The first video in a series highlighting rtNOW’s amazing telerespiratory therapists. This video introduces Kathy Waterhouse. For more information, visit https://rtnow.net
Our CSO Curt Merriman spoke recently at the AARC Congress on the topic of ‘Telehealth: Past, Present, and Future. This presentation will define telehealth in the context of respiratory care, discuss its usage during COVID-19 and the associated health outcomes, and identify how telehealth can be used in the respiratory care of the future. In addition, the presenters will discuss Medicare benefits that allow respiratory therapists to provide telehealth and which provisions are likely to become permanent after the pandemic.
Click here to view on the AARC’s page: https://www.aarc.org/webcasts/telehealth-past-present-and-future/
Being a HME company in America isn’t easy. You want to provide quality care for patients, but every year it seems to get harder. There are respiratory therapist shortages, dwindling dollars, mountains of regulations, and billing rates that are simply not adequate?
The good news is that there is a pressure-release valve, and it’s name is “HME On-Call”. If these problems sound familiar, read on for 5 reasons you should consider a telehealth solution.
Patient Safety
Prior to the coronavirus pandemic, attitudes toward telehealth were mixed at best. The prevailing attitude (among the elderly in particular) was that visiting a hospital or having a provider visit the home were the “safest” options, and many people simply didn’t question whether or not this was accurate for their particular circumstances. The reasons for this range from personal habit to lack of physician adoption, but one thing that can be said for certain is that coronavirus has dramatically shifted public opinion – especially in elderly populations.
Hospitals and providers that used to be considered safe are now viewed as potential dangers – and for good reason. It makes little sense to get in-person training or troubleshooting on a piece of equipment while being potentially exposed to coronavirus.
Enter telehealth.
Telehealth can mitigate unnecessary trips to patient homes, reduce hospital readmissions, and provide patient confidence that they are getting the safest form of care possible in a pandemic and post-pandemic world. This can reduce stress and at times provide working equipment faster than dispatching a technician, further contributing to the overall health of the patient.
Provider Safety
The same reasons for mitigating exposure to patients can also apply to providers. Coronavirus has shown that danger exists not only to patients, but to clinicians and technicians entering the home environment. With the delay in onset of symptoms, challenging access to testing, and an ongoing growth of knowledge of the virus, the best answer to protect providers (and the companies that employ them) is to limit contact with patients. As such, telehealth has emerged as a powerful and necessary resource to handle all but the most essential home visits. It protects providers, preserves essential supplies, limits liability, and fosters a confidence with employees that their lives are protected and valued, resulting in both tangible and intangible benefits.
Telehealth Reduces Expenses
Is there any HME cost more unnecessary than dispatching an RT or technician to plug in a machine? The great news is that there are numerous ways that telehealth can be utilized to reduce these trips. From tracking a line problem to confirming that a GFCI outlet has been reset, telehealth can be utilized as a first line of defense before sending someone to a patient’s home.
A potentially greater, although harder to define, reduction of expenses can be found in reducing “RT Burnout”. With the current shortage in respiratory therapists, it is more important than ever to keep RTs satisfied in their job. As such, removing on-call demands – especially the unnecessary ones – goes a long way to showing respiratory therapists they are valued. This boosts morale and reduces attrition, reducing the HR burden associated with replacing an RT, as well as the costs associated with downtime.
The Competitive Edge
Telehealth is still in its infancy – especially in the HME/DME space. As with most new technological solutions, those who reap the greatest benefits are those who adopt the changes early enough to maintain a competitive edge. The use of telehealth can be communicated to your clients – providing another value-add that shows you are on top of industry changes. The associated benefits to patient and provider health are selling points that can position your company as the vendor of choice. Speaking of positioning, it also allows the ability to scale your business in ways previously unattainable as some of the limits of time and space are removed from everyday tasks.
Patient Satisfaction
Moving a step beyond patient safety, we can begin to focus on areas of customer service. Telehealth technology and workflow can provide a level of patient feedback that is consistent and reportable. Is the technician or provider representing your company well? What areas of improvement or innovation can be found? Giving the patient a voice while taking care of their problems remotely can be a powerful way to create lasting relationships with your company without sacrificing time or money.
