Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Pneumonia readmissions on the decline

It appears Shoreline Medical is doing something right, at least when it comes to pneumonia readmission rates. As, compared to the national pneumonia readmission rate of 18%, our hospital had only a 2% readmission rate for the given time period of about a year.

Because of this, I was chosen to give a presentation to a group of respiratory therapy supervisors and managers. This was a unique and exciting opportunity for me, especially considering I was the lowest ranking RT at this meeting. Plus my boss chose me among all my peers to give the presentation.

I worked with the Quality Assurance Analyst for our hospital and created this really nice presentation. Then I spent quality time interviewing, going through charts, and researching all the things we do once a patient is diagnosed with pneumonia, and what we do to keep pneumonia rates down.

I actually learned quite a bit in this process about the administration side of things. What follows here is a summary of my presentation:

A goal at Shoreline Medical is that we all have our priorities in order.

Shoreline Medical is in a small town only a few miles off the shore of Lake Michigan. It's in a small town, a close nit community. And being a close nit community results in a close nit hospital. One of the reasons I chose to work here is because I felt Shoreline was kind of had a down home feel to it. Everyone got along, were good friends, had pot lucks, and stuff like that.

We started the process of getting our ducks in a row by focusing on the CMS Core Measures. To make sure all doctors, nurses and respiratory therapists are always thinking about the core measures, we are all in serviced on this every year by the Quality Assurance Department.

In the chart, before the doctor's orders section, is a bright orange laminated sheet that has all the core measures on it. This way, every time anyone looks at the orders he or she has to flip this page aside. And even if you don't read it, you know what's on it: the core measures. This is one simple reminder to everyone to focus on the core measures when writing and fulfilling orders.

The Core Measures for pneumonia are as follows:

1. Initial Antibiotic Timing (given within 6 hours)
2. Pneumococcal Vaccination if eligible
3. Influenza Vaccination if eligible (October to March)
4. Blood Culture drawn before initial antibiotics
5. Appropriate antibiotic selection
6. Smoking cessation advice and counseling given if indicated (if patient has smoked within the last 12 months)

The most important of the above are the pneumococcal Vaccination, Influenza vaccination and smoking cessation, as studies have linked all three with a reduction in secondary pneumonia. So our major emphasis was on these three.

These core measures are what works according to the most recent best practice evidence to improve patient outcomes and decrease costs for pneumonia patients. The question we had to ask ourselves is: how do we use these core values to get our ducks in a row

Data from our core values back in 2007 showed that Shoreline Medical was about 80% in all of these core measures except for antibiotic timing within 6 hours. In this, we had no data whatsoever, which means we probably didn't even do it.

Yet if you look at data from the first and second quarters of 2010 you can see that we are at or near 100% on nearly every core measure. When it comes to smoking cessation we were at 92%, yet that was basically due to a miscommunication between a doctor and a nurse. So even while we've improved, we still use this data to improve even further, as there is always room for improvement.

So basically back in 2007 we did not have all our priorities in order, and in 2010 we did. So how do we get our priorities in order?

Actually, if you look at pneumonia readmission data other than the above mentioned three month period our hospital at at 16.5%, which is no different than the U.S. National Rate. .

Yet from January to March 2010. During that span we had 52 pneumonia patients, and only one readmission rate.

These improved statistics based on the core measures show we are doing something right. They prove that we have our ducks in a row. The question you are asking is: how did we get our ducks in a row?

The first thing we did was back in 2007 we joined the Keystone Collaborative. We have a champion Internist, a physician from ER, and one from surgery and general practice as our champions. Then we have one nurse from critical care, the general floors, and one from the emergency room.

We also have a representative from lab, x-ray, pharmacy, quality assurance, computer analysis, respiratory therapy (that's me) etc., and we meet every month to analyze data from core measures to create and improve clinical pathways and order sets to improve patient outcomes and reduce costs for our hospital.

The key here is that we review modern wisdom and come up with better practices for our hospital. Anyone can do research, or come up with new ideas, and can share them with any member of the keystone

committee, and then this new wisdom is brought to and reviewed by the committee and changes are made as appropriate.

Basically the point of the Keystone Committee is to do what works and skip doing what's not working.

