by Dennis Disney, RRT-ACCS, John T Murphy, MS, RRT, and Madison Fratzke, RRT-ACCS
With modern healthcare strategic and financial challenges, the discipline of Respiratory Therapy is constantly under scrutiny and challenged to be more productive and revenue-generating while reducing expenses.
The hospitals who benefit most from respiratory care services are those who permit RT to work at the “top of their license”, working truly as physician extenders and advance practitioners.
Those who tend to benefit least are left to realize they are perhaps too restrictive with privileging RTs for advanced procedures and protocol implementation. At the May 2019 Explorer Conference in Erlanger, Kentucky, Caroline Lindemann, RRT of the Christ’s Hospital in Cincinnati, Ohio spoke to our group about ECMO. She presented the challenge that her facility was faced with when she proposed that RT could staff ECMO and save the hospital significant costs compared to Perfusionists and Nursing costs. The last time I checked, both of these disciplines earned more than the average RT. Caroline was trained at the Indiana University RT program and she knows how respiratory therapy services roll out at an academic training center like IU Medical Center and Riley Hospital for Children. Even with the high-class care delivery model there, RT’s were not routinely utilized in ECMO until relatively recently. Dennis Disney, RRT-ACCS is a Clinical Specialist at Methodist in Indy and he oversees ECMO there. He reminded me about ELSO.
The Extracorporeal Life Support Organization (ELSO) provides guidelines for ECMO programs. The ELSO recommendation is that 3 disciplines should be considered when building an ECMO program: Registered Nurses, Respiratory Therapists, and Perfusionists. Most ECMO centers use a mixture of RNs & RRTs as ECMO Clinicians – those responsible for the hourly management of ECMO. Our knowledge of hemodynamics and intricate understanding of gas exchange make us the obvious choice as Clinicians. As most (not all) ECMO patients are mechanically ventilated, understanding both how the ventilator functions and its interaction with the ECMO circuit are critical. While there is an argument to be made to limit an ECMO program to a single discipline, I passionately argue that there is a greater strength to mixing the program participants. Drawing potential Clinicians from several disciplines (RN, RRT, Perfusionist) gives the program a chance to recruit the best of multiple disciplines.
Ideally, ECMO Programs are at tertiary care hospitals. In addition to the financial concerns of maintaining an ECMO program, it takes several resources available to manage these patients due to their complexity. The expertise of the Respiratory Therapist at the referring hospital is critical to the best care of an ECMO patient. Particularly with an ARDS patient, recognition of the need for ECMO in a timely manner if crucial. As we all know, there are 3 phases to ARDS (Exudative, Proliferative and Fibrotic). For ECMO to be effective, the patient needs to be placed on ECMO during the exudative phase (first 7 days). The Respiratory Therapist can readily identify patients who are not responding to conventional treatment and begin to advocate to have the patient transferred to an ECMO center. Madison Fratzke, RRT-ACCS at Franciscan Health agreed that smaller facilities should know who and where their closest resource facilities are for quick referral when needed.