Summer 2014 Long-Term Care Bulletin

Notes from the Chair

Lorraine Bertuola, BA, RRT

As you read this edition of the Bulletin, we are just a few months away from AARC Congress 2014 in Las Vegas. The meeting kicks off on Dec. 9 and runs through the 12th, with pre-courses on the 8th dealing with a range of topics, including pandemic preparation, mechanical ventilation, pulmonary function testing, ECMO, and sleep and wellness.

The program includes a wealth of presentations and symposiums designed especially for the long-term care RT. Our section submitted a number of topics this year, and we were pleased to see so many accepted for the final agenda. Topping the list: “Tricky Tracheostomies: When the Airway is the Wound,” “Liberation of the Unweanable Patient: Wean the Airway or Wean the Vent?”, and “What Every Therapist Needs to Know About End-of-Life Conversations.”

We’ll also be holding our annual section membership meeting on Wed., Dec. 10. If you are at the Congress, please plan to attend. We’ll be updating everyone on issues of concern to our section and discussing our plans for the upcoming year.

So check out the program and make plans today to join us in Vegas this December.

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Psychological Well-Being in the Long-Term Care Ventilator Setting

Lisa Ziller, RRT

As we discuss the roles of caregivers in the health care field we assign a variable amount of responsibility to each of those disciplines. The nurse’s responsibility includes, but is not limited to, delivery of medications, obtaining vital signs, communication with physicians or extenders, and specific treatments correlating to the patient’s medical condition. The physical therapist ensures maximal mobility and coordination of motor skills. The occupational therapist assists and supports the physical therapist’s progress and improves the patient’s fine motor skills and range of motion in achieving activities of daily living. The speech therapist supports the patient by developing and re-introducing communication, with a focus on effective swallowing and strengthening exercises for the larynx.

The role of the respiratory therapist in accordance with long-term care ventilation is many faceted. The respiratory therapist is not only responsible for the maintenance of the airway and the ventilator, he assumes the roles of most of the other disciplines in varied forms. The respiratory therapist delivers medications, obtains vital signs, communicates with the interdisciplinary team, performs treatments like suctioning and tracheostomy care, assists with application of speaking valves, is present for mealtime pre- and post-suctioning, and assists the patient tactility with assisted breathing devices such as positive expiratory pressure therapy and incentive spirometry. The role of the respiratory therapist demonstrates value in patient outcomes in many vital areas.

Psychological well-being

However, as respiratory therapists, we sometimes overlook one important area when caring for our long-term ventilator patients: their psychological well-being. In most cases, the long-term care patient has been through a course of acute care for 14 to 21 days, sometimes longer. These patients may have been at a long-term acute care hospital for 21-28 days as well. Add together all the time they have been separated from their homes and it can amount to 2-3 months. To top it all off, they have failed their attempts to wean from the mechanical ventilator and are now being admitted to a long-term ventilator unit indefinitely.

These patients have persevered through as much physical, medical, psychological, and financial trauma as one human being can possibly handle. Upon arrival to the long-term care facility, they have, in most cases, lost more and more of their dignity with the progression of their medical care, they have compromised immune systems due to the courses of antibiotics they have received (which impairs their resistance to infection moving forward), and finally, they have succumbed psychologically to the fact that “this is the place that I will need to call home.”

The respiratory therapist is the frontline professional who will be greeting this patient upon his admission to long-term care. This is the face he will remember due to his attachment to the mechanical ventilator. It is more than a face to that patient, it is his lifeline, and any chance of being liberated from that ventilator will be done with the reassurance of that respiratory therapist’s knowledge and skills.

The patient develops a sense of trust with that therapist, but it does not come easily. That patient has probably seen 20-30 therapists in the past, coupled with a multitude of other health care professionals who may not have identified themselves to the patient, or the patient cannot recall who they were due to impaired sensorium. The relationship is being judged by the patient with all those previous experiences in mind, and with particular emphasis on the needs of the patient and the responsiveness to those needs by the respiratory therapist.

Understanding the patient

As health care professionals, it is imperative for us to understand the patient and where she came from and what she has experienced before arriving at our facility. Secondly, we must understand the compassion component: everything she’s been through has been quite a traumatic experience and it still remains that way today. Lastly, we must understand that the patient has lost two very important human aspects, trust and dignity, throughout this entire process.

