Respiratory Therapists: The Unsung Heroes

In light of COVID-19, we saw a surge in the need for ventilators and respiratory therapists. Jai Shah, Kahuna’s Co-founder and CEO, had the opportunity to sit down with a team at Intermountain Healthcare responsible for the development and deployment of respiratory therapists within the organization. Throughout the interview, we learned about the essential role RTs have played throughout the pandemic in critical care situations, but also of the essential roles these caregivers play every day throughout healthcare organizations to care for a broad range of patients. We also learned how being proactive in knowing your caregiver capabilities with competency management, as well as creating contingency plans, helps and allows you to deploy your caregivers when and where they are needed.

Q: (Jai Shah) We’ve heard a lot about ventilators during COVID-19. What about the people who need to operate those ventilators or understand even the need to put a patient on ventilation?

A: (Ted Moon, MD) Whenever we’re faced with a crisis of ICU infrastructure, I think it’s natural to think about the what rather than the who. Our respiratory caretakers are vital members of the direct patient care team, which consists of the critical care physicians or best practice providers, the ICU nurse, and the respiratory therapist. Like any three-legged stool, if one leg fails the whole structure fails. And the ability to quickly assess a patient’s respiratory status, communicate recommendations of a team and initiate care has always been essential and part of the responsibilities and role of our respiratory therapist. The respiratory care practitioner has an essential role on our team assessing the effectiveness of the respiratory intervention, which many times isn’t about using the ventilator, but other maneuvers which can avoid intubation and mechanical ventilation. But when mechanical ventilation is necessary, it’s the RT. That’s the caregiver with the technical expertise regarding that treatment modality who can provide feedback on how the patient is interacting with the ventilator. As physicians, we deeply rely on our respiratory therapy colleagues to be active and engaged partners in our care management teams.

Q: (JS) Can you give us a general overview of what a respiratory therapist does? What is the daily regimen of services or care they’re providing?

A: (Carrie Winberg) For a respiratory therapist, we’re usually brought in when there’s difficulty with breathing. There’s this quote, the authors unknown, but it’s “Just breathing can be such a luxury at times.” That kind of captures the essence of our every day. RT’s provide care for many patient populations. We have very diverse skill sets that allow us to care for patients from their very first breath – maybe we’re at their delivery – to their very last breath, and everything in between. We’re participating in advanced care planning, home care, discharge and education, and disease management. We also respond to emergency situations within the hospital. We manage different modalities of care to avoid intubation and mechanical ventilation, and if that doesn’t work in itself, we provide the ventilator management for those patients for which we are the experts.

Q: (JS) Intermountain has a really unique, and frankly revolutionary way of conducting education and competency development. From an education perspective, how did Intermountain manage the rapidly changing information and new standards during COVID-19 for both the caregivers’ safety as well as patient outcomes?

A: (Shawna Murray) Within our system, we have 44 different models of ventilators and 33 different types of interfaces. They each have different settings, capabilities, and purposes. We have to prepare respiratory therapists to work with any of those vents they may come in contact with at any given shift, or if we have to move them from facility to facility. We developed specific COVID orientations for these different staff and the different scenarios they might encounter. Because we had previously developed basic orientations, we were able to quickly adapt to this changing situation and prepare for three different surge scenarios with training for various staff, both licensed and unlicensed to perform the tasks necessary in each scenario. We feel lucky that we had a lot of materials to draw from that had already been put in place and approved system-wide. Intermountain is a large organization with many hospitals and clinics. Having these orientations helped us establish best practices quickly.

Q: (JS) How did you proactively plan for those different scenarios while keeping in mind the capabilities of your workforce and the impact it would have on delivering care?

A: (TM) I think the really exciting news is that this plan for managing the increased need for respiratory care services has been managed by the respiratory therapists themselves, both in leadership positions and on the front lines. I really want to applaud the work all of the respiratory therapists have been doing to support the leaders and the patients. They closely analyze daily hospital censuses across the enterprise and come up with ways to proactively look at how our RT practitioners are being utilized at all of the locations they’re in. There’s another team that is closely monitoring the utilization and distribution of our mechanical ventilators throughout the system, so we’re able to be a resource for our hospital and executive leadership to provide the information they need at a glance. COVID-19 really put a lens on the importance of understanding information and integrating feedback from our first-line care providers about what is working well and what’s not working well.

Q: (JS) Do you have a good handle on how long it takes to develop or orient a respiratory therapist?

