BEST PRACTICES IN RESPIRATORY CARE PRODUCTIVITY …

1 Issue Paper BEST PRACTICES IN RESPIRATORY care . PRODUCTIVITY AND STAFFING. November 8, 2012. This paper provides guidance and considerations in the application of the AARC Position Statement: Best PRACTICES The documentation of competency in delivering RESPIRATORY in RESPIRATORY care PRODUCTIVITY and Staffing adopted by care services may be assured by applicable state licensing 1. the AARC Board of Directors in July 2012. boards and/or the attainment of RESPIRATORY therapy credentials awarded by the National Board for RESPIRATORY Background and purpose care (NBRC). All RESPIRATORY therapists employed by the hospital to deliver bedside RESPIRATORY care services must be The provision of safe RESPIRATORY care is largely dependent legally recognized by state licensing laws, where applicable, on staffing adequate numbers of competent RESPIRATORY as competent to provide RESPIRATORY care services.

2 For states therapists (RTs). Understaffing puts at risk the welfare and that do not require licensure, a CRT or an RRT credential safety of patients and may not allow care consistent with from the NBRC should be required to assure documented national guidelines and community practice. On the other competency and assure patient safety. hand, RESPIRATORY services represent a significant expense in the provision of health care and overstaffing RESPIRATORY The metrics described in this paper apply to the provision therapists is neither productive nor efficient. of care in which the RT provides direct oversight of care one patient at a time. Having therapists provide therapy to The 2012 AARC Position Paper regarding RESPIRATORY care multiple patients simultaneously may be considered as a PRODUCTIVITY and Staffing was approved and published to mechanism to reduce labor expenses.

3 This practice denies address growing concerns that inappropriate measures were patients the direct supervision of a RESPIRATORY therapist being applied to determine the number of RT staff needed at for the duration of treatment, thus diminishing quality and a given institution. This White Paper is intended to provide potentially placing the patient at risk. Medications delivered additional guidance to AARC members and to health care institutions and other providers to ensure that RESPIRATORY The 2012 AARC Position Paper regarding care PRODUCTIVITY and staffing levels are provided within acceptable standards of practice recognized by the RESPIRATORY care PRODUCTIVITY and Staffing was profession and that patient safety is protected. approved and published to address growing Considerations for rendering concerns that inappropriate measures were RESPIRATORY care being applied to determine the number of RT.

4 Staff needed at a given institution. Medicare Hospital Conditions of Participation state that 2. there must be adequate numbers of RESPIRATORY therapists , and other personnel who meet the qualifications specified by the medical staff, consistent with state law. Medicare by aerosol and other interventions provided by RESPIRATORY Hospital Conditions of Participation further require hospitals therapists are noted to have serious side effects that require that provide RESPIRATORY care services to meet the needs rapid recognition and corrective action, which can only be of their patients in accordance with acceptable standards achieved by direct observation of the patient. The practice of practice. Acceptable standards of practice as noted of providing therapy to multiple patients simultaneously in the Hospital Interpretive Guidelines for State Surveyors diminishes the RESPIRATORY therapist's time needed to observe include compliance with applicable standards that are set the patient's tolerance and compliance with the medication forth in Federal or State laws, regulations or guidelines, and to provide patient education.

5 More to the point of this as well as standards and recommendations promoted by paper, when multiple patients are treated simultaneously, the nationally recognized professional organizations ( , time standard for the treatment is no longer valid because it American Association for RESPIRATORY care , American Medical is based on the assumption that the therapist remains at the 2. Association, American Thoracic Society, etc.). bedside of each patient throughout the patient's therapy. 9425 N. MacArthur Blvd., Ste 100, Irving TX 75063 T W Therefore, performing simultaneous treatments leads to Assessment/Screening of Patients for VAP. reporting PRODUCTIVITY values that are erroneously high. Assessment/Screening of Patients for Weaning Cardio Version Monitoring of the Patient Situation analysis and considerations Continuous Oximeter Disease Management From a financial perspective, the over-estimation of staffing End Tidal CO2 Monitoring requirements leads to unnecessary and avoidable labor Endotracheal Tube Extubation expenses.