Initiating and maintaining relationships with these patients does not come easily. The respiratory therapist is the health care provider to get that relationship started with a positive inflection psychologically. The patient’s needs must be met, as part of Maslow’s hierarchy states, now more than ever due to being attached to a mechanical ventilator, coupled with the inability to speak, and quite certainly numerous other co-morbidities.

We cannot have measured outcomes on these patients if we do not meet their needs, and that includes their psychological needs. These patients may not demonstrate any clinical signs or symptoms that they are unable to perform in their physical therapy or occupational therapy sessions, or cannot tolerate their ventilator weaning session or should be refusing to wean, but observation of changes in attitude and affect can reveal a limiting factor. If we take those factors into account and try to address them by elevating the patient’s mood or attitude, we may find that these patients exceed their goals in PT and OT sessions, and have improved weaning trials from the ventilator.

Fostering trust

How this applies to the respiratory therapist scope of practice lies within that initial relationship; fostering a trust and conveying to the patient that that trust is to be inclusive of the other health care team members to achieve common goals is vital to success. Through a team approach, we can monitor the patient’s mood with a scaled scoring system that relates to progression or regression of his care. Aligning this approach can make the health care team more aware of any trends that need to be addressed when we are setting up our plan of care to achieve our stated goals. In doing so, we can also identify any larger scale needs that we may be overlooking that could call for a psychological intervention with a trained professional.

As health care providers it is our responsibility to identify patient needs and understand that the relationship foundation is a delicate matter for these patients. The responsibilities that the patient entrusts us to carry out are an honor. The patient knows the respiratory therapist is onsite 24 hours, which allows him a semblance of security and provides some much needed hope at this juncture of his care.

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Documentation: More Important than You May Think!

James Wood, Jr., RRT, Oakdale, PA

We have all heard the old saying, “if it is not documented, then it was never done,” but have you ever really thought about the significance of proper documentation during an emergency? With all of the budget and staffing changes in health care, it seems that proper documentation is sacrificed to allow time to complete other tasks. I am not here to debate the importance of our job duties, but I am here to stress the importance of proper documentation, and the impact that poor documentation may have on each of us as health care professionals.

Let’s take this scenario: Jane is the respiratory therapist involved in the care of Bob. Toward the end of Jane’s shift, Bob has an emergency that requires Jane’s assistance for a prolonged period of time. Eventually, Bob is transferred to an outside facility, but this incident has put Jane behind on the care of the other patients. In order to get back on track, Jane enters a quick note into Bob’s medical record about the incident and goes on with her other duties. Time goes by, and no one has heard anything about Bob or his condition.

Two years later, Jane is at home when she hears a knock at the door. After opening the door, Jane is handed a subpoena stating that she has been summoned to give a deposition in a wrongful death suit filed by Bob’s family. During the deposition, Jane is interrogated with questions but she cannot remember the answers. The attorney provides Jane with a copy of her documentation, which should include the details they are looking for. However, in her rush to get caught up, Jane neglected to document vital details of the event. Jane’s lack of documentation resulted in immediate job loss and a provisional license from the state. Additionally, the court found judgment in favor of Bob’s family, resulting in the facility paying out millions of dollars in damages.

Proper documentation is a vital part of our care delivery, and shortcuts should not be taken when completing this important task. Only document your own observations and actions and remember that others will be responsible for their own documentation. Here are a few questions to ask yourself in an effort to ensure you are compliant with documentation during an emergency:

• What alerted you to the event?
• What was your initial observation?
• What was your first action?
• What was the outcome of your interventions?
• Does the timeline reflect when the emergency started and stopped?

The next time you are documenting an emergency, skip the shortcuts and take a few extra minutes to ensure all of the appropriate details are captured in your documentation. If you are ever summoned to give a deposition, you will be glad you did!

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Drugs to Market: The FDA’s Role in Keeping the Drug Supply Safe

Karen Hamilton, CRT, Austin, TX

The United States has a long history of working to protect consumers from faulty medications. Attempts to ensure a safe drug supply date back to the early 1800s, when, due to deaths from adulterated smallpox vaccines, Congress passed the Vaccine Act of 1813.

