Quality and Evidence-Based Respiratory Care

Quality and Evidence-Based Respiratory Care

Lucy Kester and James K. Stoller

Quality is defined as a characteristic reflecting a high degree of excellence, fineness, or grade. Ruskin, a nineteenth-century British author, stated, “Quality is never an accident. It is always the result of intelligent effort.” Conclusions drawn from the assessment of quality are only temporary because the components of quality are constantly changing. Specifically, quality, as applied to the practice of respiratory care, is multidimensional. It encompasses the personnel who perform respiratory care, the equipment used, and the method or manner in which care is provided. Determining the quality of services provided by a respiratory care department requires intelligent efforts to establish guidelines for delivering quality care and a method for monitoring this care. The conclusions derived from monitoring the respiratory care provided change as clinical practice and expectations change. In the current cost-attentive era of health care, quality can be challenged by pressures to minimize cost, making the measurement and monitoring of quality even more important.

This chapter reviews issues related to the quality of respiratory care. First, we review the elements of a hospital-based respiratory care program, focusing on medical direction, practitioners, and technical direction. With the objective of quality being the competent delivery of indicated care, we discuss respiratory care protocols as one strategy to ensure quality. Methods for monitoring quality are discussed next, with attention to the role of The Joint Commission (TJC) and peer review organizations (PROs). We then discuss the effect of several health care delivery strategies on respiratory care quality. Finally, we review the concept of evidence-based medicine as it applies to the practice of respiratory care.

Elements of A Hospital-Based Respiratory Care Program: Roles Supporting Quality Care

Medical Direction

The medical director of respiratory care is professionally responsible for the clinical function of the department and provides oversight of the clinical care that is delivered (Box 2-1). Medical direction for respiratory care is usually provided by a pulmonary/critical care physician or an anesthesiologist. Whether the role of a respiratory care service medical director is designated as a full-time or part-time position, it is a full-time responsibility; the medical director must be available on a 24-hour basis for consultation with and to give advice to other physicians and the respiratory care staff. The current philosophy of cost containment and cost-effectiveness, dictated by medical care market forces, poses a challenge to the medical and technical leadership of respiratory care services to provide increasingly high-quality patient care at low cost. A medical director must possess administrative and medical skills.1

Perhaps the most essential aspect of providing quality respiratory care is to ensure that the care being provided is indicated and that it is delivered competently and appropriately. Traditionally, the physician has evaluated patients for respiratory care and has written the specific respiratory therapy orders for the respiratory therapist (RT) to follow. However, such traditional practices have often been shown to be associated with misallocation of respiratory care.24 This misallocation may consist of ordering therapy that is not indicated, ordering therapy to be delivered by an inappropriate method, or failing to provide therapy that is indicated.5 Table 2-1 reviews studies evaluating the allocation of respiratory care services and the frequency of misallocated care.3,612 These studies provide ample evidence that misallocation of respiratory care occurs frequently. Such misallocation has led to the use of respiratory care protocols that are implemented by RTs (as described under Methods for Enhancing the Quality of Respiratory Care).


Frequency of Misallocation of Respiratory Care Services in Selected Series

Type of Service Author Date Patient Type No. Patients Frequency of Overordering Frequency of Underordering
Supplemental oxygen Zibrak et al6 1986 Adults NS 55% reduction in incentive spirometry after therapist supervision began NA
  Brougher et al7 1986 Adult, non-ICU inpatients 77 38% ordered to receive oxygen despite adequate oxygenation NA
  Small et al8 1992 Adult, non-ICU inpatients 47 72% of patients checked had PaO2 > 60 mm Hg or SaO2 > 90% but were prescribed oxygen NA
  Kester and Stoller3 1992 Adult, non-ICU inpatients 230 28% for supplemental oxygen 8% for supplemental oxygen
  Albin et al9 1992 Adult, non-ICU inpatients 274 61% ordered to receive supplemental oxygen despite SaO2 ≥ 92% 21% underordered, including 19% prescribed to receive inadequate O2 flow rates
  Shelledy et al12 2004 Adults 75 0 5.3% indicated but not ordered
Bronchial hygiene techniques Zibrak et al6 1986 Adults NS 55% reduction in incentive spirometry after therapist supervision began NA
  Shapiro et al10 1988 Adult, non-ICU inpatients 3400 evaluations 61% reduction of bronchial hygiene after system implemented NA
  Kester and Stoller3 1992 Adult, non-ICU inpatients 230 32% 8%
  Shelledy et al12 2004 Adults 75 37.5% 8%
Bronchodilator therapy Zibrak et al6 1986 Adults NS 50% reduction in incentive aerosolized medication after therapist supervision began NA
  Kester and Stoller3 1992 Adult, non-ICU inpatients 230 12% 12%
  Shelledy et al12 2004 Adults 75 34.4% 5.3%
  Kester and Stoller3 1992 Adult, non-ICU inpatient 230 40% 6.7%
ABGs Browning et al11 1989 Surgical ICU inpatients 724 ABGs 42.7% inappropriately ordered before guidelines implemented NA


NS, Not stated; NA, not assessed.

