However, these traditional tools are rapidly being replaced by mechanical or electronic pressure-measuring devices. Even so, these new instruments must be calibrated against a mercury or water column before making measurements.

The simplest mechanical pressure gauge is the aneroid barometer, which is common in homes. An aneroid barometer consists of a sealed evacuated metal box with a flexible, spring- supported top that responds to external pressure changes (Figure 6-16). This motion activates a geared pointer, which provides a scale reading analogous to pressure.

This same concept underlies the simple mechanical manom- eters used to measure blood or airway pressure at the bedside (Figure 6-17). However, rather than the pressure acting exter- nally on the sealed chamber, the inside is connected to the pressure source. In this manner, the flexible chamber wall expands and contracts as pressure increases or decreases.

A flexible chamber also can be used to measure pressure electronically. These devices are called strain-gauge pressure transducers. In these devices, pressure changes expand and contract a flexible metal diaphragm connected to electrical wires (Figure 6-18). The physical strain on the diaphragm changes the amount of electricity flowing through the wires. By

FIGURE 6-16 Aneroid barometer.

Indicator

Spring

Subatmospheric pressure

Pivot

FIGURE 6-17 Mechanical manometer used to measure a patient’s airway pressure.

RULE OF THUMB

One kilopascal equals approximately 10.2 cm H2O. A pressure of 10 kPa equals approximately 100 cm H2O. Conversely, a pressure of 60 cm H2O equals approximately 6 kPa.

measuring this change in electrical voltage, we are indirectly measuring changes in pressure. Most modern medical devices use small, solid-state, piezoelectric pressure sensors. These devices work on the principle that certain materials generate an electric charge in response to applied mechanical stress.

Although millimeters of mercury and centimeters of water are still the most common pressure units used at the bedside, they do not represent the SI standard. The SI unit of pressure is the kPa; 1 kPa equals approximately 10.2 cm H2O or 7.5 torr. To convert between these pressure units accurately, use the factors provided in the rear inside cover of this book.

116 SECTION I • Foundations of Respiratory Care

the resulting PO2 is 0.21 × 282, or 59 torr, just more than one- third of that available at sea level. Because the PO2 (not its percentage) determines physiologic activity, high altitudes can impair O2 uptake by the lungs. Mountain climbers must some- times use supplemental O2 at high altitudes for this reason. By increasing the amount of O2 more than 0.21, we can raise its partial pressure and increase uptake by the lungs. For a practical application of this principle, see the accompanying Mini Clini.

Partial Pressures (Dalton’s Law) Many gases exist together as mixtures. Air is a good example of a gas mixture, consisting mainly of O2 and N. A gas mixture, similar to a solitary gas, exerts pressure. The pressure exerted by a gas mixture must equal the sum of the kinetic activity of all its component gases. The pressure exerted by a single gas in a mixture is called its partial pressure.

Dalton’s law describes the relationship between the partial pressure and the total pressure in a gas mixture. According to this law, the total pressure of a mixture of gases must equal the sum of the partial pressures of all component gases. The prin- ciple states that the partial pressure of a component gas must be proportional to its percentage in the mixture.8

A gas making up 25% of a mixture would exert 25% of the total pressure. For consistency, the percentage of a gas in a mixture is usually expressed in decimal form, using the term fractional concentration. A gas that is 25% of a mixture has a fractional concentration of 0.25. For example, air consists of approximately 21% O2 and 79% N. To compute the partial pres- sure of each component, simply multiply the fractional concen- tration of each component by the total pressure. Assuming a normal atmospheric pressure of 760 torr, the individual partial pressure is computed as follows:

Partial pressure Fractional concentration Total pressure= × PO torr torr2 0 21 760 160= × =. PN torr torr= × =0 79 760 60.

As predicted by Dalton’s law, the sum of these partial pres- sures equals the total pressure of the gas mixture.

What if the total pressure changed? Barometric pressure changes, in addition to minor fluctuations caused by weather, are mainly a function of altitude. Considering only O2, we know that its fractional concentration, or fractional inspired O2 (FiO2), remains constant at approximately 0.21. At a PB of 760 torr, the PO2 is equal to 0.21 × 760, or 160 torr. At 25,000 feet, the FiO2 of air is still 0.21. However, the PB is only 282 torr, and

FIGURE 6-18 Strain-gauge pressure transducer. A, No pressure is applied. B, Pressure is applied to the transducer. An ammeter shows a change in electrical current proportional to the magnitude of pressure applied.

Wired diaphragm

Pressure chamber

Ammeter

A B

MINI CLINI Why Are Oxygen Masks Needed on Airplanes?

PROBLEM: People who have traveled by air are familiar with the safety instructions given by the crew before flight. Instruc- tions are included on how to use the O masks. When and why are these masks needed?

DISCUSSION: At a typical cruising altitude of 30,000 feet, the PB outside the airplane cabin is approximately 226 torr. The inspired partial pressure of O2 (PiO2) is calculated as follows:

PiO torr torr2 0 21 226 47= × =.

If the cabin were to depressurize, travelers inside would be exposed to this low PiO2. At this PiO2, most people become unconscious within seconds and eventually die of lack of O2 (anoxia).

To overcome this problem, emergency O2 masks are avail- able when the cabin depressurizes. These masks, assuming a tight fit, probably provide approximately 70% O2, or an FiO2 of 0.70. The PiO2 of a person wearing a mask under these conditions is calculated as follows:

PiO torr torr2 0 70 226 158= × =.

This PiO2 (about the same as at sea level) is sufficient to keep the passengers alive until the crew can bring the plane down to a safe altitude.

Physical Principles of Respiratory Care • CHAPTER 6 117

molecules are squeezed closer together. If a gas-filled container could be enlarged, the gas would expand to occupy the new volume. Figure 6-19 illustrates the concepts of gas compression and expansion.

Gas Laws

Several laws help define the relationships among gas pressure, temperature, mass, and volume (Table 6-4). Using these laws,10,11 the behaviors of gases under changing conditions can be pre- dicted. Underlying all these laws are three basic assumptions: (1) No energy is lost during molecular collisions, (2) the volume of the molecules themselves is negligible, and (3) no forces of mutual attraction exist between these molecules. These three assumptions describe the behavior of an “ideal gas.” Under normal conditions, most gases exhibit ideal behavior.

Effect of Water Vapor

In clinical practice, most gas law calculations must take into account the presence of water vapor. Water vapor, similar to any gas, occupies space. The dry volume of a gas at a constant pres- sure and temperature is always smaller than its saturated volume. The opposite is also true. Correcting from the dry state to the saturated state always yields a larger gas volume.

In contrast, high atmospheric pressures increase the partial pressure of inspired O2 (PiO2) in an air mixture. Pressures above atmospheric are called hyperbaric pressures.9 Hyperbaric pres- sures commonly occur only in underwater diving and in special hyperbaric chambers.9 For example, at a depth of 66 feet under the sea, water exerts a pressure of 3 atm, or 2280 mm Hg (3 × 760). At this depth, the O2 in an air mixture breathed by a diver exerts a PO2 of 0.21 × 2280, or approximately 479 mm Hg. This is nearly three times the PO2 at sea level.

The same conditions can be created on dry land in a hyper- baric chamber. Hyperbaric chambers are used for controlled depressurization of deep-sea divers and to treat certain types of diving accidents. Clinically, hyperbaric chambers and O2 are used together to treat various conditions, including carbon monoxide poisoning and gangrene. Chapter 41 provides more details on this use of high-pressure O2.

Solubility of Gases in Liquids (Henry’s Law) Gases can dissolve in liquids. Carbonated water and soda are good examples of a gas (CO2) dissolved in a liquid (water). Henry’s law states that at a constant temperature, the amount of a given gas that dissolves in a given type and volume of liquid is directly proportional to the partial pressure of that gas in equilibrium with that liquid. For O2 dissolved in blood, the equation is

C kPdO O2 2=

where CdO2 is the concentration of O2 of dissolved O2 in the blood at standard temperature and pressure dry conditions (milliliters per deciliter of blood, equivalent to mL/100 mL, also called volume percent), k is the constant of proportionality, or solubility coefficient (for blood k = 0.0031 mL/mm Hg/dL blood at 37° C). Note that this term shows up in the equation for the total O2 content of blood (see Chapter 12). For example, if the PaO2 is 100 mm Hg, the concentration of dissolved O2 is:

C mL dLdO2 0 0031 100 0 3= × =. .

Temperature plays a major role in gas solubility. High tem- peratures decrease solubility, and low temperatures increase solubility. This is why an open can of soda may still fizz if left in the refrigerator but quickly goes flat when left out at room temperature. The effect of temperature on solubility is a result of changes in kinetic activity. As a liquid is warmed, the kinetic activity of any dissolved gas molecules is increased. This increase in kinetic activity increases the escaping tendency of the mol- ecules and partial pressure. As an increasing number of gas molecules escape, the amount left in a solution decreases rapidly. For a practical application of this principle, see the accompanying Mini Clini, which discusses blood gases and patient temperature.

GAS BEHAVIOR UNDER CHANGING CONDITIONS

Gases, with large distances between their molecules, are easily compressed and expanded. When a gas is pressurized, the

MINI CLINI Blood Gases Versus Patient Temperature

PROBLEM: Respiratory therapists (RTs) frequently need to sample and measure the partial pressures of O2 and CO2 in patients’ arterial blood. These samples are called arterial blood gas (ABG) samples. Typically, ABG samples are measured in analyzers kept at a normal body temperature of 37° C. However, not all patients have normal body temperatures. Many are feverish (hyperpyrexia), and some have low body temperatures (hypothermia). What effect does this have on the measurements?

DISCUSSION: The direct relationship between temperature and partial pressure causes higher arterial PO2 and PCO2 read- ings at higher temperatures. At 37° C, the arterial PO2 in a normal adult is approximately 100 torr. However, at 47° C, the PO2 would be nearly twice as high. A smaller increase from 37° to 39° C increases the arterial PO2 less markedly from 100 torr to approximately 110 torr. Likewise, an increase in temperature increases the arterial PCO2. Arterial PCO2 values increase approximately 5% per degree Celsius. An increase in tempera- ture from 37° to 39° C increases the PCO2 by approximately 10%, from 40 torr to 44 torr.

The reverse is also true. Decreased temperatures decrease the arterial partial pressures of O2 and CO2. Correction equa- tions are available to help compute these corrections; however, they correct only for the relationship between temperature and pressure and do not take into account metabolic and cardio- vascular changes that accompany a change in a patient’s tem- perature. For this reason, the use of corrected PO2 and PCO2 readings remains controversial.

118 SECTION I • Foundations of Respiratory Care

FIGURE 6-19 A mass of gas in the resting state exerts a given pressure (P) at a given temperature (T) in cylinder A. In cylinder B, as the piston compresses the gas, the molecules are crowded closer together, and the increased energy of molecular collisions increases both the temperature and the pressure. Conversely, as the gas expands in cylinder C, molecular interaction decreases and the temperature and pressure decrease.

T P T PT P

A B C

TABLE 6-4

Laws Describing Gas Behavior Under Changing Conditions

Gas Law Basic Relationship Constants Description Working Formula* Clinical Applications

Boyle’s law P × V = k Temperature, mass

Volume of a gas varies inversely with its pressure

P1V1 = P2V2 Ventilation (see Chapter 11) Body plethysmography

(see Chapter 19) Compressed volume (see

Chapter 38) Charles’ law V

T k= Pressure, mass

Volume of gas varies directly with changes in its temperature (°K)

V T

= ATPS to BTPS corrections (see this chapter) Gay-Lussac’s

law P T

k= Volume, mass Pressure exerted by a gas varies

directly with its absolute temperature

P T

= Cylinder pressures (see Chapter 38)

Combined gas law

PV = nRT — Interaction of above (none held constant)

P V nT

1 1

2 2

= Complex interactions of variables

*Use the working formulas to calculate the new value of a parameter when a gas undergoes a change in P, V, n, or T. For example, to solve for a new volume (V2) using Boyle’s law, you would simply rearrange its working equation as follows:

V V P P2 1 1 2= ×

n, Mass; P, pressure; R, the gas constant (a combined constant of proportionality); T, temperature (°K); V, volume.

The pressure exerted by water vapor is independent of the other gases with which it mixes, depending only on the tem- perature and RH. The addition of water vapor to a gas mixture always lowers the partial pressures of the other gases present. This fact becomes relevant when discussing the partial pressure of gases in the lung, where the gases are saturated with water vapor at body temperature.

Corrected Pressure Computations To compute the new or corrected partial pressure of a gas after saturation with water vapor, the following formula is applied:

P F P PC gas T H O= × −( )2

PC is the corrected gas pressure, Fgas is the fractional concentra- tion of the gas in the gas mixture, PT is the total gas pressure of

Physical Principles of Respiratory Care • CHAPTER 6 119

In each case, the new volume equals the original volume times the correction factor.

