Okay, it is 7.15. We will go ahead and get started. Welcome to the last day of CHEST. I am Kevin O'Neill. I am a critical care and sleep physician in Wilmington, North Carolina and involved with respiratory therapy education through COARC. I am current president for another month or so of the COARC training program. It is my pleasure to introduce our panelists for today. First, Dr. Sarah Mirza, who is the medical director for both respiratory therapy and for one of the respiratory therapy training programs in Chicago. She has been the respiratory therapy director for about seven years and initially trained in Pakistan and then did residency in the University of Illinois system and her pulmonary fellowship and a master's in clinical research at Rush, where she stayed on as faculty with a focus in neuromuscular disease. She is going to address kind of changing the practice of respiratory care from the standpoint of the medical director and what physicians can do to facilitate an excellent respiratory care program and excellent respiratory care for patients. Next to Dr. Mirza is Dr. David Vines. Dr. Vines got his undergraduate degree from the LSU Shreveport system and then also advanced degrees in health care sciences and a PhD from Rush, where he has stayed on in a variety of administrative and leadership positions. He is currently the associate dean for the Department of Health Sciences and a professor and former program director and department manager, so a wealth of experience. I'm going to turn podium over to our presenters and we'll go from there. Thank you. All right. So 7.15, you must be here because you're passionate and this is something that is appealing to you. So you either must be a medical director in your own institution or are a big champion for respiratory care services or you may be in leadership from respiratory care itself. So going straight over to who I am, you've already heard the introduction. I don't have any pertinent disclosures. We'll move forward to our objectives for today. First of all, I'll just talk a touch a bit about how healthcare, the landscape is changing and how that impacts our department, respiratory care department and that relationship. And then we'll talk about how that relationship can be used to add value towards providing good optimal patient healthcare. And then we'll talk about what are the key components that makes it an effective collaborative relationship. And then we'll finally touch upon some strategies. Of course, this is not an exhaustive list. This is something that we implement and we use and it seems to work. So I'll share with you our experience. So just to start off with, you know, nothing I do, as mentioned, I've been a medical director for the last seven years. I come on the shoulders of people who've done work before me. So I'm only going to take credit for what I have done. But that being said, that's our goal and our hope that we leave our institutions in a better place or our positions in a better place. So I'm only standing on the shoulders of the giants before me. A bit of a cliched slide, but I think it illustrates the most important point that if we need to work and provide the best possible care going forward, we need every part of that car, of that all four wheels to be as complete and thriving and efficient as possible. So I cannot do my work in the ICU or in the pulmonary world. David cannot do his work in the respiratory therapy world if we're not working together, if we're not managing each other up, and if we're not helping each other achieve the best that they can from their potential perspective. So from an aspect of change, a couple of things that I would say in the last decade or couple of decades has changed. So for starters, the paradigm of, okay, you're doing this because I'm telling you so. That culture has changed. And that's not a bad thing. That's a good thing. It just means we just need to reset and reorient ourselves to say, okay, this is how we're going to do it. And let's see how we can do this together rather than an autocratic dictator giving that instruction. So that I think is an important integral part of that change in that landscape. We are all working in a world where every institution is facing that pinch. Every institution is, you know, getting their CME funds being looked at. You're being asked to say, okay, how can I cut expenses? How can I be the most cost efficient as I can be? And that is a pinch that every healthcare institution is facing in all over. I would say not just in our little pocket, but all over the world. And then we are on the, you know, back end of recovering from a pandemic. Burnout is at the highest. We are seeing a lot of, and the burnout is not just because of the workload. It's about folks leaving the field and those who are left behind are having to do the extra work. Which institution here is not understaffed. If you know, we certainly are understaffed. We still have some FTEs to fill, and I'm sure that all of you are facing exactly the same pinch. So it does create that extra pressure on the folks who are left behind. Folks are looking for fields outside healthcare, just as they're recovering out of the pandemic. So to recover from all of this, to be able to recognize that these are the new challenges that we are facing now, a multidisciplinary approach where we can really work together and collaborate and really lift each other up is the key to having that success. Now just a little background. I know I'm lucky that I work at an institution where our respiratory care program is, you know, it's being led by very, very motivated people