The following is our pneumonia order set:

Our order set includes the following as options for the doctor to check:

• Code status
• Vitals routine or ___________
• Record input and output, daily weight, pulse oximetry every shift
• EKG on admission
• Chest x-ray on admission and on day 3
• Lab work (if not already done): CBC, CMP, UA, Sputum for gram stain, culture and sensitivity, blood culture prior to administration of antibiotic (this has to be done within three hours of admission)
• AM labs_______________
• Oxygen at _______ lpm or per protocol or _________
• Respiratory treatments: Albuterol 2.5mg with 3cc normal saline Q6 hours, up to ____ hours prn
• Respiratory treatment: Atrovent 0.5 mg in 2.5 ml normal saline QID
• Antibiotic therapy (1st dose to be given in ER) or immediately after blood culture drawn)
• Community Acquired Pneumonia (non CCU): Levaquinn 500 mg IVPB Q24 hours times 3 days, then Levaquin 500 mg PO daily
• Community Acquired Pneumonia (CCU or stepdown patients): Rocephin 1 gm IVPB Q24 hours and Zithromax 500 mg IVPB Q24 hours and Levaquin 750 mg IVPB Q24 hours and Azactam 2 GM IVPB Q12 hours
• Nosocomial Pneumonis (check all that are indicated from list of meds and doses)
• IV Fluid ____________
• Tylenol 650 MG PO Q4 hours prn for pain
• Xanax 0.25 mg PO Q6 prn for anxiety
• Restoril 15 MG PO QHS prn for insomnia
• MOM 30 ML PO BID prn for constipation
• Robitussin 10 ml PO Q4 hours prn for cough

(I left a few things off, but that's basically the gist of it).

This is our pneumonia hymn book. It's all the things that the best practice evidence shows works to help pneumonia patients get well. It's one sheet of paper, which makes it very simple.

As you'll note, some of the things on here are automatically ordered -- the doctor has no choice. For instance, x-ray on admission and in the am times three days, and certain labs on admission and in the am.

The ER nurses are involved right away, because if that patient is in the ER at the five hour mark, they have to make sure a sputum is obtained, and that the patient has been given that initial antibiotic within 6 hours. They have a system to assure this is done, and checks and balances.

As soon as the patient is admitted, the orders are entered into the computer system, and reminders are automatically sent to all the respective departments as to what they have to do and when. In RT department sheets are printed off so we know what our role is for that patient.

For lab and x-ray, what they have to do is printed up on their respective printers, and plus the procedures they have to do are put on the tracker when they are due so they are reminded in that way too.

It's simple. This order sheet is our hymn book: it makes sure we are all singing from the same hymn book.

Then we have our extubation protocol (to see our extubation protocol click here). This order set is part of the ventilator bundle. It works similar to the pneumonia bundle, in that when it comes to intubated patients, it makes sure we are all singing from the same hymn book.

The neat things about our extubation protocol is that when we were in school in 1995 we learned that the cuff pressure should never exceed 20 cwp. Now we are taught to always exceed 20 cwp. The reason is to prevent aspiration , and to prevent ventilator acquired pneumonia.

Another thing to prevent pneumonia is that the circuit not be broken. To do this we use MDIs instead of nebulizers. Also, we do not disconnect the circuit to suction, and use in line suction catheters instead.

Another key is the daily sedation protocol. Every night around 2 a.m. we automatically take all our patients off sedation so that by 6 a.m. we can analyze the patient for readiness to wean.

Here comes another laminated sheet. As part of our ventilator protocol we have a sheet that acts as an algorithm to speed time from intubation to extubation. Actually, the key to a good extubation protocol is that as soon as the patient is intubated we start thinking about extubation.

If the patient can be extubated in 2 hours, now that's possible. Years ago if the attending went on vacation the other doctors didn't extubate because they didn't want to offend the attending. Sometimes we RTs would wonder why the patient was still intubated. Now, that never happens, or rarely happens.

Our Algorithm goes something like this:

Weaning Screen:

1. FiO2 less than or equal to 40%
2. PEEP less than or equal to 5
3. HR greater than 50 or less than 120
4. Temp. less than 100.5
5. SpO2 greater than 90 unless otherwise directed by physician
6. Systolic BP greater than 90
7. Minimal or no sedation
8. No Vasopressors
9. No signs of respiratory distress
10. Able to follow commands
11. Adequate cough
12. Secretion thin and minimal
13. Plateau pressure less than 30 cwp

If the answer is no, then you stop and reanalyze the next day. If the answer is yes, then you move on to the next step, which is to do a 5 minute spontaneous breathing trial (SBT). (ETT 8.0 or greater use a CPAP of 5 and PSV of 0, ETT 7.5 or smaller use CPAP of 5 and PSV of 5)

Now you do a second weaning screen based on the same criteria as above.

If the patient fails the screen, the SBT is stopped and patient returned to previous settings.
If the patient passes, the following is completed and analyzed:

1. NIF greater than 20
2. VC greater than 10 ml/kg
3. VT greater than 5
4. RR less than 30
5. VE greater than 5 and less than 15
6. RSBI (f/vt) less than 100

If the patient passes this criteria, continue SBT for 30-120 minutes. Then do another weening screen as mentioned above. If patient passes do an ABG and call physician for order to extubate.

So basically we no longer simply do weaning parameters every day, we are actually completely assessing the patient using the common sense, best practice evidence approach. Patients are getting extubated quicker, and VAP is now pretty much nonexistent at our hospital.

