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BACKGROUND: The emerging challenges in the healthcare system require a vision for the future of respiratory care to ensure a successful transition to practice for new graduate respiratory therapists (RT). The nursing profession has recognized the need to acknowledge the successes and failures of graduates' transition to practice so that these programs can be continuously improved. The challenge is in identifying aspects of the transition to practice that may improve job satisfaction, retention, professional development, and patient care for RTs. This research aimed to explore the perceptions of new graduate RTs' experiences during their first year of practice and identify barriers and facilitators to a successful transition to practice. METHODS: This qualitative descriptive study surveyed new graduate RTs who transitioned to practice from May 2019 to December 2021 at a New England academic medical center respiratory care department. RESULTS: Twenty-eight new graduate RTs responses were included in the study. The majority of the respondents experienced a successful transition to practice; however, they faced many barriers. New graduate RTs reported that their orientation did not provide enough experience and exposure to gain confidence in critical skills and procedures. They also experienced stress due to COVID-19 and interpersonal relationships, felt overwhelmed by their workload, and were subject to negative workplace behavior. CONCLUSIONS: New graduate RTs experienced many barriers to their transition to practice. Respiratory care leadership should identify barriers faced by new graduate RTs during their transition to practice. A nurse residency model may provide a framework for RT transition-to-practice programs. Improving transition-to-practice programs for new graduate RTs and surveying their experiences may lead to an increase in job satisfaction, retention, and improved patient care.
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Background: In patients with moderate to severe coronavirus disease 2019 (COVID-19), awake prone positioning improves oxygenation and clinical outcome. Despite prone positioning incorporated in the protocol, it's not followed in true letter and spirit. Aims and objectives: The objective of this study was to compare the effect of strict versus routine awake proning among patients hospitalized with Covid-19. Method(s): PCR positive COVID-19 patients admitted to the Khyber Teaching Hospital Peshawar's isolation unit were randomly allocated to 2 groups, Group A prone positioning (PP) was ensured for at least 12 hours by helping proning during rounds by the respiratory therapists and nurses. Further, prone positioning was ensured by the use of telemedicine, whereas Group B just followed the standard care in which awake proning was emphasized on a routine basis without doing any intervention. Their biochemical and clinical parameters, outcomes related to oxygen requirement, intubation, and mortality were followed weekly for two weeks or till discharge. Result(s): Out of the 58 patients, 29 patients with PP had a better outcome in terms of oxygenation (p<0.01), respiratory rate (P<0.05), and inflammatory markers such as serum ferritin (p<0.02) and C reactive protein (p<0.03). Additionally, ventilatory support (18% VS 42%, p<0.05) and mortality rate 21.4% Vs 64.3%) were significantly lower in the PP group. Conclusion(s): Strict compliance of awake prone positioning improved oxygenation in COVID-19 patients, resulting in a clinically better outcome.
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Background: Respiratory therapists (RTs) provide various types of patient care in different clinical settings. Burnout can have an undesirable effect on RTs and their patients. Managing the COVID-19 pandemic, specifically in hospitals, could induce stress in RTs and increase the likelihood of burnout. Therefore, this study aimed to measure the level of burnout among RTs during the COVID-19 pandemic.Method: A validated cross-sectional questionnaire was used to identify the prevalence and characteristics of burnout among RTs. The questionnaire was administered by the respiratory care department of a tertiary healthcare center in Riyadh, Saudi Arabia. The data analysis included descriptive, inferential, and correlational tests.Results: The survey was distributed among 100 RTs with a response rate of 66%. Most respondents reported high burnout levels in the three domains of burnout: 77% reported emotional exhaustion, 98% reported depersonalization, and 73% reported low personal achievement. Univariate analysis revealed that emotional exhaustion was significantly higher among RTs who were male, married, or working in critical care settings. Female RTs and those working in general care settings reported feelings of reduced personal achievement. Furthermore, the analysis revealed a moderate positive correlation between the years of experience and emotional exhaustion (r=0.6, p<0.001).Conclusions: A high prevalence of burnout was observed among RTs in one Saudi tertiary hospital. Burnout is associated with several factors, and interventions should target all domains of burnout. RT management and staff are responsible for addressing their needs and collaboratively working together to overcome burnout. Further investigations focusing on techniques and strategies to alleviate burnout are required.
