Hospital Death Probe Spurs Call for Reforms

Reformers are using the “angel of death” case as a springboard for higher standards in the field of respiratory therapy, in which the limited duties of a low-level trade are quickly giving way to the demands of a new and sophisticated profession.

Proponents of change say the case of Efren Saldivar, who allegedly confessed and then recanted the murder of dozens of hospital patients, highlights problems with an occupation where an average of 29% of applicants have criminal records.

“Where in other professions a bad seed could do minimal damage, in respiratory care, it literally can cost someone their life,” said Kim Kruser, president of the California Respiratory Care Board.

Although regulators gripe about the pool of applicants, therapists in the workplace increasingly contend with the growing complexity of their field. Once a rote technical job, respiratory therapy now requires familiarity with a variety of computer-driven equipment, as well as knowledge of the subtler art of reading patients’ ever-changing conditions.

Yet it is not these changes that have drawn recent public attention, but the case of Saldivar, who police said confessed in March that he had killed up to 50 patients at Glendale Adventist Medical Center.

He and four colleagues at Glendale Adventist were fired in connection with the ensuing investigation, although no one has been charged, and police are still investigating.

On Thursday, regulators with the state board revoked Saldivar’s license, after police notified the state. But the board has taken no action to investigate whether the other four still merit licenses because the hospital--at the request of police--has not reported any information about the firings to the state, said executive officer Cathleen McCoy.

Reformers have targeted that lack of regulatory bite in proposals to strengthen oversight of the profession and the hospitals that employ them.

A bill now before the state Senate to require hospitals to report certain disciplinary actions against therapists is among a series of efforts the board has made to clamp down on respiratory workers. Currently, only high-level practitioners such as doctors are governed by such reporting requirements. There is no mandatory reporting requirement for disciplining nurses.

Also in the works is an increase in educational requirements for therapists from one year to two in California, which is expected to be followed nationwide.

16,000 Therapists in California

Respiratory therapists are second only to nurses in numbers among hospital ancillary staff. About 16,000 practice in California, most so inconspicuously that many patients may never know they’ve been treated by one.

Those who do know may see them as just another one in the river of indistinguishable blue-smocked technicians streaming through hospital wards.

But new evidence suggests that therapists educated beyond the technician level can vastly improve patient care and a hospital’s bottom line--saving costs of keeping patients in intensive care.

The change was apparent on a recent morning at Olive View/UCLA Medical Center, when a woman on a ventilator and suffering from pancreatitis abruptly went into crisis.

Ventilators are breathing machines that tear the lungs and provide entry to infection even as they keep patients alive. The machine’s fine balance between hurting and helping patients, which is the therapist’s job to maintain, can go awry at any moment.

This time, the pressure of the ventilator abruptly shot up as the woman’s vital signs diminished. Doctors, nurses and technicians rushed to the bedside, where the woman lay unconscious, tubes running from her body to a large digitized machine on wheels.

Jane Baking, the respiratory therapist on the job, had been the first to notice the woman’s changing condition. She was also the first to suggest--during a hurried patient conference with doctors and nurses--that the medical team switch to a newer, more complex ventilator to save the woman’s life.

The doctors didn’t--at first. But when their own remedies didn’t work, they took Baking’s advice. The ventilator she chose was rolled to the bedside, the switch made and the woman’s condition stabilized.

Such a discussion may never have happened in the early days of respiratory care, when so-called inhalation therapists chiefly followed orders in operating early breathing devices such as iron lungs, said Edward R. Lind, Olive View’s manager of pulmonary and respiratory care service.

“Twenty-five years ago, we took orders,” Lind said. “Today it is a collaboration.”

The changes in respiratory jobs also take the form of complicated protocols--plans for patient care, decided in advance and carried out by therapists. Protocols require therapists to be much more skilled in assessing patients’ problems so that they administer the right treatments, said respiratory services director Rick Ford of the UC San Diego Medical Center.