Making the Move to a HME Telehealth Solution
rtNOW pioneered a HME telehealth solution called “HME On-Call” – a service that provides telerespiratory therapists to HME patients up to 24/7/365. HIPAA-compliant telehealth software is utilized, and the therapists are trained to troubleshoot HME equipment in any state. If your HME company has trouble with “RT Burnout”, unnecessary dispatches, and patient/provider safety, then visitrtnow.net/HME, call (833) 786- 6948, or email Curt Merriman atcurt@rtnow.net.
Initiative aims to reduce “RT Burnout” while improving patient care.
FRANKENMUTH, MI, October 13, 2020– Telerespiratory pioneer rtNOW announced a new service aimed at solving respiratory therapy problems in the HME/DME healthcare industry. Named “HME On-Call”, the service provides 24/7/365 access to a respiratory therapist who is trained to troubleshoot HME calls using proprietary telehealth software.
“HME Companies have had a rough time keeping respiratory therapists – especially during the current RT (respiratory therapist) shortage,” said Chuck Stadler, Jr., President and CEO of rtNOW. “A large part of the reason is that too much is required of them. Our telerespiratory therapists have been trained to navigate the complexities of HME equipment, patient interactions via telehealth, and how to dispatch a client’s RT only when necessary. As a result, patients and providers are safer, disease exposure is mitigated, and respiratory therapists are able to have the work-life balance necessary for a long-term position. This also reduces costs associated with RT turnover, downtime, and continuity of care.”
The concept of telerespiratory care has been rapidly gaining momentum in recent years. rtNOW has had success as the first respiratory-care specific telehealth company in the nation.
“We have been fortunate to maintain a culture of innovation, and our services have been well received. HME On-Call utilizes our CoreLink software solution, making HIPAA-compliant telehealth easily accessible to most patients. We know the industry well, we want to connect patients and providers, and we have a passion for empowering respiratory care,” Mr. Stadler said.
rtNOW is a respiratory care telehealth solution that provides up to 24/7/365 access to an experienced, licensed respiratory therapist. It provides inpatient and outpatient respiratory care solutions, as well as solutions for higher education and HME/DME companies.
Please note, with the unprecedented demands COVID-19 has placed on our profession, the distribution of certificates for the CEU will be slightly delayed. We apologize for this. As you can imagine, we are doing our best to be responsive to the needs of the participants, but our first priority has to be responding to the immediate needs of this pandemic.
We have done our best to post and answer all of the questions posted in the webinar below. Please note that there are a few questions to Shawna and Sarah that do not have an answer. We will post the answers as we get them.
Clinical Practice Questions
Q: what are we doing about performing PFT s :Comments below are taken from the Diagnostic section of AARConnect:
A: Infection Prevention Team, we have been (obviously) extra conscientious about hand hygiene and monitoring for staff and patient symptoms. We have also been instructed to wear masks, eye shield and gloves when performing PFTs, given that PFTs can be cough-inducing, i.e. being at higher risk of exposure.
We have also instructed our team to wear masks, eye shields and gloves when performing PFTs. Additional screening has been put into place prior to testing. We are postponing all testing in patients who have been symptomatic (flu-like symptoms) within 21 day prior to the appointment. If a patient comes in symptomatic, we are obtaining a temperature and following our emergency room protocol.
Calling patients prior to testing and asking health screening questions to help determine if they should come in for testing or not.
I have also been hearing many health organizations are looking to halt OP testing of any sort if it is routine or does not have an impact on other treatment or surgical interventions.
Q: For patients who are having a hard time oxygenating, is proning appropriate?
A: There are good article references in the AARConnect “Resources for COVID-19” community if you are an AARC member. Also from what I have been reading using ventilation/oxygenation techniques as you would for any patient would be appropriate.
Q: RT can perform PCR NASOPHRAYNGEAL swap?
A: This would be up to your facility & lab policy.
Q: How many days Do patients is expected to remain intubated?
A: This will vary from patient to patient due to all the individual variables factoring into the specific case.