Modified from Stoller JK: The rationale for therapist-driven protocols. Respir Care Clin N Am 2:1–14, 1996.

Respiratory Therapists

In addition to capable medical direction and the application of well-constructed respiratory care protocols (see p. 26), capable RTs are an indispensable element of a quality respiratory care program. The quality of RTs depends primarily on their training, education, experience, and professionalism. Training teaches students to perform tasks at a competent level, whereas clinical education provides students with a knowledge base they can use in evaluating a situation and making appropriate decisions.13 Both adequate training and clinical education are required to produce qualified RTs for assessment of patients and implementation of respiratory care protocols.14

Designations and Credentials of Respiratory Therapists

There are two levels of general practice credentialing in respiratory care: (1) certified respiratory therapists (CRTs) and (2) registered respiratory therapists (RRTs). Students eligible to become CRTs and RRTs are trained and educated in colleges and universities. After completion of an approved respiratory care educational program, a graduate may become credentialed by taking the entry-level examination to become a CRT. A CRT may be eligible to sit for the registry examinations to become a credentialed RRT. Students who complete a 2-year program graduate with an associate degree, and students who complete a 4-year program receive a baccalaureate degree. Some RTs go on to complete a graduate degree (e.g., master or doctorate) with additional study in the areas of respiratory care, education, management, or health sciences. The further development of graduate education in respiratory care has been encouraged by the American Association for Respiratory Care (AARC), and programs are both currently available and under development.15

Respiratory care education programs are reviewed by the Committee on Accreditation for Respiratory Care (CoARC). This committee is sponsored by four organizations: the AARC, the American College of Chest Physicians (ACCP), the American Society of Anesthesiologists (ASA), and the American Thoracic Society (ATS). The CoARC is responsible for ensuring that respiratory therapy educational programs follow accrediting standards or essentials as endorsed by the American Medical Association (AMA). Members of the CoARC visit respiratory therapy educational programs to judge applications for accreditation and make periodic reviews. The mission of the CoARC, in collaboration with the Association of Specialized and Professional Accreditors, is to promote quality respiratory therapy education through accreditation services. An annual listing of accredited respiratory therapy programs is published. As of November 2010, there were approximately 415 CoARC-approved respiratory care programs.

Credentialing is a general term that refers to the recognition of individuals in particular occupations or professions. Generally, the two major forms of credentialing in the health fields are state licensure and voluntary certification. Licensure is the process in which a government agency gives an individual permission to practice an occupation. Typically, a license is granted only after verifying that the applicant has demonstrated the minimum competency necessary to protect the public health, safety, or welfare. Licensure laws are normally made by state legislatures and enforced by specific state agencies, such as medical, nursing, and respiratory care boards. In states where licensure laws govern an occupation, practicing in the field without a license is considered a crime punishable by fines or imprisonment or both. Licensure regulations are based on a practice act that defines (and limits) what activities the professional can perform. Two other forms of state credentialing are less restrictive. States that use title protection simply safeguard the use of a particular occupational or professional title. Alternatively, states may request or require practitioners to register with a government agency (registration). Neither title protection nor state registration constitutes a true practice act, and because both title protection and registration are voluntary, neither provides strong protection against unqualified or incompetent practice.

Certification is a voluntary, nongovernment process whereby a private agency grants recognition to an individual who has met certain qualifications. Examples of qualifications are graduation from an approved educational program, completion of a specific amount of work experience, and acceptable performance on a qualifying examination. The term registration is often used interchangeably with the term certification, but it may also refer to a type of government credentialing. As a voluntary process, certification involves standards that are often higher than the minimum standards specified for entry-level competency. A major difference between certification and licensure is that certification generally does not prevent others from working in that occupation, as do most forms of licensure. Both types of credentialing apply in respiratory care.

