Keystone Project to improve patient outcomes

For a more updated and thorough post about the Keystone Project, Click here.

As I have mentioned before, we at the RT Cave believe it is important for each respiratory therapist to be involved in the entire process of patient care as much as possible, as opposed to simply focusing on the respiratory side of the patient's needs.

The main reasoning for this is that, as we learned in respiratory school, "all the organs of the body combined effect the respiratory system in one way or another." Not only is it important for nurses to pick up on the early signs that a patient is failing, it is the job of the respiratory therapist. After all, we are a team, we are all responsible for taking care of the patient.

Most doctors agree that most people do not go into respiratory failure without showing early signs that this is going to happen. It is our job as part of the hospital team to pick up on these early signs and prevent a patient from getting so bad that he or she has to be moved to the critical care unit (CCU).

And, once in the patient is admitted to the CCU, it is our job, along with the nurses, that we continue to monitor the patient for signs of impending failure, besides treating the patient for the critical issue that landed the patient in the CCU.

According to the MHA Keystone Center, "It is estimated that, "over 5 million people are admitted annually (to the CCU) in the U.S., consuming approximately 30% of acute care costs or $180 billion annually. In addition to consuming health care costs, these patients suffer preventable morbidity and mortality. Previous studies suggest that nearly every one of the 5 million patients admitted to an ICU suffer a potentially life threatening adverse event (emphasis added)."

It was the goal of the Keystone Project make recommendations based on the most up to date research to improve costs and, most important, recommend steps that hospitals can take to improve patient outcomes regarding illnesses that do show early signs. And the project recommends each hospitals voluntarily create its own Keystone Team to implement these recommendations.

One of the early recommendations was to create a rapid response team , which would get nurses and respiratory therapists on the patient floors to be on the look out for early signs, and to call the rapid response team into action, to generate early intervention, and thus to prevent the patient's illness from progressing to the point that a move to the CCU is necessary.

Creating ventilator protocols is another recommendation of the Keystone Project in order for the doctors and the respiratory therapists to begin thinking about weaning the moment the patient is placed on the ventilator. Since we have initiated our ventilator protocol, we have seen patient length of time on a ventilator decline sharply.

The Keystone Team at Shoreline where I work has decided that the next step they want to tackle is creating a Sepsis protocol.

I'm not sure what steps we will take, but a few years ago I went to an MSRC conference and one doctor gave a presentation "Everything a respiratory therapist needs to know about Sepsis." And he made us aware that the number one killer in the CCU is sepsis. But people do not get spontaneous sepsis any more than they get spontaneous DIC or ARDS, so it is very important for nurses and RTs to pick up on the early signs.

I couldn't remember everything this doctor said because he went so fast I couldn't keep up with my notes, so as soon as I had a slow night at work I looked this up on the Internet, and was surprised at how much I found.

I found that the MUST protocol was created to make hospital staff aware that sepsis, according to aacnjournals.org, "affects more than 750,000 patients and accounts for more than 215,000 deaths in the United States each year at a cost of $16 billion. Mortality to septic shock has decreased only slightly between 1970 and the late 1990s; it remains the most frequent cause of death in noncardiac intensive care units (emphasis added)."

The MUST protocol makes recommendations in making hospital staff aware of the early signs of sepsis and what to do in the event these signs are prevalent. And while sepsis is not necessarily a respiratory illness, if it progresses, it may result in respiratory failure. Thus, when the RT is present with the patient, or part of the rapid response team, it is essential that he or she knows what the early signs of sepsis are.

While I'm not going to get into the nursing end of sepsis (and you RNs can check out the links above if you are interested), I will address everything that an RT needs to know about Sepsis in the next few days. It's also to know which patients are at risk for Sepsis, ARDS, DIC and PE so they can be closely monitored. At some point in the future I will address all of these as well.

We have met resistance in every step of the way in initiating these protocols, but so far at Shoreline we have managed to create our own rapid response team and a ventilator protocol, and we are currently in the process of creating a sepsis protocol.

