Envisaging an Expanded Role
Envisaging an Expanded Role
RTs' Airway Skills Valuable to Conscious Sedation
Charles Durbin, MD, hates to hear about deaths that could have been avoided.
"People have died who are healthy," he laments. "They were having elective procedures and interventions, and they shouldn't have died."
Dr. Durbin suggests these deaths most often occur in physicians' offices and dentists' chairs, and he links them with inadequate monitoring during conscious sedation. "The thing that kills these patients is the failure to recognize and manage airway obstruction," he says.
Dr. Durbin, a professor of anesthesiology and medical director of respiratory care at the University of Virginia Medical Center in Charlottesville, envisages an expanded role for respiratory therapists assisting physicians during conscious sedation because they understand airway management. He expects better patient outcomes with additional staff and more aggressive monitoring.
"The patient will survive because (respiratory therapists) are not thrown off when patients stop breathing," he says. "They are used to patients who don't breathe. They have lots of ways of fixing that."
Conscious sedation, also known as sedation and analgesia, is the preferred anesthetic for procedures like bronchoscopy and percutaneous tracheostomy. Physicians also employ conscious sedation for a real-time X-ray procedure known as fluoroscopy, which is often combined with bronchoscopy to give physicians a clearer view of damaged tissue and enables them to take better biopsies. Although this is a longer procedure and the patient needs more sedation, most are completed within an hour.
By administering narcotic drugs and tranquilizers, clinicians sedate their patients without taking them deep into anesthesia. Maintaining light sedation is the trick.
"Here's the problem as I see it," Dr. Durbin says. "Conscious sedation leads to deep sedation." Clinicians involved in the procedure need to know if their patient passes that line. This is easily identified when the patient stops talking and answering.
"When they stop answering you, they are too far under or sedated," Dr. Durbin explains.
Tactile response is another indicator of sedation. Patients experiencing conscious sedation will "open their eyes and shake their heads when you tap them lightly on the forehead," he adds.
RTs HAVE MUCH TO OFFER
Although Dr. Durbin acknowledged that RTs would need to learn new skills, such as IV drug administration, he said, "I think the patient will do better with airway skills, and you can learn these additional skills without a whole lot of effort."
Many therapists have already grasped this role, especially in bronchscopy suites where their colleagues recognize their expertise in managing airways. Kyla Boswell, RRT, CPFT, for example, recalls being "called out of a bronchoscopy to assist the nurses with a code" in an adjoining endoscopy suite. A staff therapist at the University of New Mexico Health Sciences Center in Albuquerque, she has assisted with conscious sedation for three years.
"It goes back to our respiratory training," Boswell explains. "We are often better equipped to deal with emergency situations. Our training and expertise is on the patient's airway, breathing and circulation. When a patient arrests, we can remain calm and deal with the crisis because that is the nature of our profession."
With patients' lives on the line, clinicians possessing a background in airway management have much to offer in the anesthetic arena, especially as nursing shortages have opened the door for expanded roles in other professional disciplines.
"I am not suggesting turf wars. I am suggesting opening up the positions to other qualified people," says Bruce Riser, MA, RRT, director of pulmonary services at the University of New Mexico.
The American Society of Anesthesiologists (ASA) lists respiratory therapists among the disciplines of non-anesthesiologists who can play a role on the care team, but state law and hospital policies may restrict their activities. Dr. Durbin recalled a time when RTs were not permitted to intubate and urged them to lobby for new policies in restrictive states. Phil Weintraub, a public relations official for the ASA, also notes that non-physicians need to be supervised by a physician.
Jeffrey S. Vender, MD, chairman of the Department of Anesthesia at Evanston Northwestern Health Care in Evanston, Ill., does not yet have therapists assisting with conscious sedation at his facility, but he does think "they are an appropriate group" to participate. "I think they are well in tune with the administration in general...they are good surrogates for this type of thing when they are trained and educated," he says.