Another key is education. As soon as the pnuem order set is initiated the emergency nurse educates the patient about pneumonia. Then the nurse on the floor educates the patient, and then the RT is in the room every six hours, and he or she educates the patient some more.

We make sure not only do our patients learn about pneumonia, they also know about their disease. For example, if they have COPD we make sure they know the early warning signs of an exacerbation so they can nip it in the bud next time and don't have to be readmitted.

We make sure they know if they start to get more short of breath than usual, or have increased cough or sputum production, or change in color of sputum, that they call their doctor or come into the emergency room.

Plus, as soon as pneumonia order set is entered in the computer, an order for RT to do smoking cessation is printed off in the RT department. Several studies show that if when a patient is vulnerable, when he's sick in the hospital, that if someone nudges them to quit they are more likely to quit.

And then when the patient is discharged another paper is printed off that is a pneuminia fact sheet for the patient to take home with them. It is basically a reinforcement of everything they've learned about pneumonia, and is reviewed by the discharge planner.

It's also a reminder to the RN to make sure the patient has had his vaccines while admitted, and to reinforce to the patient that they get their annual pneumonia and flu vaccines.

So basically the pneumonia order set is our hymn book: it gets everyone on the same page from the RT to lab to nurse and x-ray and lab and doctor. We all know exactly what our role is for that patient

Another thing we have an emphasis no is good hand washing. We have signs over every sink that remind of the importance of hand washing. Another sign over every sink describes proper hand washing technique.

We also have hand sanitizer in every room and in various locations, and we encourage or professionals to use this between every patient, and after touching anything in the room, and before touching anything even on their own possession. We also encourage use of hand sanitizers before leaving the room, even if they ultimately wash their hands.

We have some of our nurses are anonymous spies who make note of who they see not washing their hands, or not doing so correctly. We have other pamphlets around the hospital that remind nurses, RTs, and even patients to keep your eyes open, and "It's okay to ask."

So good hand washing is key to preventing the spread of infection.

Another bonus at Shoreline is we are a close nit hospital. This results in really good communication. For example, if I'm in the room and I see something wrong with the patient, I talk to the nurse or sometimes I go right to the doctor.

Instead of the nurses calling the doctor and assuming they know what's wrong with the patient, they often call RT instead so we can use our experience and education to work with the nurse in deciding what needs to be done.

Likewise, many times the doctor calls me up and asks me what I'm thinking is wrong with the patient and what we should do. This is great for morale.


We also have a Rapid Response Team. And another thing is we have good support and encouragement. For example, if an RN calls me to assess a patient, and the patient is fine when I get their, is on the crapper or something, I don't say, "You stupid dummy. Why did you waste my time?"

Instead I say, "Hey, that's fine. You were being proactive. That's good. It's better to be safe than sorry. You did great."

Besides, it's better to be proactive than reactive. If you're proactive you are nipping it in the bud. If you're proactive you may stop the problem from occuring, and then you get no credit. But it's better to be proactive and get no credit becasue the problem never occured, than to be reactive. If you're reactive, that means the problem already occured.

It means the patient is already septic, or in failure, or whatever. If you're being reactive, it means the patient is already in need of critical care services, and may need to be in the hospital longer, and cost the hospital more. If your'e proactive, that means improved outcomes and reduced costs.

So it's better to be proactive than reactive.

So starting with the core measures, the keystone collaborative and weekly keystone meetings, to the pneumonia bundle, and then with the small town close nit touch, we have been able to get all of our priorities in order here at Shoreline Medical. That's how we did it.

Thank you. Any questions.

For more information, check out the following resources:

• AHRQ (Agency for Healthcare Research and Quality) http://www.ahrq.gov/
• MHA Keystone Center http://www.mhakeystonecenter.org/
• MPRO http://www.mpro.gov/
• Quality Net http://www.qualitynet.org/
• Blue Cross/Blue Shield www.bcbs.com/innovations

Rapid Response Teams

Studies show that most people do not have spontaneous heart attacks or strokes or go into sepsis without first showing early signs that something is going on. Therefore, the vigilant nurse or respiratory therapist who picks up on these signs can save a life and prevent a prolonged hospital stay.

In this way, we might prevent a catastrophe we might not even ever get credit for. And that, in my opinion, is the greatest job of working in the medical profession. We like to call it being proactive.

Thus, being proactive is the purpose of Rapid Response Teams. It's about educating nurses and respiratory therapists on what signs and symptoms are worrisome, and when to call the doctor. To learn when to call the doctor, click here.

