The Ottawa Hospital - Respiratory Therapy Society of Ontario

Transcription

Winter 2012
RTSO
Airwaves
www.rtso.ca
The 12th Annual Focus on Respiratory Care,
Sleep Medicine & Critical Care Nursing Conference
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www.rtso.ca
RTSO
Airwaves
Winter 2012
Dr. Mika Nonoyama’s President's Message
Hello fellow RTs
Jim McCormick, the president
of the CSRT presented her
with a lifetime membership to
the CSRT. Fortunately because
of our joint agreement with
the CSRT she also gets a
lifetime membership to the
RTSO! Stepping up to take
on the role of registrar is the
wonder-RT Kevin Taylor. He
will do a fabulous job due
to his drive to promote and
better our profession. We also
welcome a new President
of the CRTO, Carrie-Lynne
Meyer whom we will work
closely with in the upcoming
year.
Welcome to our first edition
of Airwaves for 2012. I hope
you all had a wonderful
time with family and friends
over the holiday season.
Hopefully you all have
renewed energy for 2012 to
make leaps and bounds in
respiratory therapy – make
this one of your New Year’s
resolutions! Fortunately you
have already taken the steps
to do this because you are
a member of the RTSO and
CSRT and know the benefits
of joining. Go forth and
spread the benefits of joining
to your colleagues, friends
and families!
Since our last issue, I
have noticed RTs have
been in the spotlight in
hospital newsletters and
on mainstream media. I saw RTs
featured in publications at Mt.
Sinai Hospital and Toronto East
General Hospital. Had I visited other
hospitals, I would have seen more
of the same. I was also impressed
by Melanie Deremo, the RT unsung
hero that was interviewed during
CBC radio’s “Black Coat White Art”
– great advocating! It’s inspiring
to know that RTs have stepped up,
become noticed and moving both the
profession and their personal goals
forward and to new heights.
During this past month, we also said
goodbye to Christine Robinson who
retired as the registrar of the CRTO.
She has done great work with RTs
and will be missed. We will think of
her as an honorary RT and hope she
will keep in touch with us to see how
she is doing. In recognition of this,
We at the RTSO are working
hard to bring you all sorts of
great things for the upcoming
year. Stay tuned to learn what
we are up to. Until then, have
a wonderful winter and I look
forward to talking to you as the days
get longer and the temperatures get
warmer.
Best wishes,
Mika L. Nonoyama RRT, PhD
4
RTSO Airwaves Winter 2012
Thank You
To Our Contributors
Gloria Bello, RRT
RTSO Board Members
Student Affairs Committee
Christina Dolgowicz RRT, CRE
Michener Stethescope Ceremony
Page 6
General campus- Acting Corporate Professional Practice
Coordinator (CQI)
Charge Respiratory Therapist HBU
Welcome to the Ottawa Hospital
Page 16
Angela Herd, RRT
Life (of an RRT) in a Northern Town
Page 13
Michael S. Kampen BSc, RRT
Respiratory Therapy Excellence Award at
Hamilton Health Sciences
Page 10
Andrea White Markham, RRT
Michener Stethescope Ceremony
Page 7 and cover
Kelly Muñoz, RRT
Ontario Lung Association to Government of Ontario:
Lung Health Must be Provincial Priority
Page 9
Temiskaming Hospital
Chief of Respiratory Therapy Practice
Professional Affairs, Hamilton Health Sciences
RTSO Director
Michener Institute, Instructor
Chair, Ontario Lung Association
Brooke Sobczak RRT
Home is Where the Heart Should Be
Page 23
Kevin Taylor, RRT
President, CRTO
Christine Robinson, Registrar and CEO of the
College of Respiratory Therapists of Ontario, retires
Page 11
Cary Ward, RRT RSPGT Hons. BSc.
MEd.
Spotlight on Cary Ward
Page 35
RTSO Board Member
RTSO Airwaves is a publication of
Editor - Dave McKay, RRT BAHSc (c)
Layout/Design - Elisabeth Biers
Opinions expressed in RTSO Airwaves do not necessarily represent
the views of The RTSO. Any publication of advertisements does
not constitute official endorsement of products and/or services.
and may not be copied or duplicated in full or in part
without prior permission.
5
Congratulations
the Michener Institute for Applied Health Sciences
Stethescope Ceremony
The Stethoscope Ceremony that took place
over lunch on Friday October 28, 2011 at
the Michener Institute was celebrated by the
many eager and enthusiastic members of the
second year Respiratory Therapy class. The
ceremony has been a tradition since 2003
and has become one of the most anticipated
and memorable events in the Respiratory
Therapy program at the Michener.
The students are responsible for purchasing
a stethoscope before the beginning of their
second year as they will be required to use
them for the first time when they enter the
simulation labs. The majority of the class
spends some time debating whether to get a
plain black one or that nice raspberry colour,
whether to get a Littman or not, and whether
it is worth the extra money to invest in a
Cardiology III.
The ceremony takes place over lunch in
the middle of a school day, traditionally in
October. The students come to school all
dressed up in a casual business attire, take a
few group pictures, eat lunch and socialize.
In addition, a few speakers from the school,
the College of Respiratory Therapists of
Ontario, and the Respiratory Therapy
Society of Ontario come to congratulate the
students, give a few words of advice, and
help celebrate.
A focal point of the celebration is an oath
that is recited by the students. The idea of
creating an oath was originally introduced
by Felita Kwan because her sister was going
to naturopathic college in Arizona where
they did both a stethoscope ceremony and
a white coat ceremony. She thought it was
a great idea, a rite of passage, and a great
point of celebration during the program.
Martha Williams and Felita Kwan created
the Respiratory Therapy Student Oath and
it is based on a compilation of the Yale's
physician's oath and CSRT code of ethics.
Looking around the room, it was clear that
these individuals with varying personalities
(assumed based on the array of colorful
stethoscopes) were enthusiastic about what
lies ahead for them as future Respiratory
Therapists.
At his time the RTSO would like to offer
its sincere congratulations to the Michener
Institute’s Respiratory Therapy class of 2013
and thank you for inviting us to join in your
celebration!
Contributed by;
Gloria Bello RRT
RTSO Director,
Student Affairs
Committee
Photos contributed by:
Andrea White Markham, RRT
Michener Institute Instructor
Front Cover: Students at the Michener Stethescope Ceremony
6
Congratulations
The Michener Institute for Applied Health Sciences Stethescope Ceremony
7
be a member of the
RTSO / CSRT
One Membership - Two Dynamic Associations
Now being a member has even more advantages:
• Both the RTSO and the CSRT are advocates for the profession of
Respiratory Therapy on a Provincial and National level, attesting to our
strength and integrity.
• Feel the excitement of our profession by engaging with both the
RTSO and CSRT.
• Develop your career with the regular training opportunities, provincial
and national education forums and support networks that are offered
• Receive informative newsletters and journals to keep you abreast of
new developments & trends.
• Personal Liability Insurance available at a low cost.
Take advantage of the many additional benefits the RTSO/CSRT have to offer.
www.rtso.ca / www.csrt.com
8
Ontario Lung Association to Government of Ontario:
Lung Health MUST be Provincial Priority
Lung disease is escalating in Ontario – affecting
millions of people and costing the economy billions
of dollars. Today, more than 2.4 million people in
Ontario are living with lung disease, a number that –
without changes to the province’s approach to lung
health – is expected to rise by 50 per cent over the
next 30 years to 3.6 million Ontarians.
The recently released Ontario Lung Association
report, Your Lungs, Your Life, predicts the cumulative
economic burden over the next 30 years in three
disease areas: COPD: $310 billion; asthma: $96
billion and lung cancer: $33 billion. Yet, based on this
research and additional and consultations with allied
healthcare partners, the Ontario Lung Association has
calculated that for every $1 invested in lung health
now, $3 could be saved in future healthcare costs.
This is in addition to the hundreds of thousands of
lives that would be saved by such investments.
The Ontario Lung Association is using this evidence to
urgently call upon the provincial government to make
lung health a priority and to establish a province-wide
Ontario Lung Health Action Plan.
It is clear that many people and organizations will
need to work together to improve lung health in
Ontario. The Ontario Lung Association believes a
comprehensive Ontario Lung Health Action Plan
should be built in consultation with those who are
directly and indirectly affected by lung disease. It
should be a coordinated and consolidated effort
among front-line healthcare providers, specialists,
researchers, economists, and most important, the
patients and families themselves. We also believe
government should take a leadership role and be
involved in every step of the way.
“In order to move respiratory health forward in the
province, an ongoing mechanism including dedicated
staff and funding should be created,” says George
Habib, president and CEO, Ontario Lung Association.
“This body should have a mandate to coordinate
and support the management of lung health-related
policies, programs, services and surveillance in
Ontario.”
The time for an Ontario Lung Health Action Plan
is now. An Ontario Lung Health Action Plan
can be built by expanding existing expertise and
infrastructure, with modest investments. It makes
sense for the millions of Ontarians with lung disease;
it makes sense for their families and caregivers; it
makes sense for the healthcare community; and, it
makes fiscal sense.
Your Lungs, Your Life: Insights and Solutions to Lung
Health in Ontario presents an overwhelming life and
economic burden that lung disease accounts for in
the province today, while offering a daunting 30-year
forecast if immediate action isn't taken. The report
also offers evidence-based intervention scenarios,
which, if implemented, could avert the projected
spending levels associated with the continuing
upward trend in lung disease.
The Respiratory Therapy Society of Ontario and its
members, can and must play a key role in advocating
for a better tomorrow. We have the knowledge,
expertise and commitment needed to make a
difference. Please join me in our call to action.
Visit www.on.lung.ca/actionplan to download your
copy of the report and learn what you can do to help
move lung health forward in Ontario.
Contributed by;
Kelly Muñoz, RRT
Chair, Ontario Lung
Association
9
Respiratory Therapy Excellence Award at
Hamilton Health Sciences
Brian Taylor, a respiratory therapist in the Intensive Care Unit at the
Juravinski Hospital, receives the Respiratory Therapy Excellence Award at HHS
dedication,” says Chrysti. “It is RTs like Brian that have
helped our profession become so liked and respected.”
At Hamilton Health Sciences, there are about 150
respiratory therapists working in various areas and
departments. Typically, RTs work in high-risk areas, such
as the Intensive Care Unit and Emergency Department,
caring for patients by evaluating, treating and maintaining
cardiopulmonary (heart-lung) function. In essence, RTs
help patients to keep breathing and, for that reason, they
are an invaluable member of the health care team.
His job is to help people keep breathing – a challenging
task, indeed.
But, according to his colleagues, Brian Taylor meets each
new challenge with a smile and a positive attitude. As a
result, he’s the 2011 recipient of the Respiratory Therapy
Excellence Award at Hamilton Health Sciences.
At the age of 28, Brian was laid-off from his job. Although
times were tough, he saw the silver lining in the midst of a
difficult situation: this was an opportunity to begin down a
new path.
Following his intuition, Brian researched career options
in the healthcare field. After applying and being accepted
to both nursing and respiratory therapy (RT) programs, he
made the decision to become a respiratory therapist.
“I thought it would be a good path for me,” says Brian.
That was more than 14 years ago. Today, Brian works as
an RT at the Juravinski Hospital and is being recognized
for his years of commitment and advocacy toward the RT
profession.
The RT Excellence Award acknowledges clinical,
educational, research, leadership and professional
excellence in the field of respiratory therapy. Candidates
are nominated by their colleagues, and the recipient is
determined by an internal selection committee. Brian was
nominated for the award by his colleague and fellow RT,
Chrysti Lawrence.
“Brian is a mentor to me as well as many others. I believe
he should be acknowledged for all his hard work and
“When we have opportunities to further the profession,
whether they’re through education within our institution or
externally, we take advantage,” says Brian. “We do a lot of
educational teaching to the public about who we are, and
what we do.”
Brian’s nominator, Chrysti, says that Brian’s dedication
to increasing recognition of the RT profession is
demonstrated in his enthusiasm toward new challenges
and opportunities.
“He is always excited to start new trials or support new
advancements in ventilation,” says Chrysti.
It’s clear that Brian’s determination is propelled by a
genuine interest in enhancing the quality of patient care.
“He not only shows great workmanship but fantastic
bedside care, supporting the patients and their families,”
says Chrysti.
Brian says that, for him, the daily interaction he has with
his patients and colleagues is the greatest reward.
