Nurses, Doctors Decry Respiratory Staff Cut

Recent cutbacks in Henry Mayo Newhall Memorial Hospital’s system of treating patients with lung ailments are reducing its quality of care for these patients, say doctors, nurses and respiratory therapists at the hospital.

On June 9, the 134-bed Valencia hospital became one of the first hospitals in the country to abolish its respiratory therapy department and transfer most of the responsibilities of the department to the nursing staff.

Leann Strasen, a hospital vice president and the director of nursing, said the change is expected to save the hospital $300,000 a year at a time when government and private insurers have greatly reduced their reimbursements for specialized medical costs.

Before the change, the hospital had three respiratory therapists on duty during the day and two at night, Strasen said. There is now one therapist per shift, 24 hours a day.

Six full-time jobs were eliminated, plus several part-time positions, according to current and former respiratory therapists.

Hospital staff said that, despite the transfer of many respiratory tasks to nurses, there was no increase in the total nursing staff, which stands at around 300, according to Strasen.

A survey of respiratory care delivery standards around Los Angeles turned up no hospitals of Henry Mayo’s size that have only one respiratory therapist per shift.

Customary Duties

Respiratory therapists study for one to four years and take a series of examinations before being certified by a national medical board. Their duties range from relatively simple tasks, such as administering oxygen and taking sputum samples, to responding to “code blues” or “code traumas,” alarms that signal a medical emergency, said Virginia Wiprud, director of clinical education of the respiratory therapist program at Los Angeles Valley College.

Some of the equipment being deployed and maintained by Henry Mayo’s nurses is exceedingly complex, like the ventilator, a life-support system that breathes for a patient and incorporates computers and sensors that monitor the condition of the patient’s respiratory system.

No hospital in the United States has gone as far as Henry Mayo, transferring a task as complex as handling ventilators to nursing, said Jerome Sullivan, chairman of the allied health department at the University of Toledo in Ohio and a member of a medical task force that recently completed a nationwide survey of respiratory care delivery.

Strasen said nurses can do respiratory therapy within the scope of their licenses and the law and, by better organizing their daily duties, can assume the extra duty and still provide good patient care.

No other hospital officials would talk about the changes.

But a wide range of hospital employees said the nursing staff has not received adequate training. And, with only one respiratory therapist on duty per shift, six nurses said they are fearful.

‘Scary’ Situation

“We don’t know all the equipment, how to set it up or anything,” one nurse complained. “Here we are, lost, and we have a patient who’s probably going to die on us. Who’s going to be responsible? We are. That’s the part that’s scary.”

The situation is particularly bad, many employees said, because Henry Mayo is classified by the county as a rural trauma facility. Thus, it accepts accident victims from a wide area that is traversed by the Golden State Freeway and includes many recreational sites.

The hospital staff’s main complaint was that nurses received only one day of classroom instruction and practice with equipment, plus several short supplementary sessions, before the change was made, four weeks after it was announced.

Dr. Steven Baron, an internist on Henry Mayo’s medical staff, said he is telling patients with chronic lung problems to avoid the hospital because of the cutbacks. “Certainly, I feel ethically that I have to tell my patients this is not the best hospital for you,” he said.

Relatively New Field

Respiratory therapy as a profession evolved over the past 20 years as the technology of caring for patients with lung problems became more demanding and time-consuming, Wiprud said.

Respiratory therapy departments at hospitals expanded tremendously in recent years, partly because the cost of services performed by therapists was billed item by item to an insurance company or Medicare, while the cost of the same services, if provided by nurses, had to be absorbed by the hospital.

In 1984, the federal government dramatically changed the system of reimbursement for medical costs so that a hospital received a fixed fee for treatment of a specific medical condition. That turned respiratory therapy from one of the hospitals’ biggest moneymakers into a loser.

“Respiratory therapists are just caught right in a shift in economics,” Strasen said.

“When I have to make the trade-off between ‘do I get rid of nurses’ or ‘do I get rid of respiratory therapists,’ I look and see who can do the most.”

She said she determined that “nurses can do the most things.”

Cheryl Brown, a nurse in Henry Mayo’s intensive care unit, characterized the nurses’ predicament this way: “There isn’t a whole lot we can’t do. . . . Housekeeping could leave, and we could sweep or vacuum the floor. . . . It’s like going back to the origin of nursing, when nurses did everything.”

Changes Outlined

The change at Henry Mayo began on May 9, when Duffy Watson, president of the hospital, sent a three-page letter to its respiratory therapists saying they would no longer constitute a separate department; instead, one therapist would work each shift. The rest of the respiratory patients’ care would be “provided by the nursing staff,” he said.

Nurses would assume the respiratory therapy functions “with no additional staffing,” according to a hospital document dated April 22.

The hospital’s respiratory therapists were invited to apply for five new positions, Strasen said. Three did so, and were hired as respiratory care specialists; two took positions in a different department, and the rest left the hospital.

Four weeks were allotted for the transition. During that time the departing respiratory therapists were asked to help train nurses to take care of patients with breathing problems, according to hospital documents.

The training consisted of four hours of classroom courses in such things as equipment maintenance, trouble-shooting and respiratory physiology, as well as a clinical tour in which nurses were to be familiarized with procedures and instruments, Strasen said. Some supplementary sessions have been added since then, she said.

Many respiratory therapists, nurses and educators--in and out of Henry Mayo--called the hospital’s amount of training inadequate.

One intensive-care nurse at Henry Mayo said: “They tried to hammer all this knowledge all at once at us, and there’s no way we can possibly absorb it when it takes months and years for these people to get it down pat.”