At UCSD, where protocols are used extensively, the cost of providing respiratory care for patients has dropped by nearly a fourth. Workloads decreased so much that Ford was forced to lay off employees.

By giving therapists more autonomy and responsibility, Ford said, “patients are receiving 40% fewer therapies, but outcomes are the same. The patients are getting out of the hospital in the same time frame, and there’s no increase in complications.”

Other benefits include getting patients off ventilators more quickly, a change that saves hospitals money and patients agony: “If you have a tube down your throat, the sooner it’s out the better,” said George G. Burton, medical director of respiratory services at Kettering Medical Center in Ohio.

But even as responsibilities for therapists have grown, state regulators have become increasingly dissatisfied with the quality of license applicants.

Staff at the respiratory care licensing board are swamped with applicants whose histories of driving under the influence, drug or assault charges must be probed. Additionally, these investigations often turn up a large number of false statements made by applicants during the licensing process. As many as one in four a year are found to have lied on their applications, McCoy said.

In contrast to the respiratory board’s 29% hit rate on criminal background checks, the agency that licenses registered nurses found only 1% of applicants last year had criminal records. That number is typical of recent years, the agency said.

The reasons for this difference are unclear. Some therapists say it is a result of abundant, moderately well-paying jobs in recent years combined with relatively light schooling requirements. These have “invited people in who otherwise wouldn’t have gotten into” the profession, said Terry McHale, a lobbyist for the California Society of Respiratory Care.

‘Diploma Mills’ Source of Concern

Respiratory care has in the past been singled out by job counselors as a good way to get poor and unemployed people back into the work force. At times, the field has been plagued by poorly run “diploma mills,” said Burton, a physician who helps accredit training programs.

Most crimes the board digs up on respiratory applicants aren’t serious, or are years old.

Between 1994 and 1996, regulators issued probationary licenses to just one-quarter of the applicants they found had criminal backgrounds and denied licenses to only 6% of them. Denial is now automatic in certain instances, such as sex crimes and chronic drug crimes.

Nor is there evidence to suggest that misconduct by practitioners is widespread. Kruser said there are few problems with probationers. Each year, the board’s records show that it takes action against only a small number of therapists--171 between 1994 and 1997--mostly for drug or alcohol related problems.

Julianne D’Angelo Fellmeth, a lawyer for the Center for Public Interest Law at the University of San Diego, calls the criminal conviction rate among therapists “just amazing,” and says reforms, especially the proposed reporting requirements, are needed to protect patients.

“The thing that may set respiratory care aside from other fields,” she said, “is that the patients are often unconscious” and thus more helpless, and far less likely to complain about their care.

She said the proposed reporting requirements could become a model for weeding out problem workers all the way down the medical hierarchy. “There is a danger with all health care professionals,” she said. “[The state] is not doing a good job of detecting patterns of misconduct and revoking licenses.”

Dr. Bruce Spurlock, executive vice president of the California Healthcare Assn., says that reporting requirements are probably a good idea for respiratory therapists and other medical workers.

But he said people should not be concerned if a large number of applicants have criminal records. What matters is how therapists perform on the job, not their past lives, he said.

Similarly, increased educational requirements should be approached with caution, he said. A seemingly good idea on the surface, the requirements can lead to shortages of workers down the line, especially in underserved areas, he said.

Other hospital lobbyists question why respiratory therapists are being singled out for increased scrutiny, especially given that no other ancillary medical professions have mandatory reporting requirements.

“What’s so special about respiratory therapists?” asked Jim Lott, senior vice president of the Healthcare Assn. of Southern California, a group representing 226 hospitals and physicians groups in the region.

Lott fears that the reporting requirements would create burdensome paperwork and leave hospitals vulnerable to employee lawsuits. Saldivar had no prior criminal record.

The bizarre case couldn’t be prevented by any law, Lott said, adding that the California Respiratory Care Board is “seizing the [Saldivar] case and sensationalizing it” to push its legislative goals.