“I like the patients, and I like the camaraderie I have with
my fellow RTs,” he says.
And, although humble, Brian appreciates the recognition.
“It’s nice to be noticed for the work that you do,” he says.
Contributed by;
Michael S. Kampen BSc, RRT
Chief of Respiratory Therapy
Practice
Professional Affairs, Hamilton
Health Sciences
RTSO Director
10
Christine Robinson, Registrar and CEO of the College
of Respiratory Therapists of Ontario, retires
In December 2011 Christine Robinson retired from her
transparency, operational alignment and
effectiveness. Her quiet confidence
position as the Registrar and Chief Executive Officer of
has been the foundation of our valuesthe College of Respiratory Therapists of Ontario (CRTO).
based
culture and, through her emphasis
This will mark the end of a 25 year career in health
on outreach, communication and
regulation, the last 12 of which have been with the
fostering relationships, she has
CRTO.
built an unprecedented degree
of trust and collaboration
Originally trained as a Chiropodist in the UK,
between the CRTO and
Christine worked as a clinician and educator
the profession
in the early years of her career at a number of
membership. She
hospitals and academic institutions across
has achieved the
Toronto and southwestern Ontario. She was
same at a national
elected to Council on the Board of Regents
level. Christine sits
Christine Robinson
formed under the Chiropody Act in 1986
as she received the RTSO President's Award
on the Executive
and originally served as both the Chair of the
of the National
Complaints Committee and as the Secretary
Association of Respiratory Therapy Regulatory Bodies
Treasurer. She assumed the position of Registrar at the
(NARTRB) where her expertise in policy, her experience
College of Chiropodists in 1992 and sat as a member
in regulation, her eloquent diplomacy, and her ability to
of the Executive Committee at the Federation of Health
Regulatory Colleges of Ontario from 1996-1997. In 1999, listen have represented a significant influence on issues
of national interest for Respiratory Therapy regulation.
Christine joined us at the CRTO as the Coordinator of
They have also resulted in her being a mentor and
Investigations and Legislation, a position which later
resource for many as the self-regulation of Respiratory
evolved into the Manager of Policy and Investigations. In
Therapy has grown across Canada.
a demonstration of the strength of character and ability
that we have come to know and appreciate so well, she
has served as the interim Registrar at the CRTO twice:
the first from December 2001-April 2002; the second
following the sudden passing of our sitting Registrar,
Gord Hyland, in 2006. During the weeks that followed,
Christine’s calm confidence and grounded leadership
eased the College through this challenging period in our
history, making her the unanimous choice of the entire
Council when selected as Registrar and CEO in May
2007.
During her tenure as Registrar, Christine has guided
the organization through the development and
implementation of two strategic planning cycles. She
has led the College to new levels of accountability,
Christine will be greatly missed by the staff, the Council
and committee members of the CRTO and the respiratory
community itself. I am certain she will be equally
missed by her peers and colleagues across the regulatory
environment. She leaves behind a legacy to be proud of
and we wish her all the best as she embarks on this next
phase in her life and all the adventures it will bring.
Sincerely,
Kevin Taylor, RRT
President, CRTO
11
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12
Life (of an R.T.) in a Northern Town
W
ell, half way through my
tea I sit and think of how to begin
my contribution to our journal.
Looking around for inspiration, I
glance out my office window into
our hospital’s courtyard
and see that the north
has yet to reveal its
full
winter blanket of
Temiskaming
snow despite the fact
Hospital
Aspiring to be a Model that my bed does have
for Rural Health Care
its favourite electric
blanket. I must confess,
I have island blood in my body and own more
than my fair share of jackets. I live in the north
and therefore I also live in arenas as a hockey
mom to two active players. In fact, I’d like to
believe that I
justly deserve
all of that
warm fashion
as my home
and work
place can be
found half way
up the map of
Ontario.
As you attempt
to visualize
the Ontario
map in your
head, I’ll accept that today most of you likely drive by
way of the GPS so maybe you cannot appreciate the vast
whiteness of the other side of the highway map because it
still remains wrongly folded in your glove box, not having
seen the light of day since its original purchase. But, if
you use your GPS, note the hours of ETA should you type
in Temiskaming Hospital’s address of 421 Shepherdson
Rd, New Liskeard, Ontario. Yes, you can drive to the King
City Tim Horton’s first but once there you will have a jaw
dropping realization that you still have over 5 hours of
driving during which you will encounter remote areas that
do not offer a quick service exit in order to refuel or empty
one’s bladder. However, once you arrive on the shores of
Lake Temiskaming and view the small village of ice huts
dotted in lucky fishing locations, you will no doubt be
ready to pull on an extra pair of socks, flatten out the hair
on your head with a toque and want to breathe in the cold
northern air until the snot in your nostrils crystallize while
you absorb the serene beauty of a northern community.
Bring a scarf, bring a thermos and bring your French/
English dictionary.
Angela Herd RRT
In the RT office (above)
At the RT office door (left)
Hospital Courtyard (below)
In a community that does have a pace much slower than
the larger cities, we still experience over capacity for our
bed counts but it is a rare occurrence for an emergency
overflow. Temiskaming Hospital is a spacious, bright one
story building that is described as a 59-bed facility that is
comprised of 40 acute beds, 11 chronic beds, 5 obstetric
13
beds and 3 special care unit beds. The Respiratory Therapy
department has had 7 locations in my 10 years of service
and it is now located within the inpatient area hallway, right
next to the chapel. Were they trying to tell me something
when they moved me here?
Respiratory Therapy is only a 15 year old profession for
Temiskaming Hospital. Like most teens, personal and
professional growth is still in its discovery phase. “You can
do that?”, “You learned that in school?” and “Having the RT
here has been a great help” are still comments from staff
and physicians as I open their eyes to the expanse of the
RT’s role and the benefit that my skill-set can offer to them.
How did I get here? What time is it? Where am I? The
alarm has gone off, the room is cold and the window is
dark. I dress in layers and head out to walk Maisy, my 6
year old retriever. I can see the stars are still shining and
my breath is puffs of mist as I head around my 15-minute
route that may be extended to 25 minutes if the temperature
seems tolerable. I can inhale without my nostrils pinching
closed; frozen with ice crystals that are offered by most of
the -25 degree mornings.
Most of my workdays start with the “get the 40+ year old
legs moving” stroll. I take in my first cup of tea while
goating over the GTA breakfast television’s road report. My
commute into work is a laughable 9-minute drive along the
shores of Lake Temiskaming. The small villages of ice huts I
take in on my commute are once again beginning to appear
on the lake. I pull into the gated lot where visitors pay a
Ice Huts
flat rate of $2 for the day. I park my SUV where the outlets
assigned to the parking spaces at the Temiskaming Hospital
are the norm and for most facilities located along Highway
11 north of North Bay. A high of – 10 means I can opt not
to plug back in and know I will have ignition leaving 8
hours later. As the only RT for our 59 bed facility, I cover
out-patient diagnostics while taking calls for any of the inhouse services that exist within our walls. I work Monday
to Friday, 0800-1600, no weekends and no shiftwork. It’s a
dream job that allows me to follow my two aspiring hockey
players and cover the household chores for a traveling
husband managing his projects from Thunder Bay to
Arnprior. You must realize that those of us in the north do
like to travel and have no problem touring between towns
on single lane highways. Tim Horton stops are few and far
between but the four lane rush hours are a thrill when we
venture back south of Orillia.
I grew up in Stoney Creek but was moved “to the other side
of the map” to Haileybury when my dad, who was with the
OPP, had our family transferred north. The city girl became
the first female hockey player in this locale and it was quite
a surprise to the boys that a girl could shoot a puck with
accuracy. My teen years remained in the north attending
the local secondary school. Oh the fun I had, until another
transfer with dad’s job to North Bay interrupted life once
again. During my last year of a second high school, it was a
co-op course that provided me with a glance at the career I
would later choose to be my own. Graduating with friends
I had made after only two years gave me the focus to push
forward.
My next step in life was a drive south to Fanshawe College’s
Respiratory Therapy program which had accepted me
fresh from high school. As dad’s job continued to move
him and mom around, I eventually caught
back up with my parents in Sault Ste. Marie
where I was hired part-time at Plummer
Memorial Hospital until a full-time position
was awarded to me in Timmins at St. Mary’s.
While there, I was one of four RT’s that
moved the hospital to its current Timmins
and District location. It was a day I will never
forget as I was proposed to after many a flow
meter was screwed into the wall as patients
arrived. And yes, of course I accepted!
Eight busy years in Timmins, with a team that
continued to grow, was filled with transports to Toronto’s
Sick Kids as these were the days prior to Ornge ventilating
on their own. Bitter cold days in the winter followed
blackflies during backyard barbeques in the summer.
14
and with the staff as I stepped in to help fill
the void as any R.T. could in emergency and
in scheduled C-Sections.
The Temiskaming Hospital Respiratory
Therapy department was only a few years
old when I first arrived and it is now a young
but firmly rooted 15 years of age. Like most
teens, unsure of whom they are and of their
full potential, I feel that growth is expected
as the voice of R.T. matures for my one
person show. Moving from the ward to the
ER, the nursery to the O.R. has provided our
physicians a taste of the power play line that
should be made available every working day.
The Shores of Haileybury
Many spirometries there revealed the occupational toll our
miners’ lungs have taken. The stories and rescues, told by
my patients, fill in the history of mining in the north.
An opportunity to enroll in the Michener’s Sleep Medicine
Technology course was then offered to me, which I
subsequently accepted and completed. Two weeks away
from a toddler was difficult, not to mention trying to stay
awake while someone was talking in great length about
sleep. While attending the course, I also discovered that I
was pregnant with our second; a first-trimester narcolepsy
was torture, reading k-complexes and sleep spindles.
Timmins was gearing up to open a sleep lab but another
transfer of jobs was in play, only this time for my husband.
As fate would have it, it landed us back in our hometown
where, as teenagers, we camped in the summer and
snowmobiled during our winters. In Timmins, I left my
friends and a team that would always be my sounding
board for R.T.-related questions but my next adventure
was about to begin in the role as the part-time respiratory
therapist at the Temiskaming Hospital.
I quickly realized that this community was not in the know
of our role in healthcare delivery. I approached getting the
word out there by volunteering with Community Living,
coaching soccer and hockey as well as initiating a park
revitalization project in our neighborhood. When those
asked where I worked and were informed that I was not a
nurse, my enthusiasm to educate slowly made its way back
to my workplace. My energy was shared within the hospital
Having a full team to care for our clients
lightens the load, improves communication
and provides expert insight to achieve
healthcare goals. I provide full pulmonary function testing
for which I have an approved Medical Directive to reorder
Spirometry. Calls to assess on the floor or in ER are sporadic
and covered between outpatient services. Trying to cover
a workload with one R.T. that is growing is somewhat
frustrating as I know I am not able to focus my skills. I feel
as if I am constantly playing short handed and when the
heck is my other player going to get out of the penalty box?
Yes I do compare my work day to my favourite sport, our
favourite sport, the one and only past time of the winter….
and for me spring, summer and fall. Hockey! I am a player
and have learned to play every position except goal. I have
to; the concept of the R.T. is still in its growing phase on
Highway 11 north. It is taking off and those of us that have
been lacing up and covering the corners and cycling the
end zone are making a difference! She shoots, she scores!
We are ahead of the game and it looks like another season
at the top of our field. I don’t just survive; I thrive in the
north, on the ice and in the hospital!
Submitted by
Angela Herd RRT
15
Welcome to the
Ottawa Hospital
Introduction
T
he Ottawa Hospital is an
academic health sciences center
which encompasses six campuses:
the General, the Civic, the Riverside, The Rehabilitation
Centre (including the Irving Greenberg Family Centre) and
the Heart Institute. The Respiratory Therapy department of
The Ottawa Hospital (TOH) provides support and services
to these multiple sites in Ottawa and the surrounding
area. With approximately 160 full-time, part-time and
casual staff, coverage is provided to all facets of in-patient
care, out-patient and emergency patients. Services
are also provided to chronically ventilated patients at
our sister facility in Ottawa, St. Vincent’s, and our RTs
act as preceptors and mentors to students from La Cite
Collegiale and Algonquin College.
Anesthesia Assistant intervened to stop a fellow anesthesia
resident from inserting a block on the wrong side. This
demonstrated our knowledge and capability of ensuring
patient safety in a teaching hospital and our value of
being at the bedside working in collaboration with other
members of the Anaesthesia Care Team.