According to "Respiratory Therapists Play Unique Role on Rapid Response Teams," by Steve Babyak (RRT) in the AARC Times (June 2007), studies performed show the following:

• 66-84% of patients exhibit abnormal signs and symptoms within 6 hours of an arrest, including altered mental status, chest pain, fluctuations in heart rate, respiratory rate and blood pressure, tachypnea (58%), tachycardia (54%), hypotension (46%) and decreased urine output (29%)
• Elevated respiratory rate is an indicator of muscle weakness and fatigue. 54% of patients requiring CPR had at least one documented increase in respiratory rate above 27 breaths per minute within 72 hours of arrest.
• 65% drop in cardiac arrests and 56% decrease in deaths from cardiac arrest following the placement of a medical emergency team (rapid response team)

Babyak notes rapid response teams were first "pioneered" in Australia in 1990 and were found to be so successful (see statistics above) that they quickly found their way to hospitals around the world.
Rapid Response Teams generally consist of one critical care nurse, the nursing supervisor, respiratory therapist, and the patient's nurse. In some hospitals it would also include a physician, yet Shoreline does not have an inhouse physician. So this makes it even more important for us, because it allows us to use our skills to save a patient using the guidelines and policies created for the team.

For instance, we are allowed to do EKGs, ABGS, give certain medications, and even order X-Ray and labs even before the doctor is notified, all in an attempt to get the patient fixed and to prevent the patient from getting worse.

We are also allowed to place patients on oxygen, give beta-agonists, morphine and initiate BiPAP if needed. Actually, we aren't allowed to initiate BiPAP, although some hospitals allow for this.

Another advantage of RRTs is that they decrease the number of patients transferred to critical care, and decrease length of stay. I imagine they also increase patient outcomes and satisfactions.

As a nurse is doing rounds, or the RT is doing his rounds, we assess the patient. If we notice mental changes, vital signs that are critical, low oxygen saturations, altered breathing patterns or cardiac rhythms, changes in blood pressure (too high or too low), or simply if we think something is wrong and don't know what, then we can trigger the team.

Thus, as Babyak writes, rapid response teams are a great "opportunity for respiratory therapists to bring their experience and expertise to a progressive format that is rapidly improving the safety and well-being of the hospitalized patient."

Further reading:

1. Do rapid response teams work?
2. How to know when to call a doctor
3. AARCs Rapid Response Team Page

Core Measures

As a medical care professional, whether you're a respiratory therapist or a registered nurse, it's important you understand the behind the scenes politics. Sure you may wonder why you're doing breathing treatments on someone who doesn't need them, yet believe it or not, there is a good method to the madness -- most of the time.

Or if it's not a good method, at least it's a method nonetheless.

Whether or not you think government involvement in the health care system is a good or bad thing, the Centers for Medicare/Medicaid Services (CMS) established what they call "core measures" as a means of improving quality of hospital care and reducing costs. While I don't care for government involvement, I think the idea of "core measures" is a good thing.

Yes, it may result in some overkill, yet sometimes some overkill is needed to meet the ultimate goals of an institution and the overall health care system to the benefit of the patient and to assure cost effectiveness. Bare with me, because by the time this post is complete hopefully you'll have a better overall understanding of what I mean.

So, what are core measures? Please forgive me if I don't get this exactly straight, because I'm learning along with you. Yet after participating in a year's worth of administrative meetings, given presentations, interviewed coworkers and completed a ton of research where I think I have enough information to write about this nearly inexplicable subject.

Core measures are the things the medical staff must do when a patient is admitted under a specific core measure set: acute mycardial infarction, heart failure, pneumonia, and surgical care. Within these four sets there are 27 core measures that are based on scientifically-researched standards of care that have been shown to result in improved clinical outcomes for patients.

Basically, for each particular diagnosis, or diagnosis related group (DRG), the core values are all the things that the latest wisdom has proven work to increase recovery time for that patient.

They have also provided a focus for the development of Clinical Pathways and Standard Orders (post on this coming soon too), both of which assist in the consistent provision of optimal care to patients.

By Clinical Pathways we mean the creation of a system throughout the hospital that makes sure what needs to be ordered is getting ordered, and then completed. One example of this is our hospital has created order sets and protocols for several DRGs.

Now I am of the impression that order sets are bad and protocols are good. This is a topic I will discuss in more detail in an up and coming post.

These order sets and protocols act as a hymn book to make sure every professional taking care of the patient, from the doctor to RT, from the nurse to the lab techs to the x-ray tech, know exactly what their roll is for the patient.

A protocol is a standard order approved by the medical staff that gives the nurses and respiratory therapists the opportunity to do what is best for the patient given the circumstances. If used properly, these work to the benefit of the patient (improved care when needed), the staff members involved (improved morale) and the physician (decreased irritating calls).

