Potential Conflicts of Interest

Conflict of Interest Disclosure Robert M Kacmarek Creating a Vision for Respiratory Care 2015 and Beyond Bob Kacmarek PhD, RRT Harvard Medical School Massachusetts General Hospital Boston, Massachusetts I disclose the following financial relationships with commercial entities that produce healthcare-related related products or services relevant to the content I am presenting: Company Relationship Content Area Covidien Consultant Mech Vent Maquet Honorarium/Lecturing Mech Vent Venner Medical Grant Artificial Airways 5-9-15 FOCUS Potential Conflicts of Interest Received research grants from Hamilton, Received honorarium for lecturing from Maquet and Hamilton Consultant for Newport, Bayer and KCI Task Force/Planning Committee, 2007 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 h(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? 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 1

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 May 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. Conference 3 Summer Forum July 2010 focused 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. Kacmarek RM, Durbin CM, Barnes TA, Kageler WV, Walton JR, O Neil EH. Respiratory Care 2015 and Beyond: Charting a Future for the RT Profession. Respiratory Care 2009;54:375 Barnes TA, Gale DD, Kacmarek RM, Kageler WV Competencies Needed by Graduate Respiratory Therapists in 2015 and Beyond, Respiratory Care 2010;55:601 Barnes TA, Kacmarek RM, Kageler WV, Morris MJ, Durbin CG. Transitioning the Respiratory Care Workforce for 2015 and Beyond. Respiratory Care 2011;56:681 Results of Conference One Drivers of Health Care Change Cost of Care 16-18% 18% 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 self- care 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 2

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 i Most RC provided in the acute care setting COPD 12 to 14 million diagnosed, another 12 million undiagnosed, 4 th leading cause of death, 2004 37 billion cost of care 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 2000 111,706 2005 132,651 Bureau of Labor Statistics 2006 122,000 2016 145,000 Respiratory Therapists per 100,000 Population District of Columbia 56.00 Indiana 52.74 Ohio 46.25 Kansas 46.06 Nebraska 42.35 Top Five Bottom Five Wyoming 23.69 Alaska 22.89 New Jersey 22.76 Minnesota 22.54 Utah 19.97 United States mean 32.10/100,000 population Graduates From Associate Degree and Baccalaureate Degree CAAHEP Accredited Programs Year 2004 2005 2006 2007 Total BS Degree AS Degree 445 486 591 569 2,091 4,634 5,570 6,612 5,241 22,083 Total 5,079 6,056 7,203 5,812 24,174 Respiratory Care in the Beginning - 1947! Oxygen Therapy H-Cylinders and O 2 Tents! Schwartz Rebreathing Tubes! Aerosol Therapy! Negative pressure ventilation! IPPB! ABG analysis and PFTs! 3

Puritan Bennett TVTV-2P and PRPR-2 The Role of the Respiratory Therapist in the Beginning - 1947! Technician (O2 Technician) Setup and operation of basic equipment Delivery of aerosol therapy Provision of IPPB Assistance with ventilatory support Performance of diagnostic tests Role of the Respiratory Therapist Today Provider of Basic Respiratory Care Ventilator management Delivery of aerosolized medication T Transport t off critically iti ll ill patients ti t Extracorporeal Life Support Performance of diagnostic studies Patient Education! Disease management!! Consultant on Patient Care!!! Respiratory Care 2015 and Beyond! ICU - increased Technical and Clinical Sophistication, Expanded Monitoring Explosion of Aerosol Therapy Applications Genetic Based Aerosol Therapy py Sleep, Transport, Extracorporeal Life Support Subacute Care, Physician Offices and Home Disease Management, Patient and Staff Education, Team leadership 4