The RTs have a dynamic role in all areas of the hospital.
For example, we are an integral member of the
interprofessional team in the intensive care unit, neonatal
intensive care unit, on the RACE team, the operating
room, hyperbaric unit and rehabilitation centre. Our RTs
are able to provide 24/7 coverage to all acute care units
and in-patient wards.
We are thankful to the RTSO for allowing us this
opportunity to show the respiratory therapists of Ontario
how our RTs are an important part of the team at one of
the largest hospitals in Canada. With writing this, let us
say: Welcome to the Respiratory Therapy Department at
the Ottawa Hospital!
Anesthesia
At TOH, there are 13 Anaesthesia Assistants that provide
care Monday to Friday. Despite limited resources, our
accomplishments have been able to show our dexterity,
knowledge, versatility and efficiency. This was certainly
evident in 2010 with our assistance of more than 1000
anesthetic cases for remote sites. At that time, we were
able to contribute by administering conscious sedation
and assisting with general anesthetics among a large
proportion of the 12,000 ophthalmology cases performed.
So far this year, we are on our way again to assist with
over 1000 anesthetic cases in remote sites. Our assistance
with the regional nerve block program has increased the
availability, efficiency and patient safety. Recently, an
Anaesthesia Assistant: Christine Belisle, RRT
In the MOR, our ability to be able to relieve anesthetists
by managing and monitoring intraoperative general
anesthetics through medical directives has enabled
anesthetists to increase their availability to offer more
services. We are presently finishing cases for anesthetists
by waking up patients while they are able to go assess
their next patient, attend to a previous patient in PACU or
able to insert a block for their next case. All this increased
flexibility for anesthetists translates into increased
efficiency, safety and less OR cancellations.
Performing pre-op assessments decreases wait time
between cases. Our involvement with a variety of
16
The Ottawa Hospital
different surgical specialties in the MOR has given us an
opportunity to master our skills such as intubation, IV or
arterial line insertion, LMA insertions, spinal insertions
and much more. With the hope of increased funding,
we will be able to offer our highly skilled professional
anesthetic assistance 24-hours a day, every day. The strong
background of RTs with critical care, ventilation, technical
training and knowledge, demonstrates why we are the
best prepared to assume this role as Anesthesia Assistants.
This is a proven point as RTs at The Ottawa Hospital Heart
Institute have been established in the COR for the last 25
years.
The Rehabilitation Centre
The RTs at this campus are involved primarily in two
programs: chronic lung disease rehabilitation and neurorespiratory rehabilitation. The chronic lung disease
rehabilitation is designed to help persons principally with
chronic obstructive lung disease increase their ability to
live independently in the community and overcome the
physical limitations resulting from their disease.
The RTs are actively involved in the comprehensive
assessment and tailoring of the rehabilitation program to
individual patient needs. Group and individual education
sessions pertaining to respiratory-improvement goals also
contribute to improved management abilities with regards
to the challenges associated with living with a chronic
lung condition.
Patients suffering from a neuromuscular disease or spinal
cord injury (SCI) who are respiratory compromised
(e.g., ALS, multiple sclerosis, post-polio and spinal
cord injury) require a variety of respiratory muscle
aids which differ from patients with chronic lung (e.g.
chronic bronchitis, emphysema) diseases. Patients with
neuromuscular diseases and SCI generally have weak
breathing and coughing muscles. Breathing is minimally
affected by daily activities until infection is present
or the disease becomes more advanced. Preventative
airway management measures initiated at an early stage
can prevent unnecessary hospital visits and emergency
admissions, while at the same time allowing the patient to
maintain independence in a home-based setting.
The Ottawa Hospital Rehabilitation Centre RTs work
within the Respiratory Services- CANVent (Canadian
Alternatives in Noninvasive Ventilation) unit. They
have championed noninvasive airway management
for this patient population since 1995. This group has
driven improvements in the care of neuromuscular
disease patients throughout Canada. Increased expertise
and patient satisfaction have resulted in international
consultation and education requests.
The most important innovative feature of Respiratory
Services - CANVent is the identification of patients at
risk of long-term ventilation early in the disease cycle.
This team provides consults and education related to
noninvasive ventilation, empowering patients and families
to choose treatment options that are most suited to their
lifestyle.
Our treatment program includes the following features:
• Pulmonary function tests designed for this patient
population
• Increase lung volume
• Increase suppleness of the lung and rib cage
• Improve cough efficiency
• Prevent infection
• Permit independence through lung hygiene
• Assess the presence of sleep disordered breathing
• Assist breathing muscles up to 24 hours a day
with mechanical aids such as bi-level devices and
home ventilators
• Provide education and strategy on how to prevent
the need for a tracheostomy
• Facilitate ventilation decision-making
• Train patients and caregivers on the use of
breathing and respiratory muscle aids
Neonatal Intensive Care Unit
General Campus
The Ottawa Hospital General Campus has a level 3
NICU that cares for babies of 23 weeks gestation and
up. The RTs play a vital role in the delivery room such as
providing the essential transitional care that babies require
when they are born.
In the NICU, RT’s play an important role in the daily
interdisciplinary rounds. They work in collaboration with
other members of the healthcare team to optimize patient
care and speed recoveries. Our facility stays up to date
with current evidence based practices and uses the latest
equipment. For example, our center recently became
one of the few in Canada to offer jet-ventilation. The RT’s
have therefore become proficient with several modes of
ventilation, effectively improving our ability to adapt to
the needs of our small patients.
The NICU staff at the General campus also work in close
partnership with other hospitals in the region. The Civic
Campus, CHEO, Queensway-Carleton, and Montfort
17
The Ottawa Hospital
Hospitals all work collaboratively with the General
Hospital to provide exceptional care for the newborn
babies and their families. As well as providing high
standards of care to patients, the General prides itself in
being a teaching hospital and continues to strive to be an
excellent learning environment for students. Respiratory
Therapists are a vital part of any Labour and Delivery unit
and NICU, their many diverse roles and highly developed
skills are a fundamental asset in an ever changing and
evolving world.
Rich Little Special Care Nursery
Civic Campus
The Rich Little Special Care Nursery at the Civic site
is a 17 bed unit, Level 2 enhanced nursery that can
accommodate up to 27 patients. The unit has a pool of
4 Drager Babylog ventilators and 5 Viasys SiPAP units
and can accommodate neonatal patients greater than 32
weeks. Infants below this threshold are stabilized and
transferred to the level 3 unit and the General Campus.
The RTs cover the unit 24 hours a day, 7 days a week.
They are called for all expectant hig- risk deliveries,
any resuscitation activities and for obstetrical
emergencies (L&D , MOR or emergency dept.). They
also have responsibilities to 4 other in-patient units as
well. The RT team is backup for intubation following
the on-duty neonatologist or paediatrician. The RTs
responsibilities include ventilation management,
surfactant administration, airway management and patient
respiratory assessment/rounds.
The neonatal team is a close knit group that facilitates the
interprofessional model of patient care and are positively
supported in professional development and skills
acquisition.
Wards – Emergency Room
Because of the vast size of TOH and large number of
medical and surgical services, the role of the RT on
wards has evolved dramatically over the past decade.
We perform most of the duties that RT’s do at many
facilities, but we have also managed to adopt many new
responsibilities which have enhanced patient care greatly
and facilitate speedy discharge.
At our facility, the RTs have taken the lead in the
tracheostomy weaning process, including performing
tracheostomy changes, downsizes and decannulations.
This has been a huge help in decreasing our patients’
time with a tracheostomy. We also take part in
multidisciplinary rounds to further aid the services in
optimizing patient care. One of the most unique services
we provide is to have chronically ventilated patients in
specific ward beds so that they are not occupying ICU
beds once they are stable. These patients may be waiting
for discharge home or to a chronic care facility. The RTs
receive extra training in many rehabilitation modalities so
that we can provide these patients with top notch care.
Intensive Care Unit
Respiratory Therapists are members of the
multidisciplinary academic programs based in
the Intensive Care Units of the Civic, General
campus and the Heart Institute of The Ottawa
Hospital. The TOH has a total of 85 funded
ICU between all three sites. The department
serves as a tertiary referral intensive care
service for hospitals and patients throughout
Eastern Ontario. Patients from Baffin Island
that are critically ill are transferred to our
Hospital. We are fortunate to work with some
of the most skilled health care professionals.
Claudia Vienneau, RRT working in the neonatal Intensive Care Unit
The function of the ICU is to provide intensive
resuscitation, treatment, and monitoring to
a wide range of patients referred from the
region and reflective of the medical and
surgical specialties of the hospital. We
continuously work with the team to assure
our patients are well ventilated within the
requirements of their respective disease
process. This is accomplished by making
18
The Ottawa Hospital
competent in using advanced techniques to make sure
we provide the best care possible. Through the use of
oscillators (6 oscillators between each campus), APRV,
trans-esophageal balloons and even the Nova-Lung, the
RTs are providing enhanced respiratory care equal to
anywhere in the world today.
Within our ICU, we have our own satellite blood gas
laboratory that is run by an RT. This ensures quick results
and efficient patient care. Early insertion of arterial lines
is done by many RTs who are certified for insertion. We
are able to provide teaching to the medical team and offer
support to residents during off hours.
Our VAP committee is co-chaired by Respiratory Therapy.
Our last 2 quarters average rate is 0.88 VAP per number
of ventilated days. In those 2 quarters, we had a total of
5,160 ventilator days between both campuses. Following
SaferhealthCare Now bundles, the RTs audits and report
these bundles to ensure compliance. This allows us to
make sure we are continuously aware of VAP initiatives
and also allows us to help educating at the bedside as
we are doing the audits. This initiative allows us to be
successful with this implementation.
Kelsey Young, RRT trying out the heated
high-flow humidity
sure that our patients are well managed by optimizing
ventilation using our mechanical ventilation protocol
and making sure we are protecting the lungs by applying
ARDSnet when appropriate. The RTs in ICU are
The department also participates in a variety of research
studies and clinical trials at both ICUs, and is very
active in critical care education. We currently actively
participate in the OSCILLATE Study, WAVE and Surfactant
study.
Critical Care Response
Team (CCRT)
In January of 2005, The Ottawa
Hospital became the first hospital
in Ontario to develop an outreach
team or RACE team. RACE stands
for Rapid Assessment of Critical
Events and focuses on early
identification and resuscitation of
patients whose general well-being
is deteriorating. The RACE Team
relies on nurses and RTs to identify
patients at risk, by monitoring vital
signs and the general well-being of
their patients.
RTs in the Intensive Care Unit (from left to right): Catherine Crichton, RRT;
Andria Darlington, RRT; Luce Gougeon, RRT; Juliana Najak, RRT; Joanne
Sigouin, RRT; Jessica Gosselin, RRT; Julie Boulianne, RRT, Charge ICU;
Sarah Goyer, RRT
An extensive educational campaign
was undertaken throughout TOH.
As well, posters and cards have
been provided to the nursing and
respiratory therapy staff throughout
the hospital with specific guidelines
outlined. These guidelines are to
19
The Ottawa Hospital
be used in assessing whether RACE should be called.
The patient’s doctors are also called at the same time,
ensuring good communication and teamwork in the care
of the patient.
Civic and General Campus. Advanced bronchoscopies
unique to TOH include interventional pulmonology
(Argon, Debulking, Stenting, EBUS, brachytherapy) and
pleuroscopy.
RACE has been well received at TOH and is now being
trialed at 22 other Ontario hospitals.
A new service that we are able to offer is a sputum
induction clinic. This clinic accepts referrals from
Respirologists and we are able to rule out the diagnosis
of tuberculosis or assess non-tuberculosis mycobacterium
(NTM) post treatment.
Pulmonary Function Laboratory
The PFT at TOH has just over 6 full-time staff working
Monday to Friday. Services provided include:
full spirometry, methacholine challenge testing,
cardiopulmonary exercise testing and high altitude
oxygen testing.
Finally, our PFT lab actively participates in ongoing
research. This includes studies on asthma and obesity,
the efficacy of respiratory medication, over-diagnosis of
asthma in obese and non-obese patients, and the benefits
of oxygen in COPD patients during exercise testing.
