A Dose of Reality


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A Dose of Reality

  1. 1. A Dose of Reality: Using Available Resources as an Agent for Change Jim Fink, MS, RRT, FAARC Fellow, Respiratory Science Nektar Therapeutics Mountain View, CA [email_address]
  2. 2. Background <ul><li>BS in Philosophy </li></ul><ul><ul><li>Student of Eastern Philosophies </li></ul></ul><ul><ul><li>Breathing as center of the universe </li></ul></ul><ul><ul><li>Conversant with practices to improve pulmonary delivery </li></ul></ul><ul><li>Looking to make sense of the universal truths </li></ul><ul><li>What’s a lad to do? </li></ul><ul><ul><li>Consult Your Spiritual Advisor </li></ul></ul>
  3. 4. Time to Find a Career: What to Be When I Grow Up? I searched the literature.
  4. 6. Healthcare Looked Like A Promising Profession
  5. 7. Heroic Expectations for Respiratory Care <ul><li>Make a difference </li></ul><ul><li>Help people </li></ul><ul><li>Be An Area Expert </li></ul><ul><li>Be An Active Member of the Team </li></ul><ul><ul><ul><li>Role in decision making </li></ul></ul></ul><ul><ul><ul><li>Sharing expertise </li></ul></ul></ul><ul><ul><ul><li>Problem solving </li></ul></ul></ul><ul><li>Interesting and varied work </li></ul><ul><li>Reasonable quality of life </li></ul>
  6. 8. Inhalation Therapy Florida 1971 <ul><li>Staring salary $2.10/hour </li></ul><ul><li>On the Job Trained - Two weeks training </li></ul><ul><ul><li>Best hospital training in town </li></ul></ul><ul><ul><li>No Respiratory Training Programs in the Community </li></ul></ul><ul><li>First treatment given </li></ul><ul><ul><li>IPPB to 24 year old bunionectomy </li></ul></ul><ul><ul><li>IPPB was 80% of floor therapy </li></ul></ul><ul><ul><ul><li>>50% of patients in hospital </li></ul></ul></ul><ul><ul><ul><li>Oh yes, IT departments were revenue centers </li></ul></ul></ul><ul><li>Crowning achievement – 20 IPPB Txs before Breakfast trays </li></ul>
  7. 9. Puff Parlors for COPD Pts
  8. 11. IPPB was killed…Due to Over Utilization and Lack of Evidence <ul><li>Evidence suggested little support for use </li></ul><ul><li>Feds did not want to pay millions without proof of benefit </li></ul><ul><li>But respiratory was still a cost center </li></ul><ul><ul><li>Substitution to maintain revenues </li></ul></ul><ul><ul><ul><li>Incentive spirometry </li></ul></ul></ul><ul><ul><ul><li>Chest physiotherapy </li></ul></ul></ul><ul><ul><ul><li>Aerosol therapy </li></ul></ul></ul>
  9. 12. Later … NPPV filled the unmet medical need <ul><li>Better patient selection </li></ul><ul><li>Better Clinical Evidence Base </li></ul><ul><li>More appropriate utilization </li></ul>
  10. 13. Evidence Based Medicine <ul><li>Most medicine does not have a sufficient evidence base </li></ul><ul><ul><li>Practice based on evidence alone is not practical </li></ul></ul><ul><li>Most clinician practice is based on what we learned (or didn’t learn) in school </li></ul><ul><li>As evidence base is established, it is not readily adopted into practice </li></ul>
  11. 14. We Are Area Experts <ul><li>Respiratory Therapists as a whole get more training in mechanical ventilation, airway management, oxygen therapy, aerosol therapy, and respiratory pharmacology than any other allied health group, and all but a few physicians </li></ul><ul><li>Stay current, know your stuff, share it with the team and your patients. </li></ul>
  12. 15. Training in Aerosols: A Textbook Example <ul><li>Physicians </li></ul><ul><ul><li>1 -2 pages </li></ul></ul><ul><li>Nurses </li></ul><ul><ul><li>5 – 10 pages </li></ul></ul><ul><li>Respiratory Therapists </li></ul><ul><ul><li>30 – 40 pages </li></ul></ul><ul><ul><ul><li>3% of typical 1200 page textbook </li></ul></ul></ul><ul><ul><ul><li>60 – 80% of RT practice </li></ul></ul></ul>
  13. 16. Management of chronic disease (such as asthma, CF and COPD) is 10% medication and 90% education