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Background: Highly effective modulator therapy and the COVID-19 pandemic have transformed cystic fibrosis (CF) care. Increased use of telehealth has resulted in fewer in-person visits, although close monitoring continues to be crucial in preventing complications. Home spirometry is a useful, accessible tool that people with CF can use to monitor their lung function. In spring 2020, the University of North Carolina (UNC) Adult CF Clinic began to distribute home spirometers to their patients through the Cystic Fibrosis Foundation (CFF). At the time, we lacked a standardized home spirometry program and found it challenging to engage patients in regular use of the device. As a result, the UNC adult CF advanced practice provider (APP) and respiratory therapist (RT) collaborated to lead a quality improvement (QI) project aimed at improving home spirometry at their center. Method(s): Goals of the QI effort were to provide individual education for all patients with a home spirometer, incorporate home spirometry assessments into the RT workflow, and provide monthly interpretation of home spirometry results. The CF RT used Epic MyChart messages to engage patients who needed education and to remind patients to use their device before all visits (virtual or face-to-face). The RT and APP also provided inperson teaching and troubleshooting in clinic, and an educational handout was created. Lastly, one-on-one educationwas provided over the phone on nonclinic days. Between November 2021 and January 2022, people with CF who had received a device and adult CF clinicians were surveyed for anonymous feedback on the program. Survey questions used a 5-point Likert scale to indicate agreement with the survey statement and were adapted from a previous home spirometry survey in lung transplant patients [1]. Result(s): Two hundred sixty-five patients (of 327 total adults with CF at UNC) have received a home spirometer through the CFF or another source;250 of these (94%) have received one-on-one education. All six adult CF clinicians completed the feedback survey. The results indicated a high level of satisfaction and a sense that spirometer use was clinically useful (Figure 1). Seventy-eight patients completed the feedback survey. Regarding the program's utility, respondents agreed or strongly agreed with the following statements: spirometer is easy to use (81%), received adequate training (88%), spirometer is accurate (78%), team is interested in my results (96%), makes me feel secure in detecting problems with my lungs (60%), helpful to share results on the provider dashboard (68%), and am overall satisfied with the home spirometry program (78%). When patients were asked about barriers to use of their home spirometer, 48 (62%) selected "none." The most commonly identified barriers (number of responses)were anxiety (5), too difficult to use (4), too time consuming (3), forgetfulness (3), and accuracy (2).(Figure Presented) Figure 1. Adult cystic fibrosis clinician survey results on home spirometry Conclusion(s):Wewere able to leverage thewidespread availability of home spirometers to create a successful home spirometry program within the UNC adult CF clinic. Our survey results indicate that clinicians and patients felt that home spirometry was useful and were highly satisfied with the program Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
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SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Discontinuing mechanical ventilation is a difficult process and takes time. Some patients succeed while others fail and remain on full ventilator support for a longer period. Extubation failure can result in many complications for the patient and a prolonged stay in the ICU. It's a common practice to have an SAT and SBT protocol in the majority of ICUs. Spontaneous awakening trial (SAT) is a nurse-driven protocol for discontinuation of sedation hypnotic drug to facilitate recovery to her baseline level of consciousness/responsiveness and assessment of intrinsic respiratory drive in the critical care setting. In general SAT protocol is followed and most ICUs are in the morning hours. If the patient needs the initial safety screening for SAT the sedative infusion is interrupted with a goal to awaken the patient or SAS 3-4. If the patient is showing signs of SAT failure with either tachypnea or desaturation or cardiac dysrhythmia or unacceptable ventilator asynchrony that the patient is resumed sedation/analgesia at 50% of the previous dose and bolus as needed dose of sedation is also utilized to achieve stability. A spontaneous breathing trial (SBT) is a protocol for systematic weaning of a patient from a mechanical ventilator in preparation for extubation. Before SBT protocol again safety screening is done and if the patient meets the criteria for SBT protocol, the patient is placed on spontaneous breathing mode that his CPAP of 5 to 8 cm of water for 30 to 120 minutes at the same FiO2. Various tools are utilized to analyze the success of the SBT trials including the RSBI index. Each institution has its own assessment of the average length of ventilator stay and the average length of ICU stay. The majority of hospital does SAT/SBT trials once a day for evaluation and successful liberation from ventilator. This project was done with the assumption that if compliance of SAT/SBT huddle is improved and if it is done twice in a day rather than only once the outcome in terms of length of ventilator stay, length of ICU stay, and rate of successful extubation improves METHODS: This is a prospective quality improvement study done at Einstein Medical Center Philadelphia. This is a 16-bed MICU unit and we implemented twice daily hurdle from August 2021 to April 2022. ( Study Period) This project was happening during the COVID pandemic during which the average length of ICU stay and the average length of ventilator stay was already high due to the natural course of COVID ARDS. The SAT/SBT Huddle involved interaction between our respiratory therapist, ICU fellow, and the nurse involved in the patient care. It had a checklist of SAT SBT protocol which needed a signature (electronic or manual) to consider it completed. This was done twice a day from the period of August 2021 to April 2022 (STUDY PERIOD). This study period was compared to the control period (August 2020 to April 2021). The reason for selecting this control period was to remove outlier and increased length of stay due to the COVID pandemic itself with the assumption that the COVID pandemic was present throughout the study and control period. RESULTS: In the control period- ie August 2020 to April 2021 the average ventilator length of stay is 6.85 days. In the study period from August 2021 to April 2022, the average length of a ventilator was 6.21. There is a clear decrease in ventilator length of stay with the intervention and no other change in the sample size. It should be noted that the COVID pandemic with the third surge was happening in both the control and study period. This is approximately a 10% decrease in length of stay. This