Non-Invasive Cardiology
Respiratory Therapists at TOH have been working in
the Non-Invasive Cardiology Laboratory (NIC) since the
1970’s. NIC initially began with RTs performing stress
testing, nuclear stress testing, Holter monitoring, and a
pacemaker Clinic. In the 1980s, adult echocardiography
was added. This was followed by neonatal echo,
transeosophageal echo and stress-echo.
The NIC provides optimal care and treatment for
patients because of the role of Respiratory Therapy.
The background knowledge and expertise of RTs are
extremely important for sonographers in cardiology. We
are the perfect discipline to be able to offer these services.
As well, the majority of RTs in the NIC are Registered
Cardiac Sonographers (ARDMS and CARDUP certified)
Pulmonary Function Lab: Caroline Tessier, RRT, CRE;
Lori-Ann Seguin, RRT, CRE; Michelle Maynard, RRT,
CRE; Joanne Cassidy, RRT, CRE; Mélodie Rancourt, SRT
The majority of the RTs who work in the PFT lab are also
Certified Respiratory Educators (CRE). They are able to
provide asthma and COPD education to emergency room
patients, out-patients from the Respirology Clinic as well
as some in-patients. Providing education to the patients
ensures that they are able to self-manage their disease,
have less emergency room visits and enjoy an improved
quality of life.
One of the unique services that we offer is the assistance
of advanced bronchoscopies. We have a full-time
RT dedicated to the bronchoscopy suite at both the
Hyperbaric Unit
A very unique service we offer at the Ottawa Hospital is
hyperbaric therapy. We have two multi-place chambers
situated at the General Campus. With 20 Respiratory
Therapists trained in hyperbaric therapy, we are able to
offer services in the two chambers, Monday to Friday.
Wound care, diabetic ulcers and post-radiation therapy
are examples of patients that we treat on a daily basis.
In this role, RTs assist in the assessment of referred
patients, through the use of T-Com: Transcutaneous
Oxygen Monitoring. RTs are also the operators of the
chamber and are responsible for the treatment and safety
of our patients.
This department is able to offer emergency after hour
dives for patients with CO poisoning, burn patients or
those with life-threatening ulcers. With all intubated
patients, we have dedicated hyperbaric attendants (RTs)
that will go into the chamber with the patient and assist
20
The Ottawa Hospital
our continued growth and evolution, increase our
revenues and decrease some of our expenditures
to standardize our capital equipment, our supplies,
our medical directives, our CRTO approved
certification programs and a good portion of our
policies and procedures throughout TOH. We
sincerely feel that our centralized organizational
structure has allowed us to make a positive
difference in the care that patients receive from
Respiratory Therapists at TOH.
Non-invasive Cardiology: (left to right) Front row: Colleen
Thivierge RT/ RDS, Chantal Lanoix RRT/RDS, Rachel Osborne
RRT/RDS, Sylvie Roy RT/RDS
Back row : Michel Lacroix RT/RDS, Brian Friel RRT/RDS, Joelle
Cyr RRT, Josee Potvin RRT, Denis Lavoie RRT/RDS, Chantale
Wilson RRT/RDS
in ventilation and full-care management while inside.
RT/AA/CPS Professional/Clinical Practice &
Operations Management
With a dedicated Director/Chief of Respiratory Therapy,
a dedicated Corporate RT Clinical Practice Coordinator
and many expert Charge-RT positions staffed solely by
Respiratory Therapists we have been able to self-direct
Despite our feelings of accomplishment, there
is still a lot of work to do and challenges to
overcome but it is great that our professional
group has the freedom to make these decisions
while ensuring interprofessional collaboration and
teamwork!
Conclusion
The Respiratory Therapy department at The Ottawa
Hospital lives by the hospital’s vision: “To provide each
patient with the world-class care, exceptional service and
compassion we would want for our loved ones”. Our
Respiratory Therapists are engaged and caring individuals.
We also advocate for our profession through volunteer
work, on our provincial regulatory body and through our
provincial and national associations. We believe that
through professional development and
educational activities, we are able to
provide the best, evidence-based care
for our patients. Interested in working
in the Nation’s Capital with a dynamic
team? The Ottawa Hospital is the
destination and the place to be!
Submitted by
Christina Dolgowicz RRT, CRE
General campus- Acting Corporate
professional Practice Coordinator (CQI)
Charge Respiratory Therapist HBU
Hyperbaric Unit (left to right) Dr. Peter Duffy (Director of HBO), Julie
Boulianne, RRT; Madeleine Lacroix, admin assistant; Rick Forget,Biomed;
Stephane Leduc, RRT; Nathalie Naggiar, RRT; Jean-Jacques Auger, Biomed;
Nathalie Duffy, RRT;
Sylvie Bourbonnais, RRT, Charge HBO
21
BC Welcomes 48th Annual CSRT Education Conferenc e
May 31 - June 2, 2012
Westin Bayshore Hotel - Vancouver
Conference Highlights
Please join us for the the only national conference for respiratory therapists!
Thursday, May 31st
All day Leadership and Educator’s Congress
1PM full Conference starts with Opening Remarks and afternoon Plenary
Welcome Cocktail Reception with appetizers
Friday, June 1st
All day Plenary Program, includes breakfast, lunch, and breaks
A night at the Vancouver Aquarium in Stanley Park (limited to 150) with appetizers and cocktails
Saturday, June 2nd
Full day of break-out sessions for each area of practice, includes breakfast, lunch, and breaks
President’s Banquet (complimentary with full conference registration)
includes reception, dinner, awards, and entertainment!
Keynote Speakers include:
Dean Hess,PhD, Harvard Medical School
Dr. Ira Cheifetz, Duke University
Michael Hewitt, RRT Tampa, Florida
Dr. Peter Papadakos, Rochester, New York
Pina Diana, RRT, McGill University, Robert Merry Lecturer
Promotions
• Register for the conference by April 30th to be entered in a draw to win a 16GB I-Pad 2
• New CSRT members who register for the conference before April 30th 2012, receive 50%
off membership (year begins April 1, 2012 – March 31, 2013). To take advantage of this
promotion,pleasecontactouroffice.
You’re bound to learn something new at the Conference and will collect professional
development credits as well. Plan on joining us for this outstanding national event that
focuses on your profession!
Visit our website for the latest updates www.csr t.com
22
When I was a student respiratory therapist, I had a
teacher try to explain the difference between empathy
and sympathy to our class during one of his lectures. His
point of view was that you can be sympathetic to your
patients but empathy can only be experienced when you
can say that you truly know how someone feels. This is
generally as a result of experiencing a similar situation.
Thinking back on that lecture and knowing what I know
now, I better understand
the difference.
As you walk life’s journey,
have you ever thought
of how you would feel
or react if you were told
that you or your loved
one has been diagnosed
with a life-altering
illness? Something like
Amyotrophic Lateral
Sclerosis (ALS). How
would you accept such
a fate knowing how
your world, as you
presently know it, would
change. Over time,
there would be a loss
Bilijana and
of independence, selfsufficiency and to some
extent a threat to your
dignity. This is a story about an inspirational man and his
devoted family who have had to face the realities of this
debilitating neuromuscular disease.
With the progression of ALS, simple limb movement
becomes impossible, assistance with ventilation
necessary, communication becomes very basic whereby
a single blink of the eye means no and two blinks
are for yes. Ultimately, a requirement of life becomes
Long Term Ventilation (LTV) and the decision to have a
tracheostomy. Being ventilated means that your bed is
in the ICU in most hospitals but an Intensive Care Unit is
not comparable to being home. When critically ill, the
ICU is where you need and want to be. However, with a
chronic, stable condition, that ICU bed is not for you and
the only want and desire you have is to remove yourself
from it. Imagine the crush to your spirit knowing that you
have a family, a beautiful wife, and children who miss you
dearly. You would want to be home with your family and
you would realize that your reason to live is for them.
Now, imagine what it would mean to you and your
family if someone offered you a way to make your
dream of being home come true. You realize that going
home won’t be like it was before you left, as so many
things have changed. Despite this, you want to believe
in possibility and
you want to take the
chance that being
home can still offer
a resemblance of the
quality of life that it
once did.
On October, 1
2008, the College of
Respiratory Therapists
of Ontario (CRTO)
received funding
for a proposal
that presented a
collaborative initiative
entitled “Optimizing
Respiratory
Therapy Services: A
Ivan Dulanovic
Continuum of Care
from Hospital to
Home. The CRTO had earlier presented this proposal
in collaboration with a number of other stakeholders
(The Toronto Central LHIN, the Central Community
Care Access Center, the Respiratory Therapy Society of
Ontario, West Park Healthcare Centre and ProResp Inc.)
to the Ontario Ministry of Health and Long Term Care.
The project’s purpose was “to produce an evidencebased, practice driven, inter-professional model of care in
order to facilitate a safe and timely transition for patients
with complex respiratory needs”. Funding was provided
through HealthForceOntario’s Optimizing Use of Health
Providers Competencies Fund. As a result of this initiative,
thirty patients were successfully transitioned from the
hospital to the community.
Not surprisingly, the project was a measurably successful
initiative. Key findings in the project were improved
23
quality of life for the patient; increased job satisfaction for
the community respiratory therapist; and opportunity cost
savings. As well, almost 94 percent of patients surveyed
responded that they were happier at home and over
81 percent advised they felt as healthy at home as they
did in the hospital. Comfort, security, safety and wellbeing at home is the result of determination, consistent
community support with the right expertise and open
lines of communication between the hospital, physician,
patient, family and the community care team.
Inherent challenges are faced in every project and this
pilot was certainly not without a few of its own. Learning
was significant but the community care team potential
shone through and the patients and their families proved
they could manage at home provided the necessary
community supports were in place. The community
RTs utilized core competencies in their role with these
ventilator supported patients and their skills and backing
enabled patients to be at home who may not otherwise
have had that opportunity. As a community RT, I can
speak to the sense of pride that making this kind of
transition happen for these LTV patients brings to me as a
healthcare professional.
difficult and Ivan had a big decision to make – fight or
give up. With two loving children and a devoted wife,
Ivan easily chose to fight.
Ivan, or “Mr. D” as we have all come to know him, was
brought home from the hospital in May of 2010. He
continues to require ventilation and nursing support 24
hours a day but despite this, he remains optimistic, with
a definite sense of humour. He has a very loving family
who provides him undying support to live with such a
burden. His wife Biljana is a school teacher and his best
friend, companion, and number one care giver. Ivan also
has a beautiful daughter who just recently graduated from
high school and is heading off to university for a degree
in Art. He also has a son who has graduated from school
and is now an engineer. Ivan’s sister, Cveta also lives with
the family and she too plays an important role in Ivan’s
care.
I recently asked Biljana how life has changed for her
and her family since Ivan has been home and how their
The project has now been finished for more than a year
and you may ask what has happened to these patients? I
am proud to say that ProResp continues to support these
patients and work with the broader community care team
to ensure these patients continue to reside in their homes.
How are the patients coping now? What struggles have
they faced since their transition home? What blessings
have they enjoyed? Working with ProResp as a full time
Respiratory Therapist, I have had the immense pleasure
of working closely with some of these patients and their
families. Here is the story of one of our patients, shared
with his and his family’s permission.
Ivan Dulanovic was one of the patients who became part
of this initiative as a result of an illness he never expected.
Ivan was an Aerospace Engineer and is very passionate
about his profession. In 2005, Ivan started to experience
neurological symptoms related to ALS. As a result of his
disease progression and loss of fine motor skills, Ivan had
to quit his job in 2007. However, Ivan, was not one to
give up and he continued to exercise regularly hoping
to stave off any further progression. In August of 2009,
after returning home from a trip to Europe, Ivan ended up
in hospital with aspiration pneumonia as a result of his
dysphagia. As well, his breathing was increasingly more
Scott Taylor RRT
24
priorities in life have changed. “Ivan is our main priority.
We try to keep up with all of our other responsibilities,
but that can sometimes be very challenging. However, we
are fortunate that it is possible for us to continue with our
activities of daily living with some adaptation, thanks to the
professional services provided to us,” she said.
Biljana’s response is so like her. She is never one to
complain and is truly thankful for the help she receives.
I interviewed the clinical coordinator for ProResp, Scott
Taylor who is very actively involved with this family and
has been since the day Ivan was discharged home. I asked
him to detail what his responsibilities are as a respiratory
therapist.
“As a community RT with ProResp my goal is to provide
a respiratory support system at home for the patient and
the family. Initially my role was to provide training and
teaching specific to the community caregiver and family.