An order set is a sheet of paper that the nurse pulls from a cabinet as soon as a patient is, for example, diagnosed with pneumonia. The set is a list of all possible options for that diagnosis. Some of the options that are most essential, such as making sure a sputum is ordered and obtained before the initial antibiotic is given, and giving that first antibiotic within six hours from the time the patient hits the door, are automatically ordered.

Many hospitals are incorporating order sets that automatically set in motion certain things that assure core measures are met, because these are scientifically proven to speed recovery and reduce costs. Examples are x-ray on admission and each morning for the next three days, labs on admission and each morning for the next three days, oxygen, IV, etc. These things must be done on all pneumonia patients, and the order set sets this in motion.

Another thing that is automatic is antibiotic selection, although the doctor will have options here. The emergency room nurses have a process in place where they will make sure the patient gets the antibiotic within six hours if the patient is still in the emergency room, and then there is another system in place to make sure this antibiotic is given within six hours if the patient is admitted to the patient floors.

When x-rays and labs are ordered, they pop up on a tracker board automatically through a computerized system both on a board in the emergency room and on similar tracker boards in the lab and x-ray departments. As time elapses, the color of each particular procedure changes from green (you have some time) to red, which means it needs to be done soon or right now or STAT or at least given top priority.

At Shoreline we have a bright orange laminated sheet that is inserted into the patient's chart right before the doctor's orders section, so that every person who looks at the orders is reminded of the importance of core measures.

Sure order sets might result in some overkill, yet all these reminders, all this motion, makes sure the hospital is meeting core measures for this patient. It also assures the hospital is meeting Intensity of Service. For example, on our order set, the options of IV, antibiotic selection, and breathing treatments are on the order set.

Used appropriately, one can see how order sets and protocols, when used together, can result in improved outcomes and reduced costs, improved staff morale, and decreased annoying calls to the physician.

Each individual hospital uses analysis of their own core measures as a means of evaluating performance at their own institution, and as a method of improving this performance.

Here at Shoreline Medical we analyze core measures data at our weekly keystone meetings. An example of the data we look at can be seen in the picture to the right.

The goal is to obtain a 90% rating in each core measure, as indicated by green. If the rating is less than 90%, this would be indicated as red.

The results are reported to the Joint Commission, which records this data on their website so anyone can see where each hospital stands in each area.

The Health and Human Services (HHS) has created a new website so you can check out hospital core measures. The site created is the Agency for Health Research & Quality (ahrq.gov). Another site is HHS's new site hospitalcompare.hhs.gov.

However, as I noted in this Keystone post, "It must be noted, however, that these measures must not be used as a report card to compare hospitals, rather as a tool for hospital improvement. What I mean by this is that if you consider 80-90% a B grade, and 90% or greater an A, you might actually be mislead.

"If you have a small hospital that has only admitted 10 patients with an MI over a span of a month, and a larger hospital has admitted over 100 such patients, and both hospitals forget to
properly chart two patients for whatever reason, the small hospital's stats will show 80% (a B grade) and the larger hospital will show 98% (an A grade). Yet both hospitals made the same amount of errors.

"So, again, these core measures and the percentages that go with them should not be used as a report card to compare hospitals, but as data to assist improvement."

At Shoreline, and other hospitals in Michigan, we get together in a monthly Keystone Meeting to discuss the recent core measures data, and then try to implement a systematic approach to improving our data. For example, back in 2007 there were many core measures where we were in the red, or less than 90%. Our current statistics are mostly green.

Thus, based on these core measures, we have created a a rapid response team, a sepsis protocol, an extubation protocol, a ventilator bundle, a sepsis bundle, a pneumonia bundle, an MI bundle, a heart failure bundle, a surgical bundle, among other successes that have reduced the number of patients being transported to the critical care, and obtaining nosocomial infections. This also includes a reduction in cases ventilator acquired pneumonia (VAP, other nosocomial pneumonia, and sepsis, and has likewise reduced readmission rates (post on this coming Sunday).

We have also created an array of order sets for pneumonia, CHF, sepsis, COPD, asthma, ventilator, ventilator extubation, etc.

So you can see these core measures are a good thing. The only problem I see is our hospital has incorporated all these order sets and no protocols to go with them (with the exception of the ventilator extubation protocol).

This ultimately results in a lot of overkill. For example, every sepsis patient gets ABGs, every pneumonia patient gets breathing treatments, and most patients get EKGs. While these procedures are needed for some patients admitted with said disease, they are not needed for all. Likewise, once breathing treatments are ordered, they are never discharged.

The result here is RT and RN burnout trying to get all these things done just so the hospital meets core measures, and the hospital gets reimbursed. It wrongly gives the hospital the impression of caring more for money than for patients.

The ultimate goal, however, I believe, for the government in all of this, is to use these core measures as a means of reimbursing hospitals based on performance rather than for each procedure provided to the patient. Now I'm not sure this is a good thing or not, yet that's the ultimate goal.