is a Pilot study and with better compliance with a huddle, the length of stay will decrease further is our assumption. Here the huddle compliance ranged from 60-65% and out estimate is for better power we need at least 70% or more compliance with huddle CONCLUSIONS: Conclusion- This q ality improvement project aims to improve communication amongst healthcare providers with the ultimate goal of patient safety and decreased length of ventilator stay for every patient in MICU. Clearly, the minimal intervention of documenting each huddle and doing it twice a day had a decrease in ventilator length of stay. The greatest challenge for this compliance project is to have documentation of having a twice-daily hurdle. During this period to improve her compliance we have done various methods that included paper signatures electronic signatures and also QR code signatures. Of this, the maximum Complan success rate was achieved with a QR code signature for the huddle members. CLINICAL IMPLICATIONS: Limitation to the study–due to the COVID pandemic the average length of ventilator stay has increased in all hospitals which are affected by the COVID pandemic. Though the reflection of decreased length of ventilator stay is small this gives a glimpse of how her daily communication between a respiratory therapist, nursing staff, and the physician taking care of the patient makes a difference in the patient's overall length of stay and mortality. DISCLOSURES: No relevant relationships by Raminder Cheema No relevant relationships by Megan Dondarski No relevant relationships by Yasmeen Hassan No relevant relationships by Mahwish Hussain No relevant relationships by Myriam Poindijour No relevant relationships by Arnaldo Rodriguez No relevant relationships by Kumar Sarvottam No relevant relationships by Bhavna Sharma No relevant relationships by Teresa Vizak
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SESSION TITLE: Unique Uses of Pulmonary Function Tests SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Prevention of asthma exacerbations can be done through adequate self management at home. This study aimed to evaluate the feasibility and safety of a portable spirometer for unsupervised home spirometry measurements among patients with asthma. METHODS: A single center, prospective, single-arm, open study recruited 25 patients with moderate or severe asthma. After a 45 min video training session by a respiratory therapist, patients performed daily spirometry at home with the Spirobank Smart MIR mobile spirometry system that was bluetooth connected to the KevaTalk app. Each spirometry examination was recorded and evaluated according to the ATS/ERS acceptability and repeatability criteria. Patients had to perform at least three technically acceptable maneuvers with the KevaTalk app guiding them if they had a good or bad blow. The best value of the three maneuvers were used for subsequent analyses. Patients also entered their daily check ins and symptoms via the KevaTalk Asthma app, tracked their controller and rescue medication use, filled up ATAQ questionnaires as well as were reminded of their action plans. Data obtained from spirometry was reviewed by nurses and pulmonologist and the Keva365 remote monitoring platform prompted alerts based on patient checkins, use of medication and PEF values in the red or yellow zone. Any escalations based on nurse review were reported to the office. RESULTS: Mean age of the patients was 57 years. 1155 spirometry sessions were completed over the duration of 9 months of the study. Data for FEV1, FEV6, PEF FEV1/FVC, as well as the Best Predicted and LLN values was reviewed daily for patients. Flow volume loops during the sessions were reviewed to identify if the home spirometry was done correctly and retraining was provided if needed. The reported values were tracked over the duration the patient was enrolled in the Keva program. 60.9% of patients were found to have peak flows in their respective red zones at least once and 87% were found to have peak flows in their yellow zone at least once, during the course of the study. If 3 consecutive values were in the yellow or red zone along with worsening of symptoms, the physician's office was informed for further course of action. CONCLUSIONS: The COVID-19 pandemic led to paucity of in office spirometry and face-to-face visits for asthmatic patients. Increasing the availability of spirometry with handheld devices along with a remote monitoring platform is useful for improving asthma control and reducing the risk of asthma-related hospital admissions and deaths. CLINICAL IMPLICATIONS: Remote objective spirometry yields clinically meaningful information that helps with asthma patient management and prevent an exacerbation from becoming worse. DISCLOSURES: No relevant relationships by Karim Anis No relevant relationships by Varada Divgi No relevant relationships by Jyotsna Mehta No relevant relationships by Shail Mehta No relevant relationships by Denzil Reid
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SESSION TITLE: Quality Improvement SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 pm - 2:30 pm PURPOSE: Prone positioning has been shown to improve survival in patients with Acute Respiratory Distress Syndrome (ARDS). Moving patients from prone to supine position and vice versa adds significant labor for nursing staff, who are already under great stress during the COVID 19 pandemic. We designed a nurse-driven protocol that enables nurses to identify prone intubated ARDS patients who meet criteria to be turned supine and independently implement the change in position. In order to evaluate whether this protocol reduces stress, we surveyed nurses before and after implementation. METHODS: A multidisciplinary team of critical care physicians, nurses, and respiratory therapists designed a nurse-driven protocol for supine trials for prone intubated ARDS patients in a medical intensive care unit (MICU). We designed an anonymous survey to gauge nurses’ awareness of which patients would be turned supine that day, level of difficulty planning their day, and stress level related to supining of a prone ARDS patient. We sent the survey to the nursing staff before implementing the protocol, and again one month after implementation. The survey was sent by professional email and via a private group on social media. Halfway between the surveys, a PDSA cycle was used to modify the protocol with the feedback from nurses and respiratory therapists. RESULTS: Of 82 MICU nurses who received the surveys, 42 (51%) responded to the pre-implementation survey and 33 (40%) responded to the post-implementation survey. Nurses were asked to rate how often they knew at the beginning of their shift whether their prone intubated ARDS patient would be turned supine that day on a 5 point Likert scale (5 indicating “almost never”). Nurses who rated 4 or 5 decreased from 55% (23) pre-implementation to 18% (6) post-implementation. Nurses were asked to rate the difficulty of planning their daily work with a prone intubated ARDS patient on a 5-point Likert scale (5 indicating “most difficult”). Nurses who rated 4 or 5 decreased from 52% (22) to 27% (9) post-implementation. Nurses were asked to rate stress associated with “flipping” their prone intubated ARDS patient on a 5-point Likert scale (5 indicating “most stressful”). Nurses who rated a 4 or 5 decreased from 67% (28) to 36% (12) post-implementation. CONCLUSIONS: A collaboratively developed nurse-driven protocol for supine trials in the prone intubated ARDS patient can improve clarity of the plan of care, facilitate planning the day’s work, and reduce stress amongst Medical ICU nurses who manage these patients. CLINICAL IMPLICATIONS: Institutions can assemble a multidisciplinary team to create a nurse-driven protocol for supine trials to potentially empower nurses in the care of their patients with ARDS. DISCLOSURES: No relevant relationships by Daniel Ahle No relevant relationships by Francisco Barrios no disclosure on file for Jaclyn Boozalis;No relevant relationships by Paul Harford No relevant relationships by Shailaja Hayden no disclosure on file for Jessica Ybarra;