While it's not the RTs role to insert catheters, central lines and pulmonary artery catheters, the Keystone Project believes it's the role of every person at the bedside to make sure nurses and doctors are in compliance with infection control techniques to "reduce or eliminate catheter related blood stream infections in ICUs." Since we RTs are often at the bedside, we need to be aware of proper technique.

And, while it's not our role to check sugars, an RT must be one of the team members thinking about this, especially when a patient has sudden mental changes, which may also be an early indicator of sepsis. Does the patient all of a sudden have significant change in respiratory rate, heart rate and blood pressure? Is the patient suddenly filled with Rhonchi or crackles. These are not things to be ignored, as they may be signs of impending failure.

As a respiratory therapist, I like to see the big picture above and beyond my role as an RT. Due to the recommendations of the Kestone Team, I know that it is important to do oral care on a regular basis to prevent VAP (ventilator acquired pneumonia), and to have inline suction as opposed to bag and suction, and to make sure the head of the bead is up 30 degrees, and to make sure the patient is still rotated from side to side even though he or she is on a vent.

And, while it was once recommended not to exceed 20 cwp of cuff pressure in the ETT, , it is now recommended not to let the pressure become anything less than 20. The reason for this is to prevent aspiration and VAP.

I'm not sure if this was a recommendation by Keystone or not, but while I was taught to use 1-15ml/kg ideal body weight when I was in RT school in the mid-199s, it is now recommended to go with a lower tidal volume of 6-10ml/kg ideal body weight to prevent barotrauma. And, in cases of chronic or severe pulmonary illness, it is recommended to start on the low end.

If these things are not being done, it is my responsibility as an RT to either do them, or to at least make sure the nurses or other RTs are doing them.

Not only is is a good idea to generate these teams, and these protocols, but it's also a good idea for respiratory therapists to continue to research, to attend seminars and in services, to stay up to date on all the latest research and recommendations to improving patient care. I think this is necessary even if protocols are not available.

Personally, I don't need a protocol to make me participate in the patient's care this way, but the use of protocols provide RTs with more leeway in what we are allowed to do regarding the patient, especially regarding early intervention. If the patient looks bad now, why not get a quick ABG, EKG and, perhaps, order a STAT x-ray while the nurse is calling the doctor.

When we RTs are called to the patient room to give a breathing treatment, and we observe that the patient is not having bronchospasm but is wet, and then we notice that the IV is running at 500, we would naturally make the RN aware of this. And then we would recommend a diuretic, instead of a bronchodilator.

It's not that the nurses are incapable of finding this out on their own, because they are and they do. But if we are a team, we all must be vigilant all the time. What one of us does not pick up on right away, the other hopefully will.

By keeping up on our research, participating in protocols, and making recommendations that work to benefit the patient, we are not just helping the patient, we are using the skills and education that we have accumulated. This is good for our RT morale.

We are a team, and we must all work together to the benefit of the patient, and to the benefit of ourselves and our institutions.

Respiratory Therapy School: What you need to know about complainers inside the RT Cave

I'm going to expound here on RT complainers, however, it's hard to talk about complainers without sounding like one myself. Likewise, it's hard to discern between constructive complaining and non-constructive complaining.
I've had to rewrite this a few times with that in mind.

Before you read the following, I want you to know that I really do like my job as a respiratory therapist. And, I think this is an excellent job for people to go into, especially if you want to take care and treat patients with respiratory illnesses.

It's a really great job. At times it can be challenging. At times your adrenaline will be rushing especially when you have a critical patient, and what you do or don't do could determine whether or not that person lives or moves on to meet his maker.

Many times you will be able to work with doctors determining what route to take in caring for a patient. And, of course, sometimes doctors might not want your help. Okay, so it's that way with any job.

I think the job of RT is a great job for anyone who wants a job and needs to start working right away. That's why I chose this field. You get to start working as soon as you start school. Then, as you become certified and registered, you get your pay raises.

This is an ideal job for people who want to use RT as a stepping stone to moving onto other medical related fields, such as PA or DR. To be honest, I think all doctors should be RTs first. This is an ideal job for former stay at home mom's, construction workers or others who want an easier life, and asthmatics who want to work in a clean environment.

