Patient characteristics and predictors of completion of a pulmonary rehabilitation programme in Auckland, New Zealand

AIM

Chronic respiratory diseases, such as chronic obstructive pulmonary disease, are a worldwide public health problem. Pulmonary rehabilitation is a gold-standard intervention for these diseases, yet attendance and completion rates are poor. Counties Manukau Health, in Auckland, New Zealand, has a high prevalence of chronic respiratory disease and a culturally diverse population, comprising large numbers of Māori and Pacific Island people, who are known to be disproportionately affected by chronic respiratory disease. The aim of this study was to investigate patient characteristics affecting engagement with the Counties Manukau Health pulmonary rehabilitation programme and identify factors predicting completion of the programme.

METHODS

Investigators performed a retrospective analysis using routinely collected data of 2,756 patients invited to attend the pulmonary rehabilitation programme at Counties Manukau Health. Data were analysed to compare demographic and clinical outcomes of patients who completed, did not complete or did not attend the programme, and identified factors predicting completion.

RESULTS

Significant differences were found between groups in demographic and clinical characteristics. Increasing age, higher six-minute walk test distance at programme commencement and European ethnicity were significant predictors of completion of the PR programme.

CONCLUSIONS

Compared to European people, Māori were 52% less likely and Pacific Island people were 40% less likely to complete the programme. These findings are significant for the Counties Manukau Health population. Further work needs to focus on determining how to make programmes more engaging to different cultures and how we can aim to reduce health inequities in these populations.

Characteristic of COVID-19 infection in pediatric patients: early findings from two Italian Pediatric Research Networks

Detailed data on clinical presentations and outcomes of children with COVID-19 in Europe are still lacking. In this descriptive study, we report on 130 children with confirmed COVID-19 diagnosed by 28 centers (mostly hospitals), in 10 regions in Italy, during the first months of the pandemic. Among these, 67 (51.5%) had a relative with COVID-19 while 34 (26.2%) had comorbidities, with the most frequent being respiratory, cardiac, or neuromuscular chronic diseases. Overall, 98 (75.4%) had an asymptomatic or mild disease, 11 (8.5%) had moderate disease, 11 (8.5%) had a severe disease, and 9 (6.9%) had a critical presentation with infants below 6 months having significantly increased risk of critical disease severity (OR 5.6, 95% CI 1.3 to 29.1). Seventy-five (57.7%) children were hospitalized, 15 (11.5%) needed some respiratory support, and nine (6.9%) were treated in an intensive care unit. All recovered.Conclusion:This descriptive case series of children with COVID-19, mostly encompassing of cases enrolled at hospital level, suggest that COVID-19 may have a non-negligible rate of severe presentations in selected pediatric populations with a relatively high rates of comorbidities. More studies are needed to further understand the presentation and outcomes of children with COVID-19 in children with special needs. What is Known: • There is limited evidence on the clinical presentation and outcomes of children with COVID-19 in Europe, and almost no evidence on characteristics and risk factors of severe cases. What is New: • Among a case series of 130 children, mostly diagnosed at hospital level, and with a relatively high rate (26.2%) of comorbidities, about three-quarter had an asymptomatic or mild disease. • However, 57.7% were hospitalized, 11.5% needed some respiratory support, and 6.9% were treated in an intensive care unit.

Practice pattern of aerosol therapy among patients undergoing mechanical ventilation in mainland China: A web-based survey involving 447 hospitals

BACKGROUND AND OBJECTIVE

Aerosol therapies are widely used for mechanically ventilated patients. However, the practice pattern of aerosol therapy in mainland China remains unknown. This study aimed to determine the current practice of aerosol therapy in mainland China.

METHODS

A web-based survey was conducted by the China Union of Respiratory Care (CURC) from August 2018 to January 2019. The survey was disseminated via Email or WeChat to members of CURC. A questionnaire comprising 16 questions related to hospital information and 12 questions related to the practice of aerosol therapy. Latent class analysis was employed to identify the distinct classes of aerosol therapy practice.

MAIN RESULTS

A total of 693 valid questionnaires were returned by respiratory care practitioners from 447 hospitals. Most of the practitioners used aerosol therapy for both invasive mechanical ventilation (90.8%) and non-invasive mechanical ventilation (91.3%). Practitioners from tertiary care centers were more likely to use aerosol therapy compared with those from non-tertiary care centers (91.9% vs. 85.4%, respectively; p = 0.035). The most commonly used drugs for aerosol therapy were bronchodilators (64.8%) followed by mucolytic agents (44.2%), topical corticosteroids (43.4%) and antibiotics (16.5%). The ultrasonic nebulizer (48.3%) was the most commonly used followed by the jet nebulizer (39.2%), the metered dose inhaler (15.4%) and the vibrating mesh nebulizer (14.6%). Six latent classes were identified via latent class analysis. Class 1 was characterized by the aggressive use of aerosol therapy without a standard protocol, while class 3 was characterized by the absence of aerosol therapy.

CONCLUSIONS

Substantial heterogeneity among institutions with regard to the use of aerosol therapy was noted. The implementation of aerosol therapy during mechanical ventilation was inconsistent in light of recent practice guidelines. Additional efforts by the CURC to improve the implementation of aerosol therapy in mainland China are warranted.

Race Effects of Inhaled Nitric Oxide in Preterm Infants: An Individual Participant Data Meta-Analysis

OBJECTIVE

To assess whether inhaled nitric oxide (iNO) improves survival without bronchopulmonary dysplasia (BPD) for preterm African American infants.

STUDY DESIGN

An individual participant data meta-analysis was conducted, including 3 randomized, placebo-controlled trials that enrolled infants born at  <34 weeks of gestation receiving respiratory support, had at least 15% (or a minimum of 10 infants in each trial arm) of African American race, and used a starting iNO of >5  parts per million with the intention to treat for 7 days minimum. The primary outcome was a composite of death or BPD. Secondary outcomes included death before discharge, postnatal steroid use, gross pulmonary air leak, pulmonary hemorrhage, measures of respiratory support, and duration of hospital stay.

RESULTS

Compared with other races, African American infants had a significant reduction in the composite outcome of death or BPD with iNO treatment: 49% treated vs 63% controls (relative risk, 0.77; 95% CI, 0.65-0.91; P = .003; interaction P = .016). There were no differences between racial groups for death. There was also a significant difference between races (interaction P = .023) of iNO treatment for BPD in survivors, with the greatest effect in African American infants (P = .005). There was no difference between racial groups in the use of postnatal steroids, pulmonary air leak, pulmonary hemorrhage, or other measures of respiratory support.

CONCLUSION

iNO therapy should be considered for preterm African American infants at high risk for BPD. iNO to prevent BPD in African Americans may represent an example of a racially customized therapy for infants.