Actually, the ultimate goal for the government in all this is to reduce costs, so that when the new health care reform goes into effect, and if the United States eventually adapts a Federalized Healthcare Program such as exists in Britain or Canada, the cost to the government will be minimal.

So, what are the specific core measures? Here are the core measures that are being monitored today:

1. Acute Mycardial Infarction:

• Aspirin at arrival
• Aspirin prescribed at discharge
• Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
• Smoking cessation advice/counseling
• Beta blocker prescribed at discharge
• Time to percutaneous transluminal coronary angioplasty (PTCA)
• Inpatient mortality

2. Heart Failure:

• Aspirin at arrival
• Aspirin prescribed at discharge
• Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
• Smoking cessation advice/counseling
• Beta blocker prescribed at discharge
• Time to percutaneous transluminal coronary angioplasty (PTCA)
• Inpatient mortality

Community Acquired Pneumonia:

• Oxygen assessment within 24 hours of arrival
• Pneumococcal and influenza screening and/or vaccination
• Blood cultures prior to first antibiotic dose
• Smoking cessation advice/counseling
• Arrival time to first antibiotic

Surgical care improvement project: (check out this link)

• Providing a prophylactic antibiotic within 1 hour prior to surgical incision
• Providing a prophylactic antibiotic selection for surgical patients consistent with each type of surgical procedure
• Discontinuing the prophylactic antibiotic within 24 hours after the end of surgery because prolonged use of antibiotics increases the risk of Clostridium difficile infection -- a bacterium that causes diarrhea and more serious intestinal conditions such as colitis -- and the development of pathogens -microorganisms such as bacteria, viruses or parasites that can cause disease -- resistant to antibiotics
• Controlling postoperative serum glucose in cardiac surgery patients because high blood sugar weakens the immune system and increases the risk of infection
• Clipping the hair of surgery patients rather than shaving because skin abrasions increase the risk of infection
• Maintaining immediate postoperative normothermia (normal temperature) in colorectal surgery patients because increased temperatures pose a greater risk of infection, prolonged healing of wounds and longer hospital stays.

Based on these core measures, a major initiative of the Keystone Project was to improve outcomes of the critical care. It is actually the largest statewide collaborative ever: 76 hospitals, and 120 intensive care units. By this accomplishment it has also reduced costs for both the hospital and the government.

Interventions of the project include:

• Implement a unit based safety program
• Eliminate central line associated blood stream infections
• Eliminate Ventilator associated pneumonia (VAP
• Implement daily goal sheets
• Implement sepsis bundles to reduce ICU mortality from severe sepsis and septic shock

So you can see that the overall idea of core values is a good thing to improve quality of patient care and reduce costs -- if done the right way. It's also a method Medicare uses to pay hospitals, and a means of making sure doctors, nurses, RTs, x-ray techs, lab techs, and administrators are on the same page (all singing from the same hymn book) when it comes to taking care of the patient.

Again, though, the bottom line as far as a specific institution is concerned is to make sure we are doing all we need to do to ensure that we will be reimbursed. We have set up order sets so that everything that the most recent evidence shows will benefit those patients is ordered.

The pneumonia order set has bronchodilators every 6 hours. This assures that a bronchodilator is ordered by the attending physician. Now we know full well that pneumonia does not cause bronchoconstriction, yet by ordering bronchodilator treatments the physician is making certain the hospitals foremost experts on the lungs are assessing the patient every six hours during the course of the day."

Reminders are in the charts for us RTs too. Since best practice evidence shows a speedy extubation reduces ventilator acquired pneunonia, our extubation protocol encourages us to think extubation as soon as the patient is intubated. So we have laminated sheets in the chart to remind everyone who cares for the patient what this protocol is. Another laminated sheet on the chart shows a simple step-by-step algorithm to extubation.

Reminders are everywhere. Some are laminated sheets, some are signs on bulleton boards, some are on the tracker board, some are sheets of paper that print of in respective departments. Likewise, our department supervisors double check our charting to assure we are properly charting. It's the job of your boss to make sure everything is charted properly so core measures and Intensity of Service is met.

Yes, you might think your boss is hounding you at times. You may get lots of notes. Yet this is the job of your boss. His job is to make sure you are doing everything for that patient based on core measures. If core measures are not met, the hospital may not be reimbursed. So if you get the feeling your boss is paying too much attention to your charting and not enough attention to the patient, now you know that's not actually the case.

Yes, there is some overkill. Yes, there will be some needless procedures (such as bronchodilators on all pneumonia patients), yet the ultimate goal is to improve quality and reduce costs (which is the bottom line).

The neat thing about the monthly keystone meetings at Shoreline is that any time any person who cares for the patient has an idea to improve the process, or if new wisdom is learned, this gets reviewed and better clinical pathways are created.