Q: Any idea what percentage of infected patients are experiencing respiratory symptoms?
A: I refer you to the CDC.gov web page for the most up to date information. I have not seen the statistics presented exactly as you have asked in your question.
Q: should outpatient, routine PFTs be postponed until further notice?
A: This is unfolding in realtime and would look to your internal organizations plans and following the CDC.gov web site. I have heard of some OP diagnostic centers considering postponing testing unless essential for treatment determination.
Q: Is there a special protocol for COVID-19 patients?
A: The CDC.gov has great information and suggested guidelines. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
Q: What is the course of treatment?!? My hospital does not see using NIV or HFNC has producing droplets (which I’ve always disagreed with) and are not following the proper precautions?!? How do we treat these patients when everyone says something different?!?
A: One of our speakers referenced an article from China indicating that NIV was not very effective in treating some of the patients and they also discussed using a “helmet” patient interface with NIV.
Q: Do these patients need to be in a negative flow environment?
A: CDC says to use airborne infection isolation rooms only when a known COVID-19 infection + aerosol generating procedures
Q: Still use multi canister mdi’s?
A: What I have seen is that protocols for use of multi-canister mdi are not applicable for patients in isolation.
Q: Still use multi canister inhalers?
A: What I have seen is that protocols for use of multi-canister mdi are not applicable for patients in isolation.
Q: Hand held nebulizer or MDI??? Which is best practice for covid19?
A: Because of the droplet transmission, it is recommended to minimize aerosols that may carry and disperse aerosols. It would be reasonable to consider non-aerosol generating therapeutic inter-change.
Q: What do we know about children and COVID?
A: Refer to CDC.gov, however children have not been affected as much compared with influenza viruses
Q: What is the clinical recommendations for treating COVID 19? Are they saying not to use HFNC and NIV?
A: Due to the potential aerosol/droplet dispersion of these modalities, some references discourage their use.
Q: So is the recommendation to not use nebulizers and just use MDI and DPI on these patients?
A: Because of the droplet transmission, it is recommended to minimize aerosols that may carry and disperse aerosols. It would be reasonable to consider non-aerosol generating therapeutic inter-change.
Q: Is it worth using NIV, HFNC, aerosols? Or just going straight to intubation?
A: Each patient presents a unique situation, the decision to intubate, or not, will depend on a number of factors specific to each patient. Using evidence based criteria in determining the appropriateness of intubation in any specific situation is recommended.
Q: How do you stop physicians from ordering unneeded treatments to this population. Bronchodilators does not fix hypoxia.
A: This is certainly a challenge…even when protocols are utilized! If your ordering physician is receptive to seeing information present the treatment guidelines from the CDC.
A: Like disinfection the surface & equipment etc.. Look to CDC.gov for guidance and your standard procedures
Q: After intubation how could disinfect the scope, blade,other misc equipment.?
A: Look to CDC.gov for guidance and your standard procedures
Q: Shawna, I know you recommended MDIs and DPIs in place of SVNs. For those that can’t do those and need a SVN would putting an HME (viral/ antibacterial filter on the end of the SVN a good idea to eliminate droplets in the air?
A: Shawna Strickland@Victoria Hodges – I believe the advice is to put the patient in a negative pressure (airborne infection isolation room) during that procedure if possible.
Q: How do we confirmed in the lab test if it is ncov? What kind of point of care testing ? Thank you & please take care.
Q: Alos niños los está afectando y si esos ninos tenían todas sus vacunas (Translation: Children are affecting them and if those children had all their vaccines)
Q: Los pacientes adultos que fueron afectados tenían sus vacunas completas y los que fallecieron las tenían también ,se que no hay vacuna para covide 19pero existe relación en la Morbi mortalidad de esto. (Translation: The adult patients who were affected had their vaccines complete and those who died had them too, I know there is no vaccine for covide 19 but there is a relationship in the Morbi mortality of this)
A: I don’t know that there has been enough evidence reported to date regarding other vaccinations. Underlying chronic conditions has a significant factor affecting the mortality rate in conjunction with the age of the patient. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics
Q: Is there a recommendation for facilities whose therapist who care for NICU/pediatric and adult populations? Should therapists be dedicated to one age population?