Basically, this is a great job for anyone who wants to start a career later in life and wants a guaranteed return on his investment. This is a great job for anyone who wants a career you can take with you no matter where in the world you live.

When you start working you may meet the complainers. I was lucky and didn't meet them until my third student rotation. I later found out that they often go into hiding when RT students are around.

You know them, because they are abounding in every profession. Don't let them get you down. Because you know that your job is what you make it.

You also should know that if they really hated their jobs they could easily get another one. You might tell them that at some point, but then they'd complain about you too. The truth is, they don't want to change careers. They are content with what they are doing, they simply find release in complaining.

They do not want to change jobs for reasons I stated earlier, that this is probably their third chosen career, they are getting up in age and don't want the stress of changing careers again, or they have families and don't have the resources or time to go back to school. Those are the most common reasons.

Herewith, I am going to make an attempt at explaining the RT complainer to you, because they are different from complainers of other career paths. Your teachers in RT school will not tell you any of this, so I am.

I've read a few posts this past week about RTs complaining too much about their jobs. In the post I linked to above I stated that about 60% of RTs are complainers, and someone corrected me by stating that she thinks it's more like 80%. Either way, they are abounding.

One of the biggest complaints I hear is: "What's the point of increasing my RT knowledge when doctors don't let me use it?" This is what I will focus mostly on in this post. I will not delve into "the hospital admins make decisions regarding us without consulting us," or "you'd think at a hospital they'd at least have good health insurance." I won't go there.

We'll focus on RT knowledge. As I stated above, greatest complaint regarding RTs is the result of them being over educated for the job.

Of course, you know why you should always try to increase your knowledge, because if the opportunity presents itself you want to be prepared. If a doctor is looking for ideas about what to do for a patient, you can say, "Hey, I read somewhere that..." He will be impressed with you.

The biggest advantage to improving your education is that if the career opportunity presents itself, and you are prepared and ready for it, you can apply. Now I've never had such opportunity, but if it ever comes up I will be ready.

But what's the deal with this "what's the point of learning" complaining?

The bottom line here is this: Most of us RTs feel that we are overqualified for our jobs. We have 2-plus years of education plus whatever experience we've accumulated on the job plus knowledge we obtain through continued education, all of this making us specialists in the respiratory diseases and how to fix them.

And yet, in many hospitals, we are not allowed to use this knowledge because many doctors do not want to give away any of their autonomy.

I will give you a few examples from my own personal experience.

1. Non-constructive complaining:

I feel absolutely stupid going into a room of a post-op patient with no signs of respiratory distress and telling that person I have to give a breathing treatment. There is no reason for it, and it's frustrating.

Many RTs bicker about this. It's best to keep your mouth shut.

2. Non-constructive complaining:

When I have a ton of therapies, and 70% of them are not indicated, and I still have to do every one of the non-indicated treatments while making sure my treatments on my SOB patients are never late, while still taking care of ER and STAT therapies, this can be taxing on me. It can cause unnecessary burnout.

I describe this in a recent post, "R. By the time I got to work I was already burned out, and I took it out on my co-worker. Not a good idea.

We all have our opinions, and the chronic complainers will let us know about them on a regular basis. But when I complain, it's usually when I'm burned out.

3. Constructive complaining and non-constructive complaining combined:

What if we have one patient who is SOB, and I know I have the cure for his ailments right in my pocket, but I have to wait a half hour for the doctor to respond. I have to stand idly by while my patient suffers. As a fellow asthmatic, I can't stand this part of the job.

I think I am justified in not being happy about this.

I find myself grumbling and griping, "Why hasn't the doctor called back yet?"

My solution to this problem is what I call my "Act now and apologize later protocol." I have never been written up for doing this. Never. So that solves that complaint. However, isn't this something that should be complained about.

This example could possible by non-constructive, if I grumble and gripe too much.

4. Constructive complaint:

In "Grumpiness stays in the RT cave" I detail another complaint that's really not a bad thing to complain about. I write about a nurse who called for a treatment on a patient when the treatment really wasn't indicated.

