Tuesday, September 27, 2011

Even Superman has his Frustrations

The weaning protocol that I put together wound up serving that Vencor which turned Kindred Hospital well. During severalof the years I worked there as one of the main day people in ICU and as staff educator we hit greater than 90% wean rates. Looking back it was Sept. ’98 through Sept ’02. It probably took about 6 months from the time we first took the protocol and associated documentation to the committees for approval until we started using it. I always have enjoyed my work, but this was an exceptionally good period. The protocol gave us new autonomy. It was written so that every vent patient went on and allowed us to move the patients as quickly as they would go and provided good monitoring parameters that kept things safe. I love just about everything about accomplishing a successful wean quickly, getting someone’s trach out for them, and getting them back to their  life.

Several changes occurred with the facility while I was there. When I hired on it was a THC Hospital. THC wound up getting merged with Vencor and Vencor became Kindred. When the merger with Vencor came about, I had been working previously for Vencare, the therapy division of Vencor that went into nursing homes. During slow times I worked in some of the other local Vencor Hospitals. Most of my RT career I worked multiple places usually for at least 60 hrs per week. When Vencor and THC merged, the THC hospitals became Vencor hospitals. Anyone that has worked in a Vencor or what is now Kindred hospital knows that one of the common denominators of that chain of hospitals is a documentation tool known as ProTouch, or VenTouch when I was introduced to it. I had been instrumental in the roll out of a documentation system at a county hospital where I had previously been a director, and with my experience already working in other Vencor hospitals when VenTouch was introduced into our facility I was selected as the RT “SuperUser” when VenTouch was introduced at our facility.  I was on nights at the time and got to go to days for 2 months while I was trained and while we trained everyone else.  After that was done, I went back to nights and continued as before except I had some VenTouch training and QA duties added.

In the summer of ’02 the RN SuperUser/IT Manager left to take an educator position at a local short term acute hospital. I held her in high regard and always thought she was excellent at the position. That position went unfilled for a while, and my Director came to me and let me know that the position did not require a RN but came with a RN salary/pay rate, was a 9-5 M-F gig, that he thought I should apply and would support me with administration. I applied and really to my surprise got the position. I started in Sept. ’02. It was certainly different. There were definitely percs. I worked at the SW Fort Worth facility primarily, but the other 3 Tarrant County Kindreds were often without someone in my position so if I went to one of them to help with training or IT support I got OT. The hard part for me was that since I was no longer part of the RT department I was no longer clinical in my home facility. I no longer trained the RTs or worked in what had been “my house” the ICU there. There was essentially never any opportunity for OT in RT at that facility as it was one of the most efficient Kindred RT departments. The other Tarrant County Kindreds were not so efficient and they were often requesting me to come in and help on weekends for OT. This helped some, but it was not the same. It was really a source of frustration after what I had in “my house”. None of these other departments had ventilator care by protocol. I remember once being admonished at one of the facilities to not be too aggressive with weaning their patients or I would always get floor assignments. One day I recall a lead RT telling me that under no circumstances was I to call physicians, rather I had to go through her. When I got to my patients I had one that was ordered on resting vent settings of SIMV 6, VT 500 PS 10 PEEP 0. My orders for the day aside from the routine nebs etc. was to perform a CPAP trial on CPAP 5, PS 20 for one hour and then rest for two hours as tolerated all day. First I chafe at on and off weans. I believe firmly that once a day weaning trial is usually enough. I also believe that if a patient can breathe off the vent then they should and as long as they tolerate it. Well I found this patient initially breathing at a total f of about 40+. Mandatory breaths on the 7200 were not even pressurizing so low pressure was alarming frequently and PS of 10 with the PEEP of 0 was not conducive to synchrony or rest, so the resting settings were really working the patient. When I got him to the “weaning trial” the 5 of CPAP and the PS of 20 were adequate to provide him with about 1500+ cc per breath and a f of about 4. I went to the supervisor and explained and asked for a call to the doc to request better settings and she said that he wrote the orders and he knew what was happening and that was how he wanted it. I have found that some facilities the staff do not want to wean too fast as if the vent count goes down so does OT this turned out to be one of those places. What do you do? I shied away from that particular facility.

