The Science Journal of the American Association for Respiratory Care

1999 OPEN FORUM Abstracts


Linda Allen Napoli, BS, RRT, RPFT. Agnes Saxvanderweyden, ADN, CCRN, Theresa R. Schultz, BA, RRT, CPFT, Roberta Hales, BS, RRT, Lorraine Hough, MEd, RRT, CPFT, Mark Helfaer, MD, The Children's Hospital of Philadelphia, Philadelphia, PA

Background: In an attempt to evaluate the allocation of nursing and respiratory care resources in our Pediatric Intensive Care Unit (PICU), a group of nurses (RN) and respiratory therapists (RRT) were assembled. Physician input was also solicited. The goal of the project was to determine if redundancies could be eliminated and efficiency improved by the reallocation of resources. If this goal could be met then an improvement in the quality of care would be the natural result.

Methods: The group evaluated all patient care activities and procedures performed in the PICU. The activities/procedures were placed in a table and divided to indicate which should only be performed by an RN or an RRT. This was performed according to the scope of practice for each discipline. The remaining activities/procedures were ascribed to either discipline. The group endeavored to maintain discipline specific identity and responsibilities. The approach taken was to view participants as members of a patient care team, with no one group in charge of the other. A pilot group of staff, from both disciplines, were then recruited to participate. An extensive multi-disciplinary educational process was begun. An emphasis was placed on teamwork during this training, with each participant spending clinical time with another participant from the other discipline. Competency assessment evaluation occurred for all cross-trained activities. A multi-disciplinary patient care flow sheet was concurrently developed. This would allow either group to document patient assessment and interventions in the same manner. For the pilot, one RRT (beyond the PICU normal staffing) was assigned to participate 24 hours a day from Monday to Friday for a six week period. The RRT was matched with one or two RNs and provided care to the patients assigned to the team. The ratio of RN to RRT varied according to acuity level of the patient(s), as ranked by the charge RN for the shift. The average ratio was two RNs to one RRT with two to four patients assigned to the team. There were several occasions when patients with very high acuity scores were assigned one RN/one RRT. We realized that justifying the benefits of this model would be difficult. A survey tool was developed to ascertain as much objective input as possible. Physicians, nurses and therapists, all having worked in our traditional model and the team model, completed these surveys. The outcomes surveyed were: communication between health care workers, timeliness of care, and availability of personnel along with response time. The areas were rated on a scale of 0 to 5, with 5 being best, 3 the same and 0 worst.

Results: The findings were as follows:

Communication between health care workers 5
Timeliness of care 4.5
Availability of personnel/response time 4.5

The team felt that patients received a better quality of care secondary to improvements in communication, timeliness and availability of resources.

Conclusions: Despite apprehension from both groups at the start of the pilot, participants totally supported it at completion. The desire and effort to maintain discipline specific identity and responsibilities dispelled the fears encountered in many redesign efforts. The future goal is to use this model and incorporate the RRT hours necessary to provide care into the PICU budget, while still maintaining a centralized respiratory care department structure. Preliminary data suggest implementation of this model will result in a modification of how resources are allocated to the PICU.