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SESSION TITLE: Trainees: Mental Well-Being and Performance SESSION TYPE: Original Investigations PRESENTED ON: 10/16/22 10:30 am - 11:30 am PURPOSE: Advanced Cardiovascular Life Support (ACLS) certification provides an essential foundation for the recognition and management of cardiac arrests. However, there remains a significant gap between ACLS certification and the competence and confidence required to effectively deploy gained skills to lead an ACLS team. Here we present preliminary data on a novel approach to bridge this gap in Internal Medicine second-year residents (PGY-2) at an academic center through the creation of an ACLS leadership guide and interdisciplinary manikin-based simulation program for in-hospital cardiac arrest (IHCA). METHODS: A pocket card guide for ACLS team leaders was created, focusing on providing a structured approach to leading any ACLS team. This guide included, but was not limited to, a mnemonic offering ordered steps to address during resuscitation as well as an approach for assessment and management of underlying causes of cardiac arrest (e.g. ‘Hs and Ts’), including ultrasound utilization. The simulation program, developed for training ACLS-certified PGY-2s, provides one-on-one learning for 2-4 residents per month with introduction and review of the aforementioned guide followed by cardiac arrest simulation with a resident leader, nurses, pharmacists, respiratory therapists, and medical assistants. Immediately after the simulation, there is a group followed by individual video-based feedback and debrief. Trainees are surveyed pre- and post-session on their perceptions of comfort and proficiency on variable components in leading resuscitation of IHCAs, using a 5-point Likert scale (1=strongly disagree;5=strongly agree). The program was launched on 07/15/21, but simulations were temporarily suspended during the peak Delta COVID-19 surge. The Mann-Whitney test was used for comparing pre- and post-session responses. Results are reported as frequencies and medians (interquartile range [IQR]). RESULTS: Seventeen PGY-2s have completed the training sessions to date, of which 17 and 14 have completed the pre- and post-session surveys, respectively. Compared to pre-session responses regarding leading a cardiac arrest team, there was marked post-session increase in feeling comfortable [generally] (3 [2-3] vs. 4 [4-5];p=<0.0001), feeling proficient (3 [2-3] vs. 4 [4-5];p=<0.0001), and feeling comfortable searching for the underlying cause of cardiac arrest (3 [2-3.25] vs. 4 [3-4];p=0.0359). CONCLUSIONS: These preliminary data show marked improvement in self-reported confidence and competence in leading a cardiac arrest team during IHCA among ACLS-certified Internal Medicine residents, following deployment of an ACLS leadership guide combined with a realistic, high-fidelity, and interdisciplinary, leadership-focused simulation program. CLINICAL IMPLICATIONS: This novel program may enhance trainees’ leadership performance during IHCA, though its generalizability and impact on patients’ outcomes requires further study. DISCLOSURES: No relevant relationships by Christopher Dayton No relevant relationships by Jenny Heins No relevant relationships by Lee Oud
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SESSION TITLE: Actionable Improvements in Safety and Quality SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Ventilator alarms are an audible and visual safeguard within a system which alerts clinicians to potentially critical changes within the patient or ventilator unit. They are a crucial aspect of patient care;however, not every alarm that is generated by the ventilator will provide actionable information. Unfortunately, this can contribute significantly to the overall alarm burden in the intensive care unit. This has been especially true with the marked increase in ventilator use during the COVID-19 pandemic. The individual impact of each alarm can easily become dampened due to the sheer quantity of alarms, ventilator-related and others. Excessive alarming may lead to cognitive overload and alarm fatigue for providers, and eventually, adversely impact patient outcomes. This potentially can lead to missed life-sustaining interventions and medical errors. METHODS: As part of a quality improvement initiative, we evaluated ventilator alarms through the month of October 2021 in the medical intensive care unit within Bellevue Hospital Center in New York City. Respiratory therapists recorded ventilator parameters and extracted alarm data daily from every ventilator within the medical intensive care unit. Ventilator logs were exported from each individual Servo-U ventilator unit in use onto a USB flash drive and the captured data was uploaded to a secure network for review. For each ventilator, data regarding specific alarm type and priority as defined by the manufacturer, as well as time, frequency, and duration was obtained for review. RESULTS: From October 4, 2021, to October 31, 2021, a total of 30,230 ventilator alarms were initiated over 672 hours in the MICU. This provided an approximate mean of 45 alarms per ventilator hour. Data was collected daily from all MICU ventilators in use which averaged about 12 ventilators per day (between 6-16). The top four alarms as defined by the ventilator were “airway pressure high,” “respiratory rate high,” “PEEP [positive end expiratory pressure] low,” and “expiratory minute volume low.” 18,451 alarms over the month were “airway pressure high.” 3,982 alarms were defined as “respiratory rate high.” 2,220 alarms were “PEEP low” and 2,041 alarms were “expiratory minute volume low.” CONCLUSIONS: Ventilator alarms, both nuisance and actionable alarms, contribute significantly to the alarm burden in the medical intensive care unit. Dedicated research is necessary to ensure safer alarm practices. CLINICAL IMPLICATIONS: Evaluating baseline alarm data allows for assessments as well as analyses of trends and patterns that are contributing to the excessive noise within the intensive care units. This gives hospitals an opportunity to provide targeted multidisciplinary educational initiatives and create standardized protocols to enhance the quality and safety surrounding ventilator alarms within intensive care units. DISCLOSURES: No relevant relationships by Kerry Hena No relevant relationships by Charmel Rogers no disclosure on file for Amit Uppal;No relevant relationships by Tatiana Weinstein
