The Science Journal of the American Association for Respiratory Care

2011 OPEN FORUM Abstracts

A STATEWIDE SURVEY OF PATIENT SAFETY ISSUES RESULTING FROM NON-RESPIRATORY THERAPISTS ADJUSTING MECHANICAL VENTILATOR CONTROLS IN ACUTE CARE HOSPITALS.

Daniel J. Grady4, Floyd Boyer2, Joseph Coyle1, Ronald Perkin3, Terrence Smith4, Kathy Short5, Edward Bratzke2, Michael A. Gentile6, Gregory M. Campbell4; 1Respiratory Care, University of North Carolina Charlotte, Charlotte, NC; 2North Carolina Respiratory Care Board, North Carolina Respiratory Care Board, Raleigh, NC; 3Respiratory Care, University Health Systems of Eastern North Carolina, Greenville, NC; 4Respiratory Care, Mission Health System, Asheville, NC; 5Respiratory Care, University of North Carolina Hospital, Chapel Hill, NC; 6Department of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC

Background: Mechanical ventilator control settings are sometimes adjusted by healthcare practitioners other than Respiratory Therapists. As follow up to patient care issues brought before the the North Carolina Respiratory Care Board (NCRCB), patient safety issues associated with this practice were investigated by addressing the following questions: (1) Does the practice of changing ventilator controls; without communication or written orders to Respiratory Therapists; result in patient safety issues? (2) What are the statewide scope, depth, and cost of patient safety issues associated with this practice? Methods: A voluntary, anonymous survey was developed and sent to all 4,348 licensed Respiratory Therapists in the state of North Carolina. The survey focused on ventilator control changes made in the acute care hospital setting, and excluded the operating room and recovery room areas. A separate request was sent to all Respiratory Care Department Medical Directors for completion. Results: A total of 533 (n= 533) licensed Respiratory Therapists completed the survey, for a state-wide 12% response rate. Reported patient safety issues are summarized in the table, which follows this abstract. Conclusions: This survey has identified serious patient safety, communication, cost, and competency issues associated with the practice of changing mechanical ventilator control settings without prior communication/written orders to RCP's. The safety issues are significant and identified possible patient harm. As a result of the magnitude of these findings, the NCRCB has initiated the process of developing a position statement which restricts the changing of ventilator control settings. Presentation of this preliminary data represents a first step in the development of this "Hands Off" position statement. Further, it is recommended to expand this survey nationwide to further evaluate the cost, depth, and scope of patient safety issues associated with this practice.
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Patient Safety Issues from Non-Respiratory Therapists Adjusting Mechanical Ventilator Controls