A: Facility internal resources will likely be the determining factor.
Q: As i said before I work as home care rt, do you think we can spread it if go from one home to another?
Q: How about using nebulization anti viral – specific for RNA viruses ? What’s your opinion using in-line nebulization of antiviral – RNA like Ribavirin and Zanamivir ? or other Anti-viral – RNA virus
Q: Is there a need to put a patient into a negative pressure room?
A: CDC recommends this when possible https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics
Q: Covid19 recovery patient do they have recurrent ?
A: I believe I saw a repeat case in China from one of the published studies on CDC.gov.
Q: How about checking IgM and IgG covid 19 ?
A: I believe this testing is pending FDA approval at this time
CDC Questions:
Q: Is there any idea about how widespread this could become in coming weeks/months?
Q: Is it known how many days post symptom presentation the inflammatory response peaks?
A: Information is more specific to symptom changes, the CDC has some more information on this here; https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
Q: How long do these droplet particles last on solid surfaces?
A: CDC indicates the virus may live for hours to possibly days depending on the surface. https://www.cdc.gov/coronavirus/2019-ncov/prepare/cleaning-disinfection.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcommunity%2Fhome%2Fcleaning-disinfection.html
Q: Is there a time line for how long the virus lasts or at what day it would peak?
Q: I might have missed this slide but, the virus supposedly has an incubation period 5-10 days or so, what of the chances of contracting the virus of an asymptomatic host if you don’t wear a mask if you’re not sick?
A: I don’t know if this is known however here is a good link you may find useful; Healthcare FAQ’s: https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
Q: Of the patients that have confirmed with COVID-19, What is the instance of patients needing respiratory support (ie invasive ventilation)?
A: Approximately 20-30% of hospitalized patients with COVID-19 and pneumonia have required intensive care for respiratory support.[2–3] Compared to patients not admitted to an intensive care unit, critically ill patients were older (median age 66 years versus 51 years), and were more likely to have underlying co-morbid conditions (72% versus 37%). [3] Among critically ill patients admitted to an intensive care unit, 11–64% received high-flow oxygen therapy and 47-71% received mechanical ventilation; some hospitalized patients have required advanced organ support with endotracheal intubation and mechanical ventilation (4–42%).[3–4,9] A small proportion have also been supported with extracorporeal membrane oxygenation (ECMO, 3–12%).[3–4,9] Other reported complications include cardiac injury, arrhythmia, septic shock, liver dysfunction, acute kidney injury, and multi-organ failure. Post-mortem biopsies in one patient who died of ARDS reported pulmonary findings of diffuse alveolar damage. [14];
Q: Once a person has it, and gets over it, is there a chance for re-exposure?
A: The immune response to COVID-19 is not yet understood. Patients with MERS-CoV infection are unlikely to be re-infected shortly after they recover, but it is not yet known whether similar immune protection will be observed for patients with COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
Q: I see on tv other countries are using head to toe ppe. Are we safe just using goggles, Updated PPE recommendations for the care of patients with known or suspected COVID-19:
A: Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP.
Facemasks protect the wearer from splashes and sprays.
Respirators, which filter inspired air, offer respiratory protection. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html
Q: Mask, and gown only? What if droplets from treating a COVID-19 patient get on our hair, skin, shoes. Wouldn’t that travel with us to other non-infected patient rooms?
A: We are unsure at this time. Please continue to visit the CDC.
Q: Doesn’t humidity diminish the virus?
A: We are unsure at this time. Please continue to visit the CDC.
Q: Is there evidence on how the virus will respond as our season temps warm up?
A: Not fully understood at this time continue to follow the CDC.gov page
Q: Is there a way for anyone to learn of having the virus before being diagnosed or having any symptoms?
A: There is testing in development that can be quick test self nasal swab testing.
Q: My job insists that NIV & HFNC are not droplet 🤔 Because both of these modalities involve very high flows and/or pressures, any potential moisture collected in the circuit or interface can easily be dispersed into the air and onto surfaces.