who we have a robust training program as well, which is also being led by outstanding faculty. So we have a constant influx of people who love coming to work. We have people who enjoy teaching and build that culture up. Now that may not always apply to every one of the institutions that you may be at, and we really enjoy that close relationship between our pulmonary critical care, critical care, and our respiratory care program. And we have a very strong evidence-based research focus and evidence-based delivery of medicine focus for all of our patients and with our program. So I'm just going to go ahead straight to what are the things that can, that can, that, that a medical, that medical director can actually add value to this relationship. So let's just talk about a few ways that that can happen. So promoting job satisfaction by building that healthy work environment. And just to kind of illustrate this, this was a Miller published recently on the top causes of burnout post pandemic for respiratory therapists. And if you notice that the top three were staffing issues, high workload, and finally, poor leadership. If your people at the top were not willing to go out and bat for you, that was a major cause for concern. Respiratory therapists felt it and did not like it. And that means that we need to do a better job of being champions so that we can help fight this burnout and build a more healthy work environment for our patients. And of course, if you see the others down the list, lack of recognition, lack of respect, lack of appreciation. So basic things that add value to a therapist coming to work, those would be the things that would help the therapist develop that sense of belonging to that institution and be a more efficient, effective, and a stronger team player for the department. Promoting job satisfaction by providing clinical autonomy. And this is a concept that we've all been working towards. And I'm sure every one of you has these protocols that are allowing a respiratory therapist to not just function as the hand that turns a knob or delivers a medicine as a nebulization. We need, and we are partnering with our respiratory care colleagues to develop more clinical acumen to be able to help recognize, triage, and adjust therapies based on what is needed for that patient. And of course, staying within the limits of the license, but building that sense of autonomy helps build that job satisfaction. So if someone's coming to work and feel like whatever they do, it doesn't matter, that what they're doing is not making a difference to a patient's life, whatever they're doing is not being heard, then it's not a recipe for success and a recipe for strong following for that department. Now other things. We all have folks who will do and order things that are inappropriate. That value of the medical director to be able to tackle those issues in real time and address them and fix them, that is something that is extremely, extremely important. And this is an area that, I'm just going to give you an example. Just last week, I got a message on my phone from one of our respiratory therapists that, can you please look at this? We have someone who's ordering Q4R TXA nabs, and it's for a patient who isn't even actively bleeding or does not have any indication. Of course, took a moment, had to go through everything, figure out if there was a clinical indication or not. And when there wasn't, it did involve making some phone calls, speaking to the attending who's ordering it. And actually the attending had no idea that it was being ordered. It was being ordered by, you know, three layers of authority below the attending and the attending was absolutely in agreement and said, yes, I'll take care of it. So yes, there are situations when you do have to intervene on a case by case basis, and it is the job of that medical director. And that's how we can add value and help in that prevention of burnout as well. Because if a therapist is delivering a therapy that they know is not indicated, it's not going to lead to satisfaction. So adding into that, encouraging education and skill development. Now this is an area, and I'm going to give you a couple of examples of things that, you know, we've been involved with, clinical case discussions. We did this as a bi-weekly, it fell off during COVID, but meeting with a therapist on a regular basis, discussing clinical cases, talking about how we could adjust management, what are the reasons why we're doing what we're doing, helping build that understanding. Yes, it does need time and it does need, you know, we need to coordinate and do all of that, but it's worth it because we're all building everybody's knowledge up and we're building better providers. Journal clubs, we started doing this to help increase the awareness for why we're doing what practices, improving the quality of care that we deliver for the patient. You know, certain tasks that were not uniform in terms of equal, in terms of inclusion of ultrasound for arterial access, ultrasound for lung ultrasound training for our respiratory therapists. We're in the process of training all of our respiratory therapists from that perspective as part of an ARC grant. And then simulation-based training for things that are rarely encountered. And we've done that for proning, we've done that for utilization of high-frequency oscillatory ventilation in the past. And we'll talk about that a little bit in the later, later in the presentation. And then the opportunity for research. And this is an area that I think if we combine our concerns and see what is missing, we can add to the