While most times I keep my mouth shut and just do the treatment, sometimes I like to take the time to educate the nurses. While most times they want to learn, sometimes they take it as a complaint. And, if I'm burned out, I probably come across as I'm complaining. So, I've learned it's best just to keep my mouth shut even in these situation.

5. Non-constructive complaint:

Using the above example, we know that educating is not complaining. However, when you have to do this on a daily basis, particularly over and over to the same nurse, it can become frustrating and can lead to non-constructive complaining. Most nurses, however, want to learn and will listen.

If the nurse is really busy, she might not want to hear it. This can get frustrating in itself. More than likely in this case, she just want you to make sure you take care of the patient, regardless of whether the treatment is needed or not. And, many times, RNs and doctors determine that giving a treatment is better than doing nothing, even when it's not needed.

In cases like this, I've learned to keep my mouth shut as, I'd presume, most RTs have.

6. Non-constructive complaining:

I will use all the above examples here. While RT complainers excel at this, all other RTs will complain about just about anything from time to time. It can't be helped and it's a fact of life. (If a content does this, you know you're in trouble.)

7. Constructive complaining:

I always tell my friends that I'm not complaining, I'm simply stating a fact. And, when I show people my list of 'olins (listed at bottom of blog), or I tell them some of my RT humor (plastered all over my blog), I think this is the best way to complain. Just by thinking of all this stuff we have to be learning something. So long as we don't go overboard, I think this is the best way to let off steam.

Well, at least I think so.

I can probably think of more types of complaining, but my mind is strapped at this time.

Overall, the greatest complain is regarding non-indicated breathing treatments. If you are a true professional, you would understand explaining them away like this:

When doctors and nurses call me for therapies I feel are not indicated, I like to think they simply want an RT to be assessing the patient QID or Q4 just to be on the safe side. That's not such a bad thing, is it? (It is if it leads to burnout.)

If you're still not content with non-indicated therapies, I suppose Taylor on Kid Nation says it best: "Deal with it."

The best way of dealing with the grumbling and griping is to continue to work toward impressing doctors and nurses by generating respect with them by always staying on the cutting edge of knowledge.

Likewise, if we do not have protocols already, we must study the protocols of other hospitals, continue the education process (as we do on these blogs), and work, slowly and patiently if needed, to get them implemented. Will this get rid of all non-indicated therapies, probably not.

By continuously working to better ourselves, we strain away our desire to complain. Most important, we know that by our complaining we only cause other professionals (Drs, nurses) to stray further away from us. They hate complainers. This is the best way to not make progress, as you can read about at Snotjockey's Revisited.

And you will be reminded many times that "the grass is not always greener on the other side of the fence."

You will find complainers everywhere you work. I was a journalist once, and they were there; 80% of them. I was a hotel desk clerk once, and they were there; 80% of them. I worked in the fast food business once, and they were there; 80% of them. It never ends.

Still, if you've set foot in any RT Cave, you know that RT complainers are not interested in making the RT Cave a better place, because deep down they are simply content to keep things the way they are. For reasons I listed above, they know they will be trapped in the RT Cave for the rest of their working lives.

To make themselves feel better, they gripe and groan. The rest of us are forced to take the brunt of it.

However, if you can stand to listen to a complainer, they are very intelligent people. As you know, they complain mostly because they are overqualified for the job. I really think that's true. I've obtained tons of material for this site by listening to complainers. They are up on their knowledge.

It's just too bad they don't use all that energy and focus it in on progress.

Here's a thought before I end for the day: "If it weren't for complainers, nothing would ever get accomplished in this world." I'm sure you've heard the old saying, "The squeaky wheel always gets the grease."

The six different types of respiratory therapists

There is much resistance to change inside the RT Cave. After much thought on the matter, I have figured out why. It has everything to do with the six different types of Respiratory Therapists (RTs).

Many RT Caves do not have protocols. I've heard every complaint

Very, very slowly I think doctors are becoming more and more receptive to the benefits of adding respiratory therapy patient driven protocols. In real time seems tortuously slow, but I think in ten or twenty years we might be talking about some major changes in the rolls of RTs.

