The Future of Respiratory Care in 2015 and Beyond

Transcription

1 Potential Conflicts of Interest Respiratory Care 2015 and Beyond Charting a Future for the RT Profession Bob Kacmarek PhD, RRT Harvard Medical School Massachusetts General Hospital Boston, Massachusetts Received research grants from Hamilton, Covidien, Drager, General Electric, Newport and Cardinal Medical Received honorarium for lecturing from Cardinal Medical and Covidien Consultant for Newport WSRC Task Force/Planning Committee Kacmarek RM, Durbin CM, Barnes TA, Kageler WV, Walton JR, O Neil EH. Respiratory Care 2015 and Beyond. Respiratory Care 2009;54:375 Representation Committee Members Respiratory therapy director Bob Kacmarek (MGH) Respiratory therapy educator Tom Barnes (Prof Emeritus- NE) Administrator (acute care hospital) Karen Stewart (CAMC) Administrator (healthcare system) John Walton (Resurrection Health ) Healthcare workforce expert Ed O Neal (Center for Health Profess) Patient/consumer John Walsh (Alpha One) Physician (critical care) Charles Durbin (SCCM Past Pres) Physician (critical care) Woody Kageler (Disease Mgt) 2 year college representative Jolene Miller (NN2) 4 year college representative David Gayle (ASAHP) Federal government representative Judy Blumenthal (HHS) Military representative COL Michael Morris (Brooke Army) * Questions to Be Addressed How will patients receive healthcare services in the future? How will respiratory therapy be provided? What knowledge, skills and attributes (KSAs) will respiratory therapists need to provide care safely, efficiently and cost-effectively? What educational and credentialing systems are needed to provide these KSAs? How do we get from the present to the future with minimal impact on the respiratory therapy workforce? Conferences to Address Questions Conference 1 March 2008 focused on identification of the emerging values of our nation s evolving health care delivery system and defined the potential roles and responsibilities of the respiratory therapist in 2015 Conference 2 Spring 2009 focused on the skills, knowledge and attributes that RT s in 2015 and beyond will need to possess in order to execute their roles and responsibilities and to identify the competencies required. 1

2 Conferences to Address Questions Conference 3 Fall 2009 will focus on addressing the question How do we get from where we are today to where we ll need to be in order to adequately prepare for 2015 and Beyond with minimal impact on the workforce. 1 st Conference 3/3-5/08-20 Stakeholder Organizations 37 Participants Alpha 1 Foundation American Association for Cardiovascular and Pulmonary Rehabilitation (AACPR) American Association for Respiratory Care (AARC) American College of Chest Physicians (ACCP) American Thoracic Society (ATS) California Board for Respiratory Care Center for Health Professions Commission on Accreditation of Allied Health Education Programs (CAAHEP) Committee on Accreditation of Respiratory Care (CoARC) COPD Foundation National Association for Medical Direction of Respiratory Care (NAMDRC) National Board for Respiratory Care National Heart Lung and Blood Institute National Home Oxygen Patients Association National Network of Health Career Programs in Two Year Colleges (NN2) North Carolina Board for Respiratory Care Society of Critical Care Medicine (SCCM) The Association of Schools of Allied Health Professions (ASAHP) The Joint Commission United States Public Health Service Drivers of Health Care Change Cost of Care 16% of GNP, 2 trillion dollars/yr, Medicare Part A funding a concern, private insurance more expensive, employers paying less Demographics Baby Boomers will soon be 65, US pop to grow by 20% between 2000 and 2025 Shift in the disease burden US Pop lives 35 yrs longer than 100 yrs ago, acute to chronic care, US health care must refocus to chronic care Drivers of Health Care Change Technology Information and communication will change administrative tasks, clinical work and redistribute knowledge from experts to consumers Innovation will affect all aspect of medicine Consumers of health care Will demand quality, convenience, price and satisfaction Disease Management: A system of coordinated health care intervention and communication for populations with conditions in which patient selfcare efforts are significantly expected to expand. New models of healthcare delivery (such as the Hospital at Home and Medical Home ) will emerge with increasing emphasis on coordination of care through the healthcare system including the home Public health issues, military and disaster response concerns will continue and require new skill sets for respiratory care providers Current Status of RC within the Healthcare System RC is an important and integral part of health care because of prevalence and seriousness of pulmonary disease and the freq of pulmonary complications Most RC provided in the acute care setting COPD 12 to 14 million diagnosed, another 12 million undiagnosed, 4 th leading cause of death, billion cost of care 2