The recording and characteristics of pulmonary rehabilitation in patients with COPD using The Health Information Network (THIN) primary care database

Pulmonary rehabilitation is recommended for patients with COPD to improve physical function, breathlessness and quality of life. Using The Health Information Network (THIN) primary care database in UK, we compared the demographic and clinical parameters of patients with COPD in relation to coding of pulmonary rehabilitation, and to investigate whether there is a survival benefit from pulmonary rehabilitation. We identified patients with COPD, diagnosed from 2004 and extracted information on demographics, pulmonary rehabilitation and clinical parameters using the relevant Read codes. Thirty six thousand one hundred and eighty nine patients diagnosed with COPD were included with a mean (SD) age of 67 (11) years, 53% were male and only 9.8% had a code related to either being assessed, referred, or completing pulmonary rehabilitation ever. Younger age at diagnosis, better socioeconomic status, worse dyspnoea score, current smoking, and higher comorbidities level are more likely to have a record of pulmonary rehabilitation. Of those with a recorded MRC of 3 or worse, only 2057 (21%) had a code of pulmonary rehabilitation. Survival analysis revealed that patients with coding for pulmonary rehabilitation were 22% (95% CI 0.69-0.88) less likely to die than those who had no coding. In UK THIN records, a substantial proportion of eligible patients with COPD have not had a coded pulmonary rehabilitation record. Survival was improved in those with PR record but coding for other COPD treatments were also better in this group. GP practices need to improve the coding for PR to highlight any unmet need locally.

CHRONIC LUNG DISEASE

ROLLING OUT THE REHAB: Analysis of recent UK data suggests that more patients with chronic lung disease could benefit from lung rehabilitation programmes. During pulmonary rehabilitation (PR), patients with chronic obstructive pulmonary disease (COPD) work with specialists to learn exercises and optimise breathing techniques. The programmes are recommended under current guidelines, particularly for patients with a high breathlessness score. Despite this, when Charlotte Bolton and co-workers at the University of Nottingham analysed 36,189 patient primary care records gathered since 2004, they found only 9.8% of COPD patients had ever had a coded record of being assessed, referred for, or undertaken PR. Those patients who completed PR were 22% less likely to die that those who didn't, although appeared they had also received better overall COPD care. Current smokers, those suffering from co-morbidities and younger patients were more likely to receive PR than other patient groups.

Current care services provided for patients with COPD in the Eastern province in Saudi Arabia: a descriptive study

BACKGROUND

COPD is a leading cause of morbidity and mortality worldwide. The prevalence rate of COPD in the general Saudi population is estimated to be 2.4% and 14.2% among smokers. Not much is known about current health care services for patients with COPD in Saudi Arabia. The objective of this study was to determine the current care services for patients with COPD provided by government hospitals in the Eastern province of Saudi Arabia.

METHODS

A cross-sectional study was conducted in the Eastern province of Saudi Arabia. Directors of the Department of Internal Medicine from all 22 general government hospitals that are under the responsibility of the Ministry of Health or the Ministry of Higher Education in this region were asked to participate. Data were collected using a questionnaire.

RESULTS

The study results indicated that there are limited hospital facilities for patients with COPD: no respiratory departments in any of the included hospitals, no spirometry in 77.3% of the hospitals, no intensive care units in 63.7% of the hospitals, and no pulmonary rehabilitation program in any of the hospitals. Among the included 22 hospitals, 24 respiratory physicians, 29 respiratory therapists, and three physiotherapists were involved in COPD care.

CONCLUSION

In conclusion, current care services provided by government hospitals in the Eastern province of Saudi Arabia for patients with COPD do not meet international recommendations for COPD management. Increased awareness, knowledge, and implementation of COPD guidelines by health care providers will most probably improve COPD management in Saudi Arabia. In addition, the government could improve dissemination of information about COPD management through national programs and by offering specific education regarding respiratory diseases.

Usual Care Physiotherapy During Acute Hospitalization in Subjects Admitted to the ICU: An Observational Cohort Study

BACKGROUND

Physiotherapists play an important role in the provision of multidisciplinary team-based care in the ICU. No studies have reported usual care respiratory management or usual care on the wards following ICU discharge by these providers. This study aimed to investigate usual care physiotherapy for ICU subjects during acute hospitalization.

METHODS

One hundred subjects were recruited for an observational study from a tertiary Australian ICU. The frequency and type of documented physiotherapist assessment and treatment were extracted retrospectively from medical records.

RESULTS

The sample had median (interquartile range) APACHE II score of 17 (13-21) and was mostly male with a median (interquartile range) age of 61 (49-73) y. Physiotherapists reviewed 94% of subjects in the ICU (median of 5 [3-9] occasions, median stay of 4.3 [3-7] d) and 89% of subjects in acute wards (median of 6 [2-12] occasions, median stay of 13.3 [6-28] d). Positioning, ventilator lung hyperinflation, and suctioning were the most frequently performed respiratory care activities in the ICU. The time from ICU admission until ambulation from the bed with a physiotherapist had a median of 5 (3-8) d. The average ambulation distance per treatment had a median of 0 (0-60) m in the ICU and 44 (8-78) m in the acute wards. Adverse event rates were 3.5% in the ICU and 1.8% on the wards.

CONCLUSIONS

Subjects received a higher frequency of physiotherapy in the ICU than on acute wards. Consensus is required to ensure consistency in data collection internationally to facilitate comparison of outcomes.

[[Effect of erythropoietin and its combination with hypoxic altitude chamber training on the clinical and functional manifestations of chronic glomerulonephritis]

AIM

To evaluate the efficiency of treatment for renal anemia in patients with chronic glomerulonephritis (CGN), by using erythropoietin and its combination with hypoxic altitude chamber training (HACT).

SUBJECTS AND METHODS

Sixty-three patients (41 men and 22 women) (mean age 37.1 ± 3.3 years) with CGN during the predialysis phase of chronic kidney disease (CKD) complicated by anemia. Hemoglobin (Hb), packed cell volume (PCV), and red blood cell indices (mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC)), platelet count, serum iron, fibrinogen, C-reactive protein (CRP) and creatinine levels were determined in all the patients at baseline and during a prospective follow-up. Glomerular filtration rate (GFR) was measured using with the Rehberg-Tareev test. Along with standard renal protective therapy, all the patients received either epoetin beta (n=31; Group 1) or its combination with HACT (n=32; Group 2). In Group 1 patients (n=31), erythropoietin (EPO) was given in an initial dose of 20-50 IU/kg thrice daily, followed by the dose being adjusted until the target Hb level was reached. Group 2 patients (n=32) received HACT cycles by the standard procedure in combination with EPO given in lower doses (20-50 IU/kg once weekly). A prospective .follow-up of the patients was carried out during one year.