Properties of Gases at Extremes of Temperature and Pressure

Most gases exhibit ideal behavior under normal conditions. However, gases can deviate from these expectations, especially at the extremes of pressure and temperature. The accompany- ing Mini Clini (page 6-19) provides two good clinical examples of how gas behavior can deviate from the ideal.

Weak attractive forces (van der Waals forces) between gas molecules oppose their kinetic activity. Both temperature and pressure affect these forces. At high temperatures, the increased kinetic activity of gas molecules far overshadows these forces. However, at very low temperatures, kinetic activity lessens and these forces become more important. Likewise, very low pres- sures permit gas molecules to move freely about with little mutual attraction. In contrast, high pressures crowd molecules together, increasing the influence of these forces.

The actual space occupied by gas molecules also can influ- ence their behavior. At low pressure, the total mass of matter in a gas is a negligible fraction of the total volume. However, at very high pressures, molecular density becomes important, altering the expected relationship between pressure and volume.

Critical Temperature and Pressure

For every liquid, there is a temperature above which the kinetic activity of its molecules is so great that the attractive forces cannot keep them in a liquid state. This temperature is called the critical temperature. The critical temperature is the highest temperature at which a substance can exist as a liquid. The pressure needed to maintain equilibrium between the liquid and gas phases of a substance at this critical temperature is the critical pressure. Together, the critical temperature and pressure represent the critical point of a substance.

The critical temperature of water is 374° C. At this tempera- ture, a pressure of 218 atm is needed to maintain equilibrium between the liquid and gaseous forms of water. No pressure can return water vapor to its liquid form at a temperature greater than 374° C.

Compared with liquids, gases have much lower critical points. Table 6-5 lists the critical points of four gases used in clinical practice: O2, helium, CO2, and nitrous oxide. The critical temperatures of O2 and He are well below the normal room temperature of 20° C (68° F).

the mixture, and PH O2 is the water vapor pressure at the given temperature (see Table 6-3). If only a single gas is present, Fgas equals 1, and the formula can be simplified:

P P PC T H O= −( )2

Correction Factors Correction factors can be used to convert gas volumes from one set of conditions to another. Such computations are common in pulmonary function laboratories. But they are also common to mechanical ventilators. For example, suppose you set a tidal volume on a ventilator to 500 mL. If the ventilator’s output control valve metered out 500 mL, and if the gas was heated and humidified to body conditions (fully saturated at 37° C), then the gas volume would increase because of the heat and addition of water vapor. But how much would it increase? To find out, we need to use conversion equations. As it turns out, the volume increases to 562 (assuming ambient barometric pressure of 760 mm Hg) which is a significant increase of 12%. The current standard of care for mechanical ventilation places emphasis on accurately dosing tidal volume to approximately 6 mL/kg. To maintain the desired accuracy, most intensive care unit ventila- tor manufacturers correct the set tidal volume to convert from ambient temperature and pressure dry conditions (ATPD) to body temperature and pressure saturated conditions (BTPS), which in this case would mean decreasing the volume exiting the control valves by 62 mL. Such conversions are important for research when evaluating the performance of mechanical ven- tilators in terms of volume delivery accuracy. In that case, the experiment generally involves measuring gas at (ATPD) and then converting to BTPS to make a fair comparison to the ven- tilator’s display (which is corrected to BTPS).

In gas volume conversions, the four most common compu- tations are as follows (PB in millimeters of mercury and tem- perature in °C): 1. Correction from ambient temperature and pressure dry

(ATPD) to body temperature and pressure saturated (BTPS), as is done in some mechanical ventilators.

Correction factor P

P T B

= −

× +47

310

273

2. Correction from ambient temperature and pressure satu- rated (ATPS) to body temperature and pressure saturated (BTPS).

Correction factor P P

P T B H O

= − −

× +

310

273

3. Correction from ATPS to standard temperature and pressure dry, STPD (0° C and 760 torr)

Correction factor P P

T B H O=

− ×

+ 2

760

273

4. Correction from STPD to BTPS:

Correction factor P TB

= −

× +

760

310

273

TABLE 6-5

Critical Points of Three Gases

Gas °C °F Atmosphere

Helium (He) −267.9 −450.2 2.3 Oxygen (O2) −118.8 −181.1 49.7 Carbon dioxide (CO2) 31.1 87.9 73.0 Nitrous oxide (N2O) 36.5 97.7 71.8

120 SECTION I • Foundations of Respiratory Care

According to these principles, any gas with a critical tem- perature above ambient should be able to be liquefied simply by having pressure applied. Both CO2 and N2O have critical temperatures above normal room temperature (see Table 6-5). Both gases can be liquefied by simple compression and stored as liquids at room temperature without cooling. However, both liquefied gases still need to be stored under pressure, usually in strong metal cylinders.

Liquid O2 is produced by separating it from a liquefied air mixture at a temperature below its boiling point (−183° C or −297° F). After it is separated from air, the O2 must be main- tained as a liquid by being stored in insulated containers below its boiling point. As long as the temperature does not exceed −183° C, the O2 remains liquid at atmospheric pressure. If higher temperatures are needed, higher pressures must be used. If at any time the liquid O2 exceeds its critical temperature of −118.8° C, it converts immediately to a gas.

FLUID DYNAMICS

So far, liquids and gases have been presented under static, or nonmoving, conditions. However, both liquids and gases can flow. Flow is the bulk movement of a substance through space. The study of fluids in motion is called hydrodynamics. Because many respiratory care devices use hydrodynamic principles, the RT must have a good understanding of the basic concepts gov- erning fluids in motion.

Pressures in Flowing Fluids

As we have seen, the pressure of a static liquid depends solely on the depth and density of the fluid. In contrast, the pressure exerted by a liquid in motion depends on the nature of the flow itself. As shown in Figure 6-20, A, the pressure exerted by a static fluid is the same at all points along a horizontal tube, depending only on the height (h) of the liquid column. However, when the fluid flows out through the bottom tube, the pressure progres- sively decreases all along the tube length (see Figure 6-20, B). In addition, the decrease in pressure between each of the equally spaced vertical tubes is the same.

The decrease in fluid pressure along the tube reflects a cumulative energy loss, as predicted by the second law of thermodynamics.4 Available energy decreases because fric- tional forces (flow resistance) oppose fluid flow. Frictional resistance to flow exists both within the fluid itself (viscosity) and between the fluid and the tube wall. Generally, the greater the viscosity of the fluid and the smaller the cross-sectional area of the tube, the greater is the decrease in pressure along the tube.

For any given tube length, flow resistance is defined as the constant of proportionality for an assumed linear relation between the pressure difference between the two points along the tube and the flow. The constant of proportionality (R) is simply the slope of the straight line relation:

R P P

V =

−∆ ∆

( )1 2 �

MINI CLINI Variations from Ideal Gas Behavior: Expansion Cooling and Adiabatic Compression

Boyle’s law describes gas behavior under constant temperature, or isothermal conditions.10 During isothermal conditions, the temperature of an ideal gas should not change with either expansion or contraction. For example, if an ideal gas were to escape rapidly from a high-pressure cylinder into the atmo- sphere, its temperature should not change. The rapid expan- sion of real gases causes substantial cooling. This phenomenon of expansion cooling is called the Joule-Thompson effect.

A rapidly expanding gas cools because the attractive force between its molecules is broken. Because the energy needed to break these forces must come from the gas itself, the tempera- ture of the gas must decrease. This decrease in temperature, depending on the pressure drop that occurs, can be large enough to liquefy the gas. This is the primary method used to liquefy air for the production of O2.

Isothermal processes keep gas temperature constant. The internal energy will remain constant. In an adiabatic process, the container is insulated, resulting in no heat transfer into or out from the system. If the volume increases, the internal energy decreases to perform the work and thus the temperature decreases. If the volume is increased the internal energy is also increased, resulting in a higher temperature. Adiabatic pro- cesses are used in liquefying gases.

Lung simulators are often constructed from rigid-walled containers such that the compressibility of the gas in the con- tainer represents the compliance of the lungs (particularly useful for neonatal lung simulators). Such containers are often filled with very fine strands of copper (called copper wool) to absorb the heat generated when the gas is compressed, approxi- mating isothermal conditions. However, this is not essential and adiabatic conditions can be assumed instead. The volume of the container (V in liters) required to simulate a given com- pliance (C in cm H2O/L) is given by the equations:

V P C isothermanalB I= × ×1 35. ( ) V P C adiabaticB A= × ×1 9. ( )

The derivation of these equations is described elsewhere.12

The concept of critical temperature can be applied to distin- guish between a true gas and a vapor. A true gas, such as O2, has a critical temperature so low that at room temperature and pressure it cannot exist as a liquid. In contrast, a vapor is the gaseous state of a substance coexisting with its liquid or solid state at room temperature and pressure. This is why molecular water is referred to as water vapor.

The concept of critical temperature and pressure also helps explain how gases are liquefied. A gas can be liquefied by being cooled to below its boiling point. Alternatively, a gas can be liquefied by being cooled to less than its critical temperature and then being compressed. The more a gas is cooled below its critical temperature, the less pressure will be needed to liquefy it. However, under no circumstances can pressure alone liquefy a gas existing above its critical temperature.

Physical Principles of Respiratory Care • CHAPTER 6 121

of flow through tubes: laminar, turbulent, and transitional (Figure 6-21).

Laminar Flow As discussed earlier, during laminar flow, a fluid moves in dis- crete cylindrical layers or streamlines (see Figure 6-6). The dif- ference in pressure required to produce a given flow, under conditions of laminar flow through a smooth tube of fixed size, is defined by Poiseuille’s law12:

P P nLV

r 1 2 4

8 − =

�

where P1 is the pressure (dyne/cm 2; equal to 0.001 cm H2O) at

the upstream point (point 1), P2 is the pressure at the down- stream point (point 2), n is viscosity (dyne • sec/cm2, called poise), L is length (cm), r is radius (cm) and �V is the flow (cm3/ min = mL/min). The viscosity of air is approximately 1.9 × 10−4 poises; for water it is approximately 8.90 × 10−3 poises. A pres- sure of 1 cm H2O is about 980 dyne/cm

2. Occasionally flow resistance is expressed in terms of the Poi-

seuille equation as:

R V

r = =

∆P �

8 4π

which indicates that resistance is very sensitive to changes in tube radius (e.g., doubling the tube radius decreases the resis- tance by a factor or 24 = 8). Another way to view this is that increasing the tube radius by 19% will increase the flow by 100% (i.e., double the flow; 1.194 = 2.0).

Turbulent Flow Under certain conditions, the pattern of flow through a tube changes significantly, with a loss of regular streamlines. Instead, fluid molecules form irregular eddy currents in a chaotic pattern called turbulent flow (see Figure 6-21). This changeover from

where R is resistance (cm H2O/L/sec, the most common units in pulmonary physiology), P1 is the pressure (cm H2O) at the upstream point (point 1), P2 is the pressure at the downstream point (point 2), and �V is the flow (L/sec). This equation has wide application in pulmonary physiology and respiratory care. The accompanying Mini Clini provides a good example of such application.

FIGURE 6-21 Three patterns of flow—laminar, turbulent, and transitional. (Modified from Moser KM, Spragg RG: Respiratory emergencies, ed 2, St Louis, 1982, Mosby.)

Laminar flow

Turbulent flow

Transitional flow

P = K1 × V .

P = K1 × V 2

P = K1V + K2V 2

. .

MINI CLINI Differential Pressure Pneumotachometer

PROBLEM: It is often necessary to measure and record changes in airflow as a patient breathes. How can we apply the formula for resistance to measure and record airflow?

DISCUSSION: Airflow can be measured using a device called a pneumotachometer. One of the simplest designs is the dif- ferential pressure pneumotachometer. A differential pressure pneumotachometer incorporates a flow tube with a known and constant resistance. If the formula for resistance is rearranged to solve for flow, it appears as follows:

∆ ∆�V k P P= × −( )1 1

FIGURE 6-20 A, The pressure is the same at all points along the horizontal tube when there is no flow. B, A progressive decrease in pressure occurs as the fluid flows. (Modified from Nave CR, Nave BC: Physics for the health sciences, ed 3, Philadelphia, 1985, WB Saunders.)

Patterns of Flow

The pressure difference that results from flow also varies with the pattern of flow. There are three primary patterns

122 SECTION I • Foundations of Respiratory Care

is transitional, the total driving pressure equals the sum of the pressures resulting from laminar and turbulent flow:

P P k V k V1 2 1 2 2− = × + ×( ) ( )� �

where k1 and k2 are factors indicating the respective contribu- tion of laminar and turbulent flow to overall driving pressure. When flow is mainly laminar, the pressure varies linearly with the flow. When flow is mainly turbulent, driving pressure varies exponentially with the flow. With all else equal, pressures generated during laminar flow are most affected by fluid vis- cosity, whereas fluid density is the key factor when flow is turbulent.

Flow, Velocity, and Cross-Sectional Area

Clinically, the most common units of measurement describing flow are liters per minute (L/min) or liters per second (L/sec). In contrast, velocity is a measure of linear distance traveled by the fluid per unit of time. Centimeters per second (cm/sec) is a common velocity unit used in pulmonary physiology.