body of that knowledge and do it in a very effective way. And we have really role modeled that in seeing what a fantastic output, you know, we're talking about publications in pretty high-tier journals that came out of our institution by collaborating on that piece of research. And there are multiple areas that have been looked into and we can give you examples of that. Now what are the ways that we can build that collaboration? Now some of this may sound very intuitive, but I think this part is very important. People get assigned a role without having a job description. And I know when I started, I asked the folks before me and I said, what exactly does this role entail? And the answers I got were not, you know, a hundred percent very clear. They were, they were kind of weak. So I think it's important. And I love the fact that we're working towards building that toolkit so that we can have some framework to provide to medical directors all around the country to say that this is a basic expectation of your role. So you're taking on this job with this expectation. You know, showing up, actually being aware of what is happening in terms of clinical practice meetings, in terms of knowing what are the issues that your team is facing, so that you can one, either defend them or help find workarounds. That is very important. I mean, unfortunately there's no other way around it. Thankfully now with virtual participation, it doesn't always mean that you have to be there for a 6.30 meeting every day, but yes, you could certainly phone in and video in and zoom in. And that allows you to understand and participate and provide input back and forth. Being available and involved for education needs. Again, showing that you are invested builds that relationship and builds that respect. Being available to represent and lobby for your department to other departments. I've had folks, you know, come to me and saying, oh, you know, respiratory therapy did this. And then I give them the perspective that I know from the other side. And then I'm able to bring those conflicts to resolution by, by lobbying for the division, for the department. And then serving as a bridge when we're developing policies that will involve the practice for intensivists, for pulmonologists, as well as our respiratory therapists. So looking into the evidence, building a solid foolproof policy or a protocol does involve building those bridges and discussing it with both departments to get something to finalize. Then promoting combined educational opportunities. And here I'm going to take a moment and talk to you about something that, you know, we recognize that maybe we weren't doing as well, which was because we had such a robust respiratory therapy program, our fellowship training program ended up, you know, suffering because all the dyssynchronies were being fixed. All the AVGs were being perfectly obtained. By the time a fellow looked at things, changes on the Venn had already happened. And fellows said, we feel inadequately prepared for real life when we will not have the support of a division like we have here. So the workarounds for that is we still want to provide good, safe patient care, best quality patient care where things are not delayed for hours before they're fixed. We want them fixed right away. So opportunities for having and recognizing that your bedside respiratory therapists don't just view them as a respiratory therapist, view them as your teacher. Involve them. They become now the leaders for education. We do simulation education with our therapists together for our fellows. We do training for medical residents with our respiratory therapists. Respiratory therapists lead ventilator rounds with the fellows every day in addition to providing didactic sessions. So really involving and the view of a bedside therapist as someone who's contributing to your education, we're building better team players for tomorrow. So that is something that we've really put a lot of focus on in the last few years. And this sounds silly, but socialize together, right? Why not? Why should we put ourselves in different silos and say that I'm not going to hang out with the other person? I'm not going to say how awesome David looked in a pink Ken shirt. This was a Barbie themed party. But you know, and another thing, when new faculty, new fellows join the department, that's the point when helping them meet all the key players, helping them meet the team of therapists, helping them understand what are the protocols that we have at our institution. We've instituted what we call is a meet and greet. Very early on in the academic year, when they come in, we'll have a session, have them all get together for breakfast where we'll go through, okay, these are our protocols and this is how we do it. This is the person who you call if there's something that you're not comfortable with. So helping to make that introduction before there is a negative interaction. So hoping to avoid that negative interaction and develop that collegiality before there is a negative input. And then, you know, celebrating achievements together. And then what's the vision? Let's strategize and build that vision together. So being together on our five year strategizing plans, on our 10 year strategizing plans so that we are on the same board and we can work together to get that strategy implemented. And you know, this was something that actually David came up with, which was a book reading club for leadership skills and developing that for not just their department, our department, and we can all learn and grow better together. And this seems