Prior to the patient’s discharge, my general manager
Miriam Turnbull and I organized basic airway management
and mechanical ventilation training for the community
care team. We trained new staff when necessary and
provided refreshers when required. My job was to ensure
all care members felt comfortable with the care that was
necessary for each LTV case. My role has now developed
into ongoing regular assessments. Initially at the time of
discharge, my visits were daily and sometimes more than
once a day to ensure each nurse coming in for their first
shift was comfortable with Mr. D’s respiratory care. Over
time, the visits decreased to weekly and now I visit these
patients monthly. For these patients, I provide routine
trach care, trach changes, ventilator management, ongoing
respiratory assessments and trouble shooting of equipment
support. I also keep a very open line of communication
with the physicians through monthly reports.”
On a personal note, I have worked beside Scott with the
Dulanovic family for some time now. I know Scott to be
a very dedicated, hardworking and caring individual. He
goes above and beyond to help where he can. Scott says
that he is proud of ProResp’s 24 hour on-call service to
his patients. “I feel it is our responsibility to our patients
and their families to provide such a service. During on-call
hours, a respiratory therapist is first to respond to any calls
from any member of our patients’ care team,” he said.
When working so closely with a patient and their family,
special relationships often develop. Both Scott and Janelle,
one of Mr. D’s full time nurses, stated that a bond does
evolve when working with a patient like Mr. D. They both
agreed that clinical expertise is important but more so is
the strength of the personal relationship that is eventually
established which then garners mutual trust. For a family
to take on such responsibility is not only taxing physically
but also emotionally. Bilijana acknowledges that these
relationships have aided Ivan’s care and now that he is
home, he is happier because he is surrounded by his
family and friends in his natural environment. Further
and without hesitation, Biljana stated that she would
recommend this program to other families who are going
through similar situations. In her words, “Home gives a
person and their family a better quality of life”
I think it is safe to say that caring for a patient in their
home adds a dimension to care that is not experienced in
the hospital setting. Whenever the families struggle, the
community care team experiences some of that struggle
too and when they celebrate, the care team joins in. We
experience their ups and downs.
Now that this study is completed, I asked Scott what he
had learned from this experience and if it was everything
he thought it was going to be. He replied, “Definitely! My
biggest highlight was the day we brought Mr. Dulanovic
home from the hospital. When his daughter arrived home
from school that day, she ran into his room and jumped
on his bed, hugging him and cried ‘Daddy, you’re home,
I can’t believe you’re finally home!’ I then realized some
of what it means to these patients and their families to be
home.”
The outcomes and success of this project have
demonstrated uncharted possibilities. With good fortune,
this success is a first step to many more. The benefits
to patients, to families and to the caregivers have been
bountiful. Having the insight and vision to find alternatives
to care are essential in today’s healthcare environment.
Ivan’s story is evidence of what can happen when an
innovative interdisciplinary team
works together with a patientcentred approach. The future awaits!
Submitted by
Brooke Sobczak RRT
RTSO Board Director
25
ClosedSuction Systems
The Developement of
The concept for a closed suction system was the
brainchild of a respiratory therapist by the name of
Rick Radford from Seattle, Washington and dates back
to 1974. Rick’s primary concern was to find a way to
maintain oxygen therapy and keep the lungs inflated
during the suctioning procedure. He felt that if he could
achieve such a solution, he would reduce desaturation
and improve clinical outcomes for his patients, many of
whom did not tolerate open suction techniques very well.
Rick also noted that the open suction process was a time
consuming, 2 person operation when done appropriately,
as one clinician bagged the patient and the other
performed the suction procedure. Finally, he reasoned
that if he kept the system closed, he could reduce the
potential for both staff and other patients being infected
by the contaminated aerosol released when the circuit is
broken.
The original closed suction system design was very
different from what we have today. It was rather
awkward, requiring 3 hands to operate and was made
of multiple pieces that needed to be assembled for use.
After numerous attempts to find a company interested
in commercializing his product, Rick was directed to
contact Mr. Dale Ballard, a well-respected medical
innovator and pioneer in disposable medical devices. Mr.
Ballard had recently sold his company, Deseret, which
had revolutionized the IV market with the introduction
of the Angiocath (first polyurethane IV catheter) and the
OR scrub market with the EZ-Scrub (first impregnated
disposable scrub brush). Mr. Ballard and his team of
engineers transformed Rick’s raw ideas and concepts
into an easy to use, well-engineered product. In such
process, they designed a T-piece based family of products
known as the Ballard Trach Care Closed Suction System.
That was the easy part! The greater challenge came in
convincing the medical community to put away the single
use, sterile suction catheters and kits and replace them
with a closed suction system that would remain on the
patient for 24 hours. This would require a significant
practice change.
Before any new technology is adopted, you need the
support of clinicians that are willing to think outside
the box and challenge conventional ways. In Canada,
Ballard Medical was very lucky to have such support in
the mid 1980’s when facilities such as the University of
Alberta and Victoria Hospital in London became early
adopters. Each quickly understood the importance
of being able to maintain PEEP with a closed system.
Throughout most of the 1980’s, the Ballard Trach Care
Closed Suction System remained a niche product, used
on selected patients. However, the world changed with
the advent of AIDS and the introduction of “Universal
Precautions” in the late 1980’s. Now the infection
control benefits (protecting both the clinician and the
caregiver during the suctioning procedure) became as, or
more important to many customers as the physiological
benefits to the patient. As a result, throughout the early
1990’s, the Ballard Trach Care Closed Suction System
became the standard of care throughout North American
ICU’s.
As a manufacturer, the key to maintaining market
leadership is ongoing innovation and improvements
to your product. Ballard Medical recognized this and
committed the organization to continually improving its
products. The product improvements were impressive:
• First company to offer elbow and double swivel
elbow connectors to reduce torque on the ET tube,
improve patient comfort, and reduce the possibility of
inadvertent extubation.
• First company to introduce a pediatric and neonatal
version.
• Ballard patented the design of the cleaning/lavage
port and PEEP seal which remains the gold standard
and has a proven, long term record of efficacy and
has found its way into virtually all hospital VAP
reduction programs (see below for more details on the
design of the PEEP seal).
• They introduced the concept of the extended
directional tip (coude) that offers the clinician the
ability to consistently and safely direct the tip into the
left or right stem.
• They were the first company to offer their products in
shorter sizes to accommodate the unique needs of the
trach.
• They designed and patented their LOCKING, closed
thumb control port which eliminates the possibility
of accidental suctioning, reduces hand fatigue, and
allows for withdrawal of the catheter without kinking
it.
26
Closed Suction Systems
• Added a one-way valve to the cleaning port to
prevent backflow of aerosol in direction of caregiver
during cleaning/lavage
• Ballard continually upgraded the product components
(ie, the protective sleeve) as newer/stronger materials
became available.
After, Kimberly Clark acquired Ballard, the commitment
to innovation and maintaining their market leading
position continued. With the recent introduction of the
new Kim-Vent* Turbo-Clean family, Kimberly Clark now
offers a closed suction system that is recommended for 72
Above: Full View of Turbo-Cleaning
Closed Suction System Catheter
Right: Turbo-Cleaning CSS Turbulent Cleaning Chamber and
Clean Catheter Tip
hour use. The design improvements made to the KimVent* Turbo-Clean products also lead to study results that
show, after 72 hours of use, an 89% reduction in mean
catheter tip colonization compared to the current closed
suction system at 24 hours. Now customers can leave the
system on longer AND have a cleaner system due to the
unique double PEEP seal design, location of the cleaning
port, and the turbo-cleaning chamber.
The most recent introduction to the product family is
the new Kim-Vent* Multi-Access Port (MAP) System.
It is designed to allow an easy transition between a
bronchoscope or a suction procedure, all the while
keeping the system closed and the patient ventilated.
Throughout all of these innovations, Ballard and now
Kimberly Clark have always maintained focus on one
key design point. This is the placement of the irrigation
port directly above the PEEP seal, along with an enclosed
cleaning chamber to contain the cleaning fluid, tip
and eyes of the catheter. Together, these two features
ensure ALL critical components get effectively cleaned
– the tip and eyes of the catheter, the patient side of the
PEEP seal (which, if designed properly, will clear ALL
gross contaminant off the exterior of the catheter), and
interior lumen of the catheter. On all Kimberly Clark
closed suction systems, the cleaning/irrigation port
sits DIRECTLY above the PEEP seal. The reason is the
contaminant will be on the patient side of the PEEP seal
after it has been wiped off the surface of the catheter.
When you introduce cleaning solution into a Kim-Vent*
Closed Suction System device, it washes over the PEEP
seal first, before being sucked up through the tip and
eyes of the catheter. The suctioning effect is enhanced
because of the enclosed cleaning chamber that houses
the tip and eyes of the catheter. If the cleaning/irrigation
port is placed away from the PEEP seal, near the tip and
eyes of the catheter
as is the case with
some other products
available in the market,
the cleaning solution
will be pulled directly
into the tip and eye of
the catheter and will
never effectively clean
the PEEP seal. This
increases the possibility
of re-introducing
contaminants back to
the patient during the
next suctioning procedure. Since the management and
reduction of VAP’s is a critical goal within any ICU, this
feature far outweighs the importance of all others. A
poorly designed product that does not effectively clean
the PEEP seal, tip and eye of the catheter could put
the patient at risk and quickly eliminate any potential
economic savings an inferior designed product may
seemingly offer.
The other key benefit of the Kim-Vent* Closed Suction
System design is that the cleaning fluid is contained in
the chamber and is suctioned up through the tip and eye
before it can exit the chamber. If the cleaning/irrigation
port is placed directly over the tip/eye, it can overwhelm
the system’s ability to remove it and solution can end up
in the patient’s circuit (where it can saturate the HME and
restrict air flow) or down the ET tube and into the patient.
27
Closed Suction Systems
The success of this product line as the definitive market
share leader in North America is testament to the value
and importance of listening to customers’ needs and
the continuous re-investment in product improvements.
The Kim-Vent* Closed Suction System has enjoyed an
incredible evolution from 1974 to today and much of the
change is a result of customer suggestions to improve the
performance and safety of the product. These devices are
truly a product of and for our customers.
Note: All Kim-Vent* Closed Suction System products are
distributed in Canada by Canadian Hospital Specialties.
*Registered Trademarks or Trademarks of Kimberly-Clark
Worldwide, Inc.
Closeup of MAP Catheter Rotating Manifold
Attention RRT Employers
RRT’s are reading your ad on www.rtso.ca
email [email protected] for details and to place your job posting
Our rates are cost effective - our results are outstanding
28
For more Inquiries and Orders contact
Canadian Hospital Specialties
Address: 2810 Coventry Road, Oakville, ON L6H 6R1. Phone: 1.800.461.1423
29
The following articles are reprinted from Focus Journal May/June 2010 and Winter 2011 respectively with the
permission of Robert C. Miglino RRT MPS - President
FOCUS Publications & Conferences Inc. 22 South Parsonage St. Rhinebeck NY 12572
Dr. Marini, Professor of Medicine at the Univ. of Minnesota, is a
clinicianscientist whose investigative work has concentrated in the
cardiopulmonary physiology and management of acute respiratory failure.
MECHANICAL VENTILATION
SPONTANEOUS AND CONTROLLED
VENTILATION:
SUPERFICIALLY SIMILAR, INHERENTLY DIFFERENT
by John Marini MD
We often envision mechanical ventilation as providing the
motive power to accomplish the task of breathing without
the need for respiratory muscle activation. In fact, the
image most readily brought to mind is one of temporarily
replacing the natural respiratory pump with artificial
life support. For many purposes, this imagery rings true.
However, while the raw power provided by the ventilator
is more than adequate, the imitation of spontaneous
breathing is not perfect, no matter how carefully we try to
match the natural flow contours. The differences between
spontaneous ventilation and the controlled ventilation
accomplished by positive airway pressure relate both to
the average gradients of pressure developed during the
tidal cycle and to their regional distributions
across the lungs and chest wall. These differences may
be of substantial importance during acute illness. Let’s
consider four: 1) work of breathing; 2) hemodynamics;
3) ventilation/perfusion matching; and 4) Formation and
distribution of pulmonary edema.