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 Results of Conference Two 2015 a Graduate/Practicing RT must possess 69 competencies in 7 major areas Diagnostics Disease management Evidence-based medicine and respiratory care protocols Patient assessment Leadership Emergency and critical care Therapeutics Competency Area II: Disease Management Chronic and Acute Disease Management Understand the etiology, anatomy, pathophysiology, diagnosis, and treatment of cardiopulmonary diseases (eg, asthma, chronic obstructive pulmonary disease) and comorbidities. Communicate and educate to empower and engage patients. Develop, administer, and re-evaluate evaluate the care plan. Develop, administer, evaluate, and modify respiratory care plans in the acute-care care setting, using evidence-based medicine, protocols, and clinical practice guidelines. Competency Area II: Disease Management Establish specific desired goals and objectives. Evaluate the patient. Apply a working knowledge of the pharmacology of all organ systems. Provide psychosocial, emotional, physical, and spiritual care. Education on nutrition, exercise, wellness. Environmental assessment and modification. Monitoring and follow-up evaluation. Development of action plans. Competency Area II: Disease Management Apply EBM, protocols, and clinical practice guidelines. Monitor adherence through patient collaboration and empowerment, including proper and effective device and medication utilization. Implement patient-education education materials and tools. Utilize appropriate diagnostic and monitoring tools. Document/monitor outcomes (economic, quality, safety, patient satisfaction). Communicate, collaborate, and coordinate with HCW Assess, implement, and enable patient resources support system (family, services, equipment, personnel). Ensure financial/economic support of plan/program. 5

Competency Area III: Evidence-Based Medicine and Respiratory Care Protocols Evidence-Based Medicine Review and critique published research. Explain the meaning of general statistical tests Apply evidence-based medicine to clinical practice. Respiratory Care Protocols Explain the use of evidence-based medicine in the development and application of hospital-based respiratory care protocols. Evaluate and treat patients in a variety of settings, using the appropriate respiratory care protocols. Competency Area V: Leadership Team Member: Understand the role of being a contributing member of organizational teams as it relates to planning, collaborative decision making, and other team functions. Health-Care Regulatory Systems: Understand fundamental/basic organizational implications of regulatory requirements on the health-care system Written and Verbal Communication: Demonstrate effective written and verbal communication with various members of the health-care team, patients, familie (cultural competence and literacy). Competency Area V: Leadership Health-Care Finance:. Demonstrate basic knowledge of health-care and financial reimbursement systems and the need to reduce the cost of delivering respiratory care Team Leader: Understand the role of team leader: specifically, how to lead groups in care planning, bedside decision making, and collaboration with other health-care professionals Competency Area VI: Emergency and Critical Care Emergency Care Perform basic life support (BLS), Advanced cardiac life support (ACLS), Pediatric advanced life support (PALS), Neonatal life support (NRP) Maintain current AHA certification in BLS and ACLS. Perform endotracheal intubation. Perform as a member of the rapid response team Results of Conference Three RT 2015 and Beyond: An AARC Initiative Transition Plan Goal To position respiratory therapists to fulfill the roles and responsibilities identified in conference 1 and to assist respiratory therapists to acquire the competencies identified in conference 2 6

Transition Plan Attributes The transition plan must: Maintain an adequate respiratory therapists workforce throughout the transition. Address unintended consequences such as respiratory therapist shortages. Require multiple options and flexibility in educating both students and the existing workforce. (e.g. affiliation agreements, internships, special skills workshops, continuing education, etc) Require competency documentation options for new graduates. Support a process of competency documentation for the existing workforce. Transition Plan Attributes The transition plan must: Assure that credentialing, accreditation and licensure recommendations evolve with changes in practice. Address implications of changes in licensing and credentialing Establish practical timelines for recommended actions. Assure that emerging conference recommendations must be supported by a plurality of the stakeholders in attendance. Reflect the outcomes of the previous two 2015 and Beyond conferences Identify the agencies most appropriate to implement identified elements. RT Department Director s Survey 657/2,411 or 27.3% Response Rate 96.5% Directors or Managers Preferred new graduates: 36.5% AS, 36.4% BS, 26.5% none New graduates 2005-2009: 2009: 72.9% met expectations, 15.9% fell below expectations, 11.1% exceeded New Graduates must earn RRT: NA 55.5%, 12 months 22.9%, 6 months 13.2%, 18 months 7.4%, 36 months 1.1% Require RT to maintain in addition to license NBRC credentials: NO 59.9%, YES 37.6% Tuition reimbursement: YES 83.2%, No 15.2% Clinical affiliate: YES 78%, NO 20.8% Future Graduates credential RRT 78.8%, CRT 18.3% What degree should future graduates be required to earn to be eligible for examinations, licensure and entry into practice AS 56.5%, 5% BS 40.2% What degree should future graduates be recommended to earn for continued practice beyond licensure and entry into practice as a RT 58.2% BS, 27.1% AS, 11% MS, NR 3.5%, 0.5 PhD Future graduates required to maintain active NBRC credential to practice YES 78.3%, NO 18.2% Competencies with < 80% Agreement Explain indications and contraindications for advanced pulmonary function tests. 57% Explain indications and contraindications for sleep studies. 53% Relate results of sleep studies to types of respiratory sleep disorders. 36% Explain indications and contraindications, and general hazards and complications of bronchoscopy. 68% Describe the bronchoscopy procedure and describe the RT role in assisting the physician. 71% Critique published research. 33% Explain the meaning of general statistical tests. 40% Interpret lung volumes and diffusion studies. 58% Competencies with < 80% Agreement Describe fundamental/basic organizational implications of regulatory requirements on the health-care system. 70% Describe health-care and financial reimbursement systems and the need to reduce the cost of delivering respiratory care. 61% Pediatric advanced life support (PALS). 78% Neonatal life support (NRP). 78% Perform endotracheal intubation. 78% Apply circulatory gas exchange systems (ECMO). 34% Recommend cardiovascular drugs based on knowledge and understanding of pharmacologic action. 60% 7