A: Perhaps a demonstration would provide better understanding.
Q: I work in long-term care facilities that currently do not have a respiratory protection program and N95 fit testing protocols in place. In the event that we have a resident test positive for COVID-19 how would we be protected if we were unable to transfer the patient out?
A: This is from the CDC.gov
Capacity across the healthcare continuum: Use of N95 or higher-level respirators are recommended for HCP who have been medically cleared, trained, and fit-tested, in the context of a facility’s respiratory protection program
The majority of nursing homes and outpatient clinics, including hemodialysis facilities, do not have respiratory protection programs nor have they fit-tested HCP, hampering implementation of recommendations in the previous version of this guidance. This can lead to unnecessary transfer of patients with known or suspected COVID-19 to another facility (e.g., acute care hospital) for evaluation and care. In areas with community transmission, acute care facilities will be quickly overwhelmed by transfers of patients who have only mild illness and do not require hospitalization.
Many of the recommendations described in this guidance (e.g., triage procedures, source control) should already be part of an infection control program designed to prevent transmission of seasonal respiratory infections. As it will be challenging to distinguish COVID-19 from other respiratory infections, interventions will need to be applied broadly and not limited to patients with confirmed COVID-19.
This guidance is applicable to all U.S. healthcare settings. This guidance is not intended for non-healthcare settings (e.g., schools) OR for persons outside of healthcare settings. For recommendations regarding clinical management, air or ground medical transport, or laboratory settings, refer to the main CDC COVID-19 website.
Q: If your family member gets sick, can you come to work?
A: There is not a simple answer to your question here is a link that can provide you more information. One of the recommendations is to speak with your organizations Occupational Health group for further guidance.
Q: Is the current recommendation is to wear the N95 mask for all confirmed COVID-19 patients?
A: This is from the CDC.gov –
Capacity across the healthcare continuum: Use of N95 or higher-level respirators are recommended for HCP who have been medically cleared, trained, and fit-tested, in the context of a facility’s respiratory protection program
The majority of nursing homes and outpatient clinics, including hemodialysis facilities, do not have respiratory protection programs nor have they fit-tested HCP, hampering implementation of recommendations in the previous version of this guidance. This can lead to unnecessary transfer of patients with known or suspected COVID-19 to another facility (e.g., acute care hospital) for evaluation and care. In areas with community transmission, acute care facilities will be quickly overwhelmed by transfers of patients who have only mild illness and do not require hospitalization.
Many of the recommendations described in this guidance (e.g., triage procedures, source control) should already be part of an infection control program designed to prevent transmission of seasonal respiratory infections. As it will be challenging to distinguish COVID-19 from other respiratory infections, interventions will need to be applied broadly and not limited to patients with confirmed COVID-19.
This guidance is applicable to all U.S. healthcare settings. This guidance is not intended for non-healthcare settings (e.g., schools) OR for persons outside of healthcare settings. For recommendations regarding clinical management, air or ground medical transport, or laboratory settings, refer to the main CDC COVID-19 website.
Q: As a home care provider our employees come into contact with people in their homes and in our offices. We have no idea their exposure risks. what precautions should our staff be taking?
Q: I’m over the age of 60 and being told I shouldn’t even leave my house. Thoughts on working in a hospital where it may happen that I’m giving to undiagnosed covid 19 patients.
A: Not a simple answer suggest speaking with your hospital’s Occupational Health group for further guidance.
Q: Do you recommend we stay in surgical masks while in the hospital, and then step up to N95s when caring for patients in strict isolation?
Q: In addition to COPD, are our patients with pectus excavatum also considered high risk? Also, there is an abundance of information out saying that it is droplet and an equal amount stating airborn. What is the official transmission/isolation for this virus? I have also seen a couple articles recommending intubate patients be placed prone, is this being considered best practice?
Proning may be required if clinically indicated however I don’t know that this has been established as best practice.
Q: In CF clinic they didn’t do PFT for my daughter due to her being positive for flu so I don’t think they would for COVID no reason its diagnostic from what we were told.? Her respiratory illness we were told to take extra precautions in crowds stay home as much as possible, so anyone with pulmonary issues I would think that would be the same?