The imitation of
spontaneous breathing
is not perfect, no
matter how carefully
we try to match the
natural flow contours
Work of breathing
With healthy lungs and
normally coordinated
respiratory muscles,
the energy expended to
accomplish ventilation
under resting conditions
is remarkably small—in the range of 1-2 percent of the
body’s total oxygen consumption. Assuming exhalation
occurs by passive elastic recoil, the two primary
components of the absolute power requirement for
inspiration are the average pressure developed across
the lungs and chest wall per liter of ventilation and the
minute ventilation demand. The inspiratory pressure need
per unit of ventilation is influenced by the resistance
and compliance
of the lungs and
chest wall, as
well as by gas
trapping, if present. For a lung with a specified set of
mechanical properties, the oxygen consumed per unit
time during spontaneous ventilation increases as an
exponential function of minute ventilation. The steepness
of this relationship as well as the magnitude of the
energy expenditure rise as the resistance of the airways
increases, due to progressive air trapping. A second
important consideration is that respiratory pump efficiency
degrades as the respiratory muscles are disadvantaged by
hyperinflation. Finally, activation of the expiratory muscles
occurs as minute ventilation increases. It should be clear,
therefore, that reducing minute ventilation demand is
a key therapeutic intervention for the patient in acute
respiratory distress due to ARDS or acutely exacerbated
airflow obstruction.
Hemodynamics
Relieving the respiratory workload by positive pressure
ventilation can make a major contribution to meeting
oxygen demand, and thereby taking strain off of a taxed
heart, reducing oxygen extraction and increasing mixed
venous and arterial blood saturations. A considerable
portion of the literature that addresses heart-lung
interactions explores the hemodynamic consequences of
initiating positive pressure ventilation. The negativity of
average pleural pressure increases in parallel with minute
ventilation and the impedance of the lungs through
which air flows. Apart from the associated reduction in
the work of breathing, using positive pressure causes a
marked upward shift in the pleural pressure that surrounds
the heart and central blood vessels. Depending on
30
SPONTANEOUS AND CONTROLLED VENTILATION: SUPERFICIALLY SIMILAR, INHERENTLY DIFFERENT
the contractile vigor and the loading conditions of the
ventricles, this rise in pleural pressure may impede venous
return and compromise preload, or improve the function
of the failing heart. The topic is too complex to delve into
here, but a quick synopsis is that the increase in pleural
pressure may improve RV function by reducing the wall
tension of the overstretched right ventricle as well as
relieve pressure on the shared septum between the right
and left ventricular chambers, improving both left sided
filling and afterload. Such effects may not be noticed if
the heart is healthy and able to easily compensate for
changing loading conditions, but may be dramatic for a
compromised heart whose adaptive capacity is limited
and whose circulating intravascular volume is reduced.
The widespread use of beta blocking drugs and diuretics
accentuates the impact of converting to positive pressure
ventilation—or vice versa with opposite effects when
ventilation is discontinued.
Ventilation/Perfusion Matching
Physiological observations made over the past four
decades have shown consistently that the distribution
of the tidal breath changes both with the intensity of
breathing effort and with the conversion to positive
pressure ventilation. At low levels of ventilation, the
accessory muscles are relatively silent, whereas the
diaphragm assumes the majority of the breathing
workload. This activity skews ventilation toward the
peri-diaphragmatic regions, where perfusion tends to be
richest. As minute ventilation rises, however, the accessory
muscles of inspiration contribute increasingly and active
exhalation begins. Distributions of regional distention
and ventilation change, therefore, with ventilatory
demand. Lung inflation with positive pressure will favor
the most flexible zones of the coupled lung and chest
wall, which under passive conditions are located ventrally.
Much has been made of the strong advantage of the
spontaneous pattern of breathing for gas exchanging
efficiency. While generally true, ample caution indicated.
First, at high levels of spontaneous ventilatory effort,
contractions of the expiratory muscles drive the respiratory
system below its resting functional residual capacity,
encouraging lung collapse that impairs gas exchanging
efficiency. Indeed, imposing controlled ventilation may be
associated with improved oxygenation due to increased
FRC, reduced shunt, and better match-up between oxygen
delivery and consumption.
Furthermore, ventilation perfusion matching influenced
not only by the ventilation gradient we have been
discussing, but also by the adaptability of the blood
vessels to redistribute flow according to the composition
of alveolar gas. Thus, the potentially adverse impact
of positive pressure ventilation on V/Q matching may
be minimal in a healthy lung. The existence of lung
pathology—which is often disproportionate in the
peri-diaphragmatic zones--may interfere with this
compensation and offset any advantage relating to a
favorable ventilation gradient. In practice, one cannot
confidently predict the direction of the alteration in gas
exchange that will occur when the ventilation pattern
is controlled. Spontaneous breathing is often—but not
always--better.
Distribution of Lung Liquids
It stands to reason that the central blood vessels would
be better filled during spontaneous ventilation, motivated
by the lower intrathoracic pressure, more favorable
conditions for venous return, and higher vascular
distending pressures. When the microvessels are leaky,
this tendency for vascular congestion may translate into
a greater tendency for pulmonary edema, especially if
cardiac output is high. Controlled ventilation generally
reduces cardiac output as well as the trans-vascular filling
pressures.
There is another important reason that controlling
ventilation may reduce lung water—one that is
infrequently appreciated. It is interstitial pressure that
surrounds the microvessels, and this unmeasured pressure
is usually assumed equivalent to the pleural pressure.
If one considers what the interstitial pressure is during
negative and positive pressure ventilation, the inescapable
conclusion is that for the same lung volume, it must
be higher under controlled conditions, even when end
expiratory alveolar pressure is the same or PEEP is not
used. An example may drive home the point: Suppose the
trans-lung (trans-pulmonary) pressure—the difference
between alveolar and pleural pressures--were the same
during inflation by negative and by positive pressure. (This
would mean that the lung has the same dimensions.).
Further, suppose that the chest wall and lung have similar
compliance and that a 17 Focus Journal May/June 2010
targeted end-inspiratory trans-pulmonary pressure (of 15
cmH2O, say) is accomplished using the respiratory
muscles alone or passively by positive pressure alone.
Assuming the former, the intrapleural pressure would be
minus 15 cm H2O, whereas during passive inflation it
would be positive 15 cmH2O (and the plateau would be
30 cmH2O). Because interstitial pressure is believed to
be similar to intrapleural pressure, the peak difference
in interstitial pressure that occurs when converting from
31
SPONTANEOUS AND CONTROLLED VENTILATION: SUPERFICIALLY SIMILAR, INHERENTLY DIFFERENT
spontaneous breathing to positive pressure ventilation
would be 30 cmH2O! The average difference in interstitial
pressure over the entire tidal cycle would be considerably
less, of course, because passive expiratory interstitial
pressures are not affected by the means by which the
lung is inflated. Nonetheless, assuming that average
microvascular capillary pressures (intra-luminal pressures)
remained similar, the implication for edema formation is
obvious—less fluid should form under positive pressure
conditions, even if PEEP and cardiac output were the
same.
The point of making this comparison between
spontaneous and positive pressure ventilation is that
important differences exist between them which may
inflict harm or confer benefit, depending on the clinical
circumstances we confront. With strong physiologic
grounding, the clinical caregiver can utilize knowledge
of these differences to improve the welfare of the patients
whose care we are committed to improve.
CLINICAL RESPIRATORY CARE
EVIDENCE-BASED MEDICINE FOR WEANING &
DISCONTINUING VENTILATORY SUPPORT
by Joe Sorbello, MS, Ed., RRT
Evidence-Based Medicine (EBM) is the conscientious,
explicit and judicious use of current best evidence in
making decisions about the care of individual patients.
The practice of EBM means combining individual clinical
expertise with the best available external clinical evidence
from systematic research. Good physicians and clinicians
use both individual clinical expertise and the best
available external evidence, and neither alone is enough.
Without clinical expertise, practice risks becoming
dominated by evidence, for even excellent external
evidence may be not applicable to or inappropriate for an
individual patient. Without current best evidence, practice
risks becoming rapidly out of date to the detriment of
patients.
EBM along with other related terms, Evidence-Based
Practice (EBP) and Evidence-Based Guidelines (EBG),
have garnered considerable attention the past few years
in many areas of medical practice including Respiratory
Care. The philosophical origins of EBM stretch back to
mid-19th century Paris and earlier. There are now frequent
seminars and books in how to practice and teach it
(Evidence-based Medicine: How to Practice and Teach
EBM. Sackett DL, Straus SE, Richardson WS, Rosenberg
W, Haynes RB. Second Ed., Churchill Livingstone:
Edinburg, 2000. Harcourt Brace & Co. Ltd., Phone
1.407.345.4000); there are Centers for and information
about Evidence-Based
Practice (www.ahcpr
gov/clinic/epc/. [The
Oxford-Centre for
Evidence-Based
Medicine); new
evidence based
practice journals are
being started; there are
websites at universities that are quickly building more
EBM data and information (http://www.cebm.utoronto
ca/). For more on EBM, EBP and EBG. An excellent article
on EBM appeared in Respiratory Care that is mandatory
reading for anyone interested in EBM (see: Montori VM,
Guyatt GH. "What is evidence-based medicine and why
should it be practiced?" Respiratory Care. 46(11):1201-14,
2001 Nov.).
Practical Application of EBM in Respiratory Care:
Ventilator Weaning
The U.S. Agency for Health Care Policy and Research
(AHCPR) initiated 2 projects in 1999 to answer the
question of EBM for weaning and discontinuation from
mechanical ventilation. In Respiratory Care the December
2001 issue of Chest showcased the work of the second
project of the AHCPR, which initially searched over
5,000 citations for several databases that culminated
32
EVIDENCE-BASED MEDICINE FOR WEANING & DISCONTINUING VENTILATORY SUPPORT
in 154 studies that were chosen for an evidencedbased report. This was comprised of a task force by the
American Association for Respiratory Care (AARC), the
American College of Chest Physicians (ACCP), and the
Society for Critical Care Medicine (SCCM). ["Evidencebased guidelines for weaning and discontinuation of
ventilatory support". Chest 2001; 120(suppl):375S-395S
with continuation of EBM to 484S] and then reprinted in
Respiratory Care 2002;47(1)Jan:69 with an accompanying
editorial by Dr. Neil MacIntyre entitled, "Bringing
Scientific Evidence to the Ventilator Weaning
Discontinuation Process: Evidence-Based Practice
Guidelines" on page 29 of the same journal. The first
report for the AHCPR was the McMaster University
Evidence-Based Review of Weaning from Mechanical
Ventilation (Criteria for Weaning from Mechanical
Ventilation. Summary, Evidence Report/Technology
Assessment: Number 23, AHRQ Publication No. 00EO28, June 2000. Agency for Healthcare Research and
Quality, Rockville, MD. (see: www.ahrq.gov/clinic
mechsumm.htm). Respiratory therapists, physicians or
nurses along with other members of the care team should
use this and other guidelines to their advantage.
Grades of Evidence
A. Scientific evidence provided by well-designed,
well conducted, controlled trials (randomized and
nonrandomized) with statistically significant results that
consistently support the guideline recommendation
B. Scientific evidence provided by observational studies
or by controlled trials with less consistent results to
support the recommendation
C. Expert opinion supported the guideline
recommendation, but scientific evidence either
provided inconsistent results or was lacking.
Recommendation 1. In patients requiring mechanical
ventilation for > 24 hours, a search for all the causes that
may be contributing to ventilator dependence should be
undertaken. This is particularly true in the patient who has
failed attempts at withdrawing the mechanical ventilator.
Reversing all possible ventilatory and nonventilatory issues
should be an integral part of the ventilator discontinuation
process. (Grade B)
Recommendation 2. Patients receiving mechanical
ventilation for respiratory failure should undergo a formal
assessment of discontinuation potential if the following
criteria are satisfied:
1. Evidence for some reversal of the underlying cause
of respiratory failure
2. Adequate oxygenation (PaO2/FIO2 > 150-200;
requiring positive end-expiratory pressure [PEEP] <
5-8 cm H2O; FIO2 < 0.4-0.5) and pH (e.g., > 7.25)
3. Hemodynamic stability as defined by the absence
of active myocardial ischemia and the absence of
clinically important hypotension (i.e., a condition
requiring no vasopressor therapy or therapy with
only low-dose vasopressors such as dopamine or
dobutamine < 5 micrograms/kg/min)
4. The capability to initiate an inspiratory effort
The decision to use these criteria must be individualized.