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SESSION TITLE: Acute COVID-19 and Beyond: from Hospital to Homebound SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: The aim of this study was to determine risk factors for residual pulmonary radiological and functional abnormalities and assessment of possible treatment approaches for reducing such complications in survivors with post-ARDS related to COVID-19. METHODS: There were 97 survivors enrolled, 12 weeks after severe ARDS who were intubated in COVID-19. All survivors admitted to pulmonary and critical care departments of university hospital from 30 August to 30 November 2021. 39 patients with lung radiographic abnormalities between 50-75%;58 patients with lung abnormalities more than 75%. RESULTS: At 12 weeks after discharge all patients reported persistent symptoms: dyspnea 100.0%, cough 42.3%, chest pain 51.1%, fever 29.0%, and hemoptysis 18.5%. More severe dyspnea (increased by exertion and at rest) was found with lung involvement more than 75%(OR 4.25[0.94-10.34]95%CI;p<0.0001).Pulmonary function tests were abnormal in all patients, however,more severe functional abnormalities were with lung involvement more than 75% and median FVC predicted was (46.3+_11.9 vs 64.7+_10.6;p<0.001),DLCO also was significantly lower (54.6+_9.3 vs 70.4+_8.4;p<0.01).Comorbidities such as diabetes milletus (DM) (OR 2.87[0.86-7.34]95%CI;p<0.002), obesity(OR2.44[0.79-6.98]95%CI;p=0.003), older age (OR 2.12[0.72-5.88]95%CI;p<0.004), and kidney failure (OR2.01[0.70-5.22]95%CI;p=0.005) were common in lung involvement more than 75%. Lack of dexamethasone at ICU admission with ARDS was significantly associated with more severe residual pulmonary abnormaliries: organizing pneumonia (OR 4.82[0.99-12.32]95%CI;p<0.0001),usual interstitial pneumonia(UIP)(OR 3.22[0.85-9.23]95%CI;p<0.0004),traction bronchiectasis(OR2.38[0.74-6.12]95%CI;p<0.001),and cystic changes (p<0.001) were commonest. In contrast, ground galss opacity (GGO) was commonest in use of dexamethasone (OR 2.95[0.79-7.54]95%CI;p<0.001). Multi-drug-resistant (MDR) pahtogen caused ventilator associated pneumonia (VAP) at the time intubation was significantly associated with residual OP (OR 4.76[0.91-11.66]95%CI;p<0.0001). CONCLUSIONS: There were several risk factors found for development of more severe residual pulmonary functional and radiological abnormalities: older age, and comorbidities such as DM, obesity, and kidney failure. Lack of use of dexamethasone was associated with development OP,UIP,traction bronchiectasis,and cystic changes.OP was common in patients with history of MDR-pathogen-caused VAP at intubation.The use of dexamethasone was associated with non-severe residual pulmonary functional and radiological abnormalities. CLINICAL IMPLICATIONS: The result of our investigation might be helpful for clinicians in COVID-19 practice.Our findings also may be helpful for pulmonologists, respiratory therapist, and nurses. Also our discussion may aid in correct management of ARDS and minimalizing of residual pulmonary functional and radiological abnormalities. DISCLOSURES: No relevant relationships by Alizamin Sadigov
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Purpose: We report the clinical outcomes of an Adult Respiratory ECMO (VV-ECMO) program that was rapidly established in a community hospital within a 4-week period. The program was launched in response to increasing patients presenting with acute respiratory failure due to COVID-19. Method(s): Our institution supported urgent preparedness to add VVECMO therapy to our established, nurse-run Adult VA-ECMO program. ICU nurses were trained to run VV-ECMO through interdisciplinary collaboration with neonatal-pediatric ECMO nurses, cardiac perfusionists, providers (NP, PA), respiratory therapists, and physicians. Retrospective data of VV-ECMO therapy was collected between November 2020 and June 2022. Result(s): 29 patients with ARDS due to COVID-19 received VV-ECMO. Of the 29 patients were 23 males and 6 females, of median age 48 (31-59) years and median body mass index (BMI) 31.4 kg/m2 (20.5-49.2). The mean duration of VV-ECMO was 970 hours (44.1 days) and the longest run time was 2752 hours (114.6 days). Patient survival rate to VV-ECMO explant was 66%. Patient survival to discharge with a return to pre-ECMO functional capacity was 55%, defined as supplemental oxygen requirements less than 3L nasal cannula and rehabilitating to activities of daily living. Conclusion(s): In the setting of the COVID-19 pandemic, an Adult VV-ECMO program was rapidly developed and executed in an advanced community hospital system. Our VV-ECMO program results are comparable to programs at major academic centers, with survival rates on par with statistics reported by the ELSO registry. Additionally, our outcomes demonstrate that a nurse-run VV-ECMO program can be both feasible and successful.
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BACKGROUND: Workforce development for the respiratory therapy (RT) profession is a growing concern. Upcoming staffing difficulties are expected due to retirement, attrition from the profession, and decreased enrollment in accredited RT programs nationwide. This study assessed respiratory therapists' perceptions of staffing needs and future trajectory of the RT profession. METHODS: This cross-sectional study utilized a modified 39-question survey tool delivered via e-mail to 618 Louisiana members of the American Association for Respiratory Care (AARC) between November 2019-February 2020. RESULTS: The response rate was 19% (118/618). Although 50% of respondents perceived understaffing, 77.6% indicated the importance to remain in the RT profession. A majority (93.1%) agreed on the importance of maintaining an active membership in the AARC. Respondents working in a hospital setting perceived understaffed work environments more often than other groups. Salary was most important to the employee (33.6%, 39/116), followed equally by room for growth (14.7%, 17/116) and scope of practice (14.7%, 17/116). For the future of the profession, the ability to assess patients and develop care plans and the ability to receive reimbursement for services were indicated as most important factors. Most (69.8%) agreed that the entry-level minimum should be increased to the bachelor's degree, and 21.6% agreed the master's degree in RT should be supported to increase scope of practice. CONCLUSIONS: This study indicated a consistent perception of understaffed work environments in respiratory care, and respondents expressed a perceived importance of remaining in the RT profession. This study also indicated support for raising the entry-level standard in RT and a desire for higher education to achieve professional growth and advancement.
