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Moving Forward

Emerging areas offer potential for growth in respiratory care.

How does an RT advance? It's a question that comes up often in the context of this checkered belt-tightening age. When ADVANCE blogger Kevin Johnson, RRT, wrote about his personal uncertainty concerning his evolving career path, a reader/fellow RT posted a stern warning:

"With reimbursements and state aid shrinking, it is only a matter of time before floor therapy becomes the RN's responsibility. Of course hospitals won't phase out [respiratory] positions completely, but they will reduce their departments. . PA or RN is the sad logical choice for those who want to have a more secure future in healthcare.."
However there are those who believe respiratory therapists still have some important moves to make on the chessboard of healthcare. Robert McCoy, BS, RT, FAARC, recently trumpeted a message of opportunity at a 2013 conference of the Oregon Society for Respiratory Care.
Home Care Signals Opportunity

"This it an exciting time in respiratory care," McCoy told ADVANCE of his view of the field. "Yes, we are in a transition process. We've got a disaster on our hands, and respiratory therapy should step up to the plate and fix it."

The "disaster" McCoy referred to is competitive bidding for home oxygen therapy supplies meant to drive down costs. The problem with that approach, according to McCoy, is that DMEs may well provide oxygen to home care patients, but therapy? Not so much.

"What the healthcare industry has gotten into is equipment delivery," he stressed. "You are not getting outcomes based on a DME delivery person who knows how to turn machinery on, change filters and tell a patient how long tubing might last. This is not oxygen therapy. And it's the therapy that ultimately will deliver better outcomes."
McCoy believes respiratory therapists have an opportunity to step into the role of home oxygen therapy providers and supply an invaluable service at this crucial time when preventing hospital readmissions is key to reimbursements.

But that word - reimbursements - is also part of the challenge. Indeed payers, hospital administrators, discharge planners and case workers still regard home respiratory care largely as "a check-off item on their care sheet that says 'oxygen,'" said McCoy. "It's amazing to me - hospitals have teams of people geared toward preventing readmissions, yet they are doing it with hospital-based clinicians who know very little about the home environment. You may have visiting nurses, but they are not necessarily skilled in respiratory care. All of the equipment may appear to be in place, but the patient could be under-oxygenated, unable to move, filling up with secretions and on his way to being hospitalized with pneumonia. We need to put hefty resources into the home environment, but right now home care is the black hole of clinical care."

McCoy said the key to finding RT job security through home care will be educating payers to value the service and place a reimbursement code on it. It will take time, and possibly pilot programs to test and prove the value of in-home therapy.

"For now, home equipment drop-offs continue, and patients are at risk," he lamented. "But you know, until there is a fatality on the corner, you don't get the stoplight. And until bean counters see that costs go up astronomically when patients get sick from lack of real oxygen therapy and get hospitalized, we're still waiting for the respiratory stoplight."
Embracing Transport
Scott Hubbell, MHSc, RRT-NPS, C-NPT, CCT, a former Kansas college RT program director, has taken his own career to new heights by becoming a member of a flight transport team. "Transport is a biggie - a specialty field that RTs often miss," he noted. "It's huge - any type of critical care transport is fertile ground for RTs. On most crews you have an EMS, a nurse - and while they do emergent care, what if a patient is on BiPAP? Knowing how to manage that airway in an advanced situation, and knowing how to manage that vent afterward, absolutely saves lives - you need an RT to run the respiratory side of things."

Part of the lure of transport work, said Hubbell, is the extraordinary range of practice it allows. "There's no other place I know of where I can practice full-scope of practice. RTs have more than 100 clinical interventions, and I'd bet in most facilities RTs handle less than 50. During flight transport I practice all of it. If a patient needs intubation, I intubate; needs an IV, I'll start it; needs a drug push, I'll push it. It's challenging, demanding and extremely satisfying."

Hubbell said RTs should also be pushing to move more robustly into the emergency department, with the same skills - intubations, IVs, drug pushes. "At some facilities there's an implication that RTs aren't skilled enough for those tasks - they call in some other health professional at a hefty cost. Why not utilize the RTs' skills and competencies?"
Hubbell suggested that the more that can be assigned to RTs, the healthier the profession will be. However, he pointed a finger at the field in general as being too complacent.
"I teach professional outreach classes all over the region - 98% of the people who show up are nurses, doctors. Once in a while I'll get a stray RT - but it's rare. This is strictly my opinion, but I believe it's a matter of lowered expectations on the part of respiratory. That has to change."

A Multidisciplinary Approach

Liberation from LMV

Clinicians can liberate patients faster from long-term mechanical ventilation.

The Education Option
Joseph P. Coyle, MD, clinical associate professor, director, UNC Charlotte BSRT program and head of the North Carolina Respiratory Care Board, said an evolution in respiratory care is opening the door to increased opportunity. "The growing complexity of the profession is becoming more integrated with the use of protocols, clinical involvement in terms of consultations and collaboration with other healthcare providers," said Coyle. But to realize that heightened role, one thing will have to come first: More education.