The primary method of ensuring quality in respiratory care is voluntary certification or registration conducted by the National Board for Respiratory Care (NBRC). The NBRC is an independent national credentialing agency for individuals who work in respiratory care and related services. The NBRC is cooperatively sponsored by the AARC, the ACCP, the ASA, the ATS, and the National Society for Pulmonary Technology. Representatives of these organizations make up the governing board of the NBRC, which assumes the responsibility for all examination standards and policies through a standing committee. The NBRC provides the credentialing process for both the entry-level CRT and the advanced-practitioner RRT. As established in January 2006, to be eligible for either the CRT or the RRT examination, all candidates must have an associate degree or higher. An additional advanced-practitioner credential, the neonatal/pediatric specialist (NPS), has been established for the field of pediatrics. The NBRC also encourages professionals in the field to maintain and upgrade their skills through voluntary recredentialing. Both CRTs and RRTs may demonstrate ongoing professional competence by retaking examinations. Individuals who pass these examinations are issued a certificate recognizing them as “recredentialed” practitioners. In addition to the certification and registration of RTs, the NBRC provides credentialing in the area of pulmonary function testing for certified pulmonary function technologists (CPFTs) and registered pulmonary function technologists (RPFTs). Since its inception, the NBRC has issued more than 350,000 professional credentials to more than 209,000 individuals. As of 2010, there were approximately 206,150 active RTs, many of whom hold more than one credential. Table 2-2 shows the distribution of these credentialed individuals.

At the time of publication, 49 states, the District of Columbia, and Puerto Rico have some form of state licensure. Many states use the NBRC entry-level respiratory care examination for state licensing, whereas others simply verify NBRC credentials. Most licensure acts require the RT to attain a specified number of continuing education credits to maintain his or her license. Continuing education helps practitioners keep abreast of the changes and advances that occur in their health care field.

Licensure and certification help ensure that only qualified RTs participate in the practice of respiratory care. Many institutions conduct annual skills checks or competency evaluations in compliance with TJC requirements. Beyond TJC–required skills checks, experience with respiratory care protocols suggests the need to develop and monitor additional skills among RTs (Box 2-2). Assurance and maintenance of these skills require ongoing training and quality review programs, which are discussed in the section on Monitoring Quality Respiratory Care.


By definition, professionalism is a key attribute to which all RTs should aspire and that must guide respiratory care practice. Webster’s New Collegiate Dictionary defines a profession as “a calling that requires specialized knowledge and often long and intensive academic preparation.” A professional is characterized as an individual conforming to the technical and ethical standards of a profession. RTs demonstrate their professionalism by maintaining the highest practice standards, by engaging in ongoing learning, by conducting research to advance the quality of respiratory care, and by participating in organized activities through professional societies such as the AARC and associated state societies. Box 2-3 lists the professional attributes of the RT. We emphasize the importance of these attributes because the continued value and progress of the field depend critically on the professionalism of each practitioner.16

In the highly regulated careers of health care, professionalism also requires compliance with external standards, such as the standards set by TJC and by the government. One such standard is defined by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA sets standards regarding the way sensitive health care information is communicated and revealed in the transmission of medical records and in the written and verbal communication of information in the hospital. Some specific provisions of HIPAA are presented in Box 2-4. As with all hospital and health care personnel, standards of respiratory therapy professionalism require knowledge of HIPAA and compliance with its terms.

Technical Direction

Another important element for delivering quality respiratory care is technical direction. Technical direction is often the responsibility of the manager of a respiratory care department, who must ensure the equipment and the associated protocols and procedures have sufficient quality to ensure the safety, health, and welfare of the patient using the equipment. Medical devices are regulated under the Medical Device Amendment Act of 1976, which comes under the authority of the U.S. Food and Drug Administration (FDA). The FDA also regulates the drugs delivered by RTs. The purpose of the FDA is to establish safety and effectiveness standards and to ensure that these standards are met by equipment and pharmaceutical manufacturers.

Procedures and protocols related to the use of equipment and medications must be written to provide a guide for the respiratory care staff. In addition, equipment must be safety checked, and specific maintenance procedures must be performed on a regular basis. Because of rapidly changing respiratory care technology, the job of the technical director poses significant challenges. Circuit boards and computers have replaced simpler mechanical devices. New medications and delivery devices for the treatment of asthma and new strategies for treating other respiratory diseases (e.g., low-stretch ventilatory approaches for acute respiratory distress syndrome [ARDS]) continue to evolve. Individuals responsible for technical direction must ensure that these new devices, methods, and strategies not only are effective but also deliver a benefit commensurate with the cost.

Jun 12, 2016 | Posted by in RESPIRATORY | Comments Off on Quality and Evidence-Based Respiratory Care

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