silly, but just as a medical director, I find getting onto those group emails, the mass mail that goes out for the Monday and everyday simple stuff that, you know, a bonus shift is being offered. I find that to be extremely important because it helps me understand where and when we are facing problems. And then plus it helps celebrate when we have achievements, when someone has a baby, when someone has a paper published. So, and then publicly on that forum as a medical director, I think it means a lot for someone who normally may have gone unnoticed to hear it on a forum and hear that accolade being shouted out and then making a mental note to congratulate in person. I'm guilty of the fact that I'm very poor at remembering names. And I remember when I took on this role, I requested our secretary to send me a sheet of all the therapists with their names and I spent a good amount of time memorizing those names. And I made it a point that when I see that person, I am going to address them with their name. I think taking someone from just a man or woman in blue to their name, humanizing them and making them feel that they are a valued member of the clinical team, that goes a long way. So basically showing that you care and then be accessible, be available. And that can be whatever way works for you. Is it by email? If you're great at getting back to people right away by email, text, WhatsApp. I know my mode of communication WhatsApp is the best for me. And my therapists know that if they need something out of Dr. Mirza, it's going to happen fastest if they message me on that. And my phone is phone numbers passed out freely. I get texts, messages, and I know I get that message, Dr. Mirza, I need you to call me whenever you can. I know that that's something that I'm going to have to fix soon. So doing that together. I'm just going to give you an example of things were not always good and easy. Sometimes you have roadblocks from within the institution. Sometimes you have roadblocks from within your department. Sometimes you have roadblocks from outside. So just sharing an experience. Back in 2013, I remember we had just completed the simulation for high frequency oscillatory ventilation. We had trained respiratory therapists, faculty, residents, everybody on how to use an oscillator. And then Oscillator and Oscar came out and they kiboshed and showed that, okay, that's not going to be an option for us anymore. But it was also a great year because the Proceiva trial also came out that year. So we pivoted and we said, okay, that's not going to be what we're going to use. Let's do a simulation training for prone positioning. And we did that. We did a fantastic, great job. We wrote it up. We published it. We had fellows, attendings, nursing staff, respiratory therapists, everybody coming together and getting trained. Do you know what the harsh reality is? That despite us having done this aggressive training, our nurses were still choosing to use this beautiful bed over just three simple bedsheets. And it took us, it was actually the fall of 2019 when we were so frustrated because both pulmonary critical care and respiratory therapy were ready. They wanted to prone everyone, but we had push back from nurses saying, we need a checklist that needs to be created. And we're talking about six years of a Delta and that checklist still wasn't coming in. Then we had a Trojan horse planted from within the respiratory department who also happened to, you know, was at that time fiance and later on now is married to this guy who's our director of clinical education. And we worked with infiltrating and getting her to champion that checklist to finally formalize. And it was obviously just in the nick of time because we had it up and going before the first patient hit the floor for COVID. And then of course the rest is history because then, you know, our training videos got picked up by World Health Organization. It really went and we were really a resource for providing that training for folks all around Chicagoland. So I'm going to finally end here with a big thank you for all of you for coming and sharing your time with me. And, you know, I'm also, it's a little bittersweet because I'm about to change institutions. So this is also a moment for me to acknowledge and thank you to David and the team here that I hope I find the same kind of tribe that I have here. And it's emotional for me to say goodbye. So we'll be open for questions after the second talk. Thank you. So what I'm going to do for you this morning is give you a little bit of perspective of potentially what we can do with the restory care department and program and a little bit about my history. As I shared earlier, thank you, that I did start at LSU Medical Center in Shreveport, Louisiana, quite a number of years ago back in 1990. And from that point, it really laid the foundation for me to, and ended up moving into education, was involved with research there, but mostly collecting data for physicians to publish the research, moved into an education track at UT Health Science Center in San Antonio, and then the opportunity became calling. And you can see my disclosures there, they're all research funding. But Rush came calling. So Rush, if you're not familiar with the institution, is right on the outskirts of the city of Chicago and was formed in 1837, which is quite a long time ago, around the same time the city was chartered. And so from that, you can see our recent big ICU tower that's been stated as one of the state-of-the-art buildings in the country. And we're fortunate to have a university incorporated that has a