Surviving Before Thriving Part II:
Michael J Hewitt, RRT, ACCS, NPS, RCP, FAARC, FCCM
Clinical Manager, Respiratory Care Services
Rhode Island Hospital & Hasbro Children’s Hospital
Principal Teaching Hospital, The Warren Alpert Medical School of Brown University
Providence, Rhode Island
Chair; Respiratory Section, Society of Critical Care Medicine
Secretary, Rhode Island Society for Respiratory Care
Conflict of Interest Disclosures
I wish to disclose the following potential conflicts of interest:
Type of Potential
Conflict
Details of Potential Conflict
Grant/Research
Support
Consultant
Speakers’ Bureaus
Financial support
Other
Monaghan Medical, Hollister, Inc
Remember This?
The Fork In The Road….
The Road To
Extinction?
Surviving &
Thriving
Things Haven’t Gotten Any Better
Let’s Review:

The Medical Environment Is Still
Changing

Reimbursement Structures Are Worse

Payor Mixes Continue To Be Unfavorable

We Are Still Under The Microscope
What’s The Big Deal?

Our Problems As A Profession Are NOT The
Result Of Or The Fault Of The ACA

Respiratory Therapy Is Still An Easy Target
And It Is Still Our Own Fault

It’s Still All About What Value We Bring To
The Table: Now More Than Ever
How Do We Get There?
Reminder:
Incentive Spirometry, Albuterol & Mucomyst Ain’t It!
Changing Tradition Is The Key To Our Survival
It’s That Simple
Or Is It?
Payor Mixes Are At Critical Mass
Some Real Life Examples:
Hospital A:
71%
Hospital B:
54%
Hospital C:
55%
Hospital D:
69%
Where Does Your Hospital Lie?
Changing Tradition
Surgical Patients: Aggressive & Proactive
(90% Of All Surgical Patients Get Atelectasis)
Medicine Patients: Aggressive & More Effective
(COPD Is Now On The 30 Day Readmission Penalties List)
There’s a Whole New Wave Of Patients On The Way.
Who Are They?
The Baby Boomers!!
(the class of 46-64)
aka: The Silver Tsunami
69,500,000 Americans Eligible To Retire In The Next
6 Years
Is This COPD Thing Really A Big Deal?
My Own Hospital
COPD Readmissions <30 Days avg. LOS (June 12-July 14):
8.44 days actual vs. 4.17 expected (UHC)
Average Cost Per Readmission:
Floor Admission: $35,268.91
ICU Admission: $154,696.00
That = Financial Disaster
Where Does Your Hospital Lie?
So, Now What?
We Develop A Plan/Strategy To Decrease These
Readmissions:
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•
•
•
Better And More Effective Therapies
Education By RT’s (Case Manager Credentialed?)
Provide Patients With Better Home Devices
Post Discharge Home Visits By RT’s For First 30
Days
• Hard Core Data Gathering
Opportunities For Success
Redefine Oxygen Therapy
Transitioning From “The Chase”
Go From This:
To This:
Positive Pressure & Vibratory Therapy
High Efficiency Nebulizers
Monaghan AeroEclipseTM
Aerogen AeroNebTM
Aerobika* OPEP in COPD and Bronchiectasis
OBJECTIVE
– Clinical evaluation of the Aerobika* Oscillatory PEP device in
patients with bronchiectasis and COPD
• Only COPD patients with chronic bronchitis and/or chronic sputum
production were selected
METHODOLOGY
– n=29; longitudinal 6 week cross-over study
– 67 (±10) years old; 13 male, 16 female
• COPD (n=15, aged 65±9, 9 male/6 female)
• Bronchiectasis (n=14, aged 69±10, 4 male/10 female)
– Aerobika* Oscillating PEP (3 weeks)/No device (3 weeks)
EVALUATION POINTS
– Each Clinic Visit: spirometry, plethysmography, Six Minute
Walk Test, St. George’s Respiratory Questionnaire, 4x daily
OPEP administration, Symptom diary, 3He MRI
Aerobika* Oscillating PEP in
COPD and Bronchiectasis
COMBINED STUDY RESULTS
• Numerous patient outcomes were shown to be statistically
improved following use of Aerobika* OPEP
–
–
–
–
–
–
•
Breathlessness (dyspnea)
Quality of Life (SGRQ measures)
Cough Frequency
Ability to Exercise
Ease of Bringing up Sputum
Lung Function
• Resulting from decreased airway obstruction (improved Slow Vital Capacity%pred)
3He
MRI revealed changes in lung ventilation
– Increase in air transfer from previously unventilated areas
– Decrease in gas trapping (hyperinflation)
• No adverse events were recorded
Aerobika* OPEP in COPD and Bronchiectasis
Additional Opportunities
Even More Opportunities
• Pre-hospital Rescue CPAP: If You Don’t Have a Tube,
You Can’t Get a VAE/VAP.
• HFOV In Fluid Resuscitated Trauma Patients
• The Role of RT’s in Organ Procurement
• What Else? We Are Held Back Only By Ourselves
Let’s Check In With The Students:
• EMBRACE The Students:
• Stop Eating Our Young
• The Students Are The Future
Back At The Fork In The Road Again….
The Road To
Extinction?
Surviving &
Thriving
Are WE (or you) Ready And Willing To Get Past The Fork?
So, Are We Really In Trouble?
Or Am I Just a Lot Of Hot Gas?
Another Real Life Hospital Example:
250 Bed Facility
5-6 RT’s On Days; 4 On Nights
3 Adult ICU’s
Trauma ED
Typical 12 Hour Shift Workload:
•
•
35 (525 minutes) to 60 (900 minutes) scheduled RVU’s
7-8 vents, 4-6 BiPAP’s, N.O. administration, infant SiPAP’s,
bronch’s, PFT’s yada, yada, yada
New Issue:
Directed to explore replacing RT’s with “trained” non
licensed personnel.
Is This Value Based?
If You Need Still More Convincing:
Kentucky One Health System, Louisville, Ky:
Laid Off 500 People; Eliminating Additional 200 Positions
Turned Over ED Respiratory Functions To Nursing
This Includes Treatments, ABG’s, Vent Management, Etc.
Nurses Get a 4 Hour “Refresher Class” In Respiratory
Therapy
How Did We Get To This?
And Finally:
Remember These Most Expensive Words In Medicine:
“But That’s The Way We’ve Always Done It”
Questions?
Michael J Hewitt, RRT, ACCS, NPS, RCP, FAARC, FCCM
mhewitt@lifespan.org