While this is true, there are still many RTs themselves who don't seem to be receptive to change. This became ever more so apparent to me after reading an excellent column over at Snotjockeys Revisited, "Clinician Resistance to Adopting New Practices".

I agree with her, and have my own experience to add to the mix.

A fellow RT, Dale, is very fun to work with. He's intelligent, a great RT; but he is a constant complainer. He complains in a fun way, but nevertheless he is still a complainer.

"I circled all the indicated treatments on the board," he said the other day in report.

"Um," I said, looking over the list of patients, "there are none circled."

"That's my point," he said, and chuckled.

One day he handed me a list. I looked at it thinking it was serious at first, then I started to laugh. On it was a list of 'olins that he made up. (You can view parts that list at the bottom of this blog)

He said, "I bet that 60% of what we do here is absolutely not indicated."

I'm a firm believer that if you're not having fun with your job what's the point. So we make fun of our job. We make fun of doctors, we make fun of nurses, we joke around during a code. I think that's medical humor, and we do it to maintain our sanity.

I check doctor blogs and nurses blogs, and I see their humor all the time.

But humor is one thing, complaining is another. And complaining with Dale is fun, but most complaining in the RT Cave is simply annoying. I avoid it every chance I get. If I have no choice but to give report to a complainer, I give a quick report and scram.

I used to work with Dale a lot. In fact, I'm glad I had that opportunity to work with him because I learned much and he helped me develop my RT humor. However, I was never going to get anywhere via complaining. Complainers rarely get anything accomplished. But they are abounding in the department.

What's that old saying? "Complainers say more about themselves than the person they're complaining about."

I realized this, and I switched weekends. Now all the complainers work with Dale on the other weekend. The RTs who work on my shift are Jane Sage, a very optimistic, intelligent and fun to work with person. And we have Dee, who happens to be a complacent RT (see list below).

Jane had an epiphany one day, and decided the laid back RTs on our weekend are awesome, and she started referring to us at the "A" team. We called the RTs on the other weekend the "B" team. Once the "B" team got wind of this they decided that they were the New "A" team.

"That's fine," Jane said, "We won't tell them that "A" now stands for Anal and "B" now stands for Better than Anal."

Despite the complainers, we have enough "balance" of different personalities to make things work in our department. You need the complainers so we know of our faults, we need the anal people to make sure we get all our work done, we need the content people to boss around, the laid-back people to ease tensions, and the clowns to make us laugh.

I'd even go as far to say we have a great department. I suppose that means we have good balance. I'm sure the members of this RT Cave are no different than any other.

With this in mind, I created the following list. Based on my experience working with many RTs in the past 10 years, these are the six different types of RTs:

1. The stepping stones: These are the RTs who use the career of RT as a stepping stone to a more illustrious medical profession. In my humble opinion, this is the way to go. What better way to learn about medicine than through the eyes of an RT. I'm serious here.


2. The quitters: These are the RTs who don't like to work. Some "Quitters" take a job of RT because they think it will be an easy job and they won't have to do anything. As soon as they learn what RTs really do, they either quit or are forced out the door.


3. The contents: They are the happy-go-lucky RTs who never complain. They are the RTs you love to give report to because they are always happy. They rarely make any effort at learning new information other than what is required. They usually prefer not to work with critical patients, and when they do they never question doctors and they prefer to be button pushers. Usually, you will see these RTs happily knocking off treatments on the floors.


4. The complainers: This composes probably about 60% of all RTs. These are usually very intelligent people who love the career of respiratory therapy in theory, but hate the reality of it. They are usually well up on all the new technologies, and are very quick to question doctors or offer suggestions. However, while they are not happy, they do nothing to better their career field. After working for a while, they become frustrated and content and they give up. One of the reasons they are so frustrated is that they have decided that they are too old to get another job, or have families which makes changing jobs difficult. Yet, while they complain, they do not support change.