nursing school, a medical school, health sciences that has about 16 programs in it, and then a graduate college. And one of the things Rush is really proud of and known for is they like to tout this practitioner-teacher model. So, they like people who still practice to actually teach their students or be involved in practice. And they're also routinely ranked in the top five or so in quality and safety throughout the country. And I believe they're there again this year too or something like that. And so, the thought of this and when they recruited me away from UT Health Science Center in San Antonio was the problem there was the lack of collaboration between a university hospital and an educational program for me to get evidence-based research done to progress the profession. No matter, even when we had grants that was rewarding them $500 a patient, if we enrolled them back to the department, still lack of engagement. So, me well aware of Rush's practitioner-teachers model part of negotiation was a hospital operations appointment over the practice of restorative care for Rush. So, they couldn't tell me no. And so, that way whenever Rush agreed to that, that was really sealed the deal because I got to begin an entry-level master's program, which obviously requires research and a master's of science degree. At the same time, I could revamp the practice of restorative care within the facility and perhaps make some movement there. And it took me much longer to acquire the talent that we have there than I thought it would in the beginning and to get some things I'm going to talk to you today established. But now that we have some roadmap, perhaps it can happen faster for other facilities or approve upon it. So, I'm going to share that with you today. So, if you think about, and there's some of us that's been in practice for this length of time in the room today, what's really changed for restorative care over the last 30 years? What really, really has changed? If you think about it for just a moment, well, payment models changed, right? Back in the day, and you know, when I looked this up, I actually didn't even realize DRGs was an early 80s thing. Because when I started in the 90s, it was still, you know, this fee-for-service. We're going to do as many treatments as we can, and we're going to build as much as we can because revenues, restorative care is a revenue source for the hospital. We generated money, and you did not worry about whether it was needed or not needed. If they ordered it for whatever reason they ordered it, and you documented improvement, we were good to reimburse. And you know, the problem is there's that mentality still existing today, and we're way down that line, right? I mean, as I'll show you in just a minute, Jamie Stoller did some great work in the 90s here, showing how protocols change all of this and add value in these groups. But now we've even transitioned into this Affordable Care Act, which is focusing really on value and quality. And this value and quality, I struggle with my therapists with this, even with the system we run. On a routine basis, I remind them that it's about outcomes, not the number of treatments you're left with today. And I've worried about whether or not we've got all hundred of those nebulizers delivered or not. Did it make a difference in the patient's outcomes? Do what we do change outcomes? I think that becomes very important. So AARC's picking this up, and they've recently published some publications on this and have out some systems that really Chad Byrne, Richard Ford, and Gary Kaufman has been taking a lead on. And you know, you can read the definitions there, but efficiency and effectiveness is important. And their focus here is really on what is value and efficiency within the future here. And historically, and still to the day, C-suite comes back and wants to know how many activities we have done and how many therapists did we need to do those activities. It is a constant report. And so, you know, we also like to track outcomes. And I go, this is what we need to change outcomes. What do you want? You're coming back to them. So really the AARC is trying to push for this value efficiency model. So it's more than just activity hours and more than just about efficiency. And I, the websites there you welcome to this is should be open access to everyone at this point. But this is where I run into a little bit of problem with the system currently. Because their system that they're touting and calculating value is based to some degree on evidence for respiratory care practice. Well, if I don't know how much of that evidence you've lately reviewed, but it is not good. It is very poor, lack of randomized control trial, even to an example of the bashing of incentives parameters. Do you know in those randomized control groups what most of the control groups got? They were all walked around the ICU. Do you know walking is a form of lung recruitment? And so, if a patient can get up and walk around the ICU, in my opinion, they don't need a respiratory therapist. I've rarely seen one that needs a respiratory therapist unless they have, well, need lung expansion therapy at least. They might need a nebulizer if they have asthma or so forth. But people who can get up and walk around the ICU should be the goal. Wouldn't that time be better spent walking around the ICU for them in that process? So, I have a little bit in this until it's going to fall back to people's opinion of whether something's valuable or not valuable. Or they're going to look at poor data that was not generated appropriately to really answer the