3 Current Status of RC within the Healthcare System Asthma 22 million diagnosed, annual cost 19 billion, 4,000 5,000 die each year OSA still essentially undiagnosed, estimate 18 million affected, 6 million moderate to severe disease, impact of OSA on other systems still immerging Needed skills Education, protocol use, preventative care, risk factor modulation, disease self management, smoking cessation Active Respiratory Therapists State Licensure Boards 111, ,651 Bureau of Labor Statistics 122, ,000 Respiratory Therapists per 100,000 Population Top Five District of Columbia Indiana Ohio Kansas Nebraska Bottom Five Wyoming Alaska New Jersey Minnesota Utah Year BS Degree AS Degree Graduates From Associate Degree and Baccalaureate Degree CAAHEP Accredited Programs Total ,634 5, ,570 6, ,612 7, ,241 5,812 Total 2,091 22,083 24,174 United States mean 32.10/100,000 population Respiratory Care in the Beginning ! Oxygen Therapy H-Cylinders and O 2 Tents! Schwartz Rebreathing Tubes! Aerosol Therapy! Negative pressure ventilation! IPPB! ABG analysis and PFTs! 3

4 The Role of the Respiratory Therapist in the Beginning ! Puritan Bennett TV-2P and PR-2 Technician (O 2 Technician) Setup and operation of basic equipment Delivery of aerosol therapy Provision of IPPB Assistance with ventilatory support Performance of diagnostic tests Where Are We Today 2008! Sophisticated ICU Ventilators Ventilation In All Care Settings Non-invasive Ventilation Extracorporeal Life Support Aerosol, Oxygen and Bronchial Hygiene Rx Home Care, Subacute Care Sleep, Transport Patient Education Extracorporeal Life Support Role of the Respiratory Therapist Today Provider of Basic Respiratory Care Ventilator management Delivery of aerosolized medication Transport of critically ill patients Extracorporeal Life Support Performance of diagnostic studies Patient Education! Disease management!! Consultant on Patient Care!!! 4

5 Respiratory Care 2015 and Beyond! ICU - increased Technical and Clinical Sophistication, Expanded Monitoring Explosion of Aerosol Therapy Applications Genetic Based Aerosol Therapy Sleep, Transport, Extracorporeal Life Support Subacute Care, Physician Offices and Home Disease Management, Patient and Staff Education, Team leadership Clinical Application of Mechanical Ventilation Protocolized approaches to providing mechanical ventilation Modes of ventilation Integrated Monitoring Systems Diagnostic Algorithms Protocolized Ventilation ARDSnet Protocol Recruitment Procedure Determination of Correct PEEP Ventilator management protocol for Asthma, COPD, Post-Op etc! Closed Loop Ventilation-The Future Expect to see additional closed loop approaches! Approaches that manage both patients receiving assisted as well as controlled ventilation and during weaning! Ideal feedback should include: Patient effort/ ventilatory pattern Hemodynamic response Gas exchange The problem finding the correct algorithm! Lellouche, Brochard AJRCCM 2006;174:894 CDPW system operational rules: PSV 2-4 cmh 2 O steps establish a comfort zone RR 15 to 30 breaths per min, 34 COPD V T > 250 ml or 300 ml based on size P ET CO 2 < 55 or < 65 if COPD When PSV minimal, SBT at minimal settings: Trach + HH = 5 cmh 2 O Trach + HME = 10 cmh 2 O ETT + HH = 7 cmh 2 O ETT + HME = 12 cmh 2 O Ventilator indicates if patient passed SBT Pt extubated if P/F > 200 and PEEP < 5 cmh 2 O Adaptive Support Ventilation, Calculates Optimal Breath Pattern: Least Work of Breathing Vt in ml 2'000 1'500 1' a b d Frequency in breaths per minute c Avoid: a: apnea b: volu/barotrauma c: AutoPEEP d: excessive V D /tachypnea 5

6 Proportional Assist Ventilation PAV based on the equation of motion: Paw + Pmus = V x R + ΔV x E Increases or decreases ventilatory support in proportion to patient effort Similar in concept to Power Steering Tracks changes in patient effort and adjusts ventilator output to reduce work Introduced by Younes in 1992 (Younes M, ARRD 1992;145:121) Neurally Adjusted Ventilatory Assist - NAVA Sinderby Nature Med 1999;5:1433 Evidence Based Medicine The practice of evidence based medicine is the integration of: An individuals clinical experience with The best available clinical evidence from systematic research and the integration of The patient s values and expectations! The best evidence changes over time! Individual Clinical Expertise Based on clinical skills and clinical judgment The right patient, the right time, the right place, the right dose, the right resources. Used to determine if the evidence applies to the individual patient! Taubes Science 1996;272:22 1,000,000 RCTs have been carried out over the past 50 years and most have been forgotten or disregarded! The outcomes from many of these RCTs conflict with each other! and Beyond! Sophistication knowledge of multiple classes of increasing complex ventilators Expert consultant on the application of mechanical ventilation Ability to assess the validity of the evidence Research methodology Statistical analysis 6