A: (SM) We have a pretty strong process on orienting employees, but I think the answer is that it depends. The orientation for a new graduate takes longer to bring them up to speed and make them proficient and safe to work independently than it does if you’re hiring a new employee that’s moved from another facility and has 10 years of experience.

Q: (JS) Do you have a process to identify and personalize that orientation process for an experienced hire versus a new grad?

A: (SM) We have identified clinical coaches in each one of the facilities that do the bulk of the onboarding and orienting. They get really used to sharing our processes and protocols and giving the new employees an opportunity to demonstrate or verbalize that they can, that they know what they need to know, and that they’re able to do what they need to do. Then we have some evaluations that are intended to evaluate how independently that new employee could work. So it’s not, “Do we like this employee,” or “Do we think they’re a good fit today,” it’s “Are they safe to work on their own?” So we give them an opportunity to verbalize their understanding and the tasks that they need to.

Q: (JS) So all the planning is one thing, but the reality is often another. How reactive could Intermountain be if the reality didn’t match the plan?

A: (TM) I think when we talk about the COVID-19 pandemic, we kind of saw what was happening in China, Italy, and New York and I think that everybody was really concerned about what was going to happen when it came to the utilization of both physical and human resources. But when we talk about respiratory therapy, there’s been shortages in respiratory therapy that predate COVID-19 by decades. As such, Intermountain respiratory care has been very proactive in ensuring our practitioners are always working at the top of their licenses in our system and have been responsible for developing programs. So I think these efficiencies that we’re developing now as a result of COVID-19 are going to stay well beyond our pandemic and also serve as a model for innovation.

Q: (JS) Was there an opportunity to help in other areas such as New York? Can you redeploy your resources?

A: (TM) As far as the Intermountain mission to New York, we were able to learn about practices that supported patients, providers, and the crisis standards of care. As we prepare to enter into contingency and crisis standards of care here at Intermountain, we’re leveraging the experience of VR to understand how little things like expanding the reach of respiratory care through telehealth can significantly improve patient outcomes and standardized care across the system.

A: (CW) We were given the opportunity to do a 6-month pilot, and we have a group of about 21 RTs. We had about two weeks to get everyone there, get them onboarded to the technology, and develop our process. We collaborate with the physicians to make sure the patient is on the appropriate ventilator setting. We can remote in and actually see the ECG on the patient. We can see the ventilator settings and can see the waveform. We like to make sure that there are protocols being adhered to and provide feedback to those team members to make sure that we’re maintaining our regulatory compliance. We serve as a virtual resource for charting changes, protocol adherence, making sure that these are documented, and we’re also considered like a sitter for the patient. It’s a really exciting opportunity that the responsibilities and what we do every day has evolved a little bit. It’s an amazing collaboration with our nursing counterparts and physicals to work together as a virtual team to care for these patients.

Q: (JS) What are the lasting impacts of preparation on the role of respiratory therapists in a large healthcare system and how has that changed your perspective of your work in terms of staffing caregivers in general?

A: (JG) Well Intermountain, like many other healthcare organizations, has had many lessons learned during the pandemic. It’s dramatically changed how we look at performing our daily work. It’s been an iterative process as we continue to monitor, learn, and evaluate the situation. Our teams have worked diligently to make sure our caregivers are working at the top of their licenses. Ultimately, our goal now and moving forward, regardless of if it’s a respiratory therapist, a nurse, a physical therapist, no matter what the role, is ensuring that we have the right set of caregivers caring for the patients when and where they are needed across our system. I know for respiratory therapists, we sometimes forget how vital they are and what an essential role they play. I think people a lot of times think about them in that critical care setting because that’s where a lot of the stress during the pandemic has been. But, as Carrie and Shawna have noted, they play vital roles in our telehealth and in our clinics, and just in our regular med surge areas.

Key Takeaways:

Respiratory therapists play a key role in healthcare organizations, working closely with physicians to monitor and care for patients.
RTs have an essential role in assessing the effectiveness of respiratory intervention, whether this be with a ventilator or other maneuvers to avoid intubation and mechanical ventilation.
Developing basic orientations and processes, and having the right system in place, enables you to quickly adapt in changing situations.
Virtual reality, such as telehealth, has played a key role during the pandemic in helping caregivers care for patients.
Together, Kahuna and Intermountain are striving to help healthcare organizations place the right caregiver at the right place at the right time.