RESULTS

Following one year, the number of patients who had achieved the target Hb level was 74.1% in Group 1 and 87.5% in Group 2. Over time, there were increases in the concentration of Hb (from 108.6 ± 19.4 to 124.5 ± 14.09 g/l; p<0.05), PCV, and red blood cell indices (MCV, MCHC) in the patients receiving EPO (Group 1). Besides an'anti-anemic effect, there was a significant decrease in the concentrations of fibrinogen from 6655 (4884-7634) to 3776 (3330-4884) mg/dL; (p<0.05), serum creatinine from 159 (89--261) to 138 (79-258) pmol/I (p<0,05), proteinuria from 2.955 (1.024-6.745) to 2.069 (0.539-4.279) (p<0.05), which was accompanied by an increase in GFR from 62.3 (37.0 - 107.4) to 76.9 (46.0-96.0) mi/min (p<0.05). In Group 2, the rise in the concentration of Hb (from 114.1 ± 11.7 to 132.0 ± 16.5 g/I (p<0.05), PCV, MCV, and MCHC proved to be more pronounced than that in Group 1 (p<0.05) and accompanied by an elevation in the counts of platelets (from 222.7 ± 19.8.10(9)/1 to 249.3 ± 21.9.10(9)/1 (p<0:05)) and red blood cells (from 4.0 ± 0.4-10(12)/1 to 4.34 ± 0.3 X 10(12)/I (p<0.05)). There was a more marked reduction in the degree of proteinuria from 3.092 (0.764-7.694) g at baseline to 1.600 (0.677-4.078) g one year later (p<0.05) than that in Group 1 (p<0.05). The increase in GFR from 60.1 (46.0-96.0) to 79.4 (44.0-120.0) ml/min (p<0.05) and the fall in the concentration of fibrinogen from 5555 (4884-7770) to 4107 (3776-5328) mg/dL (p<0.05) and serum creatinine from 166 (92-273) to 147 (92-152) μmol/L (p<0.05), which were observed in Group 2, were comparable to those in Group 1.

CONCLUSION

Epoetin beta used in patients with CGN has an anti-anemic effect and leads to improved renal nitrogen-excretory function. Erythropoietin in combination with HACT used in CGN provides a higher anti-anemic efficacy and a more pronounced antiproteinuric effect.

Usefulness of lung-to-head ratio and intrapulmonary arterial Doppler in predicting neonatal morbidity in fetuses with congenital diaphragmatic hernia treated with fetoscopic tracheal occlusion

OBJECTIVE

To explore the potential value of intrapulmonary artery Doppler velocimetry in predicting neonatal morbidity in fetuses with left-sided congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO).

METHODS

Observed/expected lung-to-head ratio (O/E-LHR), and intrapulmonary Doppler pulsatility index and peak early-diastolic reversed flow were evaluated within 24 h before FETO in a consecutive cohort of 51 fetuses with left-sided CDH at between 24 and 33 weeks' gestation. Lung Doppler parameters were converted into Z-scores and defined as abnormal if the pulsatility index had a Z-score of > 1.0 or the peak early-diastolic reversed flow had a Z-score of > 3.5. The association of O/E-LHR and Doppler velocimetry with neonatal outcome was assessed using multiple linear or logistic regression analysis adjusted for gestational age at birth.

RESULTS

Among the 26 fetuses that survived, 18 (69.2%) had normal and eight (30.8%) had abnormal Doppler values. O/E-LHR was not associated with neonatal morbidity in surviving fetuses. Compared with the group with normal Doppler parameters, cases with abnormal intrapulmonary Doppler were associated with a significant increase in the duration of mechanical ventilation (average increase of 21.2 (95% CI, 9.99-32.5) days; P < 0.01), conventional ventilation (15.2 (95% CI, 7.43-23.0) days; P < 0.01), high-frequency ventilation (6.34 (95% CI, 0.69-11.99) days; P < 0.05), nitric oxide therapy (5.73 (95% CI, 0.60-10.9) days; P < 0.05), oxygen support (36.5 (95% CI, 16.3-56.7) days; P < 0.01), parenteral nutrition (19.1 (95% CI, 7.53-30.7) days; P < 0.01) and stay in neonatal intensive care unit (42.7 (95% CI, 22.9-62.6) days; P < 0.001), and with significantly higher rates of high-frequency ventilation (87.5 vs. 44.4%;P < 0.05), oxygen requirement at 28 days of age (75.0 vs. 11.1%; P < 0.01), gastroesophageal reflux (62.5 vs. 22.2%; P < 0.05) and tube feeding at discharge (37.5 vs. 5.56%; P < 0.05).

CONCLUSION

As previously reported, O/E-LHR did not predict neonatal morbidity. In contrast, intrapulmonary artery Doppler evaluation was predictive of neonatal morbidity in CDH fetuses treated with FETO.

Which chronic obstructive pulmonary disease care recommendations have low implementation and why? A pilot study

BACKGROUND

Clinical care components for people with COPD are recommended in guidelines if high-level evidence exists. However, there are gaps in their implementation, and factors which act as barriers or facilitators to their uptake are not well described. The aim of this pilot study was to explore implementation of key high-evidence COPD guideline recommendations in patients admitted to hospital with a disease exacerbation, to inform the development of a larger observational study.

METHODS

This study recruited consecutive COPD patients admitted to a tertiary hospital. Patient demographic, disease and admission characteristics were recorded. Information about implementation of target guideline recommendations (smoking cessation, pulmonary rehabilitation referral, influenza vaccination, medication use and long-term oxygen use if hypoxaemic) was gained from medical records and patient interviews. Interviews with hospital-based doctors examined their perspectives on recommendation implementation.

RESULTS

Fifteen patients (aged 76(9) years, FEV1%pred 58(15), mean(SD)) and nine doctors participated. Referral to pulmonary rehabilitation (5/15 patients) was underutilised by comparison with other high-evidence recommendations. Low awareness of pulmonary rehabilitation was a key barrier for patients and doctors. Other barriers for patients were access difficulties, low perceived health benefits, and co-morbidities. Doctors reported they tended to refer patients with severe disease and frequent hospital attendance, a finding supported by the quantitative data.

CONCLUSIONS

This study provides justification for a larger observational study to test the hypothesis that pulmonary rehabilitation referral is low in suitable COPD patients, and closer investigation of the reasons for this evidence-practice gap.

Controlled and uncontrolled allergic asthma in routine respiratory specialist care - a clinical-epidemiological study in Germany

BACKGROUND

Studies in the last decade showed high rates of poorly treated and poorly controlled asthma in the community. Extending these findings we describe the more recent situation in specialist respiratory care as the most frequent source of treatment provision using comprehensive clinical and patient assessments and exploring predictors for poor control.

