Subacute Care Bulletin

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1 Subacute Care Bulletin THE AMERICAN ASSOCIATION FOR RESPIRATORY CARE NUMBER 5 SPRING 1997 NOTES FROM THE CHAIR by Kevin Cornish, RRT As my first responsibility as the new section chair, I would like to welcome all of you who have an interest in this growing segment within our profession and the health care industry. For those of you who do not know me, I work with the post acute care consulting group of Ernst & Young and have been involved in the subacute care arena for over ten years. During that time I have had the opportunity to work with a variety of different post acute providers. I am a member of the board of directors for the National Subacute Care Association and have taken a particular interest in the education of the post acute care community on the attributes of the respiratory care professional. It is toward this goal that I look forward to the opportunity to chair this section. I have had the opportunity to meet with many of you at the AARC Convention in San Diego and elsewhere, and look forward to the development of our group and our presence in the post acute care community. Key to the success of our section will be avid participation by its members. The subacute care community is diverse, both in terms of the settings in which care is delivered and the tools and information needed to work effectively in this area. Many of you have experiences and information that can be invaluable to your fellow RCPs, and it is the section s responsibility to identify methods to effectively transfer that knowledge to those who wish to develop their careers in this area. There are a number of ways in which to get involved Serve as guest editor of the Bulletin: By guiding the content and structure of our official publication, you can help to get the word out about everything from the impact that government has on our practice to the latest developments in research. Submit articles to the Bulletin and/or engage in research initiatives that deal with respiratory services in post acute settings. Submit ideas that will foster the effective and efficient use of AARC resources in positively influencing the understanding that those outside of respiratory care have of the value of the RCP to post acute care providers. As the year develops, specific projects involving the specialty section will evolve that will require human resource power to accomplish. If you would like to volunteer for specific initiatives such as those listed above, or just identify yourself as a potential resource, feel free to contact me at the numbers listed on the back page of this and every issue. I look forward to being your section chair and working with, and hopefully meeting, many more of you in the year to come. A WORKING DEFINITION FOR REHABILITATION IN THE PROVISION OF RESPIRATORY CARE SERVICES IN THE SKILLED NURSING ENVIRONMENT by James R. Lankford, CRTT, MBA James Lankford is an RCP from Tempe, AZ. Over the past few years, the demand for hospital-based respiratory care services in skilled nursing facilities has grown dramatically, and this demand continues to pique the interest of acute care department managers searching for additional sources of revenue. As a result, the number of acute care managers seeking to provide respiratory care services in the skilled nursing environment continues to grow. With over 11,000 Medicare certified skilled nursing facilities in the country, it is likely that this growth will continue at least for the next few years. The complexity of the regulations imposed by Medicare relevant to the provision of respiratory care services in the skilled nursing environment, however, requires an in-depth understanding of those regulations and how they affect the practice of respiratory care. Particularly troublesome is the Medicare definition of rehabilitation for skilled nursing facilities, which is different than that used in acute care. As with most Medicare guidelines, the definition of rehabilitation is written so broadly as to leave ample room for interpretation. Still, the Medicare definition has a definite impact on the types of patients who qualify for respiratory care services in SNFs and under what conditions those patients may be treated. Lack of understanding of the Medicare definition often leads to over- and under-utilization of services. The purpose of this article is to propose a working definition of rehabilitation for the practice of respiratory care in skilled nursing facilities and stimulate debate on the subject. An open, professional dialogue will lead to a better understanding of this aspect of the Medicare regulations and the development of a standardized definition of rehabilitation. The end result will be improved consistency in the provision of respiratory care in the skilled nursing environment. To begin this process, it is important to examine the origins of Medicare. With the support of President Johnson, the United States Congress passed into law legislation creating the Social Security Act of The goal of this legislation was to ensure that all Americans had access to quality health care regardless of their ability to pay for the services received. This was achieved, in part, in Titles 18 and 19 of the Social Security Act. Title 19 created Medicaid, which is designed to provide health care services to those who are not eligible for Medicare and who cannot pay for services themselves. Medicare, created by Title 18, provides coverage for Americans who are 65 years or older and have paid social security taxes. In addition, Medicare covers those who have been disabled for two or more years, regardless of age, and those who have end-stage renal disease. Title 18 contains provisions for qualified beneficiaries to receive skilled nursing and rehabilitation services. With the

