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Spring 2014
PATIENT CARE SERVICES | RESPIRATORY
With Every Beat and Breath, Respiratory Cares in the CSICU and MICU Christopher D. Kircher, MS, RRT-ACCS and Robin L. Smith, BS, RRT
In the spring 2013 edition of News & Views, the trauma respiratory therapists were highlighted. For the general public and staff that work here at UMMC, the word Shock Trauma denotes the place where lives are saved! While many of our respiratory therapists frequently work in various trauma ICUs, there are more than a dozen additional critical care areas where work is performed utilizing the same skill set. The Medical Intensive Care Unit (MICU) and the Cardiac Surgery Intensive Care Unit (CSICU) will be the focus of this article for very good reasons. In March 2013, Robin Smith, BS, RRT, respiratory care supervisor, partnered with several UMMC physicians and a well-known member of the respiratory care field, Dean Hess, PhD, RRT, Assistant Director of Respiratory Care at Massachusetts General Hospital, to demonstrate that an appropriate respiratory care staffing model is essential in the ICU. “One of the defining characteristics of medical critical care is the demand for respiratory care services and the care of patients with respiratory failure” (Parker, 2013). In 2008, the UMMC MICU moved to the Weinberg Tower and expanded from 10 to 29 beds, with a much larger geographic footprint. Co-author of the same article, Carl Shanholtz, MD, medical director for the MICU and respiratory care department, has supported the development of the MICU for more than 15 years. In 2005, Shanholtz invited Hess to visit UMMC and evaluate the current state of respiratory care and provide recommendations as to what resources would be needed to bring the department to academic quality. Building from this assessment, the UMMC respiratory care department has grown to nearly 160 full-time therapists. For the MICU, this has resulted in regularly assigning three to four therapists per shift to the area; providing more attentive focus for these pulmonary compromised patients. Shanholtz commented that, “The partnership between the medical center’s leadership, the Department of Respiratory Care, the MICU staff, and the faculty to restructure the department resulted in improved utilization of respiratory services (Parker, 2013), a significant increase in ventilatorfree days, and contributed substantially to a reduction in mortality in the MICU patient population (Netzer, 2011). We have been redefined as one of the most pre-eminent academic respiratory care departments in the country.”
As far back as 2001, when the concept of spontaneous breathing trials was first being proposed, the MICU struggled with an early adoption of this process, incorporating many of the ARDSnet-style ventilation models that were working to prove the benefits of lower tidal volume mechanical ventilation. Now in 2014, the MICU shares a collaborative approach to ventilator weaning with all other UMMC ICUs that includes better sedation management, breathing trials and earlier extubations. In addition to mechanical ventilation, the MICU therapists manage procedures that are not routinely performed in other ICUs. In a close relationship with the pulmonary critical care physician team, there are frequent bedside bronchoscopies that require increased teamwork with the assigned therapist to cover work responsibilities of the assisting therapist. It is the large number of these bronchoscopies that has prompted many of the MICU therapists to provide support for both the pulmonary function and bronchoscopy labs. The profile of the ventilated MICU patient is often one that involves some component of chronic obstructive pulmonary disease (COPD), and often a longer ventilatory course of treatment. Additionally, the liberation from ventilation can be more challenging as the COPD process leaves these patients with little pulmonary reserve. What is often a quick reduction in support for a postoperative surgical patient, the COPD patient requires close observation with each step in the weaning process. Similar to the neurotrauma intensive care unit’s support of patients with pulmonary compromise secondary to paralysis or other neuro injuries, the COPD patient is evaluated daily to assure that secretion management and respiratory medication delivery are optimized. At times, this results in a prolonged battle against mucus and pulmonary infections. The MICU therapist is there to provide airway clearance and to perform diagnostic procedures, including mini-bronchial alveolar lavage (BAL); all with the goal of minimizing the risk of ventilatorassociated pneumonia and prolonged ventilator length of stay. One floor below the MICU, an additional two to three therapists manage a much different workflow and patient population. The CSICU has a long history with respiratory therapy. Average ventilator length of stay continues to drop and is now closely monitored as a benchmarked data point of quality care. Each day may bring as many as five to six new patients requiring mechanical ventilation and other support. The respiratory therapist is in constant motion, moving between new admissions, SBT trials, routine therapy and extubations. As stated earlier, the goal in this surgical ICU is to wean and extubate patients as quickly as possible, and to facilitate continued on page 29.