Subject(s)
Pandemics , Respiratory Therapy , Cross-Sectional Studies , Humans , Respiratory Therapy/education , Surveys and Questionnaires , United States , WorkforceABSTRACT
Aim and objective: To determine the incidence of air leak in patients who are on non-invasive ventilation in a COVID ICU at a tertiary hospital. Materials and methods: Non-invasive ventilation (NIV) is a mode of providing ventilatory support without using an invasive airway. It has become increasingly popular in managing respiratory failures in recent times. The success of NIV is multifactorial. Among these, using an appropriate interface and ensuring patient co-operation is important as air leak at the interface is a major and a common cause of NIV failure. Through this audit, we aim to look at the incidence of air-leak among patients on NIV and assess if the incidence of air-leak can be reduced via the use of checklist. The audit included patients on non-invasive ventilation and excluded patients on NIV who had air leak from any source other than the interface also patients with facial anomalies were excluded. We monitored patients on NIV in a COVID ICU twice a day for a period of 1 week and recorded the percentage of air leak as calculated by the ventilator (Hamilton G5). For the purpose of this audit, we categorised air leak into mild (10%-< 30%), moderate (30%-<50%), and severe (≥50%). Following the first cycle of the audit, we tabulated the data and discussed the results with the respiratory therapist. A checklist was formulated which included hourly observations to ensure adequate mask seal and minimize air leak along with ensuring adequate sedation. Subsequently, we conducted two post-intervention cycles of the audit to check the efficiency of the checklist in reducing air leak in patients on NIV. Results: The first cycle of the audit showed that 27.45% of patients had severe air leak and 50.98% of patients had mild to moderate air leak on NIV. In addition, it was noted only 21.57% of patients had correct positioning of the mask with a permissible air leak of <10%. Therefore, we implemented the intervention checklist for the respiratory therapist to ensure minimal air leak and subsequently repeated the audit. Following which the percentage of severe air leak in patients on NIV dropped from 27.45% to 5.09%. The percentage of patients with permissible air leak marginally improved from 21.57% to 27.12%. A third cycle of the audit was done to ensure consistent results following the intervention and it did demonstrate consistent results similar to the second cycle of the audit with a percentage of patients with severe air leak being only 5.88% in comparison to 27.45% in the first cycle. Moreover, the percentage of patients with moderate air leak also dropped to 5.88% in comparison to 24.51% from the first audit and 22.03% from the second audit. Conclusion: A simple checklist based on hourly observations helped to improve ventilation in patients on NIV by decreasing the percentage of severe and moderate air leak and the method proved to be sustainable.
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BACKGROUND: Burnout is a major challenge in health care and is associated with poor overall well-being, increased medical errors, worse patient outcomes, and low job satisfaction. There is scant literature focused on the respiratory therapist's (RT) experience of burnout, and a thorough exploration of RTs' perception of factors associated with burnout has not been reported. The aim of this qualitative study was to understand the factors associated with burnout as experienced by RTs amid the COVID-19 pandemic. METHODS: We performed a post hoc, qualitative analysis of free-text responses from a survey of burnout prevalence in RTs. RESULTS: There were 1,114 total and 220 free-text responses. Five overarching themes emerged from the analysis: staffing, workload, physical/emotional consequences, lack of effective leadership, and lack of respect. Respondents discussed feelings of anxiety, depression, and compassion fatigue as well as concerns that lack of adequate staffing, high workload assignments, and inadequate support from leadership contributed to feelings of burnout. Specific instances of higher patient acuity, surge in critically ill patients, rapidly evolving changes in treatment recommendations, and minimal training and preparation for an extended scope of practice were reported as stressors that led to burnout. Some respondents stated that they felt a lack of respect for both the RT profession and the contribution of RTs to patient care. CONCLUSIONS: Themes associated with burnout in RTs included staffing, workload, physical and emotional exhaustion, lack of effective leadership, and lack of respect. These results provide potential targets for interventions to combat burnout among RTs.
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Burnout, Professional , COVID-19 , Humans , COVID-19/epidemiology , Pandemics , Burnout, Professional/epidemiology , Burnout, Professional/psychology , Job Satisfaction , Workload/psychology , Surveys and QuestionnairesABSTRACT
Introduction: Telehealth has been widely integrated into healthcare systems during the COVID-19 pandemic and is here to stay. At the Greater Los Angeles VA Healthcare System (GLA-VAHS), for patients newly diagnosed with sleep apnea pre-pandemic, the majority of initial positive airway pressure (PAP) set-ups and education was done in person. During the pandemic, this process was transitioned to telehealth using video/phone and PAP machines were mailed out to patients. The cost effectiveness of telehealth integration has not been well characterized. As part of a larger study examining the overall efficacy of telehealth versus in-person PAP set-up, we performed a cost analysis of these two modalities at the GLA-VAHS. Methods: We performed a cost analysis of telehealth versus in-person set-up of PAP for patients newly diagnosed with sleep apnea at GLAVAHS between March and October 2021 (n = 2,662 PAP set-ups). There was an average of 16 PAP set-ups per day with 11 set-ups (68.75%) via telehealth and 5 set-ups (31.25%) in person. We used a bottom-up analysis which includes only variable direct costs and factors out the high costs of healthcare infrastructure. Results: At GLA-VAHS, the cost of telehealth PAP set-up was $98.87 per patient and in-person PAP set-up was $49.85 per patient. For telehealth set-ups, there was an additional cost of mailing the PAP machine and more respiratory therapist (RT) time spent on educating patients compared to in-person set-ups (31.2% more RT time). After initial PAP set-up, a larger subset of patients required additional troubleshooting help from RTs about proper PAP use after telehealth compared to in-person set-ups (5% versus 1%). Conclusion: Telehealth PAP setups were nearly two times the cost of in-person PAP set-ups at GLA-VAHS due to the cost of mailing the PAP machine, more RT time spent on education, and a higher rate of troubleshooting. While the costs of telehealth implementation is one factor, one must also consider the benefits of telehealth including ability to capture more patients and higher patient satisfaction which may outweigh these costs. There are opportunities for institutions to alleviate bottlenecks with telehealth use such as supplemental educational materials about PAP use ahead of set-ups or scripting RT and patient dialogue when familiarizing patients with a PAP machine. In addition, as providers and patients become more familiar with interfacing with telehealth, efficiency with use of these systems is likely to improve and reduce costs in the long run.