7 Developing Monitoring Technology Electrical Impedance Tomography Schible ICM 2006;34:400 Meier ICM 2008;34:543 Acoustic Thoracic Monitoring Tejman-Yarden Anesth Analg 2006;103:1489 Lechner Eur J Anaesthesiol 2004;21:694 Optoelectronic Plethysmography Dellaca CCM 2001;29:1801 Electrical Impedance Tomography EIT uses the variability in electrical impedance among tissue, air, and fluid to provide a map of impedance changes. It is an online dynamic monitor that is: Radiation free, Noninvasive, Portable to the bedside Relatively inexpensive Adler JAP 1997;83:1762 and Beyond! Working knowledge of and ability to utilize complex bedside monitoring techniques Increased understanding of complex physiology and Beyond! Extracorporeal Gas Exchange Intravascular Blood Oxygenator ASAIO J 2006;52:180 Implantable Oxygenator ASAIO J 2006;52:291 NovaLung Extracorporeal CO2 Removal Int J Artif Organs 2005;28:985 Pumpless Extracorporeal Lung Assist Lung 2006;184:169 7

8 Aerosol Therapy Applications Drug Delivery via the lung! Pulmonary hypertension iloprost, PGI2 Emmel Heart 2004;90:2 Diabetes inhaled insulin (Exubra) NEJM 2007;354:497 Allergen immunotherapy Inflamm Allergy Drug Targets 2006;5:43 Rejection immunosuppression in lung transplant Burckart Expert Opin Investig Drug 2006;5:43 Genetics Based Respiratory Care Genetic predisposition of Respiratory Diseases: Asthma, Alpha-1 Antitrypsin Deficiency, Cystic Fibrosis, Sepsis and ARDS Customization of therapy based on a patients genetic makeup! Human Genome Project The human genome has 3 billion pairs of bases, their order determines human diversity Genomics and Asthma Polymorphism of the beta-2 adrenergic receptor May influence airway response to inhaled beta agonists (Curr Opin Pulm med 2006;12:12) May explain response to salmeterol (AJRCCM 2006;173:519) Gly 16 alelle predisposes to nocturnal asthma (J Allergy Clin Immunol 2005;115:963) Polymorphisms of a single gene may explain variation in response to inhaled steroids (Proc Am Thorac Soc 2004;1:364) Genomics and ARDS Polymorphism in the surfactant Protein-B gene is associated with susceptibility for ARDS in women but not men (Chest 2004;125:203) Association between genetic polymorphism and risk of development of ARDS and increased mortality in ARDS ( CCM 2007;35:48) Identification of candidate genes may provide potential targets for ARDS therapy (Am J Physiol Lung Cel Mol Physiol 2006;29:1113) Gene Replacement Therapy Alpha-1 Antitrypsin deficiency (Curr Opin Pulm Med 2006;12:125) Weekly intravenous alpha-1 replacement therapy available Possible role of alpha-1 antitrypsin therapy in reducing progression of disease Role for inhaled therapy (only 2% of infused drugs reach the lung) Cystic Fibrosis (J Aerosol Med 2003;15:229) Two vectors have been used for inhaled gene therapy (CFTR): adenovirus and liposomes In vivo gene transfer to the bronchial epithelium by aerosol can be achieved 8

9 and Beyond! Administering pharmacologic agents affecting systems other then the heart and lung! Administering gene therapy agents via aerosol! Consulting on selection of a broad range of therapies! and Beyond Provision of more extensive care in the subacute setting Assessment, diagnostic evaluation and treatment in physician offices and clinics Important part of the Public Health Service and Military Key Component of Disaster Response and Beyond Assessment, initiating therapy and implementing protocols in the home Performing diagnostic tests in the home Administering a wide range of pharmacologic agents in the home and Beyond Disease Management Health Promotion Disease Prevention Community Outreach Health education Educator of other staff Leader of multidisciplinary teams and Beyond As with all aspects of health care I expect the role of the respiratory therapist to expand proportional to the continued exponential expansion of medicine in general! The expectation is that you will be a consultant providing your opinion on how respiratory care should be provided On patient rounds you are expected to contribute to the discussion of goals and direction of therapy You are the expert on Respiratory Care and you will be expected to share your expertise If no one asks for your opinion you are not necessary 9

10 Conference 2 Spring 2009 focused on the skills, knowledge and attributes that RT s in 2015 and beyond will need to possess in order to execute their roles and responsibilities and the competencies required. Conference 3 Fall 2009 will focus on addressing the question How do we get from where we are today to where we ll need to be in order to adequately prepare for 2015 and Beyond with minimal impact on the workforce. Thank You 10