I had another patient during that time that I’ll never forget who demonstrates some of the frustrations I had working outside my home unit. He was on a vent on a step down unit. I was there on a Saturday. I received report from the night shift that he was 80, s/p stroke, a DNR, should have never gone on the vent, and was a likely terminal wean for that day. All week, every time CPAP was tried he went apneic.  What I expected and what I got were completely different. I expected a comatose patient who was completely unresponsive. What I found was a man who was relatively alert with a devoted wife that was spending every night at the facility to keep watch over him and the care he received. In this case I knew the doc and had for many years. He had been my Medical Director when I was Clinical Coordinator at the nursing facility. I knew he would not mind me doing a little safe experimentation so I went forward with a CPAP trial. During the week the patient had gotten the good old CPAP 5 PS 20 trial. What I found was similar to the patient I described previously from the other facility, he had a huge VT on those settings and sure enough within only a few minutes he was setting off the apnea alarm on the 7200. I adjusted the alarm from 10 seconds to 30 and was able to continue the trial with no more apnea alarms. Within 30 minutes I had titrated him down to PS of 8 for a f of 16 with good VTs and VE. I called his doc and got an order for a t-collar trial and an ABG. An hour later I got a perfect gas on FiO2 of .28 via t-collar and he never needed the vent again. At some point during his stay he had received an SLP eval and was provided a PMV and had an old order to use it as tolerated. It had apparently been forgotten about, but I found the valve and got him talking with no problem. After the doc rounded and spoke with the patient and his wife and told them that he was fine and probably would not need the vent any more and should do fine, I got the biggest hug from the wife when I next went in. “You are an angel sent by God coming here today. This morning I thought we were going say goodbye to him. You show up and this afternoon I am speaking with him like always”.  It was somewhat of a sweet moment, except it happened because someone called a patient setting off an apnea alarm due to very high VT and low f apnea and just went about their business. This is what got back to nursing and the doc and the patient was written off. When that ship sails some times the patient will surprise you and a terminal wean results in a surviving patient, but in my experience with the high dose, high frequency narcotic orders, and the angels of mercy that give it so freely, true apnea will be the result and a totally weanable patient will be lost due to the ineptness of a team of licensed, credentialed professionals so ready to dole out mercy and call it a day.

These and many similar frustrating experiences were the clinical exposure I got while I worked my main day gig as IT manager/SuperUser. I dove into that role. While I was in that role we moved corporately from a Windows 95 environment to W2K. I wound up being on corporate steering committees for updates to ProTouch. I began working around the Southern Region training nurses. The way I trained nurses to document looked good to surveyors on review so they wanted me at facilities that were expecting surveys to get their nurses brushed up. They called me Superman. I knew the documentation pathways for all disciplines by heart. I knew the network and the information system inside and out. I was able to recognize issues before they became problems; however for me it was not fun work. I grew more and more frustrated with both my regular M-F work and my clinical RT for OT work. That was about the time the discussion of grande rounds came up for the ICU at my home facility, and I jumped on it.

Friday, September 23, 2011

Birth of a Protocol

I mentioned 2005 AARC Conference  in San Antonio. I think that was some kind of turning point or watershed for me. I was working for Kindred Healthcare as an IT Manager/Superuser/Documentation trainer between 4 hospitals and training regionally while working most weekends in RT for OT at one of the 4 hospitals. I had been doing that for about 2 years having moved from my position as Staff Edcuators in the RT department at the Tarrant County SW Kindred Hospital. The IT position came with a pay increase, but it never fit right. When I went to AARC that year I really missed doing RT FT and had really built up a passion for LTAC critical care and vent weaning.

The conference was in early December of that year. Some time in late summer I was approached by the ICU nurse manager about my thoughts about performing grand rounds in the ICU. I had encountered an article that demonstrated that daily rounds to enforce and instruct on the weaning protocol and to monitor care had a profound effect on clinical results. I developed a tool and with the nurse manager’s help and the blessing of the RT Manager we started in October.