ASA guidelines recommend training in the administration of sedation and analgesia for clinicians providing patient care. They include an understanding of the pharmacology of agents that are administered as well as pharmacologic antagonists for opiods and benzodiazepines. Physicians choose the medications and therapists work under protocols to administer them.
Clinicians should also learn how to recognize complications associated with sedation/analgesia. At least one person should be trained in establishing a patent airway and maintaining ventilation and oxygen during each procedure, a role RTs easily qualify for.
Dr. Vender includes knowledge of drug doses and side effects on his list of training skills for RTs. He suggests that physicians are "the most logical people to conduct training in anesthesia."
Most hospitals set up in-service programs to train RTs. At the University of New Mexico, for example, RTs like Boswell complete the nursing IV certificate and additional in-servicing in conscious sedation. They take yearly competency exams in conscious sedation and are expected to place at least three lines a year to maintain their IV certification.
Nancy Van Ravenswagg, BS, RRT, one of six RTs trained to administer conscious sedation at the Spectrum Health Down-town Campus in Grand Rapids, Mich., trained in-house and takes a test annually to document her competency. She stresses the importance of education for departments considering expanding their scope of practice into anesthesia.
Some hospitals also require therapists to be certified in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) in addition to the hospital in-service training.
A TYPICAL DAY
By training RTs for this expanded role, physicians are adding staff members in the anesthesia setting. Many teams depend on the RT to monitor the patients and administer the drugs while the physician operates the bronchoscope. At Spectrum, for example, Van Ravenswagg says two RTs attend each bronchoscopy. One monitors the patient, checking respiration, saturation and blood pressure every five minutes. The other therapist assists the doctor with the procedure.
Clinicians at the University of New Mexico favor a similar setup, with two therapists in attendance for most procedures. On a typical day in the bronchoscopy suite, Boswell will meet her patient and run through a pre-evaluation sheet. She takes the patient's medical history, keenly aware that "we are compromising the airway," during the procedure. Boswell and her colleagues need to know if their patients have a history of lung disease such as COPD that could jeopardize their tolerance for the procedure. On the form she uses, Boswell ranks patients for one of six categories, ranging from normal and healthy to having a life-threatening disease and presenting a high risk for anesthesia complications. She records baseline parameters for patients' vital signs.
Boswell wants to establish rapport with the patients during this time. They will not be able to speak while the bronchoscope is in place, and she finds it helpful to establish signs, such as raising their hands, to indicate discomfort or other needs.
The therapist responsible for administering the medication inserts the IV line prior to starting the procedure. Dr. Durbin believes IV access is mandatory in case resuscitation is needed during the procedure.
Once the IV is in place, the RT uses topical anesthetic to numb the upper airway. It's important that the patient be completely numb and comfortable before appropriate sedation is given just prior to beginning the procedure.
Throughout the procedure, the RT monitors vital signs every two minutes. Many protocols require monitoring every five minutes, but therapists at the University of New Mexico chose a more aggressive path.
While they use equipment like pulse oximeters, capnographs and ECG monitors, Dr. Durbin believes the therapist is the key. "The most important monitor is the person," he says. "That person should have no other significant duties in the environment that would draw them away from that task...the most important thing you can do is clinical observation...your eyes, your hands and your ears are the most important monitors."
Most conscious sedation progresses smoothly, but every once in a while a patient will code. Sometimes clinicians have to remove the bronchoscope quickly and begin bagging the patient. In extreme cases, a patient may need to be intubated. Boswell and Van Ravenswagg say the "crash cart" is right outside the doors to their bronch suites for every procedure.
More often, patients recover at the end of the procedure. Boswell and her RT colleague will supervise the patients through recovery and will not discharge them until their vital signs have returned to normal. Although they are oriented, patients cannot drive after being deeply sedated.
Boswell and Van Ravenswagg enjoy the opportunities that conscious sedation gives them. "Expanding our professional roles is what keeps our jobs fun and rewarding," Boswell said.
Francie Scott is senior editor of ADVANCE.