Although fluid flow and velocity are different measures, the two concepts are closely related. The key factor relating velocity to flow is the cross-sectional area of the conducting system. Figure 6-23 shows this relationship.

Throughout the tube, the fluid flows at a constant rate of 5 L/min. At point A, with a cross-sectional area of 5.08 cm2, the velocity of the fluid is 16.4 cm/sec. At point B, the cross-sectional area of the tube decreases to 2.54 cm2, half its prior value. At this point, the velocity of the fluid doubles to 32.8 cm/sec. At point C, the passage divides into eight smaller tubes. Although each tube is smaller than its “parent,” together they provide a

laminar to turbulent flow depends on several factors, including fluid density (d), viscosity (n), linear velocity (v), and tube radius (r). In combination, these factors determine Reynold’s number (Re).

Re = ρ

µ vdh

where ρ is the density of the fluid (kg/m3), v is the velocity of the fluid (m/sec), dh is the diameter of the tube (m), and µ is the dynamic viscosity of the fluid [kg/(m • sec)]. Flow is con- sidered to be laminar when Re is less than 2000, transient when it is between 2000 and 3000, and turbulent when it is above 3000. The equation shows that conditions favoring turbulent flow include increased fluid velocity, increased fluid density, increased tube diameter, and decreased fluid viscosity. In the presence of irregular tube walls, turbulent flow can occur when Re is less than 2000.

Flow through a tube with constant resistance is directly pro- portional to the pressure difference (P1 − P2) across the tube. By measuring this pressure difference we can measure flow. To ensure linearity between pressure and flow, the pneumotach- ometer is usually designed so that the flow pattern through the tube remains laminar, which simplifies calibration and use by having only one constant value for k.13 The pneumotachometer is calibrated by measuring (P1 − P2) at different flows, plotting flow on the vertical axis and (P1 − P2) on the horizontal axis. Then, using linear regression, the calibration factor k is derived (this is essentially drawing a straight line through the data points and calculating the slope). When using the pneumota- chometer, the pressure difference is multiplied by k to get the flow. This technique is at the heart of many pulmonary function laboratory procedures and is also used by some mechanical ventilators that have flow sensors at the airway opening portion of the patient circuit.

When flow becomes turbulent, Poiseuille’s law no longer applies. Instead, the pressure difference across a tube is defined as follows:

P P fLV

r 1 2

2 54 − =

�

where ΔP is the driving pressure, f is a friction factor based on the density and viscosity of the fluid and the tube wall rough- ness, L is the tube length, and �V is the fluid flow.

Figure 6-22 compares the relationship between pressure and flow under laminar and turbulent conditions. As can be seen, when flow is laminar (Poiseuille’s law), the relationship between driving pressure and flow is linear. However, when flow becomes turbulent, driving pressure varies with the square of the flow ( �V2). To double flow under laminar conditions, it is necessary to only double the driving pressure. To double flow under tur- bulent conditions, the driving pressure would be increased fourfold.

Transitional Flow Transitional flow is a mixture of laminar and turbulent flow. Flow in the respiratory tract is mainly transitional. When flow

FIGURE 6-22 Relationship between driving pressure and flow under laminar and turbulent conditions.

P re

ss ur

Flow

Laminar flow Turbulent flow

Physical Principles of Respiratory Care • CHAPTER 6 123

point with a certain velocity (va) and a lateral pressure (Pa). According to the law of continuity, as the fluid moves into the narrow or constricted portion of the tube, its velocity must increase (vb > va). According to the Bernoulli theorem, the higher velocity at point b should result in a lower lateral pres- sure at that point (Pb < Pa). As a fluid flows through the constric- tion, its velocity increases and its lateral pressure decreases.

This equation also helps demonstrate how heliox therapy works. The equation implies that the lower the density, the higher is the velocity (and hence flow) for the same inspiratory effort (driving pressure) or the lower is the pressure for the same velocity—either way that is a good effect for someone struggling to breathe.

Fluid Entrainment

Jet entrainment is the design principle used in simple O2 masks with variable FiO2 settings, although they are often mistakenly called Venturi masks. In this case, a pressurized gas, usually O2, serves as the primary flow source. This pressurized gas passes through a nozzle or jet, beyond which is an air entrainment port (Figure 6-25, A). In this case, air entrainment occurs as a con- sequence of fluid viscosity. The viscous shearing force that exists between moving and static layers of gas causes the nonmoving gas (room air) to be dragged into the moving stream of O2.

14 The amount of air entrained depends on both the diameter of the jet orifice and the size of the air entrainment ports. For a fixed jet size, the larger the entrainment ports, the greater is the volume of air entrained, the higher is the total flow, and the lower is the FiO2 (see Figure 6-25, B). The entrained volume can still be altered, with fixed entrainment ports, by changing the jet diameter (see Figure 6-25, C). A large jet results in a lower gas velocity and less entrainment, whereas a small jet boosts velocity, entrained volume, and total flow.

Fluidics and the Coanda Effect

Fluidics is a branch of engineering that applies hydrodynamic principles in flow circuits for purposes such as switching, pres- sure and flow sensing, and amplification. Because fluidic devices have no moving parts, they are very dependable and require little maintenance.

The primary principle underlying most fluidic circuitry is a phenomenon called wall attachment, or the Coanda effect. This

10-fold increase in the cross-sectional area available for flow compared with point B. The velocity of the fluid decreases pro- portionately, from 32.8 cm/sec to 3.28 cm/sec.

These observations show that the velocity of a fluid moving through a tube at a constant flow varies inversely with the avail- able cross-sectional area. This relationship is called the law of continuity. Mathematically, the equation is as follows:

( ) ( ) ( )A v A v A v kn n1 1 2 2× + × + × =

where A is the cross-sectional area of the tube; v is the velocity of the fluid; 1, 2, and n are different points in the tube; and k is a constant value.

Although the principle holds true only for incompressible liquids, the qualitative features are similar for gas flow. This principle also underlies the application of nozzles or jets in fluid streams. Nozzles and jets are simply narrow passages in a tube designed to increase fluid velocity. A garden-hose nozzle is a good example of this principle in action. Clinically, jets are used in many types of respiratory care equipment, including pneu- matic nebulizers (see Chapter 39) and gas entrainment or mixing devices (see Chapter 41).

Bernoulli Principle

In a steady flow, the sum of all forms of energy in a fluid is the same at all points along the path of flow. Consequently, the sum of kinetic energy, potential energy, and internal energy remains constant. The Bernoulli principle states that an increase in the velocity of the fluid results in a decrease in the sum of its static pressure, potential energy, and internal energy.11 The Bernoulli equation is:

p v gy constant+ + = 1

2 2ρ ρ

where p = pressure at some point in a tube, ρ = fluid density, v = fluid velocity, g = acceleration due to gravity, and y = eleva- tion of the pressure point above a reference plane. Figure 6-24 shows this relationship. Fluid is flowing through a tube at a

FIGURE 6-23 Fluid velocity, at a constant flow, varies inversely with the cross-sectional area of the tube. (Modified from Nave CR, Nave BC: Physics for the health sciences, ed 3, Philadelphia, 1985, WB Saunders.)

Volume flow rate = 5 L/min

A B C

Area = 5.08 cm2

Velocity = 16.4 cm/sec A = 25.54 cm2

v = 32.8 cm/sec A = 25.4 cm2

v = 3.28 cm/sec

FIGURE 6-24 According to the Bernoulli theorem, lateral pressure of a flowing fluid must vary inversely with its velocity. �Va, flow in tube “a”; va, velocity in tube “a”; vb, velocity in tube “b”; �Vb, flow in tube “b”; Pa, lateral wall pressure in tube “a”; Pb, lateral wall pressure after restriction (see text).

Va va vb •

PbPa

•

124 SECTION I • Foundations of Respiratory Care

FIGURE 6-25 Air injector. A, Basic design. B, Greater entrainment and total flow occurs with larger entrainment ports. C, Alternatively, a smaller jet increases source gas velocity and entrains more air.

Jet

Entrainment port

Larger ports

Smaller jet

Increased flow

FIGURE 6-26 Coanda wall effect. A, Entrainment into the fluid stream. B, Wall attachment initiated by negative pressure near wall.

Entrained air, lowered pressure

Ambient pressure

Negative pressure region A B

SUMMARY CHECKLIST

◗ Gases have no inherent boundary, are readily compressed and expanded, and can flow.

◗ Three temperature scales are in common use: Kelvin (SI), Celsius (cgs), and Fahrenheit (fps); conversion among these scale units can be done by using simple formulas.

◗ Transfer of heat energy can occur by conduction, convection, radiation, and evaporation.

◗ Liquids exert pressure and exhibit the properties of flow, buoyant force, viscosity, capillary action, and surface tension.

◗ The pressure exerted by a liquid depends on both its height (depth) and weight density.

◗ Surface tension forces increase the pressure inside a liquid drop or bubble; this pressure varies directly with the surface tension of the liquid and varies inversely with the radius.

◗ A liquid can vaporize by either boiling or evaporation; in evaporation, the required heat energy is taken from the air surrounding the liquid, cooling the air.

◗ Vaporization causing cooling and condensation causes warming of the surroundings.

◗ The capacity of air to hold water vapor increases with temperature.

◗ Relative humidity (RH) is the ratio of water vapor content (absolute humidity) to saturated water vapor capacity; for a constant content, cooling increases RH and warming decreases RH.

◗ The rate of diffusion of a gas is inversely proportional to its molecular weight.

◗ The total pressure of a mixture of gases must equal the sum of the partial pressures of all component gases.

◗ The volume of a gas that dissolves in a liquid equals its solubility coefficient times its partial pressure; high temperatures decrease gas solubility, and low temperatures increase gas solubility.

◗ Volume and pressure of a gas vary directly with temperature; however, with constant temperature, gas volume and pressure vary inversely.

◗ The critical temperature of a substance is the highest temperature at which it can exist as a liquid; gases with critical temperatures higher than room temperature can be stored under pressure as liquids without cooling.

◗ Under conditions of laminar flow, the difference in pressure required to produce a given flow is defined by Poiseuille’s law.

effect is observed mainly when a fluid flows through a small orifice with properly contoured downstream surfaces.15 We know that a jet or nozzle entrains any surrounding fluid, such as air, into the primary flow stream (Figure 6-26, A). If a care- fully contoured curved wall is added to one side of the jet (see Figure 6-26, B), the pressure near the wall becomes negative relative to atmospheric pressure. The atmospheric pressure on the other side of the gas stream pushes it against the wall, where it remains “locked” until interrupted by some counterforce. By carefully extending the wall contour, we can deflect the fluid stream through a full 180-degree turn.

Various fluidic devices can be designed using this principle, including on/off switches, pressure and flow sensors, and flow amplifiers. These individual components can be combined into integrated fluidic logic circuits, which function much like electronic circuit boards but without the need for electrical power.

Physical Principles of Respiratory Care • CHAPTER 6 125

8. National Aeronautics and Space Administration (NASA) Animated Gas Lab: http://www.grc.nasa.gov/WWW/K-12/airplane/Animation/frglab .html. Accessed February 2011.

9. Thom SR: Hyperbaric oxygen: its mechanisms and efficacy. Plast Reconstr Surg 127:131S–141S, 2011.

10. West JB: Robert Boyle’s landmark book of 1660 with the first experiments on rarified air. J Appl Physiol 98:31–39, 2004.

11. Eastlake CN: An aerodynamicist’s view of lift, Bernoulli, and Newton. Phys Teach 40:166–176, 2002.

12. Chatburn RL, Craig KC: Fundamentals of respiratory care research, Norwalk, CT, 1988, Appleton & Lange, pp 91–97.

13. Comroe JH, Forster RE, DuBoise AB, et al: The lung, Chicago, 1977, Year Book Medical, pp 360–361.

14. Scacci R: Air entrainment masks: jet mixing is how they work—the Ber- noulli and Venturi principles are how they don’t. Respir Care 24:928–931, 1977.

15. Ginghina C: The Coanda effect in cardiology. J Cardiovasc Med 8:411–413, 2007.

References

1. McNaught AD, Wilkinson A: Compendium of chemical terminology, IUPAC Gold Book, Oxford, 2010, Blackwell Scientific.

2. Debenedetti PG, Stillinger FH: Supercooled liquids and the glass transition. Nature 410:259–267, 2001.

3. Ojovan MI: Configurons: thermodynamic parameters and symmetry changes at glass transition. Entropy 10:334–364, 2008.

4. Leland TW, Jr: Basic principles of classical and statistical thermodynamics. https://www.uic.edu/labs/trl/1.OnlineMaterials/BasicPrinciplesByTWLe land.pdf. Accessed September 1, 2014.

5. International System of Units (SI), Bureau International des Poids et Mesures (BIPM); 2006.

6. Cohen ER, Cvitas T, Frey JG, et al: Quantities, units and symbols in physical chemistry, IUPAC Green Book, ed 3, Cambridge, 2008, IUPAC & RSC.