METHODS

This is a German cross-sectional, clinical epidemiological study in a nationally representative stratified treatment prevalence sample of N = 572 outpatients diagnosed with allergic asthma (AA; females 58.2%, aged 47.5 ± 16.3 (16-81 years). Treating physicians completed standardized clinical assessments (lung function, laboratory, clinical findings, severity, illness and treatment history, asthma control [GINA]), supplemented by patients' self-report measures (EQ5-D, AQLQ, ACT) and mental health module (CIDI-SF).

RESULTS

A total of 65.4% of patients were rated (GINA) as controlled, 30.3% partially controlled, and 4.4% uncontrolled; the patient-rated ACT showed lower rates of control (19.9% controlled, 44.2% partial, 35.8% uncontrolled, kappa: 0.2). Consistent with findings of clinical measures, controlled asthma was highest among patients with pre-treatment stage I severity (83.6%) and decreased by pre-treatment severity (stage IV patients: 29.3%). Poorer control was associated with pre-treatment severity, nocturnal attacks, diminished adherence and comorbid anxiety/depression. Patients received complex multiple drug and non-drug interventions, largely consistent with guidelines. Degree of asthma control was associated with improved and even normalized quality of life findings.

CONCLUSION

In this representative sample of longterm treated AA patients in specialist respiratory care we find better control rates and better adherence to guidelines as previous studies. Despite remarkable differences in clinician- vs patient-rated control ratings even the initially most severe stage IV patients (12.9% of patients) showed remarkable control rates and close to normal quality of life. Intensified treatment (e.g. omalizumab) was associated with improved control. Poorer control was associated with higher initial severity, diminished adherence, comorbid anxiety/depression and old age.

LIMITATION

Findings apply to AA patients in respiratory specialist care sector which is likely to treat the more severely affected patients. Thus, findings cannot be generalized to the general population, other treatment settings or asthma types.

Minimal inspiratory flow from dry powder inhalers according to a biphasic model of pressure vs. flow relationship

Inhalation therapy using the dry powder inhaler (DPI) is now the first choice for obstructive pulmonary diseases. We previously measured relationships between inspiratory pressure (PI) and flow rate of almost all of the DPIs available in Japan, and described an importance of inspiratory efforts. In the present study, we further analyzed the data obtained in the previous study. Although there were linear relationships between PI and flow2, the slope became steeper when PI was less than a certain value (critical PI, existed between 15-20 cmH2O). When PI was less than critical PI, linear rather than parabolic regression between PI and flow yielded better fits (r > 0.90, p < 0.001). Inspiratory flows at the critical PI were 53.9 (Diskus), 65.8 (Diskhaler), 45.9 (Turbuhaler for Pulmincort), 48.6 (Turbuhaler for Symbicort) and 38.0 l/min (Twisthaler). These findings suggested that flow through the DPI becomes laminar rather than turbulent flow in the range below critical PIs. We suggest that patients should inhale from the DPIs with inspiratory pressure higher than critical PI.

A survey of respiratory and sleep services in New Zealand undertaken by the Thoracic Society of Australia and New Zealand (TSANZ)

AIMS

In 2004, the NZ Branch of the TSANZ published "Standards for Adult Respiratory and Sleep Services" on the Ministry of Health's (MoH) website.1 The aim of this survey was to evaluate each of the 21 District Health Boards' (DHBs) performance against the published standards, concentrating particularly on staffing, infrastructure, clinical support services, implementation of guidelines, quality assurance activity, and basic services (sleep, lung function, and oxygen).

METHODS

Postal questionnaire survey of all DHBs in late 2006.

RESULTS

All 21 DHBs responded. Only 10 of 21 DHBs were complying with the minimum standards of care. Main deficiencies in care related to: inadequate medical staffing rates, lack of quality assurance measures and insufficient laboratory testing (sleep and lung function). The lack of monitoring of such basic activities as outpatient clinic attendances, oxygen and sleep services, and the non implementation of treatment guidelines were of particular concern. Seven-fold variations in prescription of assisted ventilation equipment and oxygen therapy exist across the country.

CONCLUSIONS

When evaluated against minimum standards of care published in 2004, major gaps in service provision exist in New Zealand. Access to services is variable. There is a lack of national leadership and insufficient regional organisation leading to large gaps in service provision of even basic respiratory services. Immediate changes to the current service provision structures are required.

Physicians' intentions and use of three patient decision aids

Background

Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them.

Methods

We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid.

Results

Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians (<60%) felt the decision aid would improve the quality of patient visits or be easily implemented into practice and very few (27%) felt that the decision aid would save time. Physicians' intentions to use the decision aid were related to their comfort with offering it to patients, the decision aid topic, and the perceived ease of implementing it into practice. While 54% of the surveyed physicians indicated they would use the decision aid, less than a third followed through with this intention.

Conclusion

Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.

[Cardio-thoracic intensive therapy--status]

Cardio-thoracic intensive care units primarily receive patients for recovery following cardio-thoracic surgery. Approximately 70% of the patients belong to this category. 18% are patients who are admitted or readmitted directly. Transplantations, pulmonary endarterectomy, congenital heart diseases and therapeutic hypothermia patients are a small group (12%) but make up a large part of the activity because of their extended length of stay. The use of ventricular assist devices and extracorporeal membrane oxygenation are both important in the future management of cardio-ventilatory recovery.

Pulmonary rehabilitation: analysis of a clinical service

BACKGROUND AND PURPOSE

There is significant research supporting the role of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD). However, less is known about real-life clinical rehabilitation services. Data were analysed from a clinical pulmonary rehabilitation service provided in the UK, consisting of seven weeks' twice-weekly training and education.

METHOD

A retrospective study. Baseline measures consisted of activity of daily living, mood state, spirometry, exercise tolerance using the Incremental Shuttle Walk Test (ISWT) and health status using the St George's Hospital Respiratory Questionnaire (SGRQ). Responders to pulmonary rehabilitation were defined as those with a mean reduction of four points on the SGRQ and a mean increase of 48 metres on the ISWT.

RESULTS

One hundred and eight patients entered the programme and 91 completed it. All outcomes showed statistically and clinically significant change after the rehabilitation programme. Responder analysis showed that 37% of patients achieved benefits for both the SGRQ and the ISWT. Twenty-eight per cent of patients were non-responders for both; 17% benefited for the SGRO only and 14% improved their exercise tolerance. Patients with restrictive disease (n = 11) showed large mean ISWT score of 98.2 m (Standard deviation (SD) 69.4 m) (p < 0.01), as did patients with moderate COPD (n = 30), who scored a mean ISWT change of 77.3 m (SD 92.0 m) (p < 0.01) and a SGRQ score of -7.6 (SD 13.7) (p < 0.01), and those with mild COPD (n = 12), who scored a mean ISWT change of 62.5 m (SD 87.4 m) (p < 0.01) and a mean SGRQ change of -3. 7 (SD 8.1) (p < 0.01). Patients with severe COPD (n = 23) showed a smaller mean change in ISWT of 32.6 m (SD 79.4 m) and in SGRQ of -2.8 (SD 7.1). However, analysis of variance (ANOVA) showed no statistical differences between the groups (p = 0.13).

