Respiratory StaffingFor Coventry’s Vent Unit

Meeting the Increasing Needs of Our Expansion and EvolutionBy: Adam J. Ross

How do we currently staff?- Each day we currently can provide:

- 1x Day Shift- 7am – 7pm

- 12 Hours- 1x Night Shift

- 7pm – 7am- 12 Hours

- 1x “Swing Shift”- 1pm – 9pm

- 8 Hours

- …for a total of 32 hours per day.

Is this enough?32 Hours divided between our average of 14 patients gives us 2.28 hours per day per patient, not including documentation.

Documentation requires, on average, 20 minutes per patient per shift. So, 40 minutes per patient at 14 patients means 9.33 hours per day are spent documenting.

32 hours minus 9.33 hours equals an actual total of 22.67 is available for actual patient care.

The adjusted 22.67 hours divided between 14 patients gives us 1.61 hours per patient per day.

RHS recommends staffing to meet the needs of each patient at an adjusted estimated 3 hours of labor per patient per day. 1.61 hours is just over half of that.

The AARC and NBRC both recommend staffing 1 RT for every 8 ventilators. At 1.3:14 RT to Ventilator ratio we are just under 60% of the way there.

Wait, there’s more!Let’s take our 1.61 hours available per patient per day and subtract our routine care. Routine care includes mandatory vent checks, tracheostomy care, and assessments.

A stable vent or tracheostomy patient with no scheduled treatments will require, at a bare minimum and done very quickly:

[1] 4x Ventilator Checks and Assessments for 40 Minutes of Labor.[2] 2x Routine Tracheostomy Tube Care Sessions for 20 Minutes of Labor

Each patient, as soon as they are admitted, will immediately have 60 minutes of labor as standing, routine orders.

Subtract 1 hour from our available 1.61 hours and we are left with 0.61 hours per patient per day.

This is just under 37 minutes available per patient per day.

But, our patient’s also need other stuff? Yes, they do!Scheduled Treatments

Most of our ventilator dependent and tracheostomy patients will have respiratory treatment orders ranging from nebulizer treatments and inhalers to intensive specialty therapies like Chest Physiotherapy, pulmonary toileting, and weaning trials. Nebulizer treatments take around 10 minutes to administer while weaning and more involved therapies can have our RTs with a patient for up to an hour.

As Needed Interventions

The AARC concluded that “PRN” interventions can account for over 40% of an RT’s daily routine. Every request for suctioning, ventilator troubleshooting, oxygen adjustments, emergent assessments, and even something as simple as getting a patient ready to travel for a shower or trip to the gym takes time.

15 Patients Under RT Care

9 Have Scheduled Treatments

2 Require Weaning Therapy

3 Require Specialty Therapy

All Require PRN Interventions

290 minutes of scheduled treatments per day.

110 Minutes are scheduled to be completed between 8am and 10 am (120 Minutes)

290 minutes of scheduled treatments per day.

110 Minutes are scheduled to be completed between 8am and 10 am (120 Minutes)

120 Minutes of scheduled specialty care per day… Between only 2 patients.

290 minutes of scheduled treatments per day.

110 Minutes are scheduled to be completed between 8am and 10 am (120 Minutes)

120 Minutes of scheduled specialty care per day… Between only 2 patients.

Add our standing routine care and there is now 225 minutes of labor that is due in a 120 minute period!

What type of patient presents the largest challenge and most amount of labor?

Ventilator and non-vent tracheostomy, believe it or now, have very similar needs from an operation standpoint. Acuity is based more on clinical status, medical condition, and mental status.

From “least” to “most” labor:[1] Chronic, stable, persistent vegetative patients.[2] Chronic stable and alert patients.[3] Weanable patients.[4] Chronic unstable patients.

However individual patients may defy this list. There will be medically stable chronic patients who make unreasonable demands, are abusing the call-bell, or have behavioral issues that demand more attention.

The patient on this list who has the largest amount of scheduled labor is a non-vent tracheostomy patient…

His scheduled treatment and intervention routine consumes almost 4 hours a day.