  14. 17. <ul><li>pMDIs, DPIs and Nebulizer can be equally efficacious </li></ul><ul><li>Key consideration for device selection </li></ul><ul><ul><li>Device/drug availability </li></ul></ul><ul><ul><li>Clinical setting </li></ul></ul><ul><ul><li>Patient age and ability to use the device correctly </li></ul></ul><ul><ul><li>Device use with multiple medications </li></ul></ul><ul><ul><li>Cost and reimbursement </li></ul></ul><ul><ul><li>Drug administration time </li></ul></ul><ul><ul><li>Convenience in both inpatient and outpatient setting </li></ul></ul><ul><ul><li>Physician and Patient preference </li></ul></ul>Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines Dolovich et al. Chest 2005; 127:335-371
  15. 18. Scope of Problem <ul><li>28 – 63% of patients do not use their pMDI or DPI well enough to get benefit of the drug </li></ul><ul><ul><li>More than 500 million pMDIs or DPIs are produced each year </li></ul></ul><ul><ul><li>At an average retail cost of $50/inhaler total retail of $25 Billion </li></ul></ul><ul><li>$7 – 15.7 Billion wasted </li></ul><ul><li>Increased ER visits and hospital admissions </li></ul><ul><li>Increased morbidity and mortality </li></ul>
  16. 19. Clinicians Can’t Teach What They Don’t Know <ul><li>28 – 68% of patients do not know how to use their pMDI sufficiently to gain full benefit of the medication </li></ul><ul><li>This correlates with 39 – 67% of RNs, MDs and RTs unable to use devices. </li></ul><ul><li>Clinicians are typically 5 – 8 years behind introduction of new devices </li></ul><ul><li>Need to upgrade clinician skills </li></ul>
  17. 20. Problems in Clinician Teaching <ul><li>Lack of familiarity with use of specific devices </li></ul><ul><li>Inadequate time to teach </li></ul><ul><li>Poor training techniques </li></ul><ul><li>Poor training materials </li></ul><ul><li>Lack of followup </li></ul>
  18. 21. Literacy <ul><li>Approximately 25% of the adult population in the US can not read and comprehend basic written instructions </li></ul><ul><ul><li>Take a pill after a meal </li></ul></ul><ul><ul><li>How to use your DPI </li></ul></ul><ul><li>There is an inverse relationship between reading grade level and correct performance of MDI technique </li></ul>Harvard Literacy Project, 1999
  19. 22. Literacy <ul><li>In a study of 483 patients presenting to ED or asthma clinic </li></ul><ul><ul><li>66% claimed to be high school graduates </li></ul></ul><ul><ul><li>27% actually read at the high school level </li></ul></ul><ul><li>Poor MDI technique ( ≤ 3 correct steps) </li></ul><ul><ul><li>89% of patient reading at 3 rd grade level </li></ul></ul><ul><ul><li>48% of patient reading at high school level </li></ul></ul>Williams et al. Chest 1998 114:1008-1015
  20. 23. The Inhaler Device with Highest Adherence: The Cigarette <ul><li>Aerosol devices </li></ul><ul><ul><li>1 – 5 µm </li></ul></ul><ul><ul><li>10 - 20% pulmonary deposition </li></ul></ul><ul><ul><li>Patients have problems using </li></ul></ul><ul><li>Cigarettes </li></ul><ul><ul><li>0.01 – 0.1 µm </li></ul></ul><ul><ul><li>80% pulmonary deposition </li></ul></ul><ul><ul><li>No problem taking a deep hit with breath hold </li></ul></ul>
  21. 24. Particle size and deposition Tobacco smoke Medical Aerosol
  22. 25. Phillip Morris Wall Street Journal, Thursday Oct 17, 2005
  23. 26. Education is key <ul><ul><li>Medication plan </li></ul></ul><ul><ul><li>Treatment plan </li></ul></ul><ul><ul><li>use of pMDI or DPIs </li></ul></ul><ul><ul><li>use of accessory devices </li></ul></ul><ul><ul><li>Use of nebulizers </li></ul></ul><ul><ul><li>Cleaning and maintenance of the device </li></ul></ul>
  24. 27. Common Myths <ul><li>Inhalers are so Simple They Don’t Require Training </li></ul><ul><li>DPIs and Nebulizers Require Less Training than pMDIs </li></ul><ul><li>Package Inserts are Sufficient </li></ul>