CONCLUSIONS

Clinical pulmonary rehabilitation programmes are effective for most patients. However for patients with more severe impairment, maximal gains may be harder, or take longer, to achieve. Patients with restrictive disease appear to do well, although future trials will be needed to test this supposition.

An assessment of the appropriateness of respiratory care delivered at a 450-bed acute care Veterans affairs hospital

INTRODUCTION

Respiratory care is expensive and time-intensive, inappropriate care wastes resources, and failure to provide necessary and appropriate respiratory care may adversely affect patient outcomes.

OBJECTIVE

To determine the appropriateness of basic respiratory care delivered at a 450-bed Veterans Affairs hospital during a 3-month interval.

METHODS

We determined (1) the percentage of delivered respiratory care that was not indicated (based on standardized clinical practice guidelines), (2) the percentage of respiratory care that was indicated but not ordered (based on standardized clinical practice guidelines), and (3) the labor cost and potential savings of protocol-based respiratory care at our hospital. We selected 5 assessment days, occurring at 2-week intervals. All patients who received basic respiratory care underwent a complete respiratory care assessment, including medical records review, patient interview, physical assessment, and measurement of blood oxygen saturation (via pulse oximetry) and inspiratory capacity. Intensive care patients were excluded from the study. The assessment instrument provided a standardized format based on American Association for Respiratory Care clinical practice guidelines.

RESULTS

We assessed 75 patients. A mean of 24.8% of the delivered respiratory therapies reviewed were not indicated. The percentages of ordered but not indicated therapies were: oxygen 17.7%; all categories of aerosolized medications (bronchodilators, mucolytics, anti-inflammatory agents) 32.4%; chest physiotherapy 37.5%; lung expansion therapy 7.7%. A mean of 11.8% of the patients assessed were not receiving respiratory care that was indicated. The percentages of indicated but not ordered therapies were: oxygen 5.3%; bronchodilator 5.3%; lung expansion therapy 36%.

CONCLUSION

A mean of 24.8% of the basic respiratory care procedures delivered were not indicated and 11.8% of patients were not receiving care that was indicated. Inappropriate utilization of respiratory care services may increase costs and adversely affect morbidity, mortality, and duration of stay. We believe that implementation of respiratory care assessment protocols based on nationally accepted clinical practice guidelines can reduce unnecessary care, optimize care delivered, and may reduce costs and improve outcomes.

Evidence for a link between mortality in acute COPD and hospital type and resources

BACKGROUND

The 1997 BTS/RCP national audit of acute care of chronic obstructive pulmonary disease (COPD) found wide variations in mortality between hospitals which were only partially explained by known audit indicators of outcome. It was hypothesised that some of the unexplained variation may result from differences in hospital type, organisation and resources. This pilot study examined the hypothesis as a factor to be included in a future national audit programme.

METHODS

Thirty hospitals in England and Wales were randomly selected by geographical region and hospital type (teaching, large district general hospital (DGH), small DGH). Data on process and outcome of care (death and length of stay) were collected retrospectively at 90 days on all prospectively identified COPD admissions over an 8 week period. Each centre completed a questionnaire relating to organisation and resources available for the care of COPD patients.

RESULTS

Eleven teaching hospitals, nine large DGHs, and 10 small DGHs provided data on 1274 cases. Mortality was high (14%) with wide variation between centres (IQR 9-19%). Small DGHs had a higher mortality (17.5%) than teaching hospitals (11.9%) and large DGHs (11.2%). When corrected for confounding factors, an excess of deaths in small DGHs was still observed (OR 1.56 (CI 1.04 to 2.35)) v teaching hospitals. Analysis of resource and organisational factors suggested higher mortality was associated with fewer doctors (OR 1.5) and with fewer patients being under the care of a specialist physician (OR 1.8). Small DGHs had fewest resources.

CONCLUSION

Significant differences in mortality may exist between hospital types. The findings justify further study in a proposed national audit.

Patient participation in decision-making on the introduction of home respiratory care: who does not participate?

OBJECTIVES

In this study we examined home respiratory patients' participation in decision-making on whether to begin home respiratory care therapy, and this participation in decision-making during the latest visit to the clinic.

SUBJECTS AND METHODS

The target population consisted of patients who were using home respiratory care devices and who were visiting the outpatient clinics. Postal questionnaires were sent to 4159 patients (40% of respiratory care device users in Finland). A total of 3336 answered (response rate 80%) and 3153 were eligible for analysis. Odds ratios, chi-square tests, Mann-Whitney U-test and stepwise logistic regression analysis were used in the data analyses.

RESULTS

Patients who did not participate in decision-making were more frequently older people, women and had lower income than the other patients. While these results parallel those of previous studies, in contrast we found more women with high education to be non-participants. Non-participants were not participating in decision-making during their latest visit to the clinic in spite of the fact that they considered participation almost as important as did the other patients. Non-participants were less satisfied with the quality of care given and felt that their life had improved less than did the other patients.

CONCLUSION

The ethical principle of equal opportunities to participate in care decisions was not applied among home respiratory care patients in this study. The results challenge health-care professionals to notice inequalities and improve their practices. The results can be generalized to all home respiratory care patients in Finland.

Respiratory therapists in home care

Since the implementation of the Medicare prospective payment system (PPS) in October 2000, many sources indicate that the average numbers of patient visits in a home care episode have decreased. Patients with respiratory system diagnosis are a significant percentage of the total episodes in home care. Respiratory therapists (RTs) can provide additional staffing, meet patient needs, and control costs through greater flexibility in resource utilization.

Neonatal respiratory therapy in the new millennium: Does clinical practice reflect scientific evidence?

Respiratory therapy has historically been considered the primary role of the physiotherapist in neonatal intensive care in Australia. In 2001 a survey was undertaken of all level three neonatal intensive care units in Australia to determine the role of the physiotherapist and of respiratory therapy in clinical practice. It appears that respiratory therapy is provided infrequently, with the number of infants treated per month ranging from 0 to 10 in 15 of the 20 units who provide respiratory therapy, regardless of therapist availability. The median number of respiratory treatments per month during the week was three, and on weekends it was one. Respiratory therapy was carried out by physiotherapists and nurses in 54.6% of units, by physiotherapists only in 36.4% of units, and by nurses only in the remaining 9% of units surveyed. There was also a diminution of the role of respiratory therapy in the extubation of premature infants. A review of the literature shows that overall the use of respiratory therapy reflects current evidence. The question remains whether it is possible to maintain the competency of staff and justify the cost of training in the current healthcare economic climate. It seems probable that the future role of physiotherapists in neonatal intensive care unit may be in the facilitation of optimal neurological development of surviving very low birth weight infants.