2 SUBACUTE CARE BULLETIN exception of respiratory care, each of those services can be provided by employees of the skilled nursing facility. Medicare requires that respiratory care in a skilled nursing facility be provided by a hospital with which the skilled nursing facility has a Transfer Agreement. Further, the respiratory care practitioners must be employees of the transfer hospital and be supervised by managers of that hospital. Once these criteria are met, Medicare recognizes claims for reimbursement for respiratory care services provided to qualified beneficiaries residing in that facility. Reimbursement for respiratory care services is subject to the application and provision of those services in compliance with the Medicare Guidelines. It is the definition of Skilled Nursing/Skilled Rehabilitation Services that, in large part, governs the types of beneficiaries who may receive respiratory care services without denial of reimbursement to the skilled nursing facility. The Medicare definition for Skilled Nursing/Rehab Services is as follows: Skilled nursing and/or skilled rehabilitation services are those services furnished pursuant to physician orders which: (1) require the skills of technical or professional personnel, e.g., registered nurse, licensed practical (vocational) nurse, physical therapist, occupational therapist, speech-language pathologist, or audiologist; and (2) are provided either directly or under the supervision of such personnel. [42 CFR (a.).] (Medicare Explained 1995). This definition fails to specify RCPs, but it is implicit that they fit the definition of skilled rehabilitation personnel. In actual practice, RCPs can provide skilled rehabilitation services only in conjunction with other skilled personnel. This is unlike the other therapies, which may skill alone. Since Congress recently recognized RCPs as skilled personnel, it is reasonable to expect that with proper guidance and education from organizations such as the AARC, Medicare may come to allow RCPs to skill alone, as is the case with the other therapies. The Medicare definition of Skilled Nursing/Rehabilitation Services covers a broad range of possible services when viewed in terms of the criteria applied by Medicare. In determining whether a service is skilled, the following criteria apply [42CFR ]: (1) If the inherent complexity of a service prescribed for a patient is such that it can be safely and effectively performed only by or under the supervision of technical or professional personnel, the service would constitute a skilled service. (2) A service that is generally nonskilled would be considered to be a skilled service when, because of special medical complications, its performance or supervision, or the observation of the patient, necessitates the use of skilled nursing or skilled rehabilitation personnel. For example, the existence of a plaster cast on an extremity generally does not constitute a need for skilled care, but a patient with a preexisting acute skin problem or a need for special traction of the injured extremity might need to have technical or professional personnel properly adjust traction or observe him for complications. In such cases, the complications and special services involved must be documented by physicians orders and nursing and/or therapy notes. (3) The restoration potential of a patient is not the deciding factor in determining whether a service is to be considered skilled or nonskilled. Even when full recovery or medical improvement is not possible, skilled care may be needed to prevent, to the extent possible, deterioration of the patient s condition or to sustain current capacities. For example, even though no potential for rehabilitation exists, a terminal cancer patient may require skilled services. The Medicare Guidelines list examples of services that could qualify as either skilled nursing or skilled rehabilitation services [42CFR (a)]. Some of these examples are: Overall Management and Evaluation of Care Plan Observation and Assessment of the Patient s Changing Condition Patient Education Services The Medicare definition of Skilled Nursing and/or Skilled Rehabilitation Services and the criteria with which the definition is applied provide guidance in the creation of a working definition of skilled rehabilitation services for the practice of respiratory care. The process of rehabilitation covers a wide range of skilled services provided by RCPs. Supported by the accurate recording and reporting of all related activities, this process facilitates the attainment of the patient s treatment plan/rehabilitation goals within the criteria for skilled rehabilitation services provided for under the Medicare Guidelines. Rehabilitation goals There are four primary goals for patient rehabilitation in the practice of respiratory care 1. Prevention of further cardiopulmonary disability/deterioration through arresting the disease process. 2. Maintenance of remaining cardiopulmonary capabilities. 3. Restoration of as much cardiopulmonary function as possible, leading the patient to attain an optimal level of wellness. 