7. Mohr PJ, Taylor BN, Newell DB: CODATA recommended values of the fundamental physical constants. Rev Mod Phys 84:1527–1605, 2012.

https://www.uic.edu/labs/trl/1.OnlineMaterials/BasicPrinciplesByTWLeland.pdf

http://www.grc.nasa.gov/WWW/K-12/airplane/Animation/frglab.html

126

C H A P T E R 7

E-Medicine in Respiratory Care

NARCISO E. RODRIGUEZ, ALBERT J. HEUER, AND MADHU SASIDHAR

CHAPTER OBJECTIVES

After reading this chapter you will be able to: ◆ Define electronic health records and their major uses in respiratory care. ◆ State the differences between the electronic health records and the electronic medical record. ◆ Identify the value of E-medicine applications in informatics and clinical decision support. ◆ Describe E-medicine applications in clinical care and management. ◆ Evaluate the trustworthiness and accuracy of health information sources. ◆ Describe major uses of E-medicine applications in health care administration. ◆ Outline steps to maintain security and confidentiality of electronic health records. ◆ Describe major E-medicine applications in respiratory care education and training.

CHAPTER OUTLINE

The Electronic Health Record and the Electronic Medical Record Computerized Physician Order Entry Enterprise Software Packages

Applications in Patient Care Applications in Diagnostics Applications in Treatment Applications in Disease Prevention

Informatics and Clinical Decision Support Business Intelligence Clinical Decision Support American Association for Respiratory Care

Benchmarking System Telemedicine and Telemonitoring Sources of Health Information

Health Information Sources for Respiratory Therapists and Other Clinicians

Health Information Sources for Consumers

Applications in Health Care Administration Documentation, Workload, Staffing, and Scheduling Financial Management Quality Assurance Regulatory Compliance Web Analytics Human Resources Privacy and Confidentiality

Application in Training and Education Clinical Simulations Full-Scale Physiologic Clinical Simulators Clinical Education Applications National Board for Respiratory Care Credentialing Learning Management Systems

Future of E-Medicine

KEY TERMS

benchmarking business intelligence clinical decision support clinical simulation computerized physician order entry continuing respiratory care

education continuous quality improvement electronic health record

electronic medical record enterprise software packages E-medicine health informatics Health Information Technology for

Economic and Clinical Health Act

information retrieval key performance indicators

learning management systems picture archiving and

communication systems point-of-care testing root-cause analysis telemedicine telemonitoring value-based purchasing

E-Medicine in Respiratory Care • CHAPTER 7 127

EHRs are more than a repository for medical records and patient-related information. EHRs are also a rich source of information that can be used in a variety of applications, including quality improvement and regulatory compliance, as detailed later in this chapter. EHRs also can serve as a vital source of data for conducting research, as discussed in Chapter 7 of this text.

Computerized Physician Order Entry

A subset of EHRs is the computerized physician order entry (CPOE) system. Through CPOEs, orders can be electronically transmitted to the EHR, saving time and reducing transcription errors resulting from handwriting clarity issues. Built in stop- gaps and prescribing templates alert physicians about potential dosing problems and drug interaction concerns. The interfacing of CPOE systems with other hospital computer systems also alerts RTs and other clinicians of new, expired, or changed orders. Thus the CPOE has helped facilitate patient care and reduce medical errors.4 All of these factors combined make both EHR and CPOE systems value-added features for health care organizations, clinicians, and patients alike. Indeed, EHRs and other computerized applications are helping transform medi- cine and enhancing both efficiency and effectiveness in essen- tially all aspects of health care and respiratory care.5

Enterprise Software Packages

An issue that had plagued health care organizations and our health care system involves the use of separate software pack- ages for individual organizational functions, including but not limited to EHRs. In the past, the need for one such system to interface or “talk” to another was dealt with on an as-needed basis through ad-hoc software “patches.” Over time these sepa- rate software packages, which were originally designed to stand alone or provide a specific or limited number of functions, became inefficient and much less able to meet the increasingly sophisticated and numerous requirements of health care orga- nizations, including hospitals and departments within them. At about the same time that this problem was reaching critical proportions, the U.S. government (as part of a larger legislative initiative) passed the Health Information Technology for Eco- nomic and Clinical Health Act, or the HITECH Act, as part of a national strategy for building a national health information infrastructure (Figure 7-1). Among other things, HITECH began providing incentives to hospitals, physicians, and other

E -Medicine is the term that relates to the use of comput-erized or digital technology to enhance efficiency and effectiveness of health care in general and more specifi- cally in patient care. E-Medicine was initially used to describe the use of basic computer applications in clinical care, record- keeping, and health education. However, because of significant and wide-spread technologic advancements, the term E-medicine now refers to a wide array of hardware and software applica- tions used in essentially every facet of health care. As a vital part of the patient care team, respiratory therapists (RTs) need to have an understanding of, and be proficient in, many aspects of E-medicine. This chapter describes digital applications related to electronic health records, direct clinical care, disease manage- ment, health care administration, health information sources, and training and education.

THE ELECTRONIC HEALTH RECORD AND THE ELECTRONIC MEDICAL RECORD

A transformation has taken place in the recent past whereby medical records formerly maintained primarily in paper form are now almost exclusively computerized and are maintained as part of the patient’s electronic health record (EHR). A closely related but different term is the electronic medical record (EMR), which represents the computerized record produced every time the patient (or consumer) uses health services. The EHR is the sum of all EMRs produced by a patient during the different encounters with various health care entities through- out a lifetime. Unlike the EHR, which is owned by the patient, the EMR (the “chart”) is owned by the hospital or health care delivery organization.1 The terms EHR and EMR are so closely related that for simplicity we will use the term EHR to describe both concepts for the rest of this chapter.

Nonclinical information is also now electronic, such as patient demographics (e.g., age, gender, religion) and health insurance, as well as clinical information, including the patient’s history and physical examination information, progress notes, physician orders, laboratory and other testing results, vital signs trending, and other information formerly found only in the hard-copy chart. This information is now readily available to authorized clinicians via secured personal computers and mobile devices. In addition to being able to access existing medical information, new records can be more readily entered making most EHRs more current than paper records. Medical imaging and laboratory tests generally become a part of the EHR immediately as the results are finalized. The net impact of these factors is that the EHR has helped make disease diagnosis quicker and more accurate by facilitating the efficient access of medical records.2,3 EHRs are also proving to be a significant asset in the realm of patient treatment. When coupled with other computerized tools such as clinical decision support applications, EHRs have enhanced treatment and disease man- agement, as discussed in more detail later. The core functions of EHRs are shown in Box 7-1.

Box 7-1 Core Functions of Electronic Health Records

• Medical records • Results reporting • Computerized physician order entry • Clinical decision support • Electronic communication • Channels between health care providers and patients • Patient-entered data

128 SECTION I • Foundations of Respiratory Care

health service providers who demonstrated that they are mean- ingfully using their EHRs by meeting predefined standards for a number of objectives. These objectives relate to the submis- sion of patient data to authorized third-party surveillance reg- istries, making clinical data more easily available to patients via secure Internet sources, including vital sign changes and office visit summaries, as well as interfacing multiple functions together, such as EHRs with CPOE.6-8

To address these issues, hospitals and other health care pro- viders often now use a single comprehensive software system or enterprise software package designed to provide integrated functionality to enhance both efficiency and effectiveness, as well as comply with the HITECH Act. A variety of such software packages are available to health care organizations (Table 7-1). These include McKesson, Cerner, Epic, Meditech, Siemens, which are major vendors of integrated software for health care organizations.7 In addition to serving as a secure repository for EHRs, these software packages provide integrated function- ality for the use of EHR data for a multitude of purposes. Some purposes are for data input, such as what occurs when a

FIGURE 7-1 Electronic health records: dimensions of the national health information structure. (From U.S. Department of Health and Human Services. Information for health: a strategy for building the national health information infrastructure. http://aspe.hhs.gov/sp/NHII/ Documents/NHIIReport2001/default.htm. Accessed September 25, 2006.)

Provider notes

Health care provider dimension

Clinical orders

Practice guidelines

Decision-support programs

Vital statistics

Population health risks

Communicable diseases

Socioeconomic conditions

Registries

De-identified information

Mandatory reporting

Community directories

Public health services

Survey data

Patient ID

Health industry

Health insurance

Consent forms

Medication alerts

Personal health dimension

Nonshared personal information

Self-care trackers

Audit logs

Personal library

Inspection reports

Public education

materials

Neighborhood

environmental hazards

Population health dimension

Infrastructure data

Planning and policy documents

Surveillance systems

Health disparities data

TABLE 7-1

Top Vendors of Enterprise Electronic Health Record Systems (February 2010 to February 2011)

Vendor Location Website

Cerner Kansas City, MO http://www.cerner.com CPSI Mobile, AL http://www.cpsinet.com Eclipsys Atlanta, GA http://www.allscripts.com Epic Systems Verona, WI http://www.epic.com Healthcare

Management Systems

Nashville, TN http://www.hmstn.com

Healthland Minneapolis, MN http://www.healthland.com McKesson

Provider Technologies

Alpharetta, GA http://www.mckesson.com

Meditech Westwood, MA http://www.meditech.com Siemens

Healthcare Malvern, PA http://www.medical.siemens

.com

Modified from Top vendors of enterprise EMR systems. Modern Healthc 41:35, 2011.

http://aspe.hhs.gov/sp/NHII/Documents/NHIIReport2001/default.htm

http://www.cerner.com

http://www.cpsinet.com

http://www.allscripts.com

http://www.epic.com

http://www.hmstn.com

http://www.healthland.com

http://www.mckesson.com

http://www.meditech.com

http://www.medical.siemens.com

E-Medicine in Respiratory Care • CHAPTER 7 129

blood gas results immediately available at the point of care and alert the clinician of critical results. Additionally, this interfac- ing enables the storage, retrieval, billing, and quality assurance of the blood gas analyzer data.

Point-of-care testing (POCT) refers to blood gas analysis performed at or near the site of a patient, in a setting that is different from a normal hospital clinical laboratory. POCT testing reduces the time required to produce blood gas test results (turnaround time) and thus improves clinical care and decision making for the clinician. POCT applications integrate seamlessly with the EHR allowing for immediate reporting of results and flagging of critical values. POCT applications can be used in a variety of clinical settings, including the operating room, critical care unit, emergency department (ED), maternity unit, and outpatient clinic.9

Medical Imaging and Picture Archiving and Communication Systems Chest imaging (see Chapter 21), is critical in the practice of pulmonary and critical care medicine. Likewise, remote access of a patient’s imaging studies has become an important element in the delivery of care. Clinical integration of all these imaging modalities with the EHR is essential for the RT and other clini- cians to help in the diagnosis of the pulmonary patient and to improve patient care and safety. A picture archiving and com- munication system (PACS) is an application that allows for imaging storage, portability, communication, and clinical inte- gration of all imaging modalities with the EHR.10 Technologic advances in E-medicine and computer applications have allowed for PACS enterprise systems to flourish. In addition to the advantages mentioned earlier, current PACS applications have enhanced medical treatment and research by providing a variety of digital tools for the manipulation and interpretation of radiologic images, including three-dimensional imaging and three-dimensional printing technology.

Pulmonary Function Testing and Interpretation Essentially all of the older volume displacement and spirograph pulmonary function test (PFT) systems have been replaced by those that use computer interfaces to measure and interpret the results. Similarly, most hospitals interface their PFT systems with the EHR, which allows clinicians to access reports and graphics from multiple workstations and remote devices.

Interpretation of Pulmonary Function Tests Computer algorithms use standard reference predicted values to aid in the interpretation of PFTs, including spirometry, lung volume, diffusing capacity, and bronchodilator response. The algorithms compare the patterns of the patient’s measured values with reference values based on age, height, gender, and race. The computer classifies the patterns of the patient’s mea- sured values as either normal or abnormal with degrees of severity. However, qualified interpreters must consider the effect of patient effort and other factors on the computer-assisted interpretation of PFTs.

physician enters an order into a CPOE or an RT documents therapy given. Other purposes are for the retrieval, review, and interpretation of existing records, such as those used to provide direct patient care, or for nondirect care functions, such as billing, process improvement, regulatory reporting, or other similar functions discussed later in this chapter.4 In addition, enterprise software systems that interface the EHRs with func- tions relevant to respiratory care and other clinical departments are almost universally in use.

APPLICATIONS IN PATIENT CARE

Applications in Diagnostics

Because the EHR contains an abundance of important clinical information, the RT needs to be able to promptly access and interpret key elements of it to assist the patient care team in accurately diagnosing the patient’s condition. This may involve hemodynamic monitoring, blood gas and point-of-care testing, medical imaging applications, and pulmonary function testing (PFT), among others.

Hemodynamic Monitoring In hemodynamic monitoring computers calculate cardiac output (CO), monitor intravascular fluid volume, and provide cardiac parameters and indices using both invasive and nonin- vasive applications. However, invasive methods using a pulmo- nary artery catheter (see Chapter 51) have a multitude of complications, including the risk for infection and death.