  25. 28. Problems with Inhaler Use - pMDI <ul><li>Inhale </li></ul><ul><ul><li>too early </li></ul></ul><ul><ul><li>too late </li></ul></ul><ul><ul><li>too often </li></ul></ul><ul><ul><li>too many times </li></ul></ul><ul><li>Failure to shake </li></ul><ul><li>Failure to prime </li></ul><ul><li>Use in cold weather </li></ul><ul><li>Cold freon effect </li></ul>
  26. 29. Problems with Inhaler Use - DPI <ul><li>Inhale too slow </li></ul><ul><li>Exhale into device prior to breath </li></ul><ul><li>Failure to hold in proper orientation </li></ul><ul><li>Failure to prime </li></ul><ul><li>Failure to pierce capsule or open blister pack </li></ul><ul><li>Failure to keep flow path open </li></ul><ul><li>Failure to breath hold </li></ul>
  27. 30. Dry Powder Inhalers-USA Device Dementia <ul><li>Accuhaler/Diskus: salmeterol; salmeterol plus fluticasone; fluticasone; (albuterol) </li></ul><ul><li>Aerolizer: eformoterol </li></ul><ul><li>Diskhaler: fluticasone (relenza) </li></ul><ul><li>Handihaler: tiotropium </li></ul><ul><li>Rotahaler: (albuterol) </li></ul><ul><li>Turbuhaler: budesonide </li></ul><ul><li>Twisthaler: (mometasone) </li></ul>www.thoracic.org
  28. 31. Diskhaler – label instructions
  29. 32. Clinician’s Role <ul><li>Device selection </li></ul><ul><li>Teaching </li></ul><ul><li>Demonstration </li></ul><ul><li>Return Demonstration </li></ul><ul><li>Evaluate adherence </li></ul><ul><li>Teaching/Demonstration </li></ul><ul><li>Return Demonstration </li></ul><ul><li>Evaluate adherence . . . </li></ul>
  30. 33. Match the Device to the Patient <ul><li>Some inhaled drugs have multiple device options </li></ul><ul><li>Device selection is key to adherence </li></ul><ul><li>Can the patient afford the device? </li></ul><ul><li>Can the patient use the device? </li></ul><ul><li>Will the patient use the device? </li></ul><ul><li>Does the patient use the device? </li></ul><ul><li>If not, why? </li></ul>
  31. 34. Sources of Information <ul><li>Product Label </li></ul><ul><li>National Standards </li></ul><ul><li>Patient instruction sheets </li></ul><ul><li>Journals – Respiratory Care </li></ul><ul><li>Published research </li></ul><ul><li>Internet </li></ul><ul><li>Text books </li></ul>
  32. 35. Questions Clinicians Should Answer: <ul><li>What should the drug do - why is it being prescribed </li></ul><ul><li>How to know the drug is working </li></ul><ul><li>How to know if the drug is not working </li></ul><ul><li>What are expected side effects </li></ul><ul><li>What are unexpected or less common side effects </li></ul><ul><li>How to take it </li></ul><ul><li>How will it taste, feel, ect </li></ul><ul><li>When to take it </li></ul><ul><li>How much to take </li></ul><ul><li>How often </li></ul><ul><li>When should dosing and frequency change </li></ul><ul><li>When should you call for help. </li></ul>
  33. 36. Simplicity and Repetition <ul><li>Match the Device to the patient </li></ul><ul><li>Use the same device when possible </li></ul><ul><li>Take time to teach </li></ul><ul><li>Use demonstration with placebo </li></ul><ul><li>Observe return demonstration </li></ul><ul><li>Follow up with each patient visit </li></ul><ul><li>Inquire - </li></ul><ul><ul><li>what patient likes and dislikes about each device and medication </li></ul></ul>
  34. 37. Improving adherence Education Make it easy Make it important Make it sexy
  35. 38. Activism Makes A Difference <ul><li>AARC </li></ul><ul><li>Chicago Asthma Consortium </li></ul><ul><li>Lung Association </li></ul><ul><li>ACCP </li></ul>
  36. 39. How To Get Started <ul><li>Show up </li></ul><ul><li>Show interest </li></ul><ul><li>Get involved </li></ul><ul><li>Take small steps </li></ul><ul><li>Take ownership </li></ul><ul><li>Make things happen </li></ul>