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Rationale: Hypoxia altitude simulation tests (HASTs) simulate changes in physiology that occur during commercial air flight (FiO2 16% in cabin pressurized to 8,000 ft) and help identify patients who may need additional respiratory support during flight. There is a paucity of literature regarding pediatric HAST studies. The purpose of this study is to identify patient characteristics, indications, and results of HAST studies at a pediatric tertiary care referral center. Methods: This IRB-exempt, retrospective chart review examined HAST studies over 5 years (2017-2021) at Nemours Children's Hospital (Wilmington, Delaware, USA). HAST studies were performed by respiratory therapists, supervised by pulmonologists, in the PFT laboratory. Standard protocol for the studies was performed including administration of 16% oxygen while monitoring SpO2 and heart rate for 10 minutes and administration of supplemental oxygen as indicated. Patient information collected included: demographic and anthropometric data, primary indication for HAST, baseline respiratory support, co-morbidities, reported prior difficulty with air travel, and results. Descriptive statistics were calculated. Results: 22 studies were ordered, and 12 were completed. Characteristics of patients who completed testing (N=12) are as follows: Mean age 77.0 (range 1.4-216) months, mean weight 21.7 kg, 58% male, 75% white, 8.3% with baseline tracheostomy/ventilatordependence, and 16.7% with baseline supplemental oxygen dependence. 25% reported history of difficulty with air flight. The most common primary indications included chronic lung disease of prematurity (41.7%), followed by restrictive lung disease (50%), followed by sickle cell disease (8.3%). Of the 12 patients who completed testing, 4 had abnormal results. Of those, the mean age was 45.6 months, mean weight 12.6 kg, 75% were male, and 50% on supplemental oxygen at baseline. The most common indications were chronic lung disease of prematurity (50%) followed by restrictive lung disease (50%). The most common co-morbidity was asthma (75%). See Table 1. Compared to patients who had normal results, patients with abnormal testing had a greater change in SpO2 (10.8 vs 4.9%) with lower mean SpO2 nadir of 87% compared to 93.6%. Discussion: The most common indications for HAST studies in this pediatric study include chronic lung disease of prematurity, restrictive lung disease, and sickle cell disease. Many studies were not completed, likely due to decrease in air travel during the Covid-19 pandemic. Patients with abnormal results were younger and more likely to have baseline oxygen requirements. Further research is needed to better understand which pediatric patients are at risk for cardiorespiratory compromise during flight or at altitude.
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Rationale: High flow nasal cannula (HFNC) is first line therapy for patients with acute hypoxic respiratory failure (AHRF). HFNC utilization among hospitalized patients with AHRF has increased substantially during the COVID-19 pandemic. While good evidence exists to guide initiation of HFNC, evidence-based strategies for HFNC weaning are lacking. Therefore, we sought to characterize HFNC weaning practices among respiratory therapists (RTs) to determine the degree of practice variability and assess general approaches to HFNC weaning. Methods: We conducted a cross-sectional survey evaluating HFNC weaning practices of adult inpatient RTs at an academic, tertiary care medical center in the United States. Survey participants were asked about their practice of HFNC weaning and whether use of an institutional protocol provided guidance for HFNC weaning. Survey questions also assessed RT knowledge of institutional policies regarding HFNC use in hospitalized patients, including location of HFNC use within the hospital, personnel involved in HFNC titration, and methods of weaning through clinical vignettes. Survey responses were analyzed using descriptive statistics. Results: Overall, 21 of 68 RTs surveyed completed the survey (response rate 31%). The majority of participants (95%) worked primarily in an ICU, general wards, or emergency department. Approximately one-third of participants were unaware of a HFNC weaning protocol at their institution. Among those who endorsed the existence of a HFNC weaning protocol at their institution, 79% reported using the protocol “always or often.” We found substantial variation in RT knowledge of institutional policies regarding which practitioners were permitted to wean HFNC, with approximately one-half of participants believing that any practitioner could wean FiO2 and 43% believing that only RTs could wean flow. Additionally, participants' approaches to weaning varied substantially in response to clinical vignettes. For example, in the vignette of a clinically stable patient on HFNC at 60L and 100%, 62% of participants chose to wean only FiO2, 14% to wean only flow, and 24% to wean both. Conclusion: Nearly one-third of respiratory therapists were unaware of the existing HFNC weaning protocol at their institution, potentially contributing to the substantial variability in HFNC weaning practices between surveyed RTs. More research is needed to identify and successfully implement optimal weaning strategies for HFNC among patients hospitalized with AHRF.