4. Teaching the patient and his or her family the correct procedures to provide continuing respiratory care and treatment in a self-sufficient manner, thereby reducing or eliminating the need for intervention by an RCP. Record keeping requirements A comprehensive record of the RCP s rehabilitation activities must be maintained in the patient record. This record must include documentation of 1. Patient s treatment plan and goals for rehabilitation. 2. Serial reevaluation of the patient s cardiopulmonary status and subsequent changes in the treatment plan and rehabilitation goals as indicated by the patient s condition. 3. Progress towards stated rehabilitation goals as outlined in the treatment plan. 4. Patient and family training and education, and progress towards self-sufficiency. 5. Treatment results and efficacy. 6. Diagnostic results and resultant changes is the treatment plan. The rehabilitation team RCPs are an integral part of the interdisciplinary rehabilitation team. They provide the following services to that team 1. Participate in the development of the patient treatment plan and the rehabilitation goals. 2. Evaluate, assess, measure, and report on the patient s progress towards his or her rehabilitation goals. 3. Provide viable treatment and rehabilitation alternatives as indicated by the patient s condition and progress towards his or her rehabilitation goals. Discussion Within this definition, what types of patients can be treated and under what conditions can skilled RCP services be provided? The prevention of further cardiopulmonary deterioration is applicable to a patient with chronic obstructive pulmonary disease that is exacerbated. The goal is to arrest the disease process in preparation for subsequent restorative efforts. In this example, it would be reasonable to expect the frequency and duration of the treatment regimen to decrease over time as the patient s disease process is 2

3 SUBACUTE CARE BULLETIN arrested, eventually reaching a point where the patient is capable of self-administration of treatment. Maintenance of remaining cardiopulmonary function applies to a patient with terminal lung cancer whose condition prevents selfadministration of treatment. This patient may require bronchodilator therapy and other modalities to maintain as much respiratory function as possible. Due to the nature of the disease process, it would be expected that the frequency and duration of the treatment regimen would increase or fluctuate over time in response to the patient s needs. Maintenance therapy provided to a patient who is capable of self-administration of treatment is, of course, not covered under this definition of rehabilitation. Such a patient may receive an initial screening and/or assessment by the RCP to ensure that he or she is self-administering his or her treatment appropriately and effectively. Additional training and education may be deemed necessary, but once completed, the patient becomes self-sufficient in his or her treatment regimen. Restoration of cardiopulmonary function in a patient with chronic obstructive pulmonary disease falls under the more widely accepted definition of pulmonary rehabilitation. The patient would have the potential for rehabilitation and the RCP would treat according to the patient s rehabilitation goals. Teaching the patient and his or her family applies to the alert patient, capable of learning safe and effective self-administration of treatments. For example, a patient admitted for recovery from hip replacement may require incentive spirometry as a prophylaxis against pneumonia. The RCP may train and educate the patient and/or his or her family in proper technique and treatment goals. Once the training and education is completed, perhaps in one or two visits, the patient is left to continue his or her treatment in a self-sufficient manner. The Medicare definition of rehabilitation provides wide latitude for the provision of services by the RCP. RCPs may treat a variety of patients in diverse situations as long as the services provided are accurately documented. Record keeping is paramount to the RCP s success in this area. The Medicare documentation requirements are significantly more demanding than those found in the acute care environment. Medicare denials of reimbursement often occur due to lack of adequate documentation. In the eyes of Medicare auditors, if it was not documented, it was not done. Inadequate documentation results in a disservice to the patient because he or she may not receive the full health care benefits to which he or she is entitled. The skilled nursing facility does not receive reimbursement for denied services and may either scale back respiratory services or eliminate them all together, decreasing the need for respiratory care staffing. The transfer hospital loses revenue and may be required to reimburse the skilled nursing facility for all or part of the costs involved. In short, everyone loses if documentation is not comprehensive. The RCP s place on the interdisciplinary rehabilitation team must be earned. This can only be accomplished through professionalism, commitment to the team and its goals, and dedication to quality patient care. As the respiratory care profession continues to earn its place alongside the other skilled services in the skilled nursing environment, the realization of the RCP s value in this segment of the health care continuum is crucial to the future of the profession. Understanding the Medicare definition of rehabilitation and applying it to the provision of respiratory care services in SNFs is an important step in gaining the acceptance of the interdisciplinary rehabilitation team