As a result, the rapid evolution of E-medicine has allowed for the development of safer noninvasive continuous cardiac output monitoring applications in perioperative and intensive care medicine. Some of these applications include thoracic elec- trical bioimpedance, thoracic bioreactance, vascular unloading technique, pulse wave transit time, and radial artery applana- tion tonometry. According to clinical studies, these technologies are capable of providing cardiac output readings noninvasively and continuously with minimal complications. Like most new technologies, their performance and accuracy needs further validation. These new applications might prove to be innovative tools for the assessment of advanced hemodynamic monitoring without the drawbacks of invasive techniques.8 However, further discussion of these techniques is beyond the scope of this chapter.

Blood Gas Laboratories and Point-of-Care Applications The accuracy and precision of blood gas data influence clinical decisions and patient safety. Computerized blood gas analyzers and computer-assisted quality assurance measures in a blood gas laboratory are crucial functions in a respiratory care depart- ment. Quality assurance data are necessary for accreditation of blood gas laboratories by the College of American Pathologists (CAP), the Clinical Laboratory Improvement Amendments (CLIA), and The Joint Commission (TJC). Blood gas laboratory applications interface analyzers with the patient’s EHR to make

130 SECTION I • Foundations of Respiratory Care

The American Thoracic Society has recommended pulmo- nary function reference standards based on the National Health and Nutrition Examination Survey. These standards for predic- tion of normal PFT values may differ from other reference values. This difference can confound the interpretation of suc- cessive PFTs in an individual patient when clinicians focus on the computer-assisted interpretation of percent-of-predicted values, rather than the actual observed values.11 Clinicians should have a clear understanding of which reference values were used for each test and interpret PFT results accordingly.

MINI CLINIC Computer-Assisted Interpretations of Pulmonary Function Tests in an Individual Patient

PROBLEM: A patient with alpha1-antitrypsin deficiency has repeat PFTs, including a diffusing capacity of the lung for carbon monoxide (DLCO). Based on a computer-assisted interpretation, there appears to be a remarkable decrease in the percent-of-predicted value for DLCO. It was previously normal; now it is 68% of predicted, indicative of emphysema. An effec- tive therapy, pooled human plasma alpha1-antitrypsin, is avail- able but expensive. What additional information should the clinician evaluate?

DISCUSSION: The clinician should determine (1) the actual observed DLCO values of the previous and repeat test and (2) whether the computer-assisted interpretations are based on different reference values among the tests. If the computer- assisted percent-of-predicted values for each test were based on different sets of reference values, it could account for the change in DLCO. Further investigation of the results is warranted.

conventional ventilators allow for updating and adding new modes of ventilation via software updates, rather than purchas- ing new ventilators.

Protocols for ventilator weaning and management of certain respiratory conditions (e.g., acute respiratory distress syn- drome) coupled with the trending capabilities of today’s micro- processor ventilators can improve patients’ outcomes and decrease length of stay. Complete, accurate, and consistent doc- umentation of ventilator settings is key to achieve these goals. However, manual ventilator charting is frequently incomplete, inaccurate, and inconsistent, particularly regarding nomencla- ture.14 Computerized ventilator charting applications have the potential to improve the quality and consistency of ventilator charting, especially when fully integrated with the patient’s EHR. Automated ventilator charting, verified by RTs, takes ven- tilator charting a step further, with the potential to improve completeness, accuracy, consistency, and efficiency.15 Figure 7-2 is an example of a computer screen for automated charting.

Therapist-Driven Protocols. Evidence-based, therapist- driven protocols can improve health outcomes.16 Under medical supervision and based on patient assessment, RTs use protocols to allocate and titrate respiratory care. Consistency and timeli- ness of implementation are keys to the effectiveness of proto- cols. Automation of protocols at the point of care can help RTs address these concerns. An automated protocol for discontinu- ation of the mechanical ventilation program on hand-held devices can decrease the time to the first spontaneous breathing trial and the length of stay in the intensive care unit (ICU) compared with a protocol without automation.17 These proto- cols allow the RTs to enter information about each mechanically ventilated patient via a hand-held device throughout the shift. When the patients meet preset criteria, the computer application prompts the RTs to conduct a spontaneous breath- ing trial to help determine the patient’s readiness for ventilator discontinuation.

Applications in Nonacute Care Settings and Chronic Diseases Management of chronic diseases presents a serious challenge to the U.S. health care system. As of 2012, approximately half of all adults—117 million people—have one or more chronic health conditions. One of four adults has two or more chronic health conditions.18 Of the top 10 causes of death in 2010, 7 were chronic diseases. Two of these chronic diseases—heart disease and cancer—together accounted for nearly 48% of all deaths.19 Chronic disease is present in 8 of 10 Americans on Medicare, and 84% of all health care spending in 2006 was for the 50% of the population who have one or more chronic medical conditions.20 As baby boomers continue to age, the proportion of the U.S. population 65 years old and older is expected to double. There is much interest in optimizing chronic disease management through advances in E-medicine technologies to improve health outcomes in a cost-effective manner. This is particularly noteworthy given the focus by the U.S. government on reducing short-term (within 30 days) hos- pital readmissions. Hospitals have begun being penalized for

Applications in Treatment

Many current devices, therapies, and protocols developed in the last decade rely on technologic advances generated by E-medicine applications. These applications can be used in acute or nonacute settings by RTs to provide support and care for the pulmonary patient.

Applications in the Acute Care Setting Mechanical Ventilators. Conventional mechanical ventila-

tors use microprocessors to deliver and monitor modes of ven- tilation.12 A “mode” of ventilation is a predetermined pattern of patient-ventilator interaction. Modes can be quite complex, as explained in detail in Chapter 45. Newer modes, such as neu- rally adjusted ventilatory assist (NAVA), aim to enhance the patient-ventilator synchrony via automation that is highly responsive to the patient.13

Microprocessors perform additional functions. They provide for graphic outputs and touch screens and interfaces; they also control ventilator alarms and archive the history of set and measured values, which can be uploaded to a computer. Current

E-Medicine in Respiratory Care • CHAPTER 7 131

outcomes include earlier identification of deteriorating symp- toms, better response to exacerbations, increased rate of sus- tained exercise after pulmonary rehabilitation and decreased ED visits and hospitalizations.27-29 Additionally, E-medicine applications can help detect comorbidities, such as sleep apnea.27

Applications in Disease Prevention

As explained earlier, through HITECH, the federal government has committed unprecedented resources to supporting the adoption and use of EHRs.30 HITECH’s goal is not adoption alone but “meaningful use” of EHRs—that is, their use by pro- viders to achieve significant improvements in care. Payments by third-party payers to health service providers are specifically

excessive short-term readmissions for their patients with certain conditions, including chronic obstructive pulmonary disease (COPD). To address this initiative, hospitals and other health care providers have developed an array of protocols to address the main reasons for such readmissions. These protocols often emphasize patient and family education and follow-up and often use computer applications to help accomplish this.21,22

Asthma. E-Medicine applications for asthma include inter- active Internet applications, such as games for children, web applications linked to cell phones for personalized or auto- mated voice or text messaging, and other telemonitoring appli- cations. Many of these applications use monitored patient data to tailor the adjustment to the plan of care. Some provide for personalized goals, calendars, and reminders. Educational tools include audiovisuals, games, and quizzes. In patients with per- sistent asthma, evidence from research studies shows that these E-medicine applications can result in an improvement in asthma knowledge, self-management skills, peak flow rates, and adherence to inhaled corticosteroid controller medications and fewer symptoms, missed school days, nighttime awakenings, activity limitations, ED visits, and hospitalizations.23-26 These applications are generally well received by patients.24

Chronic Obstructive Pulmonary Disease. Increasingly, COPD is being managed in the home. Web-based telemonitor- ing systems, smartphones, and mobile phones with computer applications extend the reach of health care providers into the home. E-Medicine applications for patients with COPD facili- tates education, self-management, and timely feedback from health care providers (Figure 7-3). Patients generally have a positive attitude about the role of this technology, and the quality of the transmitted data is generally good.27 Improved

FIGURE 7-3 Telehealth Homepod. (Courtesy Tele Health Ltd. Dublin, Ireland.)

FIGURE 7-2 Automated ventilator charting.

ADULT VENTILATOR MONITOR

Time of Tx: 06/07/05.16.02 Ventilator: PB840 Mode: ASSIST/CONTR

Settings

VT: Rate: PK Flow: Trig: Sens: O2% Set: PEEP: Waveform:

Ins Paus:

600 26 90 P - - 2.0 60 10

0.0

ml bpm L/m F/P

cmH2O %

cmH2O

sec

Alarm Settings

Hi Pres: Low Pres: Low PEEP: Low VT: Low VE: Hi Rate: Apnea Time:

0 0 0 0 0.0 0 0

cmH2O cmH2O cmH2O

ml L/m bpm sec

cmH2O cmH2O cmH2O cmH2O cmH2O

bpm L/m

Patient Data

Ppeak: Pplat: PEEP: Int PEEP: Pmean: I:E 1: Tot Rate: Tot Cor VE:

%O2 Meas: SpO2: ETCO2: Positn: Condtn: Breath sounds: Suctioned:

Last Value:

% %

mmHg

N Y/N Y/N

Airway Management

Lavage: Sputum: Airway Care:

ml ml

Y/N

Tube Data

Type: Desc: Size: Pos: Cuff Prs:

0.0 0.0 0 cmH2O

Circuit Data

Set temp: Meas temp: Bag and Mask: Circ change: Suct change: HME change: Ctube:

N N N

0.0 0.0 Y N N N 0.0

C C

Y/N Y/N U/N Y/N

ml/cmH2O

Calculated Values

M Cor VTe:

Comp: VT/Kg: 9.0

ml/cmH2O ml/kgBWP

Notes

Advs Reaction: SVC: Y/N SCD: HOB <30 degree: RCP Oral Care: Sleep Apnea: Objectives:

Duration: Comments:

12 mins N

Y/N Y/N Y/N Y/N Y/N

Y/N

F4-Save F10-Exit w/o saving HOME-return to top

132 SECTION I • Foundations of Respiratory Care

Education of the Public and Health Care Consumer Today’s savvy health care consumers understand that access to good information is essential to health-related decision making. The Pew Internet and American Life Project found that more than 80% of Internet users report seeking health information online; for those with chronic conditions, the rate is 86%.38 Those percentages will most likely increase over the coming years.

E-Medicine applications offer unique public access to health education materials through the use of a variety of interactive tools such as websites, videos and graphics, chat rooms, e-mail, games, social media, and so on, through any web-enabled device. RTs should not underestimate the impact of these appli- cations on public health education and disease prevention.

The amount of data available on health-related and wellness- related issues increases exponentially each year. RTs play an important role in helping their pulmonary patients assess accu- rate information found on E-medicine applications. Box 7-2 lists the factors to consider when educating pulmonary patients on evaluating the worthiness of E-medicine sources.39

INFORMATICS AND CLINICAL DECISION SUPPORT

Health informatics, which refers to the use of information technology in health care, combines advances in computer science and technology to improve clinical care, manage the health of populations, and accelerate research.

Business Intelligence

Business intelligence refers to a set of tools that permit capture, storage, and transformation of data into useful and actionable information. In health care, business intelligence tools are used to capture and integrate clinical data with relevant financial and

FIGURE 7-4 Example of a web-based tobacco cessation resource. (From http://smokefree.gov.)

TABLE 7-2

Websites Related to the Treatment of Tobacco Use and Dependence

Organization Website

Association for the Treatment of Tobacco Use and Dependence

http://www.ATTUD.org

Centers for Disease Control and Prevention

http://www.cdc.gov/tobacco/ quit_smoking/

International Tobacco Control Policy Evaluation Project

http://www.ITCProject.org

QuitNet http://www.quit.com/ U.S. Department of Health

and Human Services http://www.SmokeFree.gov

U.S. Surgeon General’s Office

http://www.Surgeongeneral.gov/ initiatives/tobacco/

Society for Research on Nicotine and Tobacco

http://www.TreaTobacco.net

Tobacco Free Kids http://www.TobaccoFreeKids.org World Health Organization,

Tobacco Free Initiative http://www.WHO.int/tobacco

tied to the achievement of advances in health care processes and outcomes. Disease prevention and patient education are intrin- sically part of these processes.

Treatment of Tobacco Use and Dependence In the United States, tobacco use and dependence is the leading preventable cause of death and chronic diseases.31 Health care costs attributable to tobacco use are quite significant. Effective evidence-based treatments are available, but their implementa- tion by health care providers is lagging.32 RTs can play a vital role in the treatment of tobacco-related diseases and are now using E-medicine as an aid to help tobacco users.