Re-admissions to inpatient paediatric pulmonary rehabilitation

OBJECTIVE

To describe re-admission rates, identify reasons for re-admission and examine characteristics of children requiring re-admission to inpatient pulmonary rehabilitation.

METHODOLOGY

Retrospective record review of infants and toddlers (less than three years of age) requiring oxygen or ventilator support discharged from an inpatient paediatric pulmonary rehabilitation programme between 1992 and 1999.

RESULTS

Forty-one initial admissions resulted in 45 readmissions with a mean re-admission rate of 1.1 (SD = 1.41) re-admissions per child. Children with re-admissions (n = 22, 54%) required significantly more ventilator support (p = 0.001) and nursing care (p = 0.001) and were transferred to acute care more frequently (p = 0.002) than children without re-admissions. One-half of the children re-admitted to inpatient pulmonary rehabilitation were re-admitted two or more times.

CONCLUSIONS

Based on this cohort of children, dependence on supplemental oxygen and/or mechanical ventilation and medical complexity may be indicators that children will require re-admission to rehabilitation following a transfer back to acute care. Further examination of re-admission rates and reasons and children's clinical characteristics may have predictive value and provide practice improvement opportunities.

Chest physiotherapy and porencephalic brain lesions in very preterm infants

OBJECTIVE

National Women's Hospital is one of two hospitals to report a destructive brain lesion, namely encephaloclastic porencephaly (ECPE), in extremely preterm infants. It has been associated with non-cephalic presentation, early hypotension and the number of chest physiotherapy treatments in the first month. The aim of the present study was to determine the temporal relationship between ECPE and chest physiotherapy use in very low-birth weight (VLBW) infants in our unit.

METHODOLOGY

Cerebral ultrasound scan reports, post-mortem reports, clinical and physiotherapy records and, if indicated, original ultrasound films were reviewed for all VLBW babies admitted between 1985 and 1998.

RESULTS

Over the 14 year period in question, 2219 babies with a birth weight < or = 1500 g were admitted. Encephaloclastic porencephaly was found in only the 13 previously reported babies born between 1992 and 1994. Encephaloclastic porencephaly was excluded in 1564 (70%) babies. In 621 (28%) babies who did not have late ultrasound scans, ECPE was thought to be unlikely either because the babies never had any chest physiotherapy (n=479) or because they had chest physiotherapy but were known to be neurodevelopmentally normal on follow up (n=142). Data were incomplete for 21 babies (0.9%). The number of chest physiotherapy treatments per baby decreased from a median of 95 prior to 1989 to 38 and the age of starting treatment increased from 5 to 8 days after 1990. The use of chest physiotherapy ceased in 1995.

CONCLUSIONS

Encephaloclastic porencephaly emerged as a problem at a time when the use of chest physiotherapy had decreased. The cluster of cases seen between 1992 and 1994, although associated with the number of chest physiotherapy treatments given, began to appear because of some other factor.

[Home respiratory care]

In 1980, 11,000 French patients were given home respiratory care (HRC); today there are ten times more cases, i.e. about 120,000. There are two principal conditions in this population: chronic severe lung disease (CSLD), treated mainly with long-term oxygen therapy and assisted ventilation, and sleep apnoea syndrome (SAS), treated with continuous positive airway pressure (CPAP), a treatment that first became available in 1985. The mean age of patients with CSLD is currently 67 years and is increasing annually, while for SAS it is 58 years. The constraints of treatment, prescribed for the rest of the patient's life, are incompatible with long-term hospitalization, given the daily length of treatment (12-24 h for CSLD, and 5-8 h at night for SAS). The number of medical and social workers involved in providing these types of treatment requires complex coordination for the patient to be able to benefit from such highly cost-effective medical and technical services. In the case of home respiratory care, France has benefited for almost twenty years from the services of a not-for-profit network that comprises a national coordinating body, ANTADIR, and regional HRC services administered by physicians specializing in pneumology or resuscitation, often from university hospitals.

Assessment of the effects of sugar cane plantation burning on daily counts of inhalation therapy

This study was designed to evaluate the association between sugar cane plantation burning and hospital visits in Araraquara in the state of São Paulo, Brazil. From June 1 to August 31, 1995, the daily number of visits of patients who needed inhalation therapy in one of the main hospitals of the city was recorded and used as health impairment estimation. Sedimentation of particle mass (the amount of particles deposited on four containers filled with water) was measured daily. The association between the weight of the sediment and the number of visits was evaluated by means of Poisson regression models controlled for seasonality, temperature, day of the week, and rain. We found a significant and dose-dependent relationship between the number of visits and the amount of sediment. The relative risk of visit associated with an increase of 10 mg in the sediment weight was 1.09 (1-1.19), and the relative risk of an inhalation therapy was 1.20 (1.03-1.39) on the most polluted days (fourth quartile of sediment mass). These results indicate that sugar cane burning may cause deleterious health effects in the exposed population.

Microvascular reconstruction and tracheotomy are significant determinants of resource utilization in head and neck surgery

BACKGROUND

Successful "critical pathway" design and implementation are dependent on appropriate patient stratification according to those factors that are primary determinants of resource utilization.

OBJECTIVES

To test the validity of our previously reported critical pathway design and to determine whether tracheotomy and microvascular reconstruction (MR) are primary determinants of resource utilization.

DESIGN

Cost-effectiveness analysis.

SETTING

Tertiary referral academic institution.

METHODS

Retrospective analysis of data from 133 head and neck surgery cases in which the treatment regimen was based on critical pathways over a 26-month period.

OUTCOME MEASURES

Length of stay and total patient charges were used as indices of resource utilization. One-way analysis of variance and t tests were used for statistical analysis of significance.

RESULTS

Ninety patients (67.7%) underwent MR; 43 (32. 3%) did not. Seventy-five patients (56.4%) underwent tracheotomy; 58 (43.6%) did not. Four patient groups were constructed in decreasing order of complexity as follows: group 1, patients who underwent both tracheotomy and MR (n = 58); group 2, patients who underwent MR alone (n = 32); group 3, patients who underwent tracheotomy alone (n = 17); and group 4, patients who did not undergo either procedure (n = 26). Both tracheotomy and MR were found to be independent determinants of resource utilization and were additive when both were present. The length of stay varied from 8.4 days (in patients who underwent both procedures) to 6.7 days (in patients who did not undergo either procedure), with intermediate values in cases in which only 1 procedure was performed. The total charges varied in a similar manner from a high of $33,371 to a low of $19,994. Subanalysis with respect to intensive care unit, ward, and operating room charges showed a similar stratification.

CONCLUSION

Tracheotomy and MR are both significant determinants of charges and length of stay in head and neck surgery cases and must be considered in the design of strategies to promote efficient resource utilization.