Some patients not satisfying all of the above the
criteria (e.g., patients with chronic hypoxemia below
the thresholds cited) may be ready for attempts at
discontinuation of mechanical ventilation. (Grade B)
Recommendation 3. Formal discontinuation assessments
for patients receiving mechanical ventilation for
respiratory failure should be performed during
spontaneous breathing rather than while the patient is still
receiving substantial ventilatory support. An initial brief
period of spontaneous breathing can be used to assess
the capability of continuing onto a formal spontaneous
breathing trial (SBT). The criteria with which to assess
patient tolerance during SBTs are the respiratory pattern,
adequacy of gas exchange, hemodynamic stability, and
subjective comfort. The tolerance of SBTs lasting 30 to 120
min should prompt consideration for permanent ventilator
discontinuation. (Grade A)
Recommendation 4. The removal of the artificial airway
from a patient who has successfully been discontinued
from ventilatory support should be based on assessments
of airway patency and the ability of the patient to protect
the airway. (Grade C)
ventilation for respiratory failure who fail an SBT should
have the cause for the failed SBT determined. Once
reversible causes for failure are corrected, and if the
patient still meets the criteria listed in Table 3 of the
original guideline document, subsequent SBTs should be
performed every 24 h. (Grade A)
ventilation for respiratory failure who fail an SBT should
receive a stable, nonfatiguing, comfortable form of
ventilatory support. (Grade B)
33
EVIDENCE-BASED MEDICINE FOR WEANING & DISCONTINUING VENTILATORY SUPPORT
Recommendation 7. Anesthesia/sedation strategies and
ventilator management aimed at early extubation should
be used in postsurgical patients. (Grade A)
Recommendation 8.Weaning/discontinuation protocols
designed for nonphysician health care professionals should
be developed and implemented by intensive care units
(ICUs). Protocols aimed at optimizing sedation should also
be developed and implemented. (Grade A)
Recommendation 9. Tracheotomy should be considered
after an initial period of stabilization on the ventilator
when it becomes apparent that the patient will require
prolonged ventilator assistance. Tracheotomy should then
be performed when the patient appears likely to gain one
or more of the benefits ascribed to the procedure. Patients
who may derive particular benefit from early tracheotomy
are the following:
• Those requiring high levels of sedation to tolerate
translaryngeal tubes
• Those with marginal respiratory mechanics (often
manifested as tachypnea) in whom a tracheostomy tube
having lower resistance might reduce the risk of muscle
overload
• Those who may derive psychological benefit from
the ability to eat orally, communicate by articulated
speech, and experience enhanced mobility
• Those in whom enhanced mobility may assist physical
therapy efforts
(Grade B)
irreversible disease (e.g., high spinal cord injury or
advanced amyotrophic lateral sclerosis), a patient requiring
prolonged mechanical ventilatory support for respiratory
failure should not be considered permanently ventilatordependent until 3 months of weaning attempts have failed.
(Grade B)
Recommendation 11. Critical-care practitioners should
familiarize themselves with facilities in their communities,
or units in hospitals, that specialize in managing patients
who require prolonged dependence on mechanical
ventilation. Such familiarization should include reviewing
published peerreviewed data from those units, if available.
When medically stable for transfer, patients who have
failed ventilator discontinuation attempts in the intensive
care unit should be transferred to those facilities that
have demonstrated success and safety in accomplishing
ventilator discontinuation. (Grade C)
Recommendation 12. Weaning strategy in the prolonged
mechanical ventilation (PMV) patient should be
slow-paced and should include gradually lengthening
selfbreathing trials. (Grade C)
My question as a practitioner and educator has always
been: How will clinicians use the most available evidence
and guidelines for more efficacious patient care? The
advent of the popularity of EBM and the instant availability
of the evidence through computer technology and search
capabilities via search engines and electronic databases
almost makes it too easy to access the needed information.
Will clinicians use these resources? Only time will tell.
Recommendation 10. Unless there is evidence for clearly
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34
Cary Ward,
Spotlight on:
RRT RSPGT Hons. BSc. MEd.
Respiratory Therapy (Technology) has been a passion
for me for the last 35 years. I have seen the field
develop from a technology/ therapy profession
with the RT doing nebulizer treatments, incentive
spirometry on the floor, putting together CPAP
units that bubbled with underwater CPAP levels,
homemade SIMV for the MA1 ventilator and ABG
machines that needed constant attention and
calibration to what we
have today. Ventilating
a neonate in Sudbury
when I graduated
in 1978 was with a
Cavitron ventilator
with time-cycledpressure-limited mode
only. There were
no transcutaneous
probes, capnography
or not even oximetry.
We used our clinical
judgment for settings
and adjusted
parameters from the
values obtained from
capillary blood gases.
The profession and
our importance on the
health care team are
now well recognized by the health care team.
After graduating from the University of Guelph, I
wanted some sort of career in medicine. A good
neighbor that was a nursing supervisor brought home
information on Respiratory Technology. I applied
to the Toronto Institute of Medical Technology
(Michener Institute) and graduated in 1978. At that
time RT’s were not well known outside large urban
hospitals. Of our class of 40 graduating students,
only three of us had jobs after graduation. I was
hired by Susan Groulx in Sudbury where there were
3 RT’s in 3 hospitals. Now Health Sciences North
(previously known as Sudbury Regional Hospital)
and the associated home care companies have over
50 RT’s on staff. In the early days at the hospital
we would always be told to “teach the nurses” how
to operate ventilators. As time passed, we became
more recognized for our expertise and the number
of full time positions expanded. Our role also
expanded into sleep diagnostics, the OR, the DR/
NICU, stress testing and Swan-Ganz monitoring. At
one time our hospital even had a home care oxygen
program. We began to take TIMT respiratory therapy
students which were replaced by Canadore College
students in 1993. My
interest was in teaching both
respiratory therapy students
and health care providers. I
also was interested in sleep
diagnostics and obtained my
Registered Polysomographic
Technologist certificate.
The professional membership
in the RTSO in the early
eighties was on the decline.
No one at that time wanted
to become a member as
there were only about 150
members. The North did not
even have a chapter president
so I volunteered. The
President (Shane Donaldson)
and the rest of the Board of
Directors (BOD) decided to
make the RT profession more visible. BOD meetings
were held at Shane’s house with the BOD sleeping
on couches and on the floor in sleeping bags. The
Ministry of Health at that time was reviewing the
professions that needed regulation. The profession
applied and became recognized in the RHPA. The
RTSO membership increased to over 900. The RTSO
would hold 3 day professional education events
each year in different regions. As president of the
Northern Chapter for three different terms, I was the
coordinator for two of the events in 1987 and 1991.
I became a council member of the CRTO in 1994.
At this time, the CRTO was busy with the formation
of committees, policies and procedures. There were
many challenges especially with credentialing.
Although I sat on the BOD, my many objections to
abandoning the CBRC test were overruled by many
35
Spotlight on:
Cary Ward, RRT RSPGT Hons. BSc. MEd.
of the other board members.
A position became available at Canadore College
for teaching in 1999. I loved being at the bedside
but also loved teaching. I accepted the position
but stayed on part-time basis at the hospital to stay
up-to-date with my knowledge and skills. I still get
the adrenalin rush and satisfaction of being able to
supply respiratory care to critically ill patients. Being
driven to excel at teaching, I obtained my Master of
Education degree from the University of Nipissing in
2006. Having a passion for Respiratory Therapy and
education, I applied and accepted a position on the
BOD of the CSRT as Director of Education in 2006.
Education of the students has also evolved especially
in the last few years as more provinces have became
legislated with the formation of their own College
of Respiratory Therapy. The students graduating
now must have the knowledge, skill and attitudes of
an ever expanding number of competencies. The
schools, professors and hospital RT’s also face the
challenges of developing these competencies and
promoting the profession to the new graduates.
Teaching with the great staff here at Canadore College
has brought me great pleasure. Seeing the students
develop their knowledge and critical thinking
skills as demonstrated through reflective learning
in their journals gives me the satisfaction of having
contributed to their learning.
My outside interests when I am not working at the
hospital include motorcycling with my VStrom
and BMW F650GS motorcycles, camping and
backpacking. However, despite 33 years having
passed since first graduating, my passion for
respiratory therapy and teaching still remains strong.
Our profession, although better known to the public,
is still in its infancy. Fortunately, many of the students
that are coming out of RT programs today now display
the same passion and enthusiasm as I do and that will
most certainly carry our profession to new heights.
RRT Career Search
Looking for that perfect
career?
Adult
You just may find it at
www.rtso.ca
Pediatric
Preterm
Laerdal Silicone Resuscitators
McArthur Medical Sales Inc.
1846 5th Concession West • Rockton, ON L0R 1X0
T+ 800.996.6674 / 519.622.4030
F+ 519.622.1142
www.mcarthurmedical.com
www.laerdal.ca
[email protected]
Employers are looking for
your excellent skills and
work ethics. They know they
will find you through the
RTSO web site.
©2011 Laerdal Medical. All rights reserved. #11-11210
36
Ask aRTee
Dear aRTee,
Recently, our Intensivists having been asking our
staff to report the Oxygenation Index (OI) during
rounds each morning. I am familiar with the P/F
Index but I am not as familiar with the OI Index.
Can you please shed a brighter light on this?
Thanks,
Indexed Out
Dear Indexed Out,
Many Intensivists today are starting to ask for
the Oxygenation Index of patients who are
mechanically ventilated. This equation is similar to
the P/F Index which equals PaO2/FiO2 but offers
better representation of a patient who is ventilated
because it takes the mean airway pressure into
consideration.
As you are likely aware, the P/F Index has also
been widely used for patients receiving mechanical
ventilation for some time. The result of this
calculation has been used to offer classification of
the severity of lung disease by grouping patients
into an Acute Lung Injury (ALI) category (P/F <
300) or the more severe Acute Respiratory Distress
Syndrome (ARDS) category (P/F < 200). As well,
the calculation can also offer information regarding
responses to changes in ventilator support.
The problem with the Pao2/Fio2 is that it does
not account for the functional status of the lung,
primarily any changes that may occur as a result of
changes in PEEP and/or auto-PEEP that may then
affect end-expiratory lung volume (El-Khatib &
Jamaleddine. 2004). However, PEEP is not the only
factor that may affect end-expiratory lung volumes,
using the mean airway pressure
(mPaw) takes each of them into
consideration.
According to El-Khatib and Jamaleddine (2004), the
mPaw incorporates the effect of PEEP, the effect of
inspiratory and expiratory times as well as the effect
of tidal volume and/or peak inspiratory pressure
depending on the mode of mechanical ventilation.
These variables are all important in contributing to
the lung volumes and thus the lung oxygenation
function and will therefore be a superior reflection
of the gas exchange status and lung function when
patients are receiving mechanical ventilation.
Therefore the Oxygenation Index calculation =
FiO2 x mPaw (cmH2O)
PaO2 (mmHg)
An OI of 30 or greater categorizes a patient as
having refractory hypoxemic respiratory failure.
As well, it may represent a failure of conventional
ventilation and a need for advanced modalities like
APRV or HFO.
For example, if a patient with a PaO2 of 60 was
receiving an FiO2 of 90% and the mean airway
pressure of the ventilator was 22 cmH2O, the OI
would calculate out to be 33. This result would be
reflective of severe refractory hypoxemia.
Reference:
El-Khatib, M.F., & Jamaleddine, G.W. (2004). A new
oxygenation index for reflecting intrapulmonary
shunting in patients undergoing open-heart surgery.
Chest, 125(2), 592-596.
Submit your questions to [email protected]
37
Board of Directors Profiles
The RTSO Executive and Board of Directors have specific mandates that serve as guidelines for leading your
association. This provides you, our members, with a strong, focused leadership. In order to provide a better
understanding of the actions of the Board, we are providing you with the following profiles.
RTSO Executive and Board of Directors:
The RTSO executive’s main goals are to continue to work collaboratively with and develop strong relationships with
our key stakeholders (CRTO, MOHLTC, CSRT, ORCS and RT education programs and institutions) enabling us to
advocate for the profession and its practice in Ontario. We continue to develop new programs and revenue streams
with a vision to create a full-time professional advocacy program including a dedicated budgeted staff position in the
front office. It is our hope that this will, in the future, provide our profession consistent advocacy with all levels of
local and provincial healthcare in Ontario.
