Research Week 3 Part 2.docx

So this slide really shows the tremendous versatility of volumetric capnography. Now, one of the things that we can do with the NM3 is we can measure cardiac output non-invasively. We used to measure cardiac output only invasively, and we've had to use something called thermal dilution. Here we have...

So this slide really shows the tremendous versatility of volumetric capnography. Now, one of the things that we can do with the NM3 is we can measure cardiac output non-invasively. We used to measure cardiac output only invasively, and we've had to use something called thermal dilution. Here we have a setup of how that is set up. And it involved placing a swan GANS catheter into the patient's heart, and then injecting cold injectate solutions that would use the principle of thermal dilution in order to tell us what the patient's cardiac output was. For several years now, the insertion of swan GANS catheters to do cardiac outputs has sort of diminished. And so we don't see as many of these these days as we used to in the past. You will still probably study this setup in your cardiopulmonary diagnostics class. But for right now, we're just using this as a point of comparison. We had to put all of this together. It was involved, it was complex, it was invasive. And today, we actually have a better way of determining cardiac output. Before I tell you what that better way is, let me remind you that the way that we're able to determine cardiac output is that we use the Fick equation. And in the Fick equation, shown here in green, what we use as a tracer gas is oxygen. So traditionally, in the Fick equation, we use oxygen to tell us about the cardiac output. The more oxygen transport there is, the better the cardiac output is, generally speaking. We can use a modified Fick equation to measure cardiac output. And by modified, I mean the following. Instead of using oxygen as a tracer gas, we use carbon dioxide as a tracer gas. If we transport oxygen, we also transport carbon dioxide. So we should be able to use carbon dioxide. And in fact, we do. The NM3 uses carbon dioxide as its preferred tracer gas in order to derive a cardiac output measurement. So when you are at the bedside, you will be working with a protocol/data sheet that looks like this. And if you look down toward the bottom of this data sheet, you will see that there is a place for cardiac output, C.O. And in this particular sheet, which is one that we used a couple of years ago, there is a place for one set of cardiac output measurements. And then there is another column for a second set of cardiac output measurements. And then we plot the mean. We are actually going to get a third set of cardiac output measurements. Then we will get the mean. And we will use the Excel spreadsheet to find out what the standard deviation is and to perform a t-test to see if there has been a change on the part of the patient in terms of not just cardiac output, but saturation, alveolar metabolic volume, airway resistance, and the other cardiopulmonary variables. Well, we have been talking about home health care. And previous to that, we spoke about neurorespiratory care. And later on, we are going to talk about pulmonary function testing. How do we bring all those three together? How do we provide neurorespiratory care and pulmonary function testing in a home health care context? Well, we are going to go through unit 3.5, NRC, and PFTs for rural ALS patients. This is funded respiratory therapy research. We will explain the role of transdisciplinary teams in delivering chronic clinically complex care. We will identify the Cochrane Library as an important source for systematic reviews that can be used to inform and design protocols. We will explain how role release improves the efficacy of care for patients with ALS. We will discuss the research role of RRTs in responding to the PFT NRC needs of our ALS patients in rural areas. What we are going to go over in this unit has already been covered in the article that you read for today titled Transdisciplinary Neurorespiratory Mobile Lab Improves the Health Care of Veterans with ALS. Well, if we want to provide the best available care for our patients, as you already know, we want to become conversant with the best available scientific evidence. And a really good source to do that is the Cochrane Library. This is a consortium of scientists who provide informed decisions that are based on the best available scientific evidence. Here is just one example of a systematic review that we obtained when we were trying to improve our clinical methods with regard to our ALS patients. This particular systematic review is entitled Mechanical Ventilation for ALS or Motor Neurone Disease. And it's a systematic review that was available back in October of 2017. The fact that it's a systematic review means that the recommendations provided in this review are based on the very best scientific evidence that is available. As we began to work with our ALS patients, we realized very quickly that these patients had chronic, clinically complex care. That meant that we were going to have to change the way that our team was structured. Prior to this time, our team was structured as you see here. The clinical behavior in our team was what you might call multidisciplinary or interdisciplinary. And what that meant was that the physician was at the very center, as seen in this diagram, and the physician would carry on a dialogue with occupational therapy, and with psychology, and with respiratory therapy, and with other health care providers. But there was very little, if any, sharing