If you're still confused about core measures, don't worry because so are the same people responsible for monitoring them.

The Keystone Collaborative: Michigan's success to be forced on other states by Obama administration

The Obama administration is apparently impressed with a health care collaborative in Michigan that has had great success in improving patient outcomes and reducing hospital costs. Now other states might be "forced" to follow in the same successful steps of this initiative.

The Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety and quality was created in March of 2003 as a 501 (c)(3) division of the MHA Health Foundation. MHA Keystone brings together hospitals, national experts and best practice evidence to improve patient safety by addressing the quality of health care delivery at the bedside.

Shoreline Medical joined the Keystone collaboration about two years ago, and has since developed a variety of order sets, protocols, bundles, and other initiatives that have worked wonders in assuring that patients are diagnosed swiftly, treated with the best practices that are scientifically based to improve outcomes for a particular diagnosis, and reduce costs to the hospital.

Here at shoreline we have a monthly Keystone meeting of a doctor from each department, nurses from each department, a pharmacist, x-ray tech, respiratory therapist, a member of the administration, and members of the billings and quality assurance team who are in charge of making sure the hospital is doing everything necessary to obtain the goals of the MHA keystone collaborative.

For Shoreline Medical, these meetings have resulted in a rapid response team, a sepsis protocol, an extubation protocol, a ventilator bundle, a sepsis bundle, a pneumonia bundle, an MI bundle, a heart failure bundle, a surgical bundle, among other successes that have reduced the number of patients being transported to the critical care, and obtaining nosocomial infections. This also includes a reduction in cases ventilator acquired pneumonia (VAP, other nosocomial pneumonia, and sepsis, and has likewise reduced readmission rates.

This committee also has created order sets that work to make sure the hospital meets all the core measures for each particular diagnosis that the Centers for Medicare/ Medicaid Services (CMS) require of them.

Core Measures are things the medical staff must do when a patient is admitted under a specific core measure set: acute mycardial infarction, heart failure, pneumonia, and surgical care. Within these four sets there are 27 core measures that are based on scientifically-researched standards of care that have been shown to result in improved clinical outcomes for patients.

The following are the core measures:

1. Acute Mycardial Infarction:

• Aspirin at arrival
• Aspirin prescribed at discharge
• Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
• Smoking cessation advice/counseling
• Beta blocker prescribed at discharge
• Time to percutaneous transluminal coronary angioplasty (PTCA)
• Inpatient mortality

2. Heart Failure:

• Aspirin at arrival
• Aspirin prescribed at discharge
• Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
• Smoking cessation advice/counseling
• Beta blocker prescribed at discharge
• Time to percutaneous transluminal coronary angioplasty (PTCA)
• Inpatient mortality

Community Acquired Pneumonia:

• Oxygen assessment within 24 hours of arrival
• Pneumococcal and influenza screening and/or vaccination
• Blood cultures prior to first antibiotic dose
• Smoking cessation advice/counseling
• Arrival time to first antibiotic

Surgical care improvement project: (check out this link)

• Providing a prophylactic antibiotic within 1 hour prior to surgical incision
• Providing a prophylactic antibiotic selection for surgical patients consistent with each type of surgical procedure
• Discontinuing the prophylactic antibiotic within 24 hours after the end of surgery because prolonged use of antibiotics increases the risk of Clostridium difficile infection -- a bacterium that causes diarrhea and more serious intestinal conditions such as colitis -- and the development of pathogens -microorganisms such as bacteria, viruses or parasites that can cause disease -- resistant to antibiotics
• Controlling postoperative serum glucose in cardiac surgery patients because high blood sugar weakens the immune system and increases the risk of infection
• Clipping the hair of surgery patients rather than shaving because skin abrasions increase the risk of infection
• Maintaining immediate postoperative normothermia (normal temperature) in colorectal surgery patients because increased temperatures pose a greater risk of infection, prolonged healing of wounds and longer hospital stays.

A major initiative of the Keystone Project was to improve outcomes of the critical care. It is actually the largest statewide collaborative ever: 76 hospitals, and 120 intensive care units. By this accomplishment it has also reduced costs for both the hospital and the government.

Interventions of the project include:

• Implement a unit based safety program
• Eliminate central line associated blood stream infections
• Eliminate Ventilator associated pneumonia (VAP
• Implement daily goal sheets
• Implement sepsis bundles to reduce ICU mortality from severe sepsis and septic shock
  

So shoreline has implemented all of the above in one form or another. We are also reminded via posters and departmental meetings that we are to remind doctors to stick to the keystone recommendations. In this way, we are all playing a part in reducing nosocomial infections.

For example,while it's not the RTs role to insert foley catheters, central lines and pulmonary artery catheters, 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," as noted on the MHA website.