Research Committee:
The RTSO research committee is headed up by Dilshad Moosa, Nancy Garvey and Mika Nonoyama. Together, they
have developed a strategic plan including a vision and mission statement. The proposed framework includes 1)
Training and Education; 2) Research Funding; 3) Knowledge Dissemination & Translation; 4) Peer Review; and 5)
Mentorship.
Examples include bringing poster presentations to the RTSO Forum; creating a web page (on the RTSO main site)
with information about research and; networking researchers of varied experience. We will engage members of the
RTSO who are interested in contributing to this framework.
Student Committee:
The student committee was developed to support our future generation of Respiratory Therapists. They will do this
by entering the students’ classrooms and giving them the opportunity understand what to expect as they transition
into the working world of a Graduate Respiratory Therapist and eventually to a Registered Respiratory Therapist. We
believe it is important to support the students and provide them with the knowledge that they have a professional
association that is available to them. The students of today are out Respiratory Therapists of tomorrow.
RTSO Airwaves:
Airwaves has recently developed a partnership with Bob Miglino, the publisher and editor of the FOCUS journal
for Respiratory Care and Sleep Medicine in the United States. FOCUS is an outstanding journal and this partnership
will allow Airwaves the opportunity to share articles with you that have been written by some of the most renowned
researchers and authors within our profession and across the world. We are extremely grateful to Bob and his staff
for their support.
As well, we continue to be very busy bringing you an insight into the people, the places and the products that affect
the practice of Respiratory Therapy in Ontario. We encourage everyone to write to us with your questions, stories
and triumphs because Airwaves is all about us.
38
Board of Directors Profiles
Education Committee:
This year, we have moved the location of our fall forum to the Oakville Conference Centre and expanded the
education program to a full 2 day education event scheduled for Tuesday October 16th and Wednesday October
17th. Inspire 2012 will include leadership meetings and plenary sessions, scientific programs and poster
presentations, and competencies building and skills based workshops.
This new venue will allow us to bring the whole conference together in one location. We feel this new venue and
schedule will enhance access to our vendors, increase social networking with all of our colleagues and provide easy
access to hotel accommodations with the Holiday Inn linked through a tunnel to the conference facility.
The education committee is also organizing local events across the province offering afternoon and evening
education sessions and technical workshops. This exciting new program will serve as a platform for our members to
learn about new and emerging technologies and respiratory care products, and current evidence based practices and
therapeutics relevant to our practice. This is also part of our strategic plan to retain and recruit new members into the
RTSO/CSRT joint membership program highlighting the importance and value of association membership through
continuing education programming and enhanced vendor-therapists networking.
Website Committee:
The RTSO website along with Airwaves has become a complex network of communication to allow RRTs and key
stakeholders to learn about relevant practice topics, job opportunities, professional advocacy issues, upcoming
respiratory therapy education events, on-line resource information and respiratory care related internet links. The
website also includes direct links and updates from other associations, organizations and special alerts from key
stakeholders that impact our practice in Ontario.
Corporate Partnership Committee:
Our corporate programs serve as strategic networking and communications tools between our corporate community
and the front line practicing therapists and RT leadership. Through our quarterly journal (the RTSO Airwaves), RTSO
website (www.rtso.ca), CME programs, and our extensive practice networks including our membership database and
special interest groups, we have the tools to ensure that each and every RRT in the province of Ontario is always “in
the know” and “on the cutting edge” of applied technology and advanced respiratory therapeutics as its developed
and introduced into practice by our colleagues and corporate community. A new program we are introducing
this year is the first annual RTSO Golf Classic. The intent of this program is to bring our corporate and practicing
communities together to raise money for continuing education and an appointed charity by the RTSO and the
sponsor and for a day of networking and fun. So keep your ears to the ground for details regarding the annual RTSO
Golf Classic.
Summary:
Today, the RTSO continues on its path to be what it once was. A valued membership desired by every Respiratory
Therapist practicing in Ontario. The 2012 RTSO Board of Directors is filled with passionate and enthusiastic
Respiratory Therapists who are volunteering their time for the benefit of every RRT in the province. You can be part
of the energy and growth of the RTSO and our profession through volunteerism on one of the RTSO committees or
simply through association membership. Help ensure we have a credible voice, help ensure we are respected, and
help ensure our future! Maintain your RTSO/CSRT membership and encourage others to join!
39
The Loss of a Friend and Colleague
David Jose
It is with a deep sadness and an incredible sense of loss that the RTSO
must announce the passing of another colleague. David Jose lost a
courageous and heroic 7-month battle with glioblastoma multiforme
on January 8. 2012. After graduating from the Michener Institute for
Applied Health Sciences in 1992, David began his career in KitchenerWaterloo followed by tenure at the Scarborough Hospital where he
eventually became the RT site leader at the Grace Division and most
recently at Lakeridge Health in Oshawa and Bowmanville as a valued
staff member.
David was an individual who could make light of any situation with
his dry, perceptive British wit and humour. His robust nature and jovial
approach to life was often envy to many. He only saw the good in
people and believed that every person that crossed his path was of the
same accord.
David also possessed an innate awareness of the well-being of others,
whether it was for the patients that he cared for, the people that he
worked with or those of us who were blessed and fortunate to say that
he was our friend. He genuinely cared about those he knew and those
he didn’t know and he utilized the gifts of his personality to make a
difference in the lives of those he knew for a lifetime and those he just
met.
David readily accepted the challenge that his illness offered and
would never once question why not another. He did this because he
could not bear to place that burden upon someone else’s shoulders.
This is a testament of who he was and as such the world has lost a
devoted husband, a loving father, a learned healthcare practitioner,
a resourceful coach and a remarkable friend. It has lost an incredible
human being that could offer light and warmth to the shadows and
bleakness that life sometimes offers.
The RTSO would like to offer its sincere condolences to David’s wife
Karen, his daughter Elizabeth, his mother Ann and the rest of his
immediate and extended family. He will be truly missed and never
forgotten.
160-2 County Court Blvd, Suite 440
Brampton, ON L6W 4V1
Tel: 647-729-2717/Fax: 647-729-2715
Toll Free: 1-855-297-3089
E-Mail: [email protected]
www.rtso.ca
The RTSO office address is now
160-2 County Court Blvd
Suite 440
Phone: 647-729-2717
Fax: 647-729-2725
Toll Free: 1-855-297-2089
Email: [email protected]
www.rtso.ca
Laerdal Suction Unit
McArthur Medical Sales Inc.
1846 5th Concession West • Rockton, ON L0R 1X0
T+ 800.996.6674 / 519.622.4030
F+ 519.622.1142
www.mcarthurmedical.com
www.laerdal.ca
[email protected]
©2011 Laerdal Medical. All rights reserved. #11-11209
40
An RRT Perspective
As we put the final touches on this issue of the RTSO Airwaves, I
had hoped that someone other than me would be writing this piece.
I often get concerned that people tire of reading my ramblings but
unfortunately due to the whirlwind of preparations for the holiday
season, as well as work and family life requirements, those who
I had lined up to fill this piece were unable to do so. Be what it
may, you are stuck reading my prophet or pathetic (your opinion is
inserted here) narrative for another issue.
The problem is, when I sit down, I am often fumbling for something
to write about. Most of the time, I hope when I begin to write that
I can convey some type of message that stirs something within
people and causes them to become engaged but that can be a very
difficult thing to do. The topic is another challenge but one that has
come up recently in conversations with my oldest son who has just
entered into the workforce and with others, is that of the workplace
bully. In fact, what stemmed this conversation between my son
and I was the result of a recent article in our local community
newspaper in which the writer spoke openly about his personal
experiences with all types of bullying. We’ve all experienced them
and we’ve all found different solutions to them.
My first experiences were with the typical schoolyard bully who,
for whatever reason, had a penchant to target me. For the most
part, I was always able to talk my way out of suffering any physical
harm but on one occasion I was completely blindsided. In the
fourth grade, I was riding my bike past this sixth grade tyrant when
suddenly he grabbed my handlebars causing me to take flight for
what seemed like an eternity until the April-soaked sod cradled my
landing. Before I was able to take bearing of my surroundings, he
was on top of me using some preconceived story of how I looked
at him as a justification for his actions. Fortunately for me, my older
brother had witnessed the events and he quickly came to my aid
and promptly as well as permanently took care of the situation.
While I appreciated his efforts, I often regretted not being able to
take care of it myself.
I am sure all of us have similar stories. As a teenager, I remember
being bullied by a soccer mom as I refereed a game between her
child’s team and the team I was coaching. I was 17 and these were
7 and 8 year-old kids. The referee had not shown up for the game
and because there was no other volunteer, I ended up as the referee
so that the kids could play the game. Despite my efforts, I was
constantly being verbally criticized by this one particular mother
with each call that I made. In the final minutes of the first half, I
grew weary of the abuse and blew the whistle to stop the play. I
then proceeded to walk directly in front of the culprit and took
the whistle from around my neck and held it in front of her. I can
only imagine what was going through her mind as it dangled in
front of her, swaying back and forth in the cool August breeze. She
said nothing. Instead, she quickly gathered up her belongings and
marched back to her car where she stayed for the rest of the game
as the rest of the parents gave me a resounding round of applause. I
stood up to her and it is a moment I will never forget.
Unfortunately, the work-place bully is something more difficult
to deal with. Their behaviour is often cited as an aspect of their
personality which then permits acceptance. Bullies usually target
highly dependable people, dedicated employees or innovators who
often have non-confrontational personalities. In fact, they choose
their targets, timing, locations, and approach wisely and carefully.
Bullies can possess very intimidating or outspoken personalities.
They are often filled with negative attitudes that offer malicious
comments to anything positive but they can also be the individual
that would be least expected. These individuals are perceived as
charmers and will use covert or soft techniques that employ subtle
comments, criticisms, rumours and innuendos to accomplish
their tasks. They often offer justification to their commentary as a
form of humour that has been misinterpreted. In extreme cases,
these individuals will blatantly attempt to sabotage the efforts and
accomplishments of another generally under the guise of anonymity
or the cover of the night.
Typically, workplace bullies are cowards filled with their own
insecurities and lack of self-worth but to them, their actions offer
some semblance of fulfillment. They have psychological issues and
they utilize the bullying tactics to cover up their own weaknesses
or combat life-long issues that they do not have the strength or
capacity to face. But should this justify their actions? Should this
behaviour be tolerated because it has been accepted as the norm
for this individual?
Workplace bullying is a costly consequence to any organization.
It reduces morale, employee retention as well as productivity and
efficiency. It threatens the general health of the workplace and the
culture of the environment. In healthcare, there is no place for this
sort of behaviour. Often the workplace bully is attempting to draw
attention to their self, but healthcare is not about them, it is first and
foremost about the patient. This must not be forgotten!
If you feel bullied, seek the help and support of your employer.
Talk to your supervisor, your union steward, your human resources
representative or someone in your occupational health department.
As a result of Bill 168, most organizations now have policies in
place to protect employees from workplace bullying and horizontal
violence or harassment and it should be managed similar to any
other occupational health and safety hazard. Bullying can lead not
only to mental and emotional duress and distress but it can also be
causation to physical health-impairing consequences. Speak to your
family and/or co-workers and take the courageous steps to curtail
these assaults before they do harm to you. As well, the Ontario
Safety Association for Community and Healthcare has a handbook
called “Bullying in the Workplace”. This is a great resource and
can be found online via http://www.osach.ca/products/resrcdoc/
rvioe528.pdf.
Unfortunately, the greatest asset the workplace bully possesses is
the silence of others. Silence occurs because others justify it as
a normal behaviour or they do not want to get involved or even
worse they feel that they will be subjected to the same abuse. But
remember this, silence grants permission and on the other end of
that abuse there is someone who is not deserved of this offensive
behaviour any more than you are.
Dave McKay, RRT
Editor - RTSO Airwaves
The RTSO Airwaves journal would like to invite any member the opportunity to use this space as a way to express their insight, opinion,
thoughts or experiences. Please send your contribution to the journal to [email protected]. Anonymous contributions cannot be included.
41
160-2 County Court Blvd, Suite 440
Tel: 647-729-2717/Fax: 647-729-2715
Toll Free: 1-855-297-3089
www.rtso.ca
Reflect a Positive Image
Professional
Maturity
Respect
Collaboration
Advocacy
Bring Your Best to Your Practice
Join the RTSO
Bonus: Your membership Fee now
Includes Membership in the CSRT
42
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The Ottawa Hospital - Respiratory Therapy Society of Ontario

Transcription

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