E-Medicine, including phone-based applications, provides exciting new components of treatment for tobacco use and dependence. With the extensive reach of the Internet and the demonstrated efficacy of some applications, the potential impact on health outcomes is immense. More than 10 million Internet users have searched for online information about how to quit smoking.33

Internet-based treatment programs can recruit tobacco users via search engines, or they can be an adjunct to telephone quit- line counseling. Figure 7-4 shows the smokefree.gov tobacco treatment website. When E-medicine applications are tailored to individual tobacco users, with frequent automated contacts via e-mail or text messages, rates of long-term abstinence from tobacco use are similar to those with traditional evidenced- based interventions.33-36

Consistent with the U.S. Public Health Service clinical prac- tice guideline recommendation for a high-intensity, multicom- ponent approach, web-based applications have the capacity to provide both counseling that promotes tailored quit strategies and tobacco cessation medications that have been approved by the U.S. Food and Drug Administration.37 These applications can provide sustained access to virtually limitless numbers of participants and are therefore very cost-effective. Table 7-2 lists some websites related to the treatment of tobacco use and dependence.

http://smokefree.gov

http://www.ATTUD.org

http://www.cdc.gov/tobacco/quit_smoking/

http://www.ITCProject.org

http://www.quit.com/

http://www.SmokeFree.gov

http://www.Surgeongeneral.gov/initiatives/tobacco/

http://www.TreaTobacco.net

http://www.TobaccoFreeKids.org

http://www.WHO.int/tobacco

E-Medicine in Respiratory Care • CHAPTER 7 133

alerts for drug-drug interactions and drug-allergy reactions. More advanced implementations may include examples of drug-disease interactions, such as when the selected drug dose is high for a patient whose latest creatinine value indicates renal impairment. More complex clinical guidelines, such as for weaning from mechanical ventilation, may be embedded within the EHR system. Condition-specific order sets, such as “care paths” for patients admitted with COPD, can guide the caregiv- ers to ensure provision of evidence-based care.

Documentation templates are frequently used for decision support where rules are embedded into the logic behind the templates. As an example, a template for charting may direct the therapist to chart breath sounds and then subsequently direct them to record the type of sounds and location in the chest. Similar directions also may be used to prompt the RT for volume and flow settings for volume control modes of ventilation versus pressure and inspiratory time for pressure control modes.

Summaries of patient data and patient lists created based on specific criteria are other examples of decision support. For example, a work list may summarize patients who have been on noninvasive ventilation longer than a specified time and are therefore appropriate candidates for evaluation for skin break- down. There is also increasing use of contextual reference infor- mation within the EHR, using links to internal or external resources for additional information. Examples of this include reference links to internally hosted protocol documents from order sets and links to external web-based content providers such as UpToDate.

Evidence Supporting Clinical Decision Support Several studies have evaluated the usefulness of CDS in patient care. CDS has demonstrated value in identifying high-risk patients using blood gas and laboratory results,42-44 as a diag- nostic aid and in early identification of patients for interven- tion.45,46 Knowledge-based systems have been shown to improve outcomes such as length-of-stay after myocardial infarction47 and weaning from mechanical ventilation.48

Mobile Applications Increasingly, mobile applications are being used to not only provide information to users but also capture health care data. Applications such as AirStrip allow remote users to visualize streaming vitals sign data and graphics. At the consumer level, mobile applications are driving consumer engagement via tele- health, consumer education, and health applications that use mobile devices as a data collection tool.

Administrative Decision Support Administrative decision support using electronic data takes two main forms, which could be considered as external and internal benchmarking. External benchmarking is most prominently represented by the American Association for Respiratory Care (AARC) Benchmarking System, which facilitates identification and adoption of best practices among similar respiratory care

Box 7-2 Factors to Consider When Reviewing E-Medicine Sources

• Web address: • .com—A website most likely to a for-profit company • .org—A website most likely from a nonprofit organization • .edu—A website published by an educational institution

such as a university • .go—A web page that belongs to a governmental

organization • When assessing credibility, consider the following:

• Who are the authors? • What are their credentials? • Is there a hidden agenda? • Who published the information? • Is the information peer reviewed?

• When assessing accuracy, consider the following: • Is the information current? • Is the information supported by facts? • Is the information based on scientific evidence? • Is the original source listed? • Do other sources back up the information?

• Red flags to consider: • Anonymous information. • There appears to be a conflict of interest. • The information presented is one-sided or biased. • The information is outdated. • There is a claim of a miracle or secret cure. • No evidence is cited. • The grammar is poor and words are misspelled.

operational data. Key performance indicators (KPIs) are indi- cators of quality and efficiency that are selected based on reporting or operational requirements. Commercially available business intelligence systems allow KPIs to correlate with dimensions that typically include person, time, place, and so forth. For example, a hospital may be interested in ventilator- associated pneumonia (VAP) events. In this case, KPIs may include daily ventilator census and incidence of VAP, which are then correlated with dimensions such as practitioners involved in the care of the patient before the event, hospital unit, date of VAP, and so on. This allows an institution to not only report on the aggregate rate of VAP but also recognize patterns relating to specific units and caregivers. Business intelligence also can be quite useful in research, especially in accessing data for retro- spective clinical studies, as discussed in Chapter 8.

Clinical Decision Support

Clinical decision support (CDS) has been defined as “Health information technology functionality that builds upon the foundation of an EHR to provide persons involved in care pro- cesses with general and person-specific information, intelli- gently filtered and organized, at appropriate times, to enhance health and health care.”40,41 Examples of CDS include computer- ized alerts and reminders, such as notification to a therapist that the selected tidal volume exceeds the recommended range for a patient, based on ideal weight and calculated using a previously recorded height measurement. CPOE systems, discussed else- where in this chapter, frequently incorporate decision support

134 SECTION I • Foundations of Respiratory Care

Research

Research is based on data (facts) that can be transformed into information (facts that answer questions). Thus any of the sources of data described earlier are potential research tools. Online databases provide both the framework and content for designing research studies (e.g., PubMed). Private databases (e.g., productivity and hospital business review resources) support internal process improvement initiatives.54,55 These issues are discussed in more detail in Chapter 8.

TELEMEDICINE AND TELEMONITORING

Telemedicine refers to the use of electronic and telecommuni- cation technologies to support health care at a geographically different location from the patient, increasing access to specialty and patient care. Telemedicine can allow for the evaluation, diagnosis, treatment, monitoring, triage, consultation, and follow-up of patients without travel.56,57 According to the Centers for Medicare and Medicaid Services (CMS), telemedi- cine seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at the distant site. This electronic communication means the use of interactive computerized tele- communications equipment that generally includes audio and video equipment. Telemedicine is viewed as a cost-effective alternative to the more traditional in-person way of providing medical care, such as face-to-face consultations or examinations between the clinician and patient.58 A form of telemedicine is telemonitoring, which involves the use of telecommunications and information technology to provide access to health assess- ment, diagnosis, intervention, consultation, supervision, and information across distance.

Although best-practices in this area are still emerging, tele- medicine and telemonitoring are gaining ground in respiratory care and in the overall management of all type of patients, including those with pulmonary disease. In some cases, it has facilitated the timely diagnosis and treatment of patients with limited access to health care facilities. In particular, patients in remote geographic locations or those with limited mobility such as ventilator-dependent individuals with severe neu- romuscular disease have benefited from telemedicine.59 Com- puter interfaces for telemonitoring facilitate patient assessment through the two-way transmission of key clinical data such as vital signs, pulmonary function measures, and patient-ventilator data and even the patient’s physical appearance captured by computer web cameras. Similar monitoring also can facilitate the early detection of and intervention for any deterioration in a patient’s condition. Such inventions have been shown to be helpful in reducing doctor visits and hospital admissions, a benefit to the patient and to the economics of health care.60

In addition, telemedicine has proved useful in facilitating the patient’s participation in computer-based disease manage- ment programs. In particular, selected telemedicine applica- tions have been created that bundle patient education, disease

departments. Internal benchmarking is exemplified by the hos- pital business review process. This form of benchmarking involves the creation and tracking of relevant quality and pro- ductivity metrics to inform internal process improvement activities.

American Association for Respiratory Care Benchmarking System

In the 1950s, the Xerox corporation invented a process called benchmarking as a way to identify and adopt best practices that have developed among similar organizations.49 In 1989 Robert Camp wrote one of the first textbooks on benchmarking,50 out- lining four basic steps (1) know your operation, (2) know the industry leaders or competitors, (3) incorporate the best, and (4) gain superiority.

Early in 2006, the leadership of the AARC, recognizing the need to establish a valid benchmarking resource for respiratory care, created an official benchmarking website designed for respiratory care department managers (http://www.respiratory benchmarking.org). Anyone can visit the site and take advan- tage of educational resources (from the Site Navigation drop- down menu). Department managers who are members (i.e., have a paid subscription to the AARC benchmarking system) may enter their department’s profile, including information on structure and function as well as personal contact information, although an anonymous option is provided.51 Next, managers enter productivity data on a monthly basis. This activity builds the communal database from which benchmarking reports are generated by all members.

Best practices are identified using reports. A manager creates a report based on a “compare group” comprising several other departments that are similar in structure and function. This compare group is identified by performing searches on the database using various criteria from the profile and studying the profiles of the departments matching those criteria. The report has two sections. The first section gives numeric values for various productivity metrics52 (definitions are available on the AARC benchmarking website) that indicate the depart- ment’s percentile ranking. The manager is given the option of entering a desired percentile ranking, and the report will then calculate the opportunity (both in terms of dollars and number of staff positions) associated with improving the per- centile ranking. The second section of the report is a list of all the departments in the compare group ranked according to percentile53 on each of the productivity metrics. This section of the report allows the department manager to identify the top performers. The next step for the manager is to study the pro- files and monthly productivity data of the top performers to find clues about how they are achieving best practices. The manager is also encouraged to contact the top performers per- sonally to ask questions.

The AARC Benchmarking System has grown and evolved since its inception and continues to provide essential informa- tion to forward-thinking managers. It is a valuable tool for maintaining a completive advantage in the ever more demand- ing economic environment of U.S. health care.

http://www.respiratorybenchmarking.org

E-Medicine in Respiratory Care • CHAPTER 7 135

manuscripts and other sources for clinical practice guidelines, evidence-based systematic reviews of clinical questions, accred- iting agencies, or other relevant sources of important informa- tion (Table 7-3).

Health Information Sources for Consumers

As discussed earlier, patients increasingly seek knowledge about diseases and treatments on their own. However, many users neglect to scrutinize the quality or source of the information, which is largely unregulated. Selected resources for pulmonary patients are listed in Table 7-4 and include the AARC website for patients (http://www.yourlunghealth.org), the websites of the National Lung Health Education Program (http://www .nlhep.org) dedicated to COPD patients, and MedlinePlus.gov of the National Library of Medicine. MedlinePlus features online interactive tutorials, practical instructional handouts for patients, a medical encyclopedia, and videos of surgical procedures.

APPLICATIONS IN HEALTH CARE ADMINISTRATION

E-Medicine applications also play an integral role in helping respiratory care managers and leaders maximize the value they

management, interactive communication, and other features. Such multipronged systems have been shown to be effective in helping reduce chronic disease exacerbations and enhance the daily functioning and quality of life of patients with asthma and COPD, as discussed earlier in this chapter.61 Other telemedicine programs have shown promise in helping overcome logistical barriers such as transportation and scheduling that too often prevent individuals from participating in valuable disease man- agement programs. In particular, telemedicine has helped facili- tate the participation of COPD patients in remote access pulmonary rehabilitation programs in which they otherwise would not have been able to participate. Furthermore, their participation in such computer-aided rehabilitation programs has permitted these patients to achieve similar benefits associ- ated with traditional rehabilitation programs (see Chapter 55), such as demonstrable enhancement in their tolerance for activi- ties of daily living.62

Like many aspects of E-medicine, telemedicine seems to be in its infancy. As health care resource limitations and cost- containment pressures continue, as well as improvements in the applications and the efficiencies they offer, it appears inevitable that use of this and related technologies will expand and become commonplace in health care and more specifically in respira- tory care.

SOURCES OF HEALTH INFORMATION

Considering that almost half of adults in the United States have limited health literacy, E-medicine applications have the poten- tial to improve our patients’ level of health literacy if used appropriately.63 Low health literacy compromises patient safety, limits the overall quality of health care, and accounts for increased health care costs. When patients have poor knowledge about their disease and the management of it, positive out- comes become more difficult to achieve.64

Health Information Sources for Respiratory Therapists and Other Clinicians

Effective information retrieval is essential to evidence-based respiratory care. It enhances clinical expertise by providing information for the development of evidence-based, therapist- driven protocols, and it aids in clinical decision making for the clinician. Although assessment skills of RTs generally sharpen with experience, their knowledge of the most up-to-date thera- pies may diminish over time.65 However, the best available medical evidence is dynamic rather than static and the amount of available information is staggering. RTs need to be knowl- edgeable about efficient ways to access, filter, and retrieve rele- vant information effectively. They also must be prepared to guide increasingly sophisticated patients, many of whom actively seek medical information on the Internet.