Program Director Survey ASRT vs. BSRT Population = 435 program directors, 411 colleges Sample = 100% population Responses = 356 Valid Responses = 353 Programs responding = 366 (84.1%) Colleges responding = 353 (85.9%) Non respondent colleges = 58 (14.1%) 43 44 Degree to Practice Degree Recommended After Licensure 45 46 Competencies Addressed by < 80% Relate results of sleep studies to sleep disorders: BS 74%, AS 68% Develop, administer, and reevaluate the care plan for chronic disease management BS 84%, AS 78% Critique published articles BS 89% AS 41% Explain meaning of statistical tests BS 82%, AS 33% Explain use of EBM to develop protocols BS 86%, AS 78% Contribute to organized teams BS 76, AS 66% Describe basic organizational implications of regulatory requirements on health care system BS 76%, AS 65% Describe healthcare and financial reimbursement systems and need to reduce cost of RC BS 71%, AS 56% Competencies Addressed by < 80% Lead groups in care planning, bedside decision making and collaboration with other HC professionals BS 70%, AS 52% PALS BS 58%, AS 51% NRP BS 66%, AS 60% ACLS BS 89%, AS 77% Rapid response BS 73%, AS 65% Mass Casualty Training BS 53%, AS 48% Contribute in collaborative care management based on EBM BS 82%, AS 71% 8

AARC BOD #1 That AARC recommends to the NBRC on July 1, 2011, that CRT examination be retired after 2014. That the AARC recommend to the NBRC on July 1, 2011 that the multiple choice examination components (CRT+RRT written) for the RRT should be combined after 2014. AARC BOD #2 That the AARC establish on July 1, 2011, a commission to assist state regulatory boards transition to a RRT requirement for licensure as respiratory therapist. AARC BOD #3 AARC request CoARC to change by 7/1/12 accreditation standard 1.01 to read as follows: 1.01 The sponsoring institution must be a post-secondary academic institution accredited by a regional or national accrediting agency that t is recognized by the U.S. Department of Education (USDE) and must be authorized under applicable law or other acceptable authority to award graduates of the program a baccalaureate or graduate degree at the completion of the program. Programs accredited prior to 2013 that do not currently offer a baccalaureate or graduate degree must transition to conferring a baccalaureate or graduate degree, which should be awarded by the sponsoring institution, upon all RT students who matriculate into the program after 2020. AARC BOD #4 We request the AARC to provide budgetary resources to assist associate degree programs with the transition to baccalaureate level respiratory therapist education. AARC BOD #5 We request the AARC, in cooperation with CoARC, consider development of consortia and cooperative models for associate degree programs that wish to align with bachelor degree granting institutions for the award of the bachelors degree. AARC BOD #6 We request the AARC request the ARCF to establish a restricted fund for donations to support the transition of associate degree programs to baccalaureate level respiratory therapist education. 9

AARC BOD #7 That the AARC Executive Office request that the AARC BOD ask the appropriate existing sections to develop standards to assess competency of RTs in the workforce relative to job assignments of the RT. Standards should address the variety of work sites that employ RTs Standards should address RT knowledge, skills and attributes relative to the tasks being evaluated AARC BOD #8 The AARC encourage clinical department educators and state affiliates continuing education venues to use clinical simulation as a major tactic for increasing competency levels for the current workforce. AARC BOD #9 Request that the AARC BOD explore development and promotion of career ladder educational options for the members of the existing workforce to obtain advanced competencies and the baccalaureate degree. Thank You 10