and recognition for the valuable contributions that our profession makes to the care of SNF patients. Reference: Medicare Explained, 1995, CCH Business Law Editors, CCH Incorporated, Chicago, RESPIRATORY TECHNOLOGY IN SUBACUTE CARE by Robert Heidegger, RRT Robert Heidegger is an RC manager at Integrated Health Services at Brentwood in Burbank, IL. Seven years ago, I began my career in subacute care as the respiratory care manager in a newly developed medical specialty unit in a freestanding skilled nursing facility. What I remember most of those early years are the trials and tribulations I experienced in trying to find appropriate, cost-effective equipment at a time when choices were limited either by the technology available or the physical limitations of the facility. Meeting today s needs Luckily, as the subacute care industry has grown (experts predict that subacute care could eventually replace up to 50% of current acute care hospital lengths of stay 1 ), the number of products available to meet the demands of the subacute center has increased dramatically. The types of equipment generally used in this setting can be categorized as: 1. Life support equipment, which includes mechanical ventilators and oxygen delivery devices 2. Diagnostic equipment, which includes blood gas analyzers, pulse oximeters, capnometers, and spirometry devices 3. Airway care equipment, which includes suction devices, air compressors, and therapy administration devices The amount and variety of disposable supplies designed for use in the subacute care setting are growing as well. Of all the requirements subacute respiratory care equipment must meet, portability that does not compromise advanced features stands out as perhaps the most important attribute. Life support equipment The ideal subacute mechanical ventilator would combine the features of a high-end machine within a smaller unit. A device that features portability, full weaning modes (including pressure support), ability to operate without a high-pressure gas source, and internal battery power would be a front-runner in the subacute setting, where patient mobility cannot be restricted by more stationary equipment or where space is limited. When it comes to oxygen delivery devices, subacute patients no longer have to be restricted by either the length of the oxygen tubing or the capacity of the vessel. Several manufacturers now offer portable liquid systems which are lightweight, aesthetic, and have capacities exceeding eight hours, depending on flowrate. Diagnostic equipment Whether it be determining weaning potential, assessing weaning tolerance, or performing routine spot checks, availability of diagnostic services is vital in every subacute respiratory unit. These tools include blood gas measurement, pulse oximetry, and simple spirometry. Capnometry is rapidly becoming a standard diagnostic tool in the subacute setting as well, especially where weaning is performed in frequent, small increments. Several factors, including number of tests performed and cost, can determine whether blood gas measurement is performed within the facility or through a contractual arrangement with a nearby provider. However, it is important that results be available to the 3

4 SUBACUTE CARE BULLETIN RCP no later than two hours after the time the sample is drawn. Several manufacturers offer Point of Care (POC) analyzers. These devices are fully portable, allowing analysis of samples immediately after acquisition. Perhaps the most frequently utilized diagnostic tool is the pulse oximetry spot check. While frequent measurement of blood gas samples is often impractical, routine assessment with pulse oximetry provides the subacute RCP with essential information to aid in determining weaning potential or overall respiratory status. Portability and durability are a must with any pulse oximeter. There are several hand-held models on the market which are capable of handling spot checks or continuous monitoring in one unit. There are also several manufacturers offering combination pulse oximeter/capnometer devices, providing immediate and trendable data to assist in weaning efforts. Spirometric measurement is also required in the subacute facility to determine weaning potential or measure the effects of bronchodilator or other therapies. Simple testing, including negative inspiratory force (NIF) and vital capacity (VC), is traditionally assessed utilizing a manometer and respirometer, respectively. However, some manufacturers offer these measurements at the push of a button while the patient is connected to the ventilator. Real time results are then graphically displayed on the ventilator s console. For more complex spirometry measurements, subacute respiratory departments can take advantage of several types of portable spirometry systems, which offer real time graphics, data storage, and on-board printout capabilities. Airway equipment Significant advancement has recently been made with regard to portable suction devices. When piped vacuum is not available due to cost, practicality, or structural limitation, portable electrically powered suction devices are used. The vacuum power and capacity of these devices must be sufficient, especially when secretions are thick or voluminous. Also, a battery operated suction device would be needed for some patients when proximity to a piped vacuum outlet or electrical source is not available for extended periods. Suction devices that offer portability, battery power, and vacuum pressure comparable to that of piped suction