Since we RTs are often at the bedside, we need to be aware of proper technique, and remind doctors and nurses when they veer off course. The reverse also holds true when it comes to proper technique with ABG technique.

On a monthly basis these core measures are then analyzed by the hospital Keystone Committee. As you can see by this chart, most of the core measures for this particular hospital have been met 90% of the time, as marked as green squares.

The red squares are areas where the core measure was not met 90% of the time, and may be an area that needs to be addressed by the hospital.

When I look at similar charts for Shoreline, I see a lot of red for the year 2007, and mostly green for 2010. This essentially shows how our hospital has improved. Another way to show improvement is a reduction in nosocomial infections, reduction in sepsis, reduction in VAP, and reduction in readmission rates. Another measure I should mention is a reduction in hospital costs.

These statistics are then organized by the Centers for Medicare/Medicaid Services (CMS) where anyone can go to see how each hospital is doing.

It must be noted, however, that these measures must not be used as a report card to compare hospitals, rather as a tool to for hospital improvement. What I mean by this is that if you consider 80-90% a B grade, and 90% or greater an A, you might actually be mislead.

If you have a small hospital that has only admitted 10 patients with an MI over a span of a month, and a larger hospital has admitted over 100 such patients, and both hospitals forget to
properly chart two patients for whatever reason, the small hospital's stats will show 80% (a B grade) and the larger hospital will show 98% (an A grade). Yet both hospitals made the same amount of errors.

So, again, these core measures and the percentages that go with them should not be used as a report card to compare hospitals, but as data to assist improvement.

The Michigan Keystone initiative, therefore, uses this data in a "collaborative" effort to improve patient outcomes and reduce costs. And obviously we've been doing a pretty good job, considering the Obama administration has so noticed the success.

Just for Shoreline alone, the Keystone Project has reduced the number of patients requiring intensive care services (the rapid response team helps with this), reduced VAP to zero cases over the past two years (the ventilator, pneumonia and sepsis bundles help with this), and significantly reduced morbidity and mortality due to sepsis.

Based on the success of the Michigan Keystone Collaborative, the Detroit Free Press, "Hospitals' aim: Cut infection deaths," by Patricia Anstett, "The Obama administration is disbursing $50 million to states to promote lessons learned here and will institute penalties by 2015 if hospitals have high infection rates."

In other words, the Obama administration's experts are going to force other states to incorporate Michigan's success. Likewise, the 10th Amendment states that "anything not covered in this here Constitution is left to the states." Therefore, I believe it's Un-Constitutional for the Fed to force states to comply to Federal Health care regulations.

I also believe that when you tell people they have to do it your way your "assuming" your way it the right way. What if someone has a better way? What if every car company back in the 1920s had to make cars a certain way because it was more efficient? Henry Ford's assembly line that changed a nation never would have come to be.

You can decide for yourself if this is a good thing or not, yet I'm always leery of when the government gets involved in medicine.

Regardless, the Keystone Process has had great success in reducing hospital infection rates and costs, and is a good model for other states to look at in developing their own programs.

New Vent protocol biproduct of teamwork

There has been a lot of discussion lately on the blogosphere about how hospitals may be more efficient if there was a more cohesive effort on the part of administrators in involving employees in the process of decision making.

I imagine our hospital is no different in this regards as compared with any other hospital, however we do provide one prime example of what good can come from more than one group of individuals coming together and making decisions to the benefit of all parties involved.

I've written before on this blog about the advantages of the Keystone committee and it's efforts to reduce the incidence of VAP while at the same time saving the hospital millions of dollars per year on wasted medical costs. It's main effort has been by getting administrators, doctors, nurses and respiratory therapists together to figure out a solution.

At Shoreline, the resulting decision was called a ventilator protocol. However, in retrospect, this protocol wasn't really a ventilator protocol, but a ventilator weaning protocol. However, since the protocol has been enacted, the number of days on a ventilator has been chopped by a large margin, and the incidence of VAP has been nearly evaporated.

To further improve the statistics, the doctor in charge of Shoreline's Keystone Committee approached my friend Jane Sage, the RT on the committee, about improving the ventilator protocol. She said that not only did she want it to be a weaning protocol, but she wanted to change the protocol so that RTs could change the rate and tidal volumes based on EtCO2 readings.

Likewise, instead of drawing ABGs every morning and with every vent change, we would now be able to make vent changes without doing the invasive ABG draw, but simply by monitoring the SpO2 and the EtCO2.

These new changes are yet to be approved, but this is a major revelation for an RT department that was protocol depleted as of just two years ago. When Mrs. Sage told me about this doctor approaching her with this new information, I wanted to run out of the hospital and pump my arm into the air shouting ululations like, "Woooo Hoooo."

This, I think, is a quintessential example of what good results can come about when many great minds are put together, as opposed to the administration and doctors getting all the privilege of decision making.

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.