I had been at that facility for quite some time. I believe it was about 7 years at that time. When I was there a couple of years I left and took a position as Clinical Coordinator at a Vent Program at a local nursing home. I had developed some very successful techniques for weaning while working at the LTAC. It was a THC hospital then a Vencor at the time I left back then. My greatest frustration back then was I worked 12s and I would nearly get someone weaned and go off for 3 or 4 days then come back and find them back at square 1. We did not have a protocol at that time and we had nothing to use to keep everyone on the same page. I would try writing detailed weaning orders and getting them signed off by the docs, but others could just as easily get orders to put them on hold. So when I went to the vent program at the nursing home I started by writing in detail what at the time I thought was the considerations and techniques that were making my efforts with the vent patients effective as a sort of protocol and used it at the nursing home. I have to say caring for respiratory patient in a nursing home may be some of the hardest work I have ever done. Many of our patients were neuromuscular patients and we tried to have each of them up and out of bed and outside or in a common area daily. We also made sure every patient with any potential was assessed for weaning potential daily. In a program that accepted unweanable patient from area LTACs we had real success at weaning and decannulation of the patients that came to us without criteria that would exclude them from weaning efforts. That protocol served us well for the year or so that I was there until Medicare quit paying for RT in the nursing facilities and the home essentially eliminated the program.

When I went back to the LTAC to negotiate for my old position I insisted that if I were to come back that we would make the protocol I had written into policy and put it to use in that facility.

Wednesday, September 21, 2011

Bursting to spread the word

What I hope to create here is mainly a means to educate those that might follow it on what I see in Biphasic Cuirass Ventilation (BCV). I have so much in my head and so much to say about it I have a difficult time figuring where to start. I have a long experience as a Respiratory Therapist, and I am happy to say I have had a very stimulating and satisfying career so far with very few periods of burnout and many high points. I can readily characterize my feeling about my career and vocation as passionate. I love Respiratory Therapy. I love taking care of patients, interacting with their families, working as a team with my peers, and as a matter of fact I have a strong sense of camaraderie with other RTs, particularly those that share my passion for our special profession. I will get much of my past experience in my profile, or cover it here possibly, but what this is about is discussing and describing BCV. The title of this blog is Biphasic Cuirass Ventilation and Me. It is my intention at this point to make it more about BCV than me. I do need to start somewhere and that seems best to be to start with me. Once I get some things out of the way, I will get down to BCV. I will start my introduction by returning to the 2005 AARC Convention in San Antonio, but I will save that for next time.

To wrap this first post entitled Bursting to Spread the Word up I would like to relate that almost exactly one year ago I was looking at a major change in the direction of my career. I was working as a RT Director in a small LTAC Hospital in Fort Worth Texas. I had started in the position with the opening on the facility four years prior and had enjoyed an amazing run. It was a highly satisfying and enjoyable position at a facility where I was really appreciated. I felt I had managed myself into the enviable position of big fish in the little pond. I was also very certain we were making a great difference. I knew my competition and how we compared and I was very certain our care and results were without a doubt excellent. At the TSRC Conference in August of 2010 I was offered the position I now hold, that of Clinical Coordinator for Hayek Medical. Hayek Medical is the sole distributor for United Hayek medical products in the US and Canada. The only product United Hayek currently has available in the US is the Hayek RTX Ventilator. The offer that was made me at TSRC last summer was not the first one that came for this position, but it was the most intriguing for many reasons. As I considered if the risks of leaving a well established and comfortable position for what I was not sure what were worth it I made inquiries of a few of my associates in medical sales. One inquiry went out informally to several of the long experienced clinical people in what I still call Respironics. Initially no one knew what the Hayek RTX was. Then I heard back from an old timer with the company and he remembered the Hayek Oscillator, which is an older less functional version of Dr. Hayek's RTX and what he said stayed with me. "It is a good device, but hardly anyone knows about it, and it will be a missionary sell". The more I learned about BCV and the more I thought about the other technology changes I have witnessed in my career, I was so sure that I had to take the position. I still feel that spreading the word about BCV is more than a job. It is a calling. So just like a missionary I am bursting to spread the word. In what I get posted here I hope I can do that to some additional degree. Am I biased about the benefits of BCV? Well    I have to disclaim some conflict of interest when I speak about it, but I honestly know that for what is indicated it is in most cases a better way and produces better clinical results more quickly. I say it all the time and feel it to my core: In my over 30 years as a clinical respiratory therapist whose main practice was critical care I have never seen any single device or therapeutic intervention that offers the same potential of altering the clinical course of patients with cardio-pulmonary compromise than BCV.