The role of respiratory care practitioners in a changing healthcare system: emerging areas of clinical practice

OBJECTIVE

To evaluate shifts in respiratory care practice in the context of changing healthcare system and market dynamics.

STUDY DESIGN

Telephone survey, structured interview, and case studies.

METHODS

We conducted a telephone survey of 471 respiratory care practitioners (RCPs), drawn from the membership database of the American Association for Respiratory Care. We also interviewed 10 employers of RCPs and conducted 2 in-depth case studies to supplement our survey results. We used several statistical techniques to analyze our data, including calculation of population-weighted descriptive statistics and multivariate regression models.

RESULTS

Changes in the healthcare system have prompted RCPs to broaden their practice settings, skills, and responsibilities. Respiratory care practitioners are taking part in managed care-related activities, such as cost control and disease management. We found that the need for certain skills and responsibilities varies by practice setting. In our interviews, employers considered RCPs cost effective providers for certain services.

CONCLUSIONS

The practice of respiratory care is evolving to meet the changing needs of the healthcare system. A key challenge is to ensure appropriate growth and development of the respiratory care profession, as well as the delivery of appropriate services under new care management settings and processes.

Pulmonary rehabilitation programs in Canada: national survey

OBJECTIVE

To characterize pulmonary rehabilitation (PR) programs in terms of their type, size, duration, patient population, content and staffing.

DESIGN

Surveys were sent to members of the Rehabilitation Committee of the Canadian Thoracic Society, as well as any program identified by members of the Canadian Physiotherapy Cardio-Respiratory Society, by provincial lung associations or by the respondents.

PARTICIPANTS

Of 51 surveys sent, responses were received from 44 facilities (86% response rate). In-patient or out-patient pulmonary rehabilitation programs were offered by 36 facilities.

RESULTS

Most programs (97%) admitted out-patients, and 22% had an in-patient capability. Out-patient programs enrolled 13 patients (median 11; range five to 48) at a given time for a duration of 8.3 weeks (range two to 26). In-patient programs enrolled nine patients at a given time (range two to 26) for 4.6 weeks (range one to eight). Programs included patients with chronic obstructive pulmonary disorder (100%), restrictive disease (93%), asthma (82%), adults with cystic fibrosis (46%), patients pre- or postlung transplantation (45%) and patients receiving mechanical ventilatory support (18%). Breathing retraining, education and upper extremity training were incorporated in more than 90% of all programs. Only one-third of programs offered smoking cessation as part of the rehabilitation. Education sessions on medications and inhaler usage were included in most programs, but sexuality was addressed in only half the programs.

CONCLUSIONS

This first comprehensive national survey of PR programs in Canada shows that there are similarities in the format, content and staffing of PR programs. Programs are only able to service a small percentage of patients with chronic respiratory conditions.

Pulmonary rehabilitation program survey in North America, Europe, and Tokyo

PURPOSE

To study a comparison of problems arising in pulmonary rehabilitation programs in North America, Europe, and Tokyo.

METHODS

The survey instrument was a 13-item questionnaire sent in December 1994 to institutions in North America (n = 178), Europe (n = 179), and Tokyo (n = 399).

RESULTS

Response rates were 51%, 40%, and 51% for North America, Europe, and Tokyo, respectively. Pulmonary rehabilitation programs were available at 56% of hospitals in North America and 74% in Europe, but at only 20% of hospitals in Tokyo. Most PRPs were conducted in an outpatient setting in North American (98%), whereas both outpatient (55%) and inpatient programs (65%) were adopted in Europe. Although the type of lung disease for which patients in both North America and Europe were referred to PRPs was mainly chronic obstructive pulmonary disease, this accounted for only 34% of referrals in Tokyo. However, referrals for primary tuberculosis sequelae (P = 0.028) and bronchiectasis (P = 0.021) were more common in Europe, similar to the situation in Tokyo. The following PRP items were available at significantly higher rates in North America than in Europe, and most were unavailable in Tokyo: family education, psychological support, nutritional instruction, treadmill, bicycle ergometer, walking training, and increasing the activity of daily living.

CONCLUSION

Pulmonary rehabilitation programs in North America are more multidimensional. However, target diseases differ among North America, Europe, and Tokyo. Pulmonary rehabilitation programs in Tokyo differed from those in North America and Europe and were poorly programmed. Problems arising in PRPs in the three regions include lack of staff and insufficient reimbursement.

The effect of a neonatal telecardiology system on respiratory therapy in very low birthweight infants

Factors in the U.S. healthcare system have shifted the site of care of many newborns to hospitals where subspecialty services are unavailable. This study examines whether a more rapid turn-around of echocardiogram interpretations and availability of interactive video during neonatal consultations reduces the morbidity of very low birthweight (VLBW) infants. The two groups (n = 21 and n = 28) were similar on the basis of known risk factors. A composite index of respiratory therapy intensivity and duration was used to measure the utilization of respiratory therapies. The index was similar in both groups, 89.6 +/- 12.6 before versus 89.5 +/- 13.0 with telemedicine. These results show little evidence of a reduction in RT utilization.

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service. Results of a prospective observational study

OBJECTIVE

To assess the impact of a respiratory therapy consult service (RTCS) on practices and appropriateness of ordering respiratory care services.

DESIGN

Nonrandomized prospective observational cohort study with concurrent controls.

SETTING

Adult non-ICU inpatient wards of an academic medical center.

PATIENTS

A convenience sample of 98 adult non-ICU inpatients at the Cleveland Clinic Hospital, representing 20 inpatient clinical services. Patients whose respiratory care plans were determined by respiratory care practitioners using sign and symptom-based algorithms to specify treatment comprised the treatment group (n = 51, respiratory therapy consult group). The nonconsult group (n = 47) were patients whose respiratory care plans were specified by their own physicians.

INTERVENTION

Specification of the respiratory care plan by the RTCS vs by the physicians themselves. Use of the RTCS was at the discretion of the managing physician.

OUTCOME MEASURES

Types and number of respiratory care treatments, length of hospital stay, costs of the respiratory therapy provided, appropriateness of respiratory care orders (based on comparison of the actual respiratory care orders with a reference respiratory care plan generated by a study investigator who was kept blind to the actual respiratory care plan), and adverse respiratory events.

RESULTS

Patients for whom the RTCS was requested by their physicians had a greater severity of respiratory illness based on having a lower triage score, but were otherwise similar at baseline. Fewer initial orders for respiratory care were discordant with the reference algorithms in RTCS patients (15% +/- 26% [SD]) than in nonconsult patients (43% +/- 36%; p < 0.001), and a smaller fraction of RTCS patients received at least one discordant initial respiratory care order (37% vs 72%; p < 0.001). Though provided to sicker patients with longer lengths of hospital stay, RTCS-directed care incurred similar respiratory care costs per patient ($335.63 +/- $272.69 [RTCS] vs $349.06 +/- $273.27; p = 0.72).