E-Medicine applications are a far-reaching, rich source of information. RTs can use search engines such as PubMed, MEDLINE, and Google Scholar to access, filter, and retrieve information effectively. RTs can “bookmark” helpful websites,

TABLE 7-3

Helpful websites for Respiratory Therapists

Organization Website

American Academy of Allergy, Asthma, and Immunology

http://www.aaaai.org

American Academy of Pediatrics http://www.aap.org American Academy for Sleep

Medicine http://www.aasmnet.org

American College of Allergy, Asthma, and Immunology

http://www.acaai.org

American Association for Respiratory Care

http://www.aarc.org

American Cancer Society http://www.cancer.org American College of Chest

Physicians http://www.chestnet.org

American Heart Association http://www.heart.org American Lung Association http://www.lung.org American Thoracic Society http://www.thoracic.org ARDS Network http://www.ardsnet.org Centers for Disease Control and

Prevention http://www.cdc.gov

Cochrane Collaboration http://www.cochrane.org Committee on Accreditation for

Respiratory Care http://www.coarc.com

Cystic Fibrosis Foundation http://www.cff.org Global Initiative for COPD http://www.goldcopd.com National Board for Respiratory

Care http://www.nbrc.org

National Heart, Lung, and Blood Institute

http://www.nhlbi.nih.gov/ health-pro

Society for Critical Care Medicine http://www.sccm.org U.S. Surgeon General http://www.surgeongeneral.gov

http://www.aaaai.org

http://www.aap.org

http://www.aasmnet.org

http://www.acaai.org

http://www.aarc.org

http://www.cancer.org

http://www.chestnet.org

http://www.heart.org

http://www.lung.org

http://www.thoracic.org

http://www.ardsnet.org

http://www.cdc.gov

http://www.cochrane.org

http://www.coarc.com

http://www.cff.org

http://www.goldcopd.com

http://www.nbrc.org

http://www.nhlbi.nih.gov/health-pro

http://www.sccm.org

http://www.surgeongeneral.gov

http://www.yourlunghealth.org

http://www.nlhep.org

136 SECTION I • Foundations of Respiratory Care

load. These same data can be used by most such systems to calculate productivity of an individual RT or the department as a whole. Often such productivity results are expressed as a per- centage of a certain benchmark or reference range. For example, if the productivity expectation for an RT to complete 24 aerosol treatments for an 8-hour shift (assuming no other workload), but because of several call-outs, the RT is assigned and com- pletes 30 such treatments, then that therapist would have a productivity percentage of 30 (actual)/24 (assigned) or 125%. Figure 7-5 shows an example of a worksheet for workload cal- culation. These software packages also facilitate computerized documentation, including ventilator-patient monitoring or charting the delivery of all forms of respiratory therapy, through computers or remote devices interfaced with the EHR. These documentation systems not only provide a record of the care provided and patient’s response, but are also interfaced with other facets of the comprehensive software platform, including those for billing and quality assurance.66

Financial Management

Computer hardware and software are universally used in the financial aspects of health care. The more predominant uses relate to financial accounting applications, including billing and accounts receivable, as well as managerial accounting functions, which encompass financial statement reporting, budgeting, and forecasting. A detailed description of each of these functions is beyond the scope of this text. Briefly, however, under the cate- gory of financial accounting, accounts receivable is a fancy term for billing for and monitoring of the reimbursement for services provided. Most of the billing to CMS and private health insur- ance providers and monitoring of such payments by hospitals is done through electronic software platforms. Often this pro- cess is facilitated by features within the health care organiza- tion’s EHR system, which accesses a portal to the payment system of CMS, the health insurance providers, or a subcontrac- tor acting on their behalf.66

The financial accounting systems facilitate billing and inter- face closely with the managerial platforms used for financial statement and budgeting. For example, once the software rec- ognizes that a payment has been made by CMS, higher level financial statements such as the income statement can be imme- diately updated to show an increase in revenue received. These and other computerized functions permit almost immediate updating and real-time viewing of the financial condition of the health care organizations. Software applications have enhanced managerial accounting functions in other ways, by facilitating the budgeting process, which ensure the health care organiza- tions and respiratory departments have adequate resources to provide their services and perform their functions. Likewise, computer software permits faster and often more accurate financial forecasting, as well as the ability to make predictions under various economic and environmental scenarios.67

Quality Assurance

Computer software applications are a vital tool in health care quality assurance. Chapter 3 of this text provides some detail

add to their health care organizations. In addition to the bench- marking resources and business intelligence concepts described earlier in this chapter, there are other highly useful digital appli- cations related to documentation, workload, and staffing; finan- cial and quality management; human resources; regulatory compliance; and similar tools related to management and administration.

Documentation, Workload, Staffing, and Scheduling

Increasingly, the comprehensive software systems used by health care organizations, provide features that support department- specific functions, including those essential to respiratory care departments. These software packages enable respiratory care department managers and other authorized personnel to retrieve, sort, and use information-relevant managing strategic functions such as resource use, staffing, and financial manage- ment. In addition, such software systems can link these strategic functions with day-to-day operations, such as using hospital census (e.g., percentage occupancy) and acuity (e.g., average severity of illness) data, with how many RTs are needed during a given shift or other period to adequately handle such a patient

TABLE 7-4

Helpful Websites for Pulmonary Patients

Organization Website

Medical Associations American Academy of Allergy,

Asthma, and Immunology http://www.aaaai.org

American Academy for Sleep Medicine

http://www.aasmnet.org

American College of Chest Physicians

http://www.chestnet.org

American Thoracic Society http://www.thoracic.org Society of Critical Care Medicine http://www.sccm.org

Patient Education and Support Organizations American Association for

Respiratory Care http://www.aarc.org http://www.yourlunghealth.org

American Heart Association http://www.heart.org/heartorg American Lung Association http://www.lungusa.org Cystic Fibrosis Foundation http://www.cff.org COPD Foundation http://www.copdfoundation.org/ Global Initiative for COPD http://www.goldcopd.com Healthways http://www.QuitNet.com National Lung Health Education

Program http://www.nlhep.org

SmokeFree: U.S. Department of Health and Human Services

http://www.SmokeFree.gov

Government Agencies Centers for Disease Control and

Prevention http://www.cdc.gov

Food and Drug Administration (FDA)

http://www.fda.gov

National Heart, Lung, and Blood Institute (NHLBI)

http://www.nhlbi.nih.gov

National Institutes of Health (Medline)

http://www.nlm.nih.gov/ medlineplus/

National Library of Medicine http://www.nlm.nih.gov/

http://www.aaaai.org

http://www.aasmnet.org

http://www.chestnet.org

http://www.thoracic.org

http://www.sccm.org

http://www.aarc.org

http://www.yourlunghealth.org

http://www.heart.org/heartorg

http://www.lungusa.org

http://www.cff.org

http://www.copdfoundation.org/

http://www.goldcopd.com

http://www.QuitNet.com

http://www.nlhep.org

http://www.SmokeFree.gov

http://www.cdc.gov

http://www.fda.gov

http://www.nhlbi.nih.gov

http://www.nlm.nih.gov/medlineplus/

http://www.nlm.nih.gov/

E-Medicine in Respiratory Care • CHAPTER 7 137

FIGURE 7-5 Clinivision Mobile Patient Charting (MPC). Workload estimate for 3 shifts by zone. This report is grouped by zone and then procedure to show the estimate for the number of procedures, work units, and therapists required. (Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien.)

Bennett Memorial Hospital

Workload Estimate for 3 Shifts by Zone

Procedure Name Number

of Orders ------Shift One------ ------Shift Two------ ------Shift Three------Time

Standard # of Txs Work Units # of Txs Work Units # of Txs Work Units

MED NEB

Total by Zone

# of Therapists Required for Zone

Total by Zone

# of Therapists Required for Zone

25 20 22 13 7 5 5

1 1 1 1 1 1 1

0.06

0 40 22 26 0 5 5

0.22

0 40 22 26 0 5 5

0.22

0.06

0 0 0

26 0 5 5

0.08

PEDS

RICU

Total by Zone

# of Therapists Required for Zone

20 25 30 20 10

7 5 5

2 2 1 1 1 3 1 1 2

0 0 0

40 0

14 5 5 0

0.14

40 0

30 40 20 49 5 5 0

189

0.42

40 0

30 40 20 42 5 5 0

182

0.40

SICU

ABG AIRWAY CARE CPR CPT INCENT SPIROMETER METER DOSE INHALER O2/AEROSOL O2/LPM VENT CARE/ADULT

AIRWAY CARE CPT EKG MED NEB METER DOSE INHALER O2/AEROSOL O2/LPM

Total by Zone

# of Therapists Required for Zone

20 25 30 5

22 10 13 7 5 5

25 12

3 1 1 1 1 1 2 3 1 1 1 2

0 0 0 5 0 0

26 35 10 5 0 0

0.18

60 0

30 5

22 10 26 42 15 5

25 0

240

0.53

60 0 0 5

22 0

26 35 10 5

25 0

188

0.42

CCU

ABG AIRWAY CARE ASSESSMENT CPAP EKG EQUIPMENT CHANGE MED NEB METER DOSE INHALER O2/LPM O2/VENTI MASK SPONTANEOUS MECHS VENT CARE/ADULT

138 SECTION I • Foundations of Respiratory Care

invaluable tools for human resource functions of heath care facilities and those more specific to respiratory care depart- ments by enabling them to maintain employee records, track training and education, and keep abreast of licensure and cre- dentialing renewals, among many other similar applications. In addition, web resources have proved invaluable in helping recruit talented staff. The AARC website has a “Job Bank” feature that enables employers to post openings and furnishes qualified candidates with instructions on how to apply. Many state societies for respiratory care offer similar resources, and there are many proprietary recruitment websites, including Monster.com, Indeed.com, and ZipRecruiter.com.

Beyond this, many health care organizations are using web resources to help evaluate job candidates. In addition to being able to search state agencies to confirm a candidates’ licensure and the National Board for Respiratory Care (NBRC) websites to determine credentialing status, pre-employment criminal background checks can be easily done through services offered on the web for a fee-for-service basis. Furthermore, although it is controversial, employers are increasingly performing credit checks and reviewing the social media profiles and patterns in the screening process of candidates.71

Privacy and Confidentiality

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 established standards and safeguards to protect the confidentiality of medical records, including those maintained on computers and other similar devices. Essentially all EHR software offered by reputable sources must be HIPAA compli- ant, and health care organizations are required to have their staff trained on performing their functions within the guide- lines of this law. However, in some ways technologic advance- ments are threatening the protections offered by HIPAA. Increasingly, health information maintained and transmitted on portable devices such a laptop computers, tablets, and smart- phones is circulating outside the HIPAA-protected zone. Such information is increasingly kept on, or downloaded to, storage devices such as “thumb drives” or in remote computerized servers known as “the cloud.” Furthermore, clinical datasets and databases originally intended for one purpose, such as regula- tory compliance reporting or for clinical purposes, are being acquired by other organizations for different purposes, such as research and marketing. The required protection of all pro- tected health information within such datasets is not always properly done, which poses further threats to patient confiden- tiality. Patient information on social media is another area of concern. Although it will take some time for our governmental regulators to enact updated legislation to address the impact that such technology has had on HIPAA compliance and patient privacy and confidentially, the general sense is that such regula- tion will eventually be adopted. In the meantime, RTs need to be ever mindful to protect and respect the confidentiality of patient information. Whether communicating patient informa- tion verbally, in writing, or with the combined use of computer- ized hardware and software, RTs should apply the HIPPA principles in protecting such data and using it only for its

on the principles of and tools used for quality assurance in respiratory care and health care in general. However, it is impor- tant to note that many tools used in the continuous quality improvement (CQI) model, for both enhancing and monitor- ing quality, are computer-based. For example, a root-cause analysis is a process by which the underlying primary, second- ary, and other notable causes of a medical error or other safety issues are identified, and then an action plan is created and implemented. Finally, an ongoing monitoring system is put in place to evaluate the plan’s effectiveness. Software applications exist and are commonly used to perform such an analysis. More broadly, hospital quality assurance, risk management, and even respiratory care departments use software applications that track quality data such as unplanned extubations and noninva- sive mask-induced facial sores, to examine trends and the potential impact of corrective action.68

Regulatory Compliance

In a similar way that accounts payable systems of health care organizations use portals to facilitate reimbursement of services rendered; shared applications exist for the reporting of key compliance and regulatory data. For example, compliance with the meaningful-use objectives HITECH ACT discussed earlier in this chapter is done in this manner. In addition, CMS has introduced the value-based purchasing system, whereby reim- bursement by CMS to hospitals and health care providers is partially based on their ability to meet a predefined set of stan- dards. Reporting by hospitals to CMS for this program and other similar ones, such as 30-Day Short-Term Readmission Rates, are monitored through similar computer-based report- ing systems.69

Web Analytics

Web analytics is a generic term that encompasses the study of the impact of a website on its users. It employs software to measure trends such as how many people visited a website, how many of those visitors were first-time or repeat visitors, how they came to the site (i.e., if they followed a link to get to the site or came there directly), what keywords they searched within the site’s search engine, how long they stayed on one or more web pages, what links they clicked on when they left the site, and other similar trends. Health care organizations have begun to use web analytics software for many purposes. In the realm of business management and administration, health care orga- nizations are using web analytics to measure trends of current and potential customers, to help make predictions about future market conditions and as an aid in strategic business decisions. Many clinical applications for web analytics are gaining popu- larity, including to track usage of educational websites that are designed as patient resources—for example, those used to for patients with chronic disorders such as COPD, cystic fibrosis, and neuromuscular diseases.70

Human Resources

In addition to their use in staffing and scheduling described earlier in this chapter, computer databases have proved to be

http://Monster.com

http://Indeed.com

http://ZipRecruiter.com

E-Medicine in Respiratory Care • CHAPTER 7 139

movements are exhibited that are synchronous with the phases of breathing and cough.