A nurse in a medical unit that cares for many elderly patients with respiratory problems said some of the tools of the trade can be daunting. An intermittent positive pressure breathing machine, or IPPB, is used to assist the patient’s breathing and deliver medication in the form of an inhaled mist.

“I can’t put an IPPB together, and I had like a 35-minute class,” said the nurse, who, like many people interviewed, refused to be identified out of fear of being fired.

“Ordinarily you can stand around and wait for a respiratory therapist,” the nurse said. “But suppose you have a patient here who can’t breathe? They’re having an attack, and you’ve got to give them a treatment.”

Changing Technology

One reason nurses would have trouble in a quick transition to respiratory care is that the technology keeps changing, said Jim Fink, technical director of respiratory care services at the UC San Francisco Medical Center and a past president of the California Society for Respiratory Care.

At the University of California, San Francicso, some of the simplest respiratory tasks, such as oxygen therapy, have been transferred to nursing, he said, but management of equipment is not one of them.

Even experienced respiratory therapists have trouble keeping up with the flood of various equipment, according to Fink and others. At UCSF, Fink said, “When we bring a respiratory therapist in from the street we spend 40 to 80 hours just training them for our particular systems.”

In recent years, nursing education has not stressed respiratory care, several nurses and therapists said. As respiratory therapy developed into a separate specialty, Fink said, nursing-education programs moved away from the field.

California last year became the first state to license and monitor respiratory care practitioners. There are now more than 10,000 licensed practitioners in the state, according to the Respiratory Care Examining Committee of the State Board of Medical Quality Assurance.

Critical-care nurses, who staff intensive care units, receive extra training in respiratory care, said Sandi Dunbar, president of the American Assn. of Critical Care Nurses. But she confirmed that many training programs put little emphasis on the respiratory section. The assumption, she said, is that once you are in a hospital, “the respiratory therapist will be your resource.”

“Can a nurse act like a respiratory care practitioner? Sure, 90% of the time,” said Philip von der Heydt, executive director of the American Medical Assn.’s Joint Review Committee for Respiratory Therapy Education, which sets standards for respiratory therapy curricula. “In the remaining 10%, though, the patient turns blue and doesn’t last too long,” he said.

Other hospitals in the Los Angeles area have not made as drastic cutbacks in respiratory therapists as Mayo. According to the survey made by Wiprud, at Los Angeles Valley College: “One of the 200-bed hospitals has a total of 21 full-time respiratory therapists doing adults and 16 for neonatal care. . . . One 350-bed hospital employs 34 full-time respiratory therapists and a per-diem pool of about 20.”

Dennis Belenson, administrative director of respiratory care at St. Joseph Medical Center in Burbank, said his hospital has an average of four respiratory therapists on each shift in the intensive care unit alone.

To cut costs, many hospitals around the country, like UCSF, have transferred some of the simpler tasks of respiratory therapists to their nurses, with variable success, according to a study of “non-traditional respiratory services” conducted by a task force of therapists and physicians for the American Assn. for Respiratory Care.

No Standards Violated

The transfer of respiratory duties to nursing does not violate standards for respiratory care set by the state, county or the Joint Commission on Hospital Accreditation, a body that periodically assesses quality of care at U.S. hospitals, according to authorities. It falls into what several experts said is a gray area, in which nurses are allowed to perform advanced respiratory care duties if they have adequate training.

“The regulations say ‘appropriately trained’ people,” said Strasen. “The hospital can choose how they want to implement that.”

Bud Pate, supervisor of the hospital inspection unit of the county Department of Health Services, said his group assesses the overall quality of patient care at a hospital, not specific conditions such as the ratio of respiratory staff to patients.

He said an inspector is studying the new situation at Henry Mayo, and, ‘even though it’s not a violation per se, it’s something we would be interested in looking at.”

There are an increasing number of cases where “cost-cutting and patient care are at opposite ends tugging at each other,” he said.

Henry Mayo personnel interviewed were divided on whether the change will negatively affect the hospital’s ability to manage emergencies or the general quality of patient care. But everyone agreed that there will be an adverse effect of some kind.

Brown, in the intensive care unit, said in a letter to The Signal, a Santa Clarita Valley newspaper, that her main concern is the lack of nurses’ time. “I’ve tried to visualize how and when I would fit these tasks into my day--and the only conclusion I arrive at is that I just don’t know how I’ll do it,” she said. “It frightens me. . . .”

A respiratory therapist in a position of authority at Henry Mayo said, on the condition that she not be identified, that although intensive care nurses “do know something about ventilators, . . . to know how to trouble-shoot a ventilator takes years and years.”

Worried About Licenses

“I still don’t know what mask to put on, even what they’re called,” one intensive care unit nurse said. The nurse said she and many of her co-workers fear they may be risking their licenses if something goes wrong.

Dr. Robert Baptist, who works in the hospital’s emergency room, said he has mixed feelings about the cuts in respiratory services. He acknowledged that services have been reduced, but said it is not the hospital’s fault. “Obviously, we miss the department,” Baptist said. “You can’t cut back in terms of numbers of trained people and not have some effect.”

But, Baptist said: “The government decided they’d pay for what they felt like paying for. When the government decided to do that, private carriers decided to do the same thing.”

He said administrators at Henry Mayo are “trying to survive and deliver the best level of health care they can in the economic situation they’re presented with at this point.”

Henry Mayo’s Strasen said cutbacks such as the restructuring of respiratory care are inevitable. “People have the perception that they can’t do anything more,” she said. “My role is to teach them more effective ways to do what they’re doing.”