with providers from provider to provider. And this really impeded the progress and impeded our ability to respond in a very nimble way to patients' health care needs. I want you also to realize that nowhere in this diagram do you see the patient, or the patient's family, or the patient's caregivers. So one of the things that we learned as a result of delving into the Cochrane Library and trying to understand how we could reorganize ourselves to provide high-quality patient care for patients that have clinically complex problems was that we really needed to morph into more of a transdisciplinary team. Transdisciplinary teams, as enunciated by Carol and his group, really identify these complex issues that patients have so that all team members work on specific issues together. And you can see in this diagram that I am showing in yellow how the physician is a part of the team, but is not at the center of the team. There are interactions occurring between the physicians and all of the other health care providers. But in addition to that, and this is the important part, there are also interactions occurring between each provider and other members of the health care team. And you will notice one important addition. At the very top and to the right, it says "person with brain injury." Well, this happened to be an example of a program for someone with brain injury. But the important thing to understand is there is a patient at this table. And by definition, not just a patient, but a patient's caregivers and a patient's family as well. They have input, and we're asking them for their input. And we're asking them what they'd like to see. And they are very aware throughout the entire process what the process entails and what the likely outcomes are. Also very importantly, in a transdisciplinary team, is what we call "role release." Role release is where a specific clinician releases a part of his role to another practitioner, certifies that other practitioner so that that other practitioner can provide a very specific service to that individual, to that patient when the patient is at home, and thereby increase the efficiency with which we deliver patient care. And as we continued on with this process, what we realized was that this transdisciplinary collaboration addressed the issues of ALS patients very efficiently, much more so than when we were at the multi- or interdisciplinary team level. So by changing the model, we were able to also change the level of responsiveness with regard to our patients. Patients who were in the home were in a position to coordinate much more readily with practitioners in the hospital or practitioners in the laboratory setting, so that our level of responsiveness to their needs were heightened. Let's start by going back in time to when we first started to see ALS patients come to our hospital. And if we look at this graph, you can see that individuals with ALS had average length of stays of as much as 33 days for heart and lung issues, 55 days for respiratory care issues, and the average length of stay was actually increasing slowly over time. So clearly, we were not addressing the kinds of needs that our ALS patients were presenting to us. That's why the shift toward transdisciplinary care was so important. In this graph, we see the state of affairs from fiscal year 2007 to fiscal year 2014. And if we look at the graph that shows just the white line, you can see that the number of patients began escalating about fiscal year 2010. The death rate for the patients that we had also began to escalate at about 2010 or 2011. What you also notice, however, is that if you look at the survival rate of our patients, by the time that 2010 and 2011 roll around, the survival rate is actually improved grammatically. Now, just to give you a sense for this, the interdisciplinary and the multidisciplinary model of practice was in place from 2007 through 2010. And in 2011, from that point on, we see the introduction of the transdisciplinary model of care. And you can see that in evidence here by the large rectangles, the four rectangles that are to the right of the graph. And you can see that once the transdisciplinary model was instituted, we see an improvement in patient survival, given the fact that our patients are coming in and spending a long period of time in the hospital for not just cardiovascular, but also pulmonary problems. And an even better way to see this is looking at the average survival of patients with ALS after the transdisciplinary model was adopted. The transdisciplinary model was first adopted in 2011. And right after that, into the next year, 2012, and so forth, we see an increase in the overall amount of time that the individual was able to survive. There was an increase from 1.8 years to 2.7 years in the first year. That remained rather stable into the third year. But by the fourth year of the transdisciplinary team function, we see a very sizable increase in survival up to 5.1 years. In the same year that the transdisciplinary model was adopted, there was a retrospective chart review that was conducted by Dr. Halamein, one of the pulmonologists that served on the transdisciplinary team. And his findings revealed that patients that were in the rural sections of our catchment area were being underdiagnosed and undertreated. The average time from the baseline spirometry to subsequent spirometry was delayed because it was so difficult for these patients in the outlying rural areas to come into the hospital to get their spirometry. And the main reason was because they were becoming more and more physically impaired. This may travel