Learners are able to better immerse themselves in carefully planned case scenarios and performing in a manner similar to that of real clinical situations (Figure 7-6). They develop psy- chomotor, critical thinking, decision-making, and team- building skills. In contrast, traditional methods of didactic education in combination with clinical apprenticeships can result in increased knowledge, but limited, inconsistent experi- ential learning opportunities. Clinical simulators, allow for more in-depth evaluation of learners’ competencies in a safe environment. They are an excellent tool to help respiratory care departments meet The Joint Commission (TJC) requirement of demonstrating the competencies of respiratory care staff in an ongoing manner.73 Recommended steps in clinical simulation education are diagrammed in Figure 7-7.

Clinical simulators are particularly valuable for learning how to function in rare but high-risk clinical situations. Training via simulators has resulted in improved performance of health care providers in emergency airway management, advanced life support, bronchoscopy, and surgery. Computer-based simula- tors also have become a useful tool in promoting and optimiz- ing the use of interprofessional teams within clinical settings.74,75 Clinical simulators have the potential to reduce medical errors and improve patient safety. Simulations promote relatively comprehensive learning (Box 7-3) and allow for performance in clinical settings to become more refined and automatic.

intended purpose (see Rule of Thumb). Failure to comply with HIPAA is a federal violation of the law with financial and legal consequences for those involved.72

FIGURE 7-6 Clinical simulation benefits students. (From Cummings CW, et al: Cummings otolaryngeal: head and neck surgery, ed 2, St Louis, 2005, Mosby.)

FIGURE 7-7 Steps in clinical simulation education.

Information Demonstration Practice Feedback Remediation

Measurement Diagnosis

RULE OF THUMB

Users can take steps to help prevent computer infiltration by malicious software by doing the following: • Users should never share or use their password on

public unsecured devices. • Users should regularly update their computers with

security patches from authorized sources. For example, patches for Windows operating systems are available on the Microsoft website (see http:// www.update.microsoft.com).

• Users should install a virus scanning program and regularly update it.

• Most importantly, users should be careful when opening e-mail file attachments and refrain from downloading applications from unknown sources.

APPLICATIONS IN TRAINING AND EDUCATION

Computing plays a central role in the education of respiratory care students, credentialing of graduates of educational pro- grams, and continuing education for RTs.

Clinical Simulations

Computerized clinical simulations are a powerful learning tool. Computer-based simulation is a long-standing educa- tional method for hazardous occupations that have shown remarkably low rates of failure (e.g., airline pilots, members of the military, astronauts, and nuclear power plant operators). Health care education has progressed to include the use of computer-based, full-body manikins and high-fidelity clinical simulators. These devices feature software to program clinical scenarios and simulated vital signs and physical examination findings that either improve or deteriorate in response to the actions of the learners. The simulators can reproduce situations requiring complex airway management or advanced life support. In virtual surgical simulators, certain devices allow learners to exert force against simulated tissue that offers realistic resis- tance, and in virtual bronchoscopy simulators, vocal cord

http://www.update.microsoft.com

140 SECTION I • Foundations of Respiratory Care

reporting clinical educational activities for allied health profes- sions, including respiratory care programs. The records help both students and faculty members track student progress in completing required competencies as they progress through their clinical rotation assignments (Figure 7-8). Functions may include the following: • Streamlined data entry process minimizing data entry dupli-

cation that can occur between clinical sites, students, and the academic program

• A daily log for completed procedures and activities, which instructors validate

• Competency evaluations • Automated surveys to accommodate questionnaires for stu-

dents, graduates, and clinical affiliates as required by accred- iting agencies

• Cloud-based data and backup storage A variety of such as software applications are available to

educational institutions. These include DataArc (http://www .dataarc.ws/), E*Value (http://evaluehealthcare.com), and Ty- phoon Group (http://www.typhongroup.com/), among others. Students and faculty can use any web-enabled device, including smart phones, to access these applications.

National Board for Respiratory Care Credentialing

The NBRC uses computerized credentialing examinations for both the written and clinical simulation examinations. Candi- dates must go to a designated testing center, sit at a monitored computer terminal, and take the examination during the desig- nated timeframe. Once candidates are done with the examina- tion, they receive their score immediately. In addition, to achieve the advanced credentialing level, or Registered Respiratory Therapist (RRT) designation, candidates must demonstrate their ability to gather and interpret clinical information and then make or recommend clinical actions based on a clinical scenario. In the computerized simulation examination (CSE), RRT candidates must complete a series of case-based simula- tions and demonstrate that they have adequately mastered the management of major respiratory diseases (Figure 7-9).

Full-Scale Physiologic Clinical Simulators

There are several full-scale, physiologic, clinical simulators available, two of which are SimMan (Laerdal Medical, Wap- pingers Falls, NY) and the Human Patient Simulator (HPS) (CAE Healthcare, Quebec, Canada). These simulators generate physiologic functions, including pulse, blood pressure, cardiac rhythm, breathing, exhaled carbon dioxide, lung compliance, and bowel sounds. The airways are anatomically accurate to the level of the lung segments. Interdisciplinary teams can practice scenarios such as cardiac defibrillation, hemodynamic monitor- ing, apnea, right main stem intubations, tension pneumothora- ces, anesthesia administration, occluded endotracheal tubes, high-pressure alarm limits during mechanical ventilation, and loss of medical gas.

Clinical Education Applications

Management of clinical education involves a significant amount of documentation, tracking, scheduling, evaluations, clinical competencies, reporting, and compliance with accreditation standards. E-Medicine software applications have been devel- oped to help educators manage each of these aspects of the clinical education process.

These applications are secured, password-protected, web- based database management systems for documenting and

FIGURE 7-8 DataArc documentation of clinical competencies. (Courtesy DataArc LLC, League City, TX.)

Student name and

initiator name

Kumar Patel Tonya Cook

Kumar Patel Heather

Neal-Rice

Kumar Patel Tonya Cook

Date and IP address

View record

Wednesday, December 16, 2009

144.30.0.221

Saturday, April 3, 2010 144.30.0.221

Tuesday, October 20,

2009 144.30.0.221

Submission date Delete record

Wednesday, January 6, 2010

at 1:42 PM 144.30.0.221

Saturday, April 3, 2010 at 4:37 PM

144.30.0.221

Tuesday, January 5, 2010

at 3:57 PM 144.30.0.221

Patient and competency

and summary

Adult vital signs

Satisfactory

Adult x-ray interpretation Satisfactory

Adult nasal cannula

Satisfactory

Clinical instructor

Tonya Cook

Michael Anders

Clinical site and location

Baptist Health Clinic

St. Vincent Infirmary Medical

Center Clinic

Area device

Adult floor web

Medical ICU web

Adult floor web

Box 7-3 Learner Objectives in Clinical Simulation

• Interpret data • Recognize and prioritize problems • Make decisions • Observe consequences of decisions • Develop leadership skills • Develop interpersonal communication skills • Develop team-building skills • Use available resources • Manage stress and crisis

http://www.dataarc.ws/

http://evaluehealthcare.com

http://www.typhongroup.com/

E-Medicine in Respiratory Care • CHAPTER 7 141

FIGURE 7-9 National Board for Respiratory Care. Practice simulation problem. (Courtesy NBRC, Olathe, KS.)

Continuing education is mandatory for national credential- ing for the NBRC and often a requirement for state licensure. Credentials awarded by the NBRC are valid for a period of 5 years and are subject to renewal through the Continuing Com- petency Program (CCP) requirements. RTs are required to provide evidence to the NBRC that they are continuing to meet current standards of practice and have all the requirements for renewal. Web-based continuing respiratory care education (CRCE) courses, which have been preapproved or outright sponsored by the AARC, offer RTs an easily accessible, efficient, and cost-effective means of meeting continuing education requirements for CCP and state licensure purposes, as well as keeping current in their profession.

Learning Management Systems

To an increasing extent, respiratory care educators use online, web-based learning management systems platforms such as Moodle or Blackboard to augment traditional classroom courses known as web-enhanced courses or deliver entirely web-based courses (Figure 7-10). This technology improves access and management of course content for web-enhanced courses. Web-delivered courses make respiratory care education possible for students who might not otherwise be able to attend respira- tory care programs such as those requiring flexible schedules or

students in remote rural areas. Other adjunctive applications, such as Adobe Connect, permit live interaction between the student and faculty. Students can talk to their instructors and classmates via live audiovisual platforms. Participants also can have asynchronously access to archived classes and related course content and other material by the use of podcasts or recorded sessions.

American Association for Respiratory Care The AARC provides many continuing education opportunities on the web (see http://www.aarc.org). Webinars and text-based courses are available in both live and asynchronous formats. RTs may earn CRCE credits by completing these courses (Figure 7-11). The AARC also provides web-based CRCE credits through the Respiratory Care journal. RTs can read the journal, use a copy of the test that appears in the journal to draft answers, and then complete the web-based test on the journal website (http://www.rcjournal.com/crce_ttj.cfm). The AARC maintains a transcript of members’ CRCE credits, which RTs can access on the AARC website.

Additionally, to facilitate electronic networking among RTs, the AARC offers Specialty Sections and Roundtables. Each Specialty Section features an e-mail listserv for discussions, e-newsletters, e-bulletins, and a website.

http://www.aarc.org

http://www.rcjournal.com/crce_ttj.cfm

FIGURE 7-10 Moodle Learning Management System course homepage. (Courtesy Rutgers School of Health Related Professions, Respiratory Care Program–North, Newark, NJ.)

FIGURE 7-11 America Association for Respiratory Care, Continuing respiratory care education, web-based courses. (Courtesy AARC, Irving, TX.)

E-Medicine in Respiratory Care • CHAPTER 7 143

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FUTURE OF E-MEDICINE

If the recent degree of changes in E-Medicine is a predictor of future developments, this chapter in the next edition of this book will look very different from this one. In the future, com- puterized technologic applications described in this chapter, such as telemedicine and closed-loop decision-making on mechanical ventilators, will be more widespread, as well as refined and improved and most likely able to do more in much less time. In addition, new digital applications will emerge, including a vast assortment of diagnostic, treatment, educa- tional, and disease management applications available to patients and clinicians alike. The current technology coupled with new developments hold great promise for helping opti- mize the large-scale effectiveness and efficiency our health care system, as well as providing notable benefits to health care organizations and clinicians, including the RTs operating within it.

SUMMARY CHECKLIST

◗ E-Medicine relates to the use of computerized or digital technology to enhance efficiency and effectiveness of health care in general and more specifically patient care.

◗ EMRs represent the computerized records produced every time a patient (or consumer) uses health services.

◗ The EHR is the sum of all EMRs produced by the different encounters of the consumer with various health care entities throughout a lifetime.

◗ Enterprise software packages are designed to provide integrated functionality for health care organizations to enhance both efficiency and effectiveness of patient care.

◗ E-Medicine applications can be used in acute or nonacute settings by RTs to provide support and care for the pulmonary patient.

◗ Health informatics combines advances in computer science and technology to improve clinical care, manage the health of populations, and accelerate research.

◗ Business intelligence refers to a set of tools that permit capture, storage, and transformation of data into useful and actionable information.

◗ CDS provides general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care.

◗ Benchmarking includes four basic steps (1) know your operation, (2) know the industry leaders or competitors, (3) incorporate the best, and (4) gain superiority.

◗ Telemedicine and telemonitoring allow for the evaluation, diagnosis, treatment, monitoring, triage, consultation, and follow up of patients without travel.

◗ The Internet is a rich source of information for RTs and patients when the quality and source of information are appropriate.

◗ Information retrieval is essential to practice evidence-based respiratory care. It enhances clinical expertise by providing information for the development of evidence-based, therapist-driven protocols, and it aids in clinical decision making for the RT.

◗ Computers and digital information can be useful to clinicians in optimizing quality of care and to patients and their families participating in care plans.

◗ Common sense is the best prevention against infiltration by malicious software.

◗ Emerging computer applications are expected to support management of chronic disease and potentially reduce medical errors.

◗ The role of computer applications in clinical care, diagnostics, management, and education is essential and will continue to expand.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/

http://www.cdc.gov/nchs/fastats/deaths.htm

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