"RTs will have to understand more than the respiratory procedures they learn at an associate level," said Coyle. "In its '2015 and Beyond' initiative, AARC has been advocating a move to a higher level of education - to baccalaureate status - to provide the competencies that will be needed in the future. And clearly, the future is not far off."

Coyle concurred with AARC's stance, noting "There just isn't enough time in a standard 22-month associate-level program to get into advanced competencies, evidence-based medicine, cardio pulmonary physiology, critical care patho-physiology, pharmacology, program management, communication skills and more." He added that extended education will allow respiratory providers to "think, write and communicate more broadly, to assess the literature and apply it in a better fashion, and ultimately be able to communicate more as professionals and less as technicians."

In addition to putting RTs on an even playing field with other healthcare providers, Coyle suggested that education will in time "remove the ceiling for RTs. That ceiling exists because 80% still have associate level education. So they don't move up in management or hospital administration. But with a baccalaureate degree, they can go on to pursue a higher level of RT, an MHA, an MBA. . They will be able to advance professionally through the whole spectrum of a hospital or healthcare."

Valerie Neff Newitt is on staff at ADVANCE. Contact: .

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I don't see how respiratory could ever be phased out of healthcare. By our own history, we were placed at the bedside to fill a critical need. That need has not contracted, it has expanded. Our problem, as a profession, lies in us to see past just delivering a therapy. We need to understand what is forefront is our knowledge, effeciency, and adaptablity. Since started working, I see what hospitals have done that we started. Respiratory therapists were the first rapid response responders. We were documenting VAP before it was fashionable. For those that think respiratory should go away, it may be a time for them to rethink their passions. The demand is high and the stress even greater than before. This is not the time to stop, it is the time to grow and meet our demands head on.

jason February 13, 2014

I truly do not see phasing out the world of Respiratory Care-I truly believe our profession is worthwile. I have been a practicing therapist for over 33 years and have just recently added RN to my credentialing but not because I did not love being a therapist but because I wanted to add to my responsibilities. In our small 25 bed critical access hospital we are an intergral part of a team, our department is an active department of protocols and responsibilities-our Medical Director was just recently quoted in saying our RT department was far beyond any other he was associated with-this coming from a former therapist who became a physician. I do agree Respiratory therapy, like any profession needs to evolve-the therapist I was 33 years is not the same therapsit I am today. As for scraping our profession I say NO. I think we will have to make allowances like all the other professions because of cuts for reimbursements. As for Kevin worrying about his future I would not worry-Kevin is bright therapist with many options-as for Scott I say BRAVA for his new opportunity and congratulations but take offense when he talks of not seeing therapist in his classes and being complacent in our job duties. There are many therapist out there in the world of respiratory pushing meds, putting in arterial lines and going on transports-it may not be the norm in NW Kansas but up until coming to NW Kansas, I did not have to attend classes to get my PALS, NRP or ACLS it was all taught and an expecation of my position and being a NRP instructor for over 20 years has to say something. At no time would I say therapist have lower expectations then nurses or doctors, out here we may just have fewer opportunities, and it takes an individual to want more for themselves-all of my professional advances were not because of my being a respiratory therapist, because that is just my profession, my internal and personal goals and drive made me the person/therapist I am today and I am not unique. I see Respiratory therapist every day making a difference in their patients lives, therapist who are dedicated to making a difference, therapist who run an effecient profitable department alone, with no other therapist on staff. I see therapist at the head of the bed providing care when it most matters-when someone cannot breath. If you really think anyone can just give a bronchodialor and the patient does well there are a plethora of surveys that show if/when a Respirtory therapist provides Respiratory Care for your patient there is tremendous benefits. In our hospitals we see almost 90% of the patients that come through our doors and I say, as do our providers, especially our nurses, how much of a difference we make. So shame on you for not supporting and applauding your fellow therapist, do not degrade me because I have chosen Respiratory Therapist as a profession-do not think I will be extinct because you are at the end of your career and possibly bitter, I am a proud respiratory therapist and we have come a long way from being oxygen techs and oxygen orderlies to an integral part of a healthcare team. Throughout my career I have heard that the basic floor therapist will not be around long-well there are many of us still standing. Again shame on you for not supporting and honoring your profession

Nancy Mitchell,  Manager,  CMCIJuly 10, 2013
Colby, KS

Regrettably, this field is on the way out.I have spent 33 years in this field and at times I thought we were going to finally get the reconition we deserved,and it never happened.I have a BS. I do not get treated any different than the person who is on the jobbed trained.We cannot continue to talk about reinventing our field. We have a purpose but are not utilized because we do not generate money for the hospital.I am at the end of my career but respiratory therapy school programs should close and begin phasing out a field that just never made the cut in healthcare

Janet Moore,  Registered Respiratory therapi,  HospitalJuly 09, 2013

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