5. The optimists (or learners): These are the RTs who write blogs. They may or may not be more intelligent than complainers, but they love to learn. These are the RTs that consistently do research on the Internet and read magazines. These are the RTs that attend every seminar possible. These are the RTs who write the protocols and make recommendations for new equipment, and then write the policy and procedures for this new equipment. These are the RTs who learn about things like Graphics and educate the rest on how to use them. These are the RTs who make the best of their career even though they know there are a lot of forces working against them. Most important, these are the RTs every one in the department loves to talk to because they are good listeners (they listen because they love to learn). More often than not, they work with the leaders to solve these problems as they occur. They often let other RTs take credit for the work they do. They do this to keep morale in the department high. In essence, the optimists are the strings that keep the department together. A department without optimists does not run very well.


6. The leaders: These RTs, while far and few, take charge and lead. They make changes to the RT Cave and they are resented for it. They make sure everything is stocked. They make sure all the i's are dotted and the t's crossed. They are usually opposed to protocols because they don't want to "rock the boat", but they won't say so openly. They listen to the rants of other RTs, but they usually side with the administration on issues. They question RTs who question the status quo. You might hear them at an RT meeting saying something like, "Don't you think protocols might actually create more work for you guys." When they say things like this, they are catering to the complainers, who will work with them to stymie any change. The leaders do no like change because it goes against their philosophy of "do not rock the boat." It is also important to note that while most leaders are good people with normal home lives, they are often hated and revered at work. Complainers often do not get along with them, and optimists are often seen working with them "for the better of the department."

I can give examples galore, but I'll give just one more.

Even though she had several protocols shot down years earlier, Jane wrote a new and updated ventilator set-up and weaning protocol. The complainers in our department all said it would never be approved by the doctors.

Jane trudged on nonetheless. She had the support of me, another optimist, and Dee, the easy going content on our weekend. Finally, with a bit of luck, the protocol was approved.

With our confidence on high after, Jane and I wrote a breathing treatment protocol we thought might work. We were very proud of our efforts. We thought we'd show it to our co-workers and get their support.

I showed it to Dale first. Surely he'd approve of it since he was the most outspoken RT about useless and not-indicated breathing treatments.

I couldn't have been more wrong.

"So what do you think?" I said after he stared at it for several long minutes, grunting and sighing often.

"Well," he paused while staring off, then spoke slowly, "The biggest offenders will still abuse the system. If it does anything it will just create more work."

"Okay," I said. I made no effort to change his mind. I walked away. No point in beating a dead horse.

Jane brought up the protocol at a department meeting. Gary, the department head and quintessential RT leader, said: "It is possible you might just be creating more work for yourselves by doing this."

He may be right; he may be wrong. Either way, Jane and I keep moving forward. And that's easier to do now that we know about the six different types of RTs.

Need STAT reform STAT

Aside from the need for bronchodilator reform, I've been thinking lately that we also need some major STAT reform. It's getting the the point that the word STAT has lost all credibility.

"RT STAT to ER," wailed overhead. I had a SOB patient in need of a treatment, but what was I to do? I rushed down to ER to find a kid in no respiratory distress. He didn't even need a treatment. I rushed back up to care for my SOB patient.

When I hear that word "STAT" that's what I think: drop what I'm doing and go (with a few exceptions.)

RT Rule #6: STAT means that you need to get to the patient's side right now. We are talking about a life and death situation.

I've been called to a room stat to do an EKG, only to find out the doctor wanted it done so he could go home. I consider that abuse of the STAT system.

I've been called to pre-op STAT to do an EKG prior to surgery on a scheduled surgery. Those EKGs should be completed way before the surgery so they can be inerpreted.

I've been called STAT to induce a sputum. Once I was called to STAT NT suction patient for this.

After I very reluctantly performed this not indicated and traumatic procedure, the nurse cornered me. He said, "I called that STAT because of the pneumonia protocol, and we had to give the antibiotic within four hours."

"That's a silly reason to call me STAT," I said. And you're lucky I didn't have anything else to do, or I wouldn't have come down right away either. I'm not letting my SOB patients suffer for this.

I was even called to do a STAT Halter Monitor once, but that ended up being the ER staff fooling around with me because they knew I hated doing Halters in ER. I suppose I deserved that one.

The first thing you learn as an RT is that a page to ER is considered a STAT page. I was told that I should be down in ER in about 5 minutes.