question. So, this is my definition. This is the definition we employ at Rush. This is the thing we try to get executed. And believe me, when I rolled into Rush, our department probably wasn't much different than the rest of them around the country. But I believe that it is about timely decision making around a particular goal targeted at preventing a complication or improving an outcome in patients. So, the problem is here. How many seen this cartoon? Have you seen this cartoon? So, this is the problem with all of us to a certain degree in healthcare. Well, do you know what the rational part of that figure is? So, your brain, the rational part of your brain is the little guy on top of that elephant. That little guy, and you can click on this video and watch it, it's great. But the little guy on top of that elephant is your brain going, that's the right thing to do. That's what needs to be done. Do you know what the elephant is? The elephant is the emotional side of it. It's the biggest hurdle. That elephant's six tons. Do you think that brain's going to make the elephant do anything that it's not motivated to do? It can push it, it can pull it, it can do all these things. It won't go. So, until there's an emotional connection between the rational and emotional sides of your brain, it just isn't going to move. So, to think about this is the respiratory therapist could be standing there watching you, and you are the attending, and they know exactly what to do, and they don't tell you. Because emotionally, they can't get over the hurdle to confront what you're doing. Right or wrong, they won't question you, because they can't get past the emotional side of doing that hurdle piece of that. And so, any type of history of a negative interaction is only going to make that worse, just for friends here. On the same side, how do we get there? Well, you have to give that rider direction. You have to have strong medical leadership, too. You have to have someone who thinks that they have your back, because if I say something to this attending, you know, am I going to get crucified, or can I call Dr. Merza? You know, in our institution. So, you have to have somebody having your back. They have to have knowledge provided to know what that destination is, how to change those outcomes. You have to make the path clear. You can't leave obstacles in the path. You can't make it go up a hill around the corner, do an L, you know, a figure eight, come back around. It has to be a straight path. They have to know where they're going. Have to have clear direction in that. You have to motivate them. You want to make a difference. Why'd you come to healthcare? Everybody came to healthcare at some point, because they want to help people. They want to change outcomes, and then that easy progress becomes up there, important. So, how did we get there? So, again, there need to be some type of, we use an assess and treat system that I will show you here in just a minute, but with some associated protocols that have escalations and de-escalations in them. We also treated, created a tool of to assess effectiveness of therapy. You may have saw those RAP protocols that Dr. Mirza was flashing up earlier. I know most of you, or none of you, probably even know what those are, but I'll show you what they are in just a second and where the name comes from. And then, you know, it's allocating therapy appropriately, developing staff, communication with the team, and then focus on collecting quality and effectiveness and collaborative research. But real quick, let's just tackle this question of protocols. So, protocols have been shown, as you can see here from back in the 90s, to be associated with some savings, but better alignment with clinical practice guidelines, even to the point of reducing misallocation or improving utilization here, and has only increased over time in being able to demonstrate reduced lengths of stay, right, reduced costs to patients. Even, I don't think anyone would even question ventilator weaning protocols after ABCDF bundles, right, and we still wonder about implementing those and driving those kind of change in weanings. We know it increases ventilator free days. There's meta-analysis showing that this is possible. Here's resulting in the mean duration of mechanical ventilation reduced by about 25%. Lengths of stay reduced by about 10% with using them, but they're not used. So, it is, you know, we have all of this evidence. Much do we need, like the pandemic kind of brought around proning, right? Proning was out there struggling to get a hold, and then prone, and then the pandemic came around, and boom, and even awake proning. We had a Lancet publication out of demonstrating the benefits of awake proning. So, you know, this is the thing. What is it going to take for these protocols to get adopted up and running and frequently, and these are from 25 bed to 1600 bed hospitals in this sample that we're looking at here, and it's a little dated, but I still don't think that there's big adoption. Well, what is interesting is when you ask physicians, managers, or therapists, are they cost of care better, lower? Yes. Is the quality of care better? Yes. Does it help job satisfaction? Yes. Does it help patient satisfaction? Yes. More consistency of care, not everyone's coming in the room doing something different. So, what's the issue here? What is the issue with protocols being adopted and ran more often in the ICUs across those? So, is it the fact that there's not a standard protocol that's been adopted to show that it's effective or not effective? Is that the holdup? Is there's no one in