Biomedical subjects

L Kester

Publications and source records attributed to L Kester.

8 recordsLinked to original sources

PubMed2001

The impact of turnover among respiratory care practitioners in a health care system: frequency and associated costs.

BACKGROUND: Retention of respiratory therapists (RTs) is a desired institutional goal that reflects department loyalty and RTs' satisfaction. When RTs leave a department, services are disrupted and new therapists must undergo orientation and training, which requires time and expense. Despite the widely shared goal of minimal turnover, neither the annual rate nor the associated expense of turnover for RTs has been described. STUDY PURPOSE: Determine the rate of RT turnover and the costs related to training new staff members. METHODS: The Cleveland Clinic Health System is composed of 9 participating hospitals, which range from small, community-based institutions to large, tertiary care institutions. To elicit information about annual turnover among RTs throughout the system, we conducted a survey of key personnel in each of the hospitals' respiratory therapy departments. To calculate the costs of training, we reviewed the training schedule for an RT joining the Respiratory Therapy Section at the Cleveland Clinic Hospital. Cost estimates reflect the duration of training by various supervisory RTs, their respective wages (including benefit costs), and educational materials used in training and orientation. RESULTS: Turnover rates ranged from 3% to 18% per year. Five of the 8 institutions from which rates were available reported rates greater than 8% per year. The rate of annual turnover correlated significantly with the ratio of hospital beds to RT staff (Pearson r = 0.784, r(2) = 0.61, p = 0.02). The cost of training an RT at the Cleveland Clinic Hospital totaled $3,447.11. CONCLUSIONS: Turnover among respiratory therapists poses a substantial problem because of its frequency and expense. Greater attention to issues affecting turnover and to enhancing retention of RTs is warranted.

Allied Health Personnel↗

PubMed1998

Respiratory care protocols in postanesthesia care.

Respiratory care protocols have been developed for specific therapies that include the following: oxygen titration, weaning from mechanical ventilation, sampling arterial blood gases, managing bronchospasm and secretions, treating atelectasis, endotracheal extubation, and managing the postextubation airway. Although relatively little attention has been given to using protocols in postanesthesia care, this environment lends itself to applying protocols. In this context, studies have examined and support the use of protocols for titrating supplemental oxygen, weaning patients from mechanical ventilation, and sampling arterial blood gases. As with other previously mentioned respiratory protocols, these protocols have shown efficacy for improving allocation of respiratory care services, cost savings, and favorable clinical outcomes. On this basis, while recognizing the need for further studies, respiratory care protocols implemented by respiratory therapists can be beneficial in the postanesthesia care setting.

Algorithms↗

PubMed1998

Randomized controlled trial of physician-directed versus respiratory therapy consult service-directed respiratory care to adult non-ICU inpatients.

Although current evidence suggests that respiratory care protocols can enhance allocation of respiratory care services while conserving costs, a randomized trial is needed to address shortcomings of available studies. We therefore conducted a randomized controlled trial comparing respiratory care for adult non-ICU inpatients directed by a Respiratory Therapy Consult Service (RTCS) versus respiratory care by managing physicians. Eligible subjects were adult non-ICU inpatients whose physicians had prescribed specific respiratory care services. Consecutive eligible patients were approached for consent, after which a blocked randomization strategy was used to assign patients to (1) Physician-directed respiratory care, in which the prescribed physician respiratory care orders were maintained (n = 74), or (2) RTCS-directed respiratory care, in which the physician's respiratory care orders were preempted by a respiratory care plan generated by the RTCS (n = 71). Specifically, these patients were evaluated by an RTCS therapist evaluator whose respiratory care plan was based on sign/symptom-based algorithms drafted to comply with the American Association for Respiratory Care (AARC) Clinical Practice Guidelines. Appropriateness of respiratory care orders was assessed as agreement between the prescribed respiratory care plan and an algorithm-based "standard care plan" generated by an expert therapist who was blind to the patient's actual orders. The compared groups were similar at baseline regarding demographic features, admission diagnostic category, smoking status, and Triage Score (mean, 3.8 +/- 0.9 SD [RTCS] versus 3.7 +/- 1.0). Similarly, no differences were observed between RTCS-directed and physician-directed respiratory care regarding hospital mortality rate (5.7 versus 5.6%), hospital length of stay (7.9 +/- 9.0 versus 7.7 +/- 7.3 d), total number of respiratory care treatments delivered (30.3 +/- 30 versus 31.6 +/- 30.5), or days requiring respiratory care (4.2 +/- 5.2 versus 4.1 +/- 3.6). Notably, using both a stringent (S) and a liberal (L) criterion for agreement, RTCS-directed respiratory care demonstrated better agreement with the "standard care plan" (82 +/- 17% [S] and 86 +/- 16% [L]) than did physician-directed respiratory care (64 +/- 21% [S] and 72 +/- 23% [L]) (p < 0.001). Finally, the true cost of respiratory care treatments was slightly lower with RTCS-directed respiratory care (mean, $235.70 versus $255.70/pt, p = 0.61). We conclude that (1) compared with physician-directed respiratory care, the RTCS prescribed a similar number and duration of respiratory care services at a slight savings (that did not achieve statistical significance) and without any increased adverse events; and (2) compared with physician-directed respiratory care, RTCS-directed respiratory care showed greater agreement with Clinical Practice Guideline-based algorithms.