In 1867 the USDA Division of Chemistry began looking into the adulteration of agricultural commodities. The commissioner of agriculture appointed Harvey Washington Wiley as chief chemist; his first role was to investigate the sugar-producing potential of sorghum. A former chemistry professor and an MD, Dr. Wiley became known for his rigorous scientific procedures, and he branched out from food problems to study useless and adulterated medicines. After several years, he formed a group known as the Poison Squad to look into reports by both citizens and drug companies of dangerous additives and adulteration of medication.

Laws were so ineffective that in 1901, a diphtheria antitoxin was given to 11 children in St. Louis. Of the 11, ten children died. It turned out that the antitoxin was derived from a horse that soon suffered from tetanus and died.

Dr. Wiley became known as the Father of the FDA after the Pure Food and Drug Act was passed by Congress in 1906 and he became the first commissioner. The FDA fought misleading and false claims for years. Of special interest to RTs is the Wil-Hide Exhaler, a device that claimed to cure tuberculosis. This device was widely advertised during World War I.

In 1938 President Roosevelt signed a law mandating that the FDA have authority over premarket reviews of the safety and efficacy of all new drugs and banning false claims as to the efficacy of drugs.

Modern FDA regulations were responsible for alleviating human misery in the 1960s through the FDA’s response to thalidomide, a drug widely prescribed in Europe as a sedative that provided help for women with severe nausea during pregnancy. In 1959, reports started coming into the FDA about babies born with severe birth defects and deformities of their limbs.

Dr. Frances Kelsey, an FDA researcher, found that this drug hadn’t been tested before it was released to the public in Europe and elsewhere. Based on her work, the FDA refused to allow the drug into the U.S. without testing. After this the Kefauver-Harris Act went into effect strengthening the FDA. Pharmaceutical companies had to prove that their drugs were safe and effective. Companies had to monitor safety reports and follow safety standards.

A drug company seeking FDA approval to sell a new prescription drug in the U.S. today must test that drug in different ways to show it is safe and effective. The drug will usually go through four stages of trials. I live in Austin, TX, one of the major centers in the country for phase 2 and 3 clinical trials. Drug companies work with companies that are set up solely to manage drug trials — this includes setting up the trial, finding the subjects, qualifying them, and conducting all aspects of the trial, including payment to the subject. In a clinical trial, participants can be asked to test medical products such as devices and drugs, and procedures. The stages or phases of the trials are —

Phase 0: Exploratory study involving very limited human exposure to the drug, with no therapeutic or diagnostic goals (for example, screening studies, microdose studies).

Phase 1: Studies that are usually conducted with healthy volunteers and that emphasize safety. The goal is to find out what the drug’s most frequent and serious adverse events are, and often, how the drug is metabolized and excreted as well.

Phase 2: Studies that gather preliminary data on effectiveness (whether the drug works in people who have a certain disease or condition). For example, participants receiving the drug may be compared with similar participants receiving a different treatment, usually an inactive substance (called a placebo) or a different drug. Safety continues to be evaluated, and short-term adverse events are studied.

Phase 3: Studies that gather more information about safety and effectiveness by studying different populations and different dosages, and by using the drug in combination with other drugs.

Phase 4: Studies occurring after the FDA has approved a drug for marketing. These include postmarket requirement and commitment studies that are required of or agreed to by the sponsor. These studies gather additional information about a drug’s safety, efficacy, or optimal use.

It is through these trials that drugs are shown to be safe and effective. It is estimated that it takes five to seven years for a drug or device to be approved. There is some controversy over whether this is too long and should be changed.

Indeed, pharmaceutical companies often complain that it takes too long and costs too much bring new drugs to the marketplace. Patients often feel that it takes too long for them to benefit from the drugs they are anxiously waiting for. I understand both views; however, I wouldn’t want to go back to the days of unregulated and potentially unsafe drugs.

If you are looking for information on a certain drug, go to ClinicalTrials.gov to find out if the medication is in the process of being tested or has been approved.

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Section Connection

Recruit a new member: Know an AARC member who could benefit from a Long Term Care section membership? Direct them to section sign up. It’s the easiest way to add a Long Term Care section membership to their overall membership package.

Section Discussion List: Go to the section website and click on “Discussion List” to start networking with your colleagues via the AARC’s social networking site, AARConnect.

Bulletin Deadlines: Winter Issue: January 1; Spring Issue: April 1; Summer Issue: July 1; Fall Issue: October 1.

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