these departments to build them or willing to build them? There's multiple resources published out there that could be a great starting point. So, what we run, and how many people have been to a physical therapist? Everybody, right? Almost everybody in the room's been to a physical therapist. What's the first thing a physical therapist does, right? They do some type of measurement with a tool of where you are in the beginning, and then they use a tool to measure after you've got therapy for a period of time to see if you improved or you did not improve. Is that not true? And they have a very good evidence base around those measurement tools to show. And then the therapist does whatever they need to do to get that goal to improve the score on that tool. Is that not true? So, I've envisioned that kind of practice in reality for respiratory therapists. So, how did we get there? So, there's this publication that's, you can see the date there in respiratory care, that actually has a tool that we created at Rush that actually will show you whether or not therapy's effective or not effective, and that's being allocated to the patient. And it is called the RAT score, and it stands for this respiratory assessment and allocation of therapy tool. So, that's where the RAT comes from. I know it's not a great name, but if you walk around our institution, it's like RAS and RAT. It's like, to Dr. Merza, she probably doesn't, you know, to her it's just like saying RAS. It is a RAT score. It's a RAT score. What is my RAT score today? So, we've done some validation work on these scores, and it really has narrowed down to these five, and there is a little overlap there on purpose, because not everyone will give me a vital capacity, and we use, so for us, an incendious barometer is a monitoring tool. So, the incendious barometer tells me whether or not someone can quantitatively take a deep breath or not. And so, in that process, therapy then gets allocated based on this tool to a series of protocols. So, what we figured out in a score, if a cut score of 10 is predictive, anywhere they score a 10 or higher, those are all linked to protocols like this that have escalation pieces and de-escalation pieces, so that the therapist then can score them. If the score's not getting better, they're expected to escalate the therapy. If the score is improving, they're expected to de-escalate the therapy. They communicate to you through progress notes. So, they can round with the team and update them, but they're required to write the score in a progress note and what therapy was allocated and how often it's going to be delivered for you to see, sign off on, whatever you would like to do on the other side of the assess and treats. So, it kind of closes the communication loop, and you're in progress notes. You see them. Most of our physicians wouldn't even know where to go find that respiratory care flow sheet, or what's all in it, or matter of chasing it down. So, with that thought, here you can see pretty good sensitivity and specificity on the need for positive pressure. I offer the first and second score, which is the first score should be within two hours of extubation or admission. The second score was in 12 hours of that. If either of those scores above 10, it's pretty good indication that that patient is likely to develop respiratory failure. Here's a little bit on their background. There was a little bit of age difference from those who are failing with those scores greater than 10, and you can see some of the other common diagnosis there. More exciting part of this is you can see it essentially fixed our misallocation portion of it. The only group that was five or less these people of those group, only three of this group ended up getting intubated or requiring positive pressure ventilation, and those developed secretions later after the score by about six to eight hours, or was giving some type of sedation. Then the score is only as good as as recent as it's collected, and so with that, and of the 30 percent that got therapy, 29 percent of its incentive, and incentive, I mean you can't, nursing has been doing it for years, and if they charted it, I counted it toward the data piece, and as you can see, that was something not respiratory therapist time was spent doing that, but more importantly, if you start to look at some of the outcomes that it picked up on, you can see that a far majority of the patients were caught if they had a RAT score of 10 or more, and in some preliminary data, it did pick up hospital-acquired pneumonia in that in a whole group. We need to follow this up in an MICU group to see if the population would be more likely to pick up the hospital-acquired pneumonia in that group, and then the mortality of course was much greater, which goes along with them being intubated. This is a unit-weighted analysis to determine prediction, and as you can see, as the zeros had no RAT scores greater than 10, the ones had one RAT score of 10, and the twos had two RAT scores, the first and the second were 10. This was again predictive of need for positive pressure ventilation. The more exciting part for me is the fact that if the score goes up, these people get intubated. If the score goes down, they don't. So for us, it kind of helps determine that. So how do you use this? We've also been working on not having to score every patient in the ICU, so we collected a number of and have published a series of studies on predicting respiratory failure or extubation failure in this case, and we figured out that a tool called integrated pulmonary index worked best in our institution, and