are now available which all but eliminate the need for costly piped or ineffective portable devices. Table 1 ITEM Ventilators Diagnostic Tools Blood gas analyzer Pulse oximeter Spirometry Airway Care Devices Suction machine KEY Portability, weaning modes Portability, low cost per test Portability, durability, cost portability Portability, power DESIRABLE FEATURES Operates w/o high pressure gas source(s), internal battery power Upgradable for additional tests Spot check and continuous capability, small size Built in with ventilator, on-board printing AC and battery powered Preparing for tomorrow A few years ago, subacute care was a $1 billion per year industry l,2 ; now there are seven long term care providers each reporting revenues of over $1 billion each. 3 Manufacturers of respiratory care equipment have responded to this growing market demand. With leading edge technology some of it designed specifically for this environment subacute care is likely to represent an even greater opportunity for RCP s in the future. References 1. The Growth of the Subacute Industry. ProHealth Newsletter, June Walton, J. Subacute Care: A New Opportunity for RCP s. AARC Times, May 1993;49 3. Fisher, C. Top 1996 Nursing Facility Chains. Provider, January 1997;35 Deadlines for submitting copy for publication in the Bulletin Spring Issue: February 1 Summer Issue: May 1 Fall Issue: August 1 Winter Issue: October 1 JCAHO ACCREDITATION VISIT REPORT In an effort to keep you informed regarding JCAHO site visits, the AARC has been requesting information from organizations that have recently gone through the review process. (See JCAHO Accreditation Visit Form in this issue to provide input on your visit.) Here is a recent report from a long term care facility Ambassador-Lincoln 4405 Normal Blvd. Lincoln, NE Contact: Tad Hunt, RRT, (402) Inspection Date: July What was the surveyors focus during your last site visit? LTC/Subacute care rehab. 2. What areas were cited as being exemplary? Rehab/respiratory. 3. What suggestions were made by the surveyors? Performance improvement/environment services. 4. What changes have you made to improve compliance with the guidelines? Formulated teams to implement changes. Additional comments: JCAHO accreditation in long term care and subacute care. 4

5 SUBACUTE CARE BULLETIN FYI... Editor s Note: FYI... is a regular feature of the Subacute Care Section Bulletin devoted to short news items that may be of interest to members of the section. Operation Restore Trust targets hospices Despite the fact that a 1994 Lewin study found that Medicare saved $1.52 cents for every dollar it spent on hospice care for patients with terminal cancer, the hospice industry is having to go on the offensive to maintain its place in the continuum of care. A recent government investigation of hospices in California, Texas, Florida, Illinois, and New York conducted under the Operation Restore Trust program is targeting cases where patients did not die in the prescribed amount of time and auditors are now seeking to recover millions of dollars in improper Medicare payments. The National Hospice Organization (NHO), which represents over 2,200 hospice programs and 4,100 hospice professionals, is concerned that although the OIG s efforts related to beneficiary eligibility for hospice care are well intended, the process is seriously flawed, with potentially devastating impact on appropriate patients seeking hospice care. The government investigation, which began with two hospices in Florida, is focusing on patients who outlive the standard time allotted for hospice care. Under Medicare rules, patients must have a prognosis of six months or less to live in order to qualify for hospice care. In question are those cases in which patients who were referred to hospice care with that prognosis were still alive after six months. At one of the Florida hospices, nearly 300 such cases were uncovered, but operators say they have reviewed all the cases and almost all involve patients who were, indeed, terminally ill. Says the NHO, The reviews in Florida fault the hospice for not being flawless in establishing the prognosis of the patient... it is disconcerting that OIG reviewers, with a lack of generally accepted or established criteria, are second-guessing the prognosis determined by other physicians. (Sources: Reuters Medical News, PRNewswire) Docs under-prescribe pneumonia vaccine for nursing home residents Fewer than five percent of elderly nursing home patients suffering from pneumonia had received the recommended vaccine that could have protected them from the disease, says a study conducted in three nursing homes in Massachusetts, Oklahoma, and Maryland by the Centers for Disease Control and Prevention (CDC). Documented vaccine rates at the facilities were between 1.9% and 4.5%, which is below the national average for those over age 65. One reason for the low rate in nursing homes, says the CDC, may be that physicians are sometimes hesitant to prescribe the vaccination because neither they nor their patients are sure whether an inoculation has been administered previously. The CDC suggests that when such uncertainty exists, physicians should prescribe a second dose anyway in order to ensure that the patient is protected. In the current study, 36 cases of pneumonia were identified among 267 residents, and nine of those patients died of the disease. (Source: Reuter, 1/23/97) AARP, others join in fight for quality care at the end of life A coalition of more than 40 national medical and consumer