The next most labor-intensive patient, a weanable ventilator, consumes just under 2 hours a day…

Expected and actual labor fluctuates with acuity, status, and census…

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

10

20

30

40

50

60

16 16 16 16 17 17 17 17 17 16 16 16 16 15 15 15 15 15 14 14 15 16 16 16 16 16 16 17 17 17 17

48 48 48 4851 51 51 51 51

48 48 48 4845 45 45 45 45

42 42 42

48 48 48 48 48 4851 51 51 51

Census & Expected Labor (3 Hours per Patient per Day)

Vent & Trach Census (C) Expected Labor Per Day (eL)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

10

20

30

40

50

60

32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32

Actual Labor Provided Added

Vent & Trach Census (C) Expected Labor Per Day (eL) Actual Labor Provided (aL = Actual Value)

What we need.

What we have.

Our “Labor Gap”

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

10

20

30

40

50

60

18

22

1820

2422 22

24 24

20

1618 18

1618 18

22

16 1614

20 2022 22

2422

20

24 2426

24

“PRN” Time Provided Added

Expected Labor Per Day (eL) Polynomial (Expected Labor Per Day (eL))Unscheduled Labor Provided (uL = Acutal Value) Polynomial (Unscheduled Labor Provided (uL = Acutal Value))

Remember, “PRN” treatments will take sometimes over 40% of our total expected labor…

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

10

20

30

40

50

60

14

10

1412

810 10

8 8

12

1614 14

1614 14

10

16 1618

12 1210 10

810

12

8 86

8

Scheduled Time Available Added

Expected Labor Per Day (eL) Actual Labor Provided (aL = Actual Value) Scheduled Time Actually Available (StA = aL-uL)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

0.5

1

1.5

2

2.5

Time Available per Patient per Day

Time Available Per Patient (Ta = aL/C) Actual Time Available Per Patient (aTa = StA/C)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

10

20

30

40

50

60

All Values

Vent & Trach Census (C) Expected Labor Per Day (eL) Scheduled Labor Per Day (sL = 3*C)Unscheduled Labor Provided (uL = Acutal Value) Actual Labor Provided (aL = Actual Value) Scheduled Time Actually Available (StA = aL-uL)Time Available Per Patient (Ta = aL/C) Actual Time Available Per Patient (aTa = StA/C)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

10

20

30

40

50

60

All Values

Vent & Trach Census (C) Expected Labor Per Day (eL) Scheduled Labor Per Day (sL = 3*C)Unscheduled Labor Provided (uL = Acutal Value) Actual Labor Provided (aL = Actual Value) Scheduled Time Actually Available (StA = aL-uL)Time Available Per Patient (Ta = aL/C) Actual Time Available Per Patient (aTa = StA/C)

Sometimes we have more labor SCHEDULED than labor available!

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 310

5

10

15

20

25

30

35

40

Scheduled Labor vs. Actual Time Available

Scheduled Labor Per Day (sL = 3*C) Scheduled Time Actually Available (StA = aL-uL)

Never did we have enough time to provide our scheduled labor as scheduled…

So, how are we doing it now?

The short answer is that we don’t.Treatments are sometimes missed and often provided late.

Our documentation quality and completion has suffered.

A “bare minimum” attitude to all aspects of care is assumed.

Increased sick calls are seen.

Decreased patient satisfaction has been noted.

Increased wait times on all patient requests.

Worse outcomes especially for weanable patients.

A lack of personal and individualized care…

What’s the solution?Additional Regular Staff

While attempting to staff to RHS expected labor of 3 hours per patient per day would mean often having 2 RTs on all day every day, there is an 8 hour period of time when having one RT on is okay from an expected labor standpoint.

Adding 8 hours per day will go a long way to maintaining the quality of care and positive outcomes we would like to be

known for.

Having 2 RTs scheduled from 7am until 11pm makes primary morning and evening rounds doable without defying the laws of physics. Weaning and specialty care items can be completed in a timely and comprehensive manner as having an RT spend extended periods of time with a single patient would no longer be impossible.

Having 2 RTs also decreases the impact of sick calls.