A: As currently recommended, anyone with compromise is advised to self-isolate to avoid potential infection.
Q: What is the actual treatment for this?
A: Not a simple answer, I will defer to the CDC guidelines for mgt. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
Q: Should therapist that work full-time in the hospital setting stay away from contingent jobs in the LTAC setting?
A: Might be best answered by the Occupational Health at your LTAC.
Q: I work as a RRT in LTC with most patients being in the range of 60 plus. We are allowing no visitors unless its terminal illness. Anything you think we could do or look for to help out?
A: This is a common mitigation protocol used across the nation. Stay in the know with CDC
Q: Based off of the incubation period for the virus, can you please clarify again why those who are not infected have no need to wear masks unless you’re caring for a pt with covid-19? What if the host is asymptomatic?
A: I defer to CDC however it is likely most of us will be exposed to this virus as we are to influenza etc. Most people will have non to mild symptoms unless you are in the high risk groups.
Conference/CRCE Questions
Q: Does one need to be a member to access these AARC resources? Free to Non-members?
A: There is some information on the AARC web site that does not require membership however you would be best served by becoming one to access all the resources available from the AARC, CRCE’s, access to the AARConnect communities and much much more. (not a paid endorsement for the AARC just an RT that believes in what they offer).
Q: Will this be archived, and if so, when and how to access?
Q: How can we use telemed in the home care world right now?
A: rtNOW has software available now that can be utilized by home care companies that can send a link via text or email to a patient in the home if they have a smart device or computer with camera. If you want more info email: connect@rtnow.net
Q: Anyone in the cardiac/pulmonary rehab world cancelling rehab? Our patients are the most high risk.
A: Yes seeing this in many OP settings not just PR programs
Q: What about programs such as pulmonary rehab?
A: Starting to see OP programs being postponed, telerespiratory follow in the home is a potential to stay in touch and help support them in their home environment. Not reimbursable (as of 2020-03-16) however clinically beneficial.
Q: We can’t use telehealth because we actually have to deliver equipment to the patients and set up equipment in our office. We want to protect ourselves and our workers.
A: Can be useful for follow up especially for high tech respiratory equipment being able to visualize the equipment for troubleshooting is a plus.
Q: What things have you done to use telerespiratory service scenarios?
A: rtNOW has used telerespiratory to assess patients RCAT’s, set up NIV, follow up on NIV adjustments to therapy, troubleshoot equipment alarms, just-in-time education for staff and patients as well as remote patient monitoring (RPM)
Q: It seems clear that telerespiratory is a great option. But how can RT programs be covered if they’re not approved already? how can a telerespiratory program provide without RT component?
A: rtNOW’s experience has been that organizations see the benefits of not having to transfer patients out, decreasing re-admissions from SNF’s, maximizing resources and in case of COVID-19 putting the RT remotely where the pt is: home/isolation etc. It also can be used to support our argument for reimbursement with CMS. (CONNECT ACT)
Q: No one is talking about protecting ourselves from the asymptomatic. Don’t you think telerespiratory would be a great way to teach the public how to safely wear masks?
A: Yes, it could! It could also be used for screening pt’s helping to identify the need for seeking testing or medical treatment in a facility.
AARC questions
Q: How to raise the quality of service for COVID-19: patients ??
A: Continue to follow real time updates from reliable sources, CDC, NIH
Q: What about incorporating more student RT workers?
A: I am sure this will be addressed at the local level. My comment is that because an RT student can’t work independently it increased the PPE supplies being used when they are already in short supply
Q: Do you think the AARC will post clinical practice guidelines ?
A: Shawna Strickland @Robyn Mustachccio – CPGs take an awful lot of time to develop. Right now, we’re focused on making sure all literature is getting to members as quickly as possible. There will likely be CPGs at some point, probably a joint effort from multiple organizations.
COVID-19 Clinical Presentation and Treatment
Q: Does bronchospasm present in the symptoms of Covid 19 pneumonia?
A: Likely not different that any other viral infection that can cause bronchial irritability/spasm.