from the rural areas to our PFT laboratory, very, very difficult for them, very challenging for them. So the transdisciplinary team recommended the following. Let's have the registered respiratory therapist perform PFTs in the home. Let's also have the registered respiratory therapist deliver neuro respiratory care in the home. And let's have the RRT perform a speech test in the home. Here we see a couple of photographs that attest to the difficulty that many of these families were encountering. Typically, it would mean that the ALS patient would have to board some kind of vehicle resembling this one. And then the patient, the family, the caregivers, all of the equipment that they needed and consumables that they needed would have to then make the trip into the VA hospital. And it was a day-long process. It was basically a day-long excursion where they would have to get up early in the morning and wouldn't get back home until nightfall. And one of the things that was happening was that the patients were typically so tired when they were in the pulmonary function testing laboratory that we could not tell as clinicians whether their tiredness was secondary to them simply being spent from a day of activity and a day of just trying to get to the hospital or whether what we were seeing really truly represented pathology. And that made it very difficult for us to be able to treat them in the way that we wanted to be able to treat them. Well, once we received the mandate from the transdisciplinary team, we set out to see if we could acquire pulmonary function testing equipment that might be used in the home. And we found that there was no off-the-shelf equipment available. So step one was to look for the best available scientific evidence. It was also helpful that we applied for and received a grant from the Department of Defense to determine how to get a registered respiratory therapy to perform PFTs in the home, what kind of equipment we were going to need to be able to deliver neuro respiratory care, and of course, to perform that initial speech test for PFTs. We have a research institute at the VA where we were able to bring together vendor technicians, computer programmers, biomedical engineers, and RRTs to take CareFusion products and repurpose them for in-home use. And here you can see some of those individuals at work. Next, we had to develop a prototype that we could then easily bring to the home of the rural-based patient. And you can see three prototypes here. The one at the upper left is the first prototype. And you can see that there is an aluminum bar that's stretching across an electronic wheelchair because we wanted to be able to do pulmonary function testing with the patient in the wheelchair and then have the patient go into a supine position and do a second pulmonary function test. You may recall that for ALS patients, we do two tests, one sitting upright and the other one in supine. In the second photograph, there is a composite bar that the engineers produced for us. And we tried that, but that did not work successfully. And in the third frame at the lower right, you see the final product after the engineer suggested that we use a tripod and that we marry the equipment that we had from CareFusion to that tripod. And that seemed to be a very versatile, very workable solution. Again, this is clinical research at its best. Then it was necessary to conduct field trials with the ALS/PFT/NRC mobile laboratory. How were we going to get the equipment to the patient's home? This had to be figured out, not just in terms of the van size that we're going to use, but how we're going to transport the equipment from the van into the home and then back into the van in order to bring back the equipment so that we could download the data and make it available to our pulmonologists. Among the other things that we did was to collaborate with assistive technologists to help them develop an iPad that had respiratory therapy icons. This enabled the patient to be able to be on top of appointments that he needed, whether it was a PFT appointment or whether he needed to do some sort of therapeutic intervention like a bronchodilator or maybe mechanical anaxesthylation. This was a very collaborative effort and it sprang directly from the fact that we changed from a multidisciplinary to a transdisciplinary model that really facilitated this quick collaboration, quick thinking, and quick problem solving way of handling patient care issues. You'll recall that when we have a team of researchers like this and we find something that works and works very, very well, we want to be able to publish that so that we can share that information with colleagues all over the country and indeed all over the world. Now one of the things that came out of this effort was that impulse oscillometry was actually exceptionally helpful in the early detection of different kinds of respiratory impairment in patients with ALS and that was published in Respiratory and Critical Care Medicine. Ultimately, it's about helping the patient. It really takes a team. It takes a transdisciplinary team. Impulse oscillometry, and we'll have more to say about impulse oscillometry when we do our PFT primer, was found to be more accurate than spirometry in helping to identify airway resistance. Impulse oscillometry was also much less physically demanding on the patient than spirometry. So impulse oscillometry was adopted. This significantly improved clinical surveillance. It enabled us to visit the patient's home more frequently and stay on top of respiratory changes so that decisions could be made in a timely fashion.