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 60

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Daily Scheduled Labor Hour by Hour

Scheduled Labor Column1 Column3

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 60

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Daily Scheduled Labor Hour by Hour

Scheduled Labor

Busy “spikes” are seen for 3-4 hours at 7am and 7pm…

Morning Rounds Evening Rounds

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 60

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Daily Scheduled Labor Hour by Hour

Scheduled Labor

…after 11pm expected and scheduled labor decreases…

11pm-7am “Lull”

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 60

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Daily Scheduled Labor Hour by Hour

Scheduled Labor

…after 11pm expected and scheduled labor decreases…

11pm-7am “Lull”PT, OT, weaning, PMV trials…

The “New” Staffing Plan

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 60

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Scheduled Labor Number of RTs

Day Shift 7a – 7p = 12HDay Supplement 7a – 3p = 8HEvening Shift 3p – 11p = 8HNight Shift 7p – 7a = 12H

40 Total Hours Per Day

Results in 2 RTs from 7am until 11pm.

Alternative and Additional StrategiesDelineation of routine PRN care…

-Treat the RT staff more like an acute care hospital treats their RT department.- RTs do their scheduled routine rounds and are only called for specialty needs.

- Vent changes, troubleshooting, non-nursing scope activities…- A Coventry RT will do more suctioning in a week than an MGH ICU RT will do in a

year…- Most RT departments stage in a separate office and carry pagers or

cellphones responding to PRN requests that exceed the scope of nursing.

Admission criteria shifts to accept only more “low-impact” patients…- Stable persistent vegetative patients do not impact labor unexpectedly.

Implement a limited scheduled treatment expectation…- CPT sessions, pulmonary toileting, extended weaning or PMV trials can add

hours.

Defy RHS documentation and assessment frequency policies…- Decreasing the amount of repetitive treatment and assessment notes could free

up hours per day for patient care.

Other ConsiderationsNursing Education

- The floors have relied on out vent unit RTs for routine matters for too long.- Nasal cannula retrieval and oxygen concentrator troubleshooting for 1 North isnot what you want to pay your RTs for.

CNA Education- Most of our stoma trauma and tube dislodgements are caused by poor circuit etiquette during patient repositioning and daily activities.- A formulaic and regimented educational seminar refreshed regularly will go a longtowards decreasing the number of PRN interventions your RTs need to respond to.

A Different Look at Acuity Upon Admission - Sicker patients require more time, will be sent back to the hospital more often, and are going to have poorer outcomes.- Attracting more “cardiac” patients will bring in patients of a higher acuity.- The heart and lungs have a symbiotic relationship. Bad hearts almost always means

breathing troubles. Be prepared to see more BiPAPs, higher O2 usage, and morerespiratory distress noted.

Moving ForwardEverything outside of the ventilator unit is considered “PRN” by RHS. The moment a large percentage of that patient population is demanding regular respiratory services is the moment that “PRN” label needs to go away. Certain floors, especially the 2nd floor, may need to be seen as requiring regular respiratory labor.

Regular scheduled respiratory care may benefit the entire building.

Currently 8 – 12 hours a week can be spent on the floors assessing patients, setting up BiPAPs, doing home-care qualification procedures, troubleshooting machines, and even patient and family education. Often 12 hours can be achieved while actively seeking to avoid floor labor…

The process now, however, is ad-hoc and without structure. Services are regularly rendered last-minute or hours after a new patient arrives and there is a surprise CPAP order that wasn’t in the admission packet. Frantic RNs find their way to the ventilator unit and pull the RT off the floor for everything from basic supply requisition to emergent issue assessment.

Although things seem better than in the days of the “hotline”, structure is badly needed.

Alas, in the end…We have reached, and been atop, a tipping point since being able to

maintain a census of over 12 patients over the last 16 months.

If our vent unit wants to expand, focus on weanable patients, function within a “cardiac branding”, and still provide timely high-quality care, our RTs will need to have the time to work.

At 40 hours of regular labor per day timely comprehensive care of up to 18 ventilator and tracheostomy patients of varying acuities will be possible.

Even though this will still put us way under the mark for the RHS calculated labor, sitting at a 9:1 vent to RT ratio for 66% of the day is much better than what we achieve currently.