When I first started working here I was told by the ER staff how impressed they were at how quickly I got down there to do EKGs and treatments. "You get down here almost twice as fast as any other RT."

I was perplexed. I thought we were supposed to be in ER within 5 minutes. I thought we were supposed to drop whatever we were doing and get down there.

Then I caught on. I realized that I was quitting in the middle of a breathing treatment, rushing down to ER, and doing an EKG on a patient who had leg pain, or abdominal pain, or bad fingernails or something stupid like that. Or I'd get called down there to do a treatment on a kid with a cold.

Either that or I'd get down there and the nurses were putting in a catheter and tell me I had to wait. After a few months of waiting 10-15 minutes each time this happened, I decided I could better utilize my time.

I tried to go to my boss, but they had more pressing issues to deal with. That was a dead end. I learned that other RTs had done the same thing when they first started as RTs. Now we are all slow. According to some ER RNs, we are slow getting to ER because we are lazy.

That's fine, call me lazy, but you guys need to learn how to use the word STAT. I would like a reform of the ER paging system. When I think of STAT I think of running. I think that if I don't get there right away the patinet might die or have prolonged suffering.

One day an ER nurse was blunt with me. "What took you so long to get down here?"

"I'm sorry, I'm swamped," I said. It was true.

"You should at least call so we could do it."

"I was at a code."

Twenty-minutes later I received another page to ER for an EKG, and this time I really was busy and called. An hour later I made it down to ER and the EKG was still not done.

To be fair, most ER staff at Shorline are very understanding that sometimes RT is busy, and that we have to prioritize. And, as it turned out in this case, the nurse that did complain was a rental nurse not familiar with our hospital.

And, even while ER procedures are considered STAT, the people who order them are simply following the current protocol and, thus, doing there jobs.

To correct this problem, we at the RT Cave wrote the following letter. It was signed by all my fellow RTs:

To whom it may concern:

To speed up time from door to EKG for critical patients in the ED, and to allow the respiratory therapy staff leeway in prioritizing EKGs with important therapies on the patient floors, we propose the following paging protocol be instituted for all EKGs ordered in the Emergency Department (ED).

1.EKG Priority One: This page will be sent out for all EKGs ordered on highly critical patients such as obvious MI’s, life threatening arrhythmias, failing patients, etc. Upon receiving this page, the RT will drop what he is doing and run as fast as he can to the ED. If RT is unable to complete the EKG within 5 minutes, the ED will be called and the ED staff will complete the EKG.

2. EKG Priority Two: This page will be sent out for all EKGs that fit under the ACLS protocol where the EKG must be completed within 10 minutes of the patient’s arrival in the ED. Upon receiving this page, the RT should be in the ED within 10 minutes to complete the procedure. If RT is unable meet this time frame, the ED will be called and the ED staff will complete the EKG.

3. EKG Priority Three: This page will be sent out for all EKGs that do not fit under the ACLS protocol, the patient is stable, and a time frame from door to EKG is not essential. Upon receiving this page, the RT will have leeway to complete other
essential procedures prior to arrival in the ED. This page will also be utilized for all pre-op patients, and any patient currently unavailable due to use of commode, bathroom, gone for x-ray,CT, etc.

Ideally, priority three EKGs should be completed within 20 minutes from time of page. If RT is unable to meet this timeframe, the ED will be called with an estimated time of arrival. In some cases,the ED staff may decide to complete the EKG and, if this occurs, RT will be notified the procedure has been completed so they don't have to rush down when they finish the task at hand.

If the ER staff is called to do an EKG, and the EKG is not completed in a timely manner, the RN will have to order pizza for all the RTs on duty. If this is not possible, the total sum of $50 will be extracted from the RNs paycheck and set aside for an end of year RT party.

We believe the implementation of this protocol is essential to improving staff time management, and, more important, improving patient care.

Sincerely, The RT Staff

We understand it's a hell of a lot easier to be called lazy (we're used to that) than to try to change policies and procedures that make no sense. But we had to try with this letter.

If this works, we will tackle STAT ER treatments ordered on patients not having bronchospasm next.