Adult↗

PubMed1996

Constructing a therapist-driven protocol. Spectrum of types and quality control.

Therapist-driven protocols for the implementation and delivery of respiratory care must be tailored to fit the needs of the individual institution. The method that is chosen for constructing a therapist-driven protocol depends on the type of protocol desired (disease-, symptom-, or treatment-based) and on whether a narrative or flow-diagram format is preferred. Because the goal of therapist-driven protocols is to provide a systematic method for determining appropriate respiratory care, quality control measures are necessary to ensure that desired outcomes are achieved. Quality control monitoring can be performed through the use of case-study exercises, verbal shift reports, and care-plan audits. Results of quality control monitoring techniques can be used to guide modification of protocols.

Clinical Protocols↗

PubMed1993

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: early experience at The Cleveland Clinic Foundation.

BACKGROUND: Accumulative evidence suggests that respiratory care is frequently misallocated. We report the results of a pilot study of a delivery system aimed at correcting such misallocation. METHODS: The delivery system (Respiratory Therapy Consult Service, or RTCS) allows respiratory therapists (when requested by the case-managing physician) to determine respiratory care, with decisions guided by algorithm (ie, Consult patients). In the pilot study, Therapist Evaluators responded to requests for Consults on two study wards. All staff therapists participated in implementing Evaluator-determined treatment. STUDY DESIGN: We evaluated 38 patients (20 of whom were Consult patients) randomly selected from a total of 82 patients undergoing abdominal surgery during the study period. RESULTS: Consult patients were significantly older than non-Consult patients, more likely to be heavy smokers (67 vs 43%), and sicker as suggested by a higher Triage Score. Consult patients received more types and more total respiratory care services, demonstrated a trend toward longer stay, and had significantly higher respiratory therapy charges. CONCLUSION: Our experience shows that a consult program can be successfully implemented in a large, tertiary care institution with widespread physician and nursing support. Whether the RTCS fulfills its goal of ameliorating misallocation of respiratory care has yet to be proven and awaits the completion of other studies currently under way.

Abdomen↗

PubMed1991

Cost impact of metered dose inhalers vs small volume nebulizers in hospitalized patients: the Cleveland Clinic experience.

To assess the cost impact of using metered dose inhalers (MDIs) versus small volume nebulizers (SVNs) for hospitalized adult patients not being managed in ICUs, we analyzed the labor, equipment, and medication costs associated with using MDIs at The Cleveland Clinic Foundation. Over the study interval (January 1988-December 1989), a policy was implemented to enhance MDI use, resulting in increased use of MDIs (18% of all bronchodilator treatments in 1989 vs 5% in 1988). Based on a volume of approximately 70,000 bronchodilator treatments/year in our hospital, increased MDI use with this policy reduced direct costs by $26,510, with associated savings in respiratory-therapist time. To extend this analysis of costs to other institutional settings, we present an analysis of projected changes in institutional costs when the volume of bronchodilator therapies and the percentage administered by MDI varies.

Adult↗

PubMed1986

Pulmonary edema of environmental origin--newer concepts.

Pulmonary edema of non-cardiac origin is usually an urgent clinical problem, which has recently increased in frequency throughout the world in the past few years. This is partly due to sociological factors and to pre-eminent advances in industrial technology. Recent severe massive toxic gas explosions have had national and worldwide implications. Therefore, urgent and appropriate therapy is of utmost importance in most of these patients. The use of high flow oxygen with Constant Positive Pressure Breathing are the main inhalational therapeutic approaches. Newer modalities of treatment include: (1) earlier Fiberoptic bronchoscopy in those individuals afflicted with aspiration problems and (2) certain specific chemical blocking agents for the management of phosgene intoxication and hydrogen sulfide toxicity. Preventive environmental measures are also important.

Adult↗

PubMedDate not supplied

Ordering respiratory care services for hospitalized patients: practices of overuse and underuse.

Because of recent concerns about misallocation of respiratory care services and analyses suggesting that limiting services to comply with established guidelines reduces unneeded therapies without compromising quality of care, the authors audited the records of 170 patients newly ordered to receive at least one of five respiratory therapies (oxygen therapy, incentive spirometry, bronchopulmonary hygiene, aerosolized bronchodilator therapy, or intermittent positive pressure breathing) at The Cleveland Clinic Foundation. In reviewing whether the therapies that were ordered complied with published guidelines for these services, we found that 25.2% were "not indicated." This over-ordering incurred unnecessary total charges of $11,937 ($206.16 per patient) and occupied therapist time that could have been better allocated to other services. These costs were offset by the finding that 10.5% of the patients were not ordered to receive indicated respiratory therapies. Our proposed strategy of initiating protocols for ordering and providing respiratory care services (ie, via a respiratory care consult service) is an appealing means to address this misallocation, but it requires further evaluation.

Cost Control↗