  37. 40. What About the “Good Old Boys?” <ul><li>Many organizations have the same leadership for extended periods because not enough members step up to participate </li></ul><ul><li>CSRC Experience </li></ul><ul><ul><li>1979 move to CA, attend district meeting </li></ul></ul><ul><ul><li>1981, President of CSRC </li></ul></ul>
  38. 41. Easy to Make a Difference <ul><li>Chicago Asthma Consortium </li></ul><ul><ul><li>Attended meeting </li></ul></ul><ul><ul><li>Patient education project </li></ul></ul><ul><ul><li>Chaired Patient Education Committee </li></ul></ul><ul><ul><ul><li>Produced Asthma Tool Analysis </li></ul></ul></ul><ul><ul><ul><li>20 hours over 6 months </li></ul></ul></ul><ul><ul><li>Chair of CAC </li></ul></ul>
  39. 42. ACCP Experience <ul><li>ACCP Opened Category for Allied Health </li></ul><ul><ul><li>Went to early meeting </li></ul></ul><ul><ul><li>Allied Health infiltrated major committee </li></ul></ul><ul><ul><li>Appointed to Health Science Policy </li></ul></ul><ul><ul><li>Initiated Aerosol Evidence Document </li></ul></ul><ul><ul><li>Appointed to Patient Education Committee </li></ul></ul><ul><ul><ul><li>Initiated Asthma Education Brochure </li></ul></ul></ul><ul><ul><ul><ul><li>International distribution </li></ul></ul></ul></ul><ul><ul><ul><li>Became Chair of Patient Education </li></ul></ul></ul>
  40. 43. RTs are Valuable to Physician Organizations <ul><li>We add valuable perspective </li></ul><ul><li>We tend to be able to get things done </li></ul><ul><li>Establish valuable PEER relationships </li></ul>
  41. 44. RTs - Acceptance Worldwide in Promoting Projects of Interest <ul><li>AARC – primary group </li></ul><ul><li>ATS </li></ul><ul><li>SCCM </li></ul><ul><li>ACCP </li></ul><ul><li>ISAM </li></ul><ul><li>ERS </li></ul><ul><li>ESICM </li></ul>
  42. 45. Involvement in physician and allied health based organizations help promote the agenda of the AARC, and our profession.
  43. 46. What are the responsibilities of a professional? <ul><li>Excel in providing services to patients </li></ul><ul><li>Contribute to scientific knowledge </li></ul><ul><li>Advance clinical practice </li></ul>
  44. 47. How have other professions guided practice and the future of their profession? <ul><li>Physical Therapy: Vision that all PTs will have Doctorate by 2020 - entry will be DPT </li></ul><ul><ul><li>Advancement via education </li></ul></ul><ul><li>Nursing: Advancement via clinical practice </li></ul><ul><ul><li>Changed scope of practice -licensure act </li></ul></ul><ul><ul><li>Advance practice defined as Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP) </li></ul></ul>
  45. 48. Practice Comparison: Ability to Order Medications <ul><li>Nurse practitioner </li></ul><ul><li>Physician Assistant </li></ul><ul><li>Physical Therapist </li></ul><ul><li>Respiratory Therapy training offers more hours of respiratory pharmacology than any of the above. </li></ul><ul><li>Shouldn’t we aspire to order limited therapies in the future </li></ul>
  46. 49. Where do we want to be in 2020? <ul><li>Advance Scope of practice </li></ul><ul><ul><li>Consider advancing scope of practice such as prescriptive authority for particular therapy </li></ul></ul><ul><li>Facilitate advanced practice thru education </li></ul><ul><ul><li>Prescriptive authority will require coursework </li></ul></ul><ul><li>RTs reimbursed for patient education services </li></ul>
  47. 50. <ul><ul><li>Doctors don’t listen to us </li></ul></ul><ul><ul><li>Nurses don’t like us </li></ul></ul><ul><ul><li>Patients don’t appreciate us </li></ul></ul><ul><ul><li>Not enough staff </li></ul></ul><ul><ul><li>Too much to do </li></ul></ul><ul><ul><li>No respect </li></ul></ul><ul><ul><li>No opportunities for growth </li></ul></ul><ul><ul><li>No future </li></ul></ul><ul><ul><li>No Hope </li></ul></ul>Common Dissatisfiers
  48. 51. For those who feel that this describes your reality in Respiratory Care I offer the following Public Service Message
  49. 52. Stop Whining Step Up Make A Difference