6 In contrast, understaffing may reduce salary Endotracheal Tube Repositioning and Securing cost in the short term, while producing more expense and Heliox Administration and Monitoring lost revenue in the long run. Fiscally, there is much to be Incentive Spirometry gained by staffing appropriately. Threats to revenue can Inpatient Sleep Apnea Monitoring result if prescribed treatments are not delivered and billed. Lung Recruitment Maneuvers Healthcare reforms associated with value-based purchasing Management of Patient Monitoring Devices will affect reimbursement payments from Medicare based on Moderate Sedation Monitoring both clinical outcomes and patient satisfaction. Thus, each Nitric Oxide Administration institution should be financially motivated to assure adequate Oxygen Administration and Monitoring staffing for patients to receive appropriate care and avoid Patient and Family Education, most instances lengthy hospital stays or unnecessary readmissions.

7 Further, Patient Transports Requiring Mechanical Ventilation or missed and delayed treatments increase institutional liability. Airway Maintenance Rapid Response Calls Understaffing negatively affects RESPIRATORY therapists' morale RESPIRATORY care Consultations because of inadequate time to provide needed assessments Spontaneous Breathing Trials 3. and care . Low morale may result in increased staff turnover. Tracheotomy Management These are compelling reasons to ensure adequate staffing in the provision of RESPIRATORY care . In addition, there are additional activities required to support the safe and effective delivery of care that consume therapist Any metric, model, or system that is used to define RESPIRATORY time. Many of these support activities are required by staffing levels within institutions should recognize and regulatory agencies.

8 These activities must also be accounted account for all the activities required of a RESPIRATORY care for and include but not limited to: Department in that institution. These activities vary greatly Calibration of Equipment among institutions, and therefore must be determined on Cleaning and Stocking of Equipment a case-by-case basis and approved by the medical staff and Clinical Instruction of Students administration in individual hospitals. Cylinder Inventory Management Department and Medical Center Meetings Failure to account for all medically necessary interventions, In-service Attendance or use of inaccurate metrics of workload, may lead to Maintenance of Equipment underestimation of staffing requirements. For instance: An Patient care Report/Handoff exclusive focus on Current Procedural Terminology (CPT) Patient care Rounds codes (or other standards based only on billable activities) Performance Improvement Activities can lead to the omission of a large number of non-billed Quality Control of Devices and Procedures activities from the estimated RESPIRATORY care workload.

9 Staff Education and Training Similarly, relying on internal measures, such as Total Patient Days, Average Daily Census, Adjusted Discharges per Patient Recommendations for using metrics to Day, and Nursing hours per patient day (which do not determine staffing levels accurately reflect RESPIRATORY therapist workload intensity), can lead to the omission of important and necessary tasks 1. Workload metrics used to predict staffing levels must that contribute to workload and thus provide erroneous include all clinical and support activities that RESPIRATORY estimates of required staffing. therapists perform, as stated in the AARC position statement. An organization must account for all activities The majority of clinical procedures conducted by RESPIRATORY that are driven by physician orders or medical staff therapists have not been assigned a CPT code.

10 CPT codes approved protocols. If there is an obligation to perform describe procedures and services provided by physicians and the procedure, it must be used in determining required other health care professionals who bill for reimbursement. staff, regardless of eligibility for CMS payment. Clinical However, relatively few have been assigned to procedures support activities should be included, such as labor law and activities provided by RESPIRATORY therapists. Examples of mandated paid breaks, shift report, participation in activities without CPT codes include but are not limited to: required training, or the need to safety test equipment. Airway Management Procedures 2. Because of varying time requirements for different RESPIRATORY Assessment/Screening Patients for Obstructive Sleep Apnea care procedures, systems to determine staffing should be Assessment/Screening of Patients for Treatment based upon statistically valid activity time standards for all the Assessment/Screening of Patients for Invasive and Non- services provided by a department.