CONCLUSIONS

These results suggest that the RTCS can be an effective strategy to allocate respiratory care strategies appropriately while conserving the costs of providing respiratory care.

Clinical strategies to reduce utilization of chest physiotherapy without compromising patient care

BACKGROUND

There is widespread interest in the evaluation of clinical strategies that safely reduce health-care costs. Elimination of inappropriate chest physiotherapy may represent one of those strategies.

SETTING

An academic community hospital.

METHODS

One-hundred one patients receiving chest physiotherapy were prospectively randomized to continue their chest physiotherapy or to inform their physicians that the order for the chest physiotherapy may have been inappropriate.

RESULTS

Patients who were randomized to have their chest physiotherapy discontinued received 45% fewer chest physiotherapy treatments than control patients (p < 0.01). There was no increase in the mortality rate or length of hospital stay associated with the reduction in chest physiotherapy in carefully selected patients. The estimated cost savings would be $319,000, which is 50 times greater than the cost associated with the intervention.

CONCLUSION

Chest physiotherapy is frequently provided to patients for inappropriate indications. Reducing chest physiotherapy for these patients may significantly reduce respiratory therapy costs without increasing length of stay or mortality rates.

Quality of life and quality of care data from a 7-year pilot project for home ventilator patients

A research demonstration pilot project for hospitalized adult and pediatric long-term ventilator-dependent patients was conducted by Kaiser Permanente Southern California Region from 1985 until 1992. The purpose of the pilot project was to investigate if home care was a realistic alternative to continued hospital care. Many aspects of home care as compared to hospital care were studied. The results of the quality of life and quality of care study in addition to cost data are presented in this paper. Standardized questionnaire tools were used to obtain patient data from the perspective of the patient, as well as others providing direct patient care. Respondents were asked to measure perceptions of quality of life and quality of care at home versus at the hospital in regard to health status, life satisfaction, emotional well-being, caregiver ability, and professional care and services. Quality of care was found to be similar to hospital care. Quality of life was judged to be better at home.

Respiratory care practitioners as primary providers of neonatal intubation in a community hospital: an analysis

BACKGROUND

Respiratory care practitioners (RCPs) serve as the primary providers of neonatal endotracheal intubation (ETI) in our institution. ETIs are performed by registered respiratory therapists who have completed Pediatric Advanced Life Support and Neonatal Advanced Life Support training and have successfully completed 3 intubations under the direct supervision of a senior therapist. The purpose of this study was to (1) ascertain whether RCPs can successfully provide this type of service with acceptable complications rates and (2) survey the economic impact of this practice on patient charges in our hospital.

EVALUATION METHODS

An analysis of each intubation event in which an RCP participated was collected and compiled over a 5-month period (9-94 to 2-95). Calculations were made of the success rate and complications.

RESULTS

A total of 38 ETIs were performed by the RCPs. Of these, 37 (97.4%) were performed with < or = 3 attempts; (73.7% with 1 attempt, 15.8% with 2 attempts, and 7.9% with 3 attempts). In only 1 event were more than 3 attempts required. There were no complications observed.

CONCLUSION

RCPs can successfully serve as primary providers of neonatal ETI at a Level-II nursery in a community hospital, and this practice may result in a cost reduction.

A survey of the prevalence and application of chest physical therapy in U.S. burn centers

The purpose of this study was to determine the prevalence and application of chest physical therapy (CPT) in burn centers. Respiratory therapists primarily administered CPT, and suctioning and coughing were the most frequently used modalities. Further study of the efficacy of treatment techniques is needed to develop congruous standards for CPT after a burn injury.

Benefits associated with a respiratory care assessment-treatment program: results of a pilot study

BACKGROUND

During the months of July, August, and September 1993, we implemented a respiratory care assessment-treatment pilot study on the orthopedic surgery floor in our hospital. The purpose of the study was to determine feasibility and establish cost-effective treatment plans with quality patient outcomes, while maintaining appropriate communications with physicians and nursing staff.

STUDY DEVELOPMENT & IMPLEMENTATION

The study's Task Force developed protocols for oxygen therapy, aerosolized medication therapy, volume expansion therapy, and bronchial hygiene therapy using the American Association for Respiratory Care's Clinical Practice Guidelines as supporting documents. Meetings were held with the orthopedic surgeons and nursing staff to inform them of the key components of the pilot program. Ten patient evaluators were trained to assess patients and implement treatment plans.

EVALUATION METHODS

A reference book was established that contained the protocols and support material. Patient outcomes were evaluated using previously established quality assurance plans. The length of stay, procedural volume, and cost data were collected.

EVALUATION RESULTS

More than 50% of the orders received during the pilot program were for "Respiratory Care Protocol." This allowed the patient care evaluator the flexibility to initiate one of the approved protocols if indicated. No changes in patient outcomes were noted and average length of stay remained unchanged during the pilot study compared to the base period. Treatment volumes decreased, resulting in identified cost savings of $5,318 during the study. Nurses and physicians supported protocol implementation, and increased communication among caregivers was documented. We believe that professionalism of the RCPs was enhanced without compromising the ultimate decision-making responsibilities of the physician.

CONCLUSIONS

The use of respiratory care protocols is an acceptable method of developing clinically effective and fiscally responsible care plans. RCPs at our hospital were able to implement care plans that resulted in cost savings without a measured change in patient outcomes. Approval has been extended from the Executive Committee of the medical staff to expand hospital-wide.

[Oxygen therapy and other pneumological tools for home use in Barcelones Nord i Maresme. A descriptive study]

Against a background of differences in prevalence of chronic home oxygen therapy (CHO) and other pneumological tools (nasal continuous positive airway pressure, aerosol therapy, monitoring, assisted ventilation) found in studies of the various regions of Catalonia (Spain), we carried out a descriptive study to determine how these tools were being used in the northern Barcelona and coastal plain health region (population 657,376). Three hundred sixty-six (49.8%) patients used CHO, 39 (5.3%) used aerosol therapy, 52 (7.1%) used nasal continuous positive airway pressure, 3 (0.4%) were monitored at home and 1 (0.1%) was mechanically ventilated at home. Two hundred seventy-three patients about whom we had insufficient data did not keep their appointments with the doctor. Use of CHO was considered appropriate in 302 (82.5%) of the 366 patients reviewed; 6.5% of these were active smokers as indicated by measurement of CO in expired air. The number of patients resistant to treatment (273) is very high in the northern Barcelona and coastal plain region and should be followed up more carefully. Our finding allow us to estimate that CHO is appropriately prescribed in the northern Barcelona and coastal area for 87.5 patients per 100,000 inhabitants, a prevalence that is higher than that observed for other health regions in Catalonia.