Role of RTs

As a result, respiratory therapists increasingly began to perform out-of-operating room intubations, even when physicians and residents were present but lacked the appropriate certification. The change created some controversy, which has now died down, said Sam T. (John) Sum-Ping, MB ChB, FRCA, chief of anesthesiology and pain management, at the Dallas VAMC and acting director, National Anesthesia Service, for VHA.

Sum-Ping noted that a recent survey found that out-of-operating room airway management was done by respiratory therapists at the VA 44% of the time, emergency physicians 25% of the time and critical-care physicians about 5% of the time, with the remainder spread over many disciplines.

“Somebody has to do it,” Sum-Ping pointed out. “After some initial resistance, everyone decided, ‘You know, this is the way we’ll have to do it. This is the way to go.’ It improves patient care.”

A paper describing the initiative on the Agency for Healthcare Research and Quality website called that a “real change from traditional medicine,” noting, “Airway management and tracheal intubation are dramatic and frequently life-preserving or life-saving measures. Consequently, physicians have a natural desire to be able to provide that care. However, as the literature demonstrates, physicians without specific training in airway management tend to have a relatively low success rate. The concept that intubation is now a skill that requires privileges was a real culture change, even though many other skills need to be specifically mentioned in privilege.”

That paper, by Erik J. Stalhandske, MPP, MHSA; Michael J. Bishop, MD, and James P. Bagian, MD, PE, of the VA, said the success of trained nonphysician providers in airway management was well-documented by the time the VA instituted its policy. “Paramedic success rates in field intubations generally hover in the 90 to 98 percent range under conditions that often are quite trying,” it said, while also describing how one respiratory care department had a 90% success rate in intubating patients when non-anesthesiologist physicians had failed to do so.

Even now, not all VAMCs consistently meet the requirements, however. This past summer, the VA Inspector General found that during a six-month period at the VA Northern Indiana Health Care System in Fort Wayne, IN, “we found 23 days with time periods ranging from four to 15 hours during which there were no staff in the facility with demonstrated competence in out-of-operating room airway management.” VISN management concurred with the IG’s findings and assured that appropriately trained personnel would be available at all times.

While he said he could not comment on the specific situation in Fort Wayne, Sum-Ping described the procedure at the Dallas VAMC as more typical.

“An anesthesia provider is on the code team during business hours,” he said. “Respiratory therapists are always there.” He noted that, in the rare cases where the respiratory therapists can’t successfully intubate, a member of the anesthesia team is called and arrives within 30 minutes.

“We train respiratory therapists to maintain airway until we come in to intubate. Use of respiratory therapists and other specifically trained personnel in non-operating room airway management increases patient safety,” Sum-Ping said.

With the issue of who does airway management essentially sorted out, the VA is focusing more on training and methods to assure intubation has been performed properly.

A 2002 survey, prior to the VA directive, found that more than half of VA facilities used colorimetric analyzers (CO2 analyzers) to confirm tracheal placement, in addition to clinical assessment of breath sounds, but nearly one-third used no adjunctive devices at all to confirm tube placement.

The 2005 directive followed American Heart Association (AHA) guidelines, which state that “a CO2 colorimetric device is appropriate when there is a perfusing rhythm; otherwise, use a syringe or bulb designed to confirm endotracheal tube placement.”

Video Laryngoscopes

Sum-Ping said a new directive awaiting approval calls for the use of video laryngoscopes, which can be especially important for personnel who are not anesthesia providers and are less experienced with intubation.

Video laryngoscopes employ digital technology to generate a view of the glottis, so that the trachea may be intubated.

The proposed directive also provides for more simulation in training tools.

“In the past, we only trained people in the manual skill of maintaining an airway, but it is a cognitive skill also,” Sum Ping said. He pointed out that VA is purchasing high-fidelity training mannequins for a majority of facilities.

That can be especially significant for a smaller VAMC. In those facilities, management can seek a waiver to the VA’s airway-management requirements and simply call 911 when a patient is in distress. That can be both expensive and dangerously time-consuming, Sum-Ping pointed out.

A high-fidelity simulator will make it possible for a respiratory therapist or other professional to practice intubations on the simulator, then go to a larger hospital to do enough actual intubations to meet certification requirements.

Sum-Ping also said a new VA medical simulation training center in Orlando promises to significantly improve airway-management training across the country.

The Medical Simulation Center for Excellence, SimLEARN, is expected to open in December with the Orlando VA Medical Center.

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