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RATIONALE: There is controversy regarding which factors should guide resource allocation decisions during triage. Healthcare professionals' different roles and experiences may influence their beliefs and be relevant to development and implementation of triage protocols. We therefore sought to compare views of healthcare professionals in different roles on how strongly various health factors should influence patients' likelihood of receiving life-support in triage. METHODS: Secondary analysis of UC-COVID data. We analyzed responses from an online volunteer sample of 1,935 adult participants, including 582 healthcare professionals (HCPs) recruited from community organizations and direct media messaging. The survey was fielded from May-September, 2020. The main outcome measures were how likely patients should be to receive life support, rated on a Likert scale, from 1 (should be much less likely) to 9 (should be much more likely). Responses were combined into terciles with 1-3 coded as “deprioritized”, 4-6 as “neither deprioritized or prioritized” and 7-9 as “prioritized”. Health factors assessed included patients who (1) are deemed less likely to survive, (2) have shorter expected lifespans due to chronic illness, (3) are elderly, and (4) are children. Differences between healthcare groups were assessed using Pearson's chi-squared test. RESULTS: Of the 582 HCPs, 26% identified as physicians, 8% as advanced practice providers (including, nurse practitioners, physician's assistants, or other), 33% as primary bedside providers (including nurses, medical assistants, or respiratory therapists), and 33% as some other HCP. A majority of physicians (75%), advance practice providers (67%) and primary bedside providers (64%) deprioritized patients deemed less likely to survive compared to a minority of other HCPs (46%, p<.0001). A minority in each group deprioritized patients with shorter expected lifespans due to chronic illness, but physicians were more likely to deprioritize (49%) compared to advance practice providers (42%), primary bedside providers (37%), and other HCPs (20%, p<.0001). Fewer than 25% in all groups deprioritized patients who are elderly physicians (23%), advance practice providers (24%), primary bedside providers (18%), and other HCPs (11%, p=0.046). Less than 10% in any group thought children should be deprioritized (p=0.20). CONCLUSIONS:There was broad agreement among all groups that children and the elderly should not be deprioritized in triage decisions. There was more disagreement on how to prioritize patients deemed less likely to survive or patients with shorter expected lifespans due to chronic illness. It was also notable that physicians more often deprioritized based on these health factors compared to other groups.
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Rationale: Patients with chronic obstructive pulmonary disease (COPD) suffer heightened morbidity, mortality, and readmission rates. COPD is co-prevalent with obstructive sleep apnea (OSA) in 20-60% of patients, and patients with COPD/OSA overlap are at higher risk for hospital readmission and mortality compared to COPD alone. Current COPD readmission reduction programs are focused on decreasing COPD readmissions;however, few explore impactful comorbid conditions. No study has identified peri-discharge barriers in the acute care setting from the perspective of patients with COPD/OSA or healthcare workers to identify areas of improvement. Methods: Semi-structured interviews, conducted via telephone (recorded) of hospitalized patients with COPD/OSA and acute care healthcare workers were conducted at an urban academic medical center (11/2020-1/2021) among a convenience sample of recruited participants. All recordings were transcribed and uploaded to NVivo, which facilitated thematic analysis, using an a priori codebook. Coding was conducted in rounds, and meetings were used to resolve differences and update the codebook as needed. This iterative process continued until all transcripts were analyzed. Results: Thirty-five participants were interviewed, 27 healthcare workers (HCW), 4 nurses, 6 respiratory therapists, 5 physicians, 3 case managers, 4 social workers, and 5 pharmacists, and 8 patients. The HCWs interviewed served an average of 7.5 years, were <50 years old (81.5%), and most were female (74.1%), white (81.5%), and non-Hispanic (100%). HCW respondents identified barriers that mapped to four main levels: patient, team, hospital, and the healthcare system. Select barriers HCWs identified included health literacy, patient cognitive impairments, peri-discharge time management, lack of resources for patients post-discharge, cost, and insurance. All patient interviewees were <50 years old, most were male (62.5%), white (62.5%), and non-Hispanic (87.5%). Select barriers patients identified included current SES status, care team discussions, disease burden (visits to ED/hospital), follow-up care (including transportation), and perceptions of healthcare due to COVID-19. Conclusion: Healthcare workers and COPD/OSA patients report multilevel hospital discharge barriers. To improve barriers to care for these complex patients, multilevel interventions addressing noted barriers are needed.
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Introduction: Telehealth has been widely integrated into healthcare systems during the COVID-19 pandemic and is likely to remain a part of routine clinical care. At the VA Greater Los Angeles Healthcare System (VAGLAHS), positive airway pressure (PAP) set-up visits transitioned from in person to telehealth for newly diagnosed sleep apnea patients during the pandemic. The telehealth pathway included mailing of PAP machines to patients with follow-up video/phone education by respiratory therapists (RTs). As part of a larger study examining the clinical outcomes resulting from telehealth versus in-person PAP initiation, we performed a cost analysis of these two treatment pathways within VAGLAHS. Methods: We examined the total variable direct cost of telehealth versus in-person PAP initiation for patients newly diagnosed with sleep apnea at VAGLAHS between March and October 2021 (n = 2,662 PAP set-ups) using a bottom-up analysis. There was an average of 16 PAP set-ups per day with 11 set-ups (68.7%) via telehealth and 5 set-ups (31.3%) in person. Results: The total variable direct cost of telehealth PAP initiation was $98.87 per patient. The total variable direct cost of in-person PAP initiation was $50.58 per patient. For telehealth, there was an additional cost of mailing the PAP machine and 31.2% more RT time spent on educating patients compared to the in-person pathway. After the initial PAP set-up visit, a larger subset of patients required additional troubleshooting help from RTs about proper PAP use after telehealth compared to in-person set-ups (5% versus 1%). Conclusion: The telehealth PAP initiation pathway was nearly two times the cost of in-person PAP initiation. This resulted from the additional cost of mailing the PAP machine, more RT time spent on education, and a greater need for troubleshooting after the visit. Telehealth visits may need to be supplemented by written educational materials or web-based resources to reduce the need for additional support after the initial visit.