so we automated. We told Epic to call us when that score dropped by one or less than four on any patient in the ICU, and we ran a randomized control trial of letting the monitoring data tell us who's potentially going in the respiratory failure and to page us, and we compared that to a group that got an RT assessment and scored that I just showed you would be effective or not effective, and so both groups ultimately got them, just the group that had the automation wasn't scored initially unless they appeared to have a problem, and as you can see here in the data, there's really were no differences between them except for the amount of RT time spent doing the assessment. So for us, we see this as a clear path to improve time that therapists spend at the bedside doing things that are that would be important to preventing a negative outcome, but I share with you this, and you can take it part of the study again. I'm not going to tout this as the best data, but it is data, and data is data, so you know the we in this previous study that I showed you back here, we did not do an attention to treat analysis. We didn't do an attention to treat analysis because part of the study got caught right in the middle of COVID, and there was 32 patients who did not get our standard of care at Rush, and because they didn't get the standard of care, you can't include them in intention to treat analysis. They were not even in the group, so to show why not to include them in the intention to treat analysis, I compared their outcomes in this group here that was a non-RT driven care as we normally do to what was us just waiting for normal process of care to be allocated outside our system, and if you look at those outcomes and now take this to granted this is COVID in this process here, you can see those outcomes are far worse when they were not getting our standard of care versus when they were getting our standard of care, and those are very, very small numbers, and you can even see similar allocation of therapy on the bottom there. I think this speaks highly to the timeliness of interventions needing to happen versus delaying whenever you decide an intervention should happen, and so again just to follow up, there was a lot of staff development. We used simulations. We created various ones of scores for them to get consistency and scores to fix inter-rater reliability and train a group of therapists, and we have therapists that have associate degrees, bachelor's degrees, master's degrees. We have all kinds of therapists from various backgrounds and time in practice. We use an online education component. We do simulation-based competencies and have a career ladders in place to help promote them to get more education, but the thing about our annual competencies, they're based on those protocols. They're not set up that piece of equipment. They are roll in the room. Here's a simulation. Manage it. Here's a score. What are you going to do? Here's the ventilator protocol on the back end. Here's this abnormality. What are you going to do? They have to make decisions. The problem is most people don't expect respiratory therapists to make decisions. Do they like them? Not necessarily, but they certainly are needed to get the job done in how we ensure quality and have the ability or latitude that we have at Rush. I think those are a very, very important component, and it just published and I didn't have a chance to add that, but there's some data to support that that just published in the Canadian Journal of Respiratory Care on a series of retrospective data from the pandemic that those competencies and educational background had an outcome difference for patients. So the level of education and those competencies affected patient outcomes, and this needs to happen. We have to get collaborative research. So the Lancet publication I mentioned was a meta trial, so it wasn't. It was international meta trial, and we had similar protocols enough that we could follow them, but we combined the data at an end. So instead of doing a meta analysis traditionally, we turned the meta analysis around and collected all the data from all the institutions and then published. Why can we not do this in respiratory care? Why can we not join together and combine quality improvement data to drive outcome differences and answer some questions, and it was very cost effective to run those models. This has to happen from a number of institutions that are practicing similarly to drive change in outcomes and evidence, and there is a lot of opportunity here. You just list the slides. There is a lot of opportunity for savings of serious revenue for an organization based on outcomes length of stay and reducing complications for them. So I'll conclude with again back to my value statement, and I see this with the help of medical directors is the way to improve more consistency in practice of respiratory care across this country, and I'm sure everyone's sitting out there going, man, my department doesn't look like that. My department doesn't run this. I don't have those respiratory therapists. First starts with expectation, and only the medical director is going to really for the if the manager's not doing it, you are the only other people that can do it. To say this is my expectation. It's being done. It can be done. Get there. So until that happens, I don't know that we can address that on the bottom, but I thank you, and we're glad to take any questions you have. Thank you.

collaboration

medical directors

respiratory therapists

patient care

healthcare landscape

value

job satisfaction

protocols

respiratory care