organizations, including the American Association of Retired Persons, the American Geriatrics Society, the American Nurses Association, and the American College of Physicians, is calling on the government to establish quality measures to ensure adequate and compassionate care for the terminally ill. The group, which has come up with ten principles to guide the medical community in measuring quality care for the dying, is urging the National Institutes of Health to increase research in the area. The coalition also wants Medicare and other insurers to establish minimum care standards for the terminally ill, and is asking that the Joint Commission on Accreditation of Healthcare Organizations and National Committee for Quality Assurance include such quality measures in their performance standard sets. Among the ten principles supported by the group are Ensure that the patient s physical and emotional symptoms are addressed Make better functioning and autonomy a key objective Encourage patients to plan their death wishes in advance Limit the overuse of machinery in futile cases Promote provider continuity and skill in end-of-life care (Source: Reuters Medical News, 1/8/97) Nursing home population fails to keep pace with elderly population for the first time Although the nursing home population increased by four percent between 1985 and 1995, the over-65 population grew by 18 percent, making it the first time since records have been kept that the nursing home population has not grown at the same rate as the elderly population, says the National Center for Health Statistics. The decline is being attributed to medical technology advances and the rapid growth in home care, which together are enabling many would-be nursing home residents to remain in their homes longer than they could in the past. According to the report, the number of nursing homes fell by 13 percent between 85 and 95, but the number of beds increased by nine percent, suggesting consolidation in the field. About 1.5 million people received care in 1.8 million beds in 16,700 nursing homes in Nine out of ten residents were over 65 and 35 percent were 85 or older. For-profit facilities accounted for 66 percent of all homes and over half of all facilities were part of a chain (up from 41 percent in 1985). Occupancy rates in 1995 ran about 87 percent. (Source: National Center for Health Statistics) New website focuses on elder care As the elderly population grows from about 33.5 million today to 70 million in 2030, the provision of services to Americans over the age of 65 is expected to skyrocket. Now the National Technical Information Service has established a new online service designed to get the word out about elder care issues to those catering to this growing market. The website features abstracts of research reports, along with guides on elderly nutrition, housing, transportation programs, long-term care, legal assistance, elder abuse prevention, and volunteer networks. Visit the site at (Source: PRNewswire, 1/21/97) 5

6 JCAHO ACCREDITATION VISIT REPORT FORM The following survey form is provided to enable the reporting of recent JCAHO accreditation site visits. Compiled results will be published regularly through select section newsletters and the AARC Times. Please return your completed survey to: William H. Dubbs, MHA, RRT AARC Director of Management Services Ables Lane Dallas, TX Phone # (972) Fax # (972) Inspection Date: Name: Facility: Address: Phone: If you are willing to discuss your accreditation visit with others check this box and this information will be added to a list that is available to AARC members. If you do not check the box your response will remain anonymous. Please check the type of accreditation visit you are reporting: Pathology & Clinical Laboratory Services Hospitals Home Care Long Term Care What was the surveyors focus during your last site visit? What areas were cited as being exemplary? What suggestions were made by the surveyors? What changes have you made to improve compliance with the guidelines? Please offer any additional comments about the site visit that will be helpful to others. (use additional sheet if necessary)

7 SPECIALTY PRACTITIONER OF THE YEAR Don t forget to make your nominations for the Subacute Care Specialty Practitioner of the Year. This honor is given to an outstanding practitioner from this Section each year at the AARC s Annual Meeting. The recipient of this award will be determined by the Section Chair or a selection committee appointed by the chair. Each nominee must be a member of the AARC and a member of the Section. Use the following form to send in your nominations for this important award I would like to nominate for Subacute Care Specialty Practitioner of the Year because Nominee Your Name Hospital/School Hospital/School Address Address City, State, Zip City, State, Zip Phone Phone Mail or FAX your nomination to the Section Chair at the address/number listed on the last page of this issue.

8 AMERICAN ASSOCIATION FOR RESPIRATORY CARE Subscute Care Section Ables Lane Dallas, TX (214) Fax (214) Chair and Bulletin Editor Kevin Cornish, BS, RRT Ernst & Young 100 N. Tampa St., #2200 Tampa, FL (813) FAX (813) Chair-elect To be appointed Medical Advisor James K. Stoller, MD Pulmonary-Critical Care Medicine, A90 Cleveland Clinic Foundation 9500 Euclid Ave. Cleveland, OH (216) FAX (216) American Association for Respiratory Care Ables Lane Dallas, TX Non-Profit Org. U.S. Postage PAID Permit No Dallas, TX

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