Q: Does Covid19 really produce fibrosis in the lungs which is not reversible?
Too great not to share. We recently did a webinar for a closed group of potential telerespiratory therapists. Check out this case study involving a newborn, bubble CPAP, some great nurses, and a lot of critical thinking! This is how it’s done!
DRAGONBERRY: Welcome to The Vent room where respiratory therapists can come and get a little inspiration. I’m your host Dr. Tabatha Dragonberry. Our guest today is going to be Curt Merriman. He is the chief sales officer at rtNOW which is, essentially, the first turnkey respiratory therapy telehealth solution that I’m personally aware of. I think it’s an innovative way to bring respiratory therapy farther into the digital age. Curt, can you tell me a little bit about how the idea of rtNOW came about?
MERRIMAN: Oh, absolutely. Tabatha, thank you for having me today, I appreciate the opportunity and what you’re doing with The Vent Room. So back in 2016, as you mentioned, I’m a respiratory therapist. Myself and some of my other business colleagues were getting requests from our respiratory therapy staffing company to help staff rural hospitals and healthcare institutions when they’d have new admissions for COPDs going through an exacerbation. And, unfortunately, we did not have therapists just readily available to jump in their car and drive three and a half hours to go see those patients and then drive back home. So we came up with the idea, “Well, why can’t we utilize the respiratory therapists’ critical thinking skills and our unique skill set in a telehealth format to provide our knowledge in consultation remotely via our virtual video chat?”
So we initiated some of our planning in August of 2016. We opened up our first pilot in a small town in southwestern Minnesota, Sleepy Eye, and initiated with our critical access hospital there rtNOW telehealth. And we were there for about four and a half months, and during that pilot project we found success, and basically, acknowledged our concept was actually possible and achievable.
DRAGONBERRY: That sounds amazing. I know there’s several types of telehealth. You have provider to consumer, provider to provider, and remote monitoring solutions with that. Yours is more of a provider to provider, or also that, provider to patient?
MERRIMAN: Well, so we’re actually more of the live video conferencing synchronous mode. At this point in time, we’re primarily working directly with institutions whether they be small critical-access hospitals or skilled facilities that do not have respiratory therapists either available to them 24 hours a day and in some cases, they just do not have respiratory therapists available to them at all. We don’t intend nor do we think that we can replace the boots on the ground so to speak, of a respiratory therapist , but we have significant shortages. I think all of us are aware of respiratory therapy personnel across the country and, especially in rural America to recruit and retain individuals is a challenge.
So most of our work is done as live video conferencing. We’re communicating and working with the nurse or the provider at the bedside as well as speaking with the patient. At this point in time, we’re not in the home setting although there’re some new avenues coming about with remote patient monitoring that you had mentioned with some codes that may allow that to be a more successful advantage for telerespiratory to actually be seeing these patients in their homes to help eliminate hospital readmissions or, at least redu them.
So with the goal of using evidence-based practice, we’re always focused on those outcomes.
DRAGONBERRY: What have the outcomes been for the rtNOW services?
MERRIMAN: Actually, when we first got into this, we weren’t quite sure what we would come up with. And what we found is, even during that first pilot study of the four and a half months, that particular hospital identified– the nurses identified, themselves, three patients that they would have transferred out that they were able to keep because they utilized rtNOW, the telerespiratory therapist, to help them achieve successful non-invasive ventilation on patients and keep them there at the hospital and not having to transport them out.
DRAGONBERRY: Which is great for that small-world community because, then, they’re keeping the money within their organization not having to ship those patients out.
MERRIMAN: Exactly. And it’s not only just the money, but the community hospitals really play an integral part of that community. I mean, they’re typically one of the larger employers within that community, and they have family members that they’re taking care of. And one of the examples that we talk about in some of our studies happened over their Christmas holiday, and a COPD patient that exacerbated was able to be kept there on-site at their local hospital. The family was able to visit them without having to travel 60-plus miles to a larger tertiary care facility.
DRAGONBERRY: And that, again, goes to that holistic care of taking care of not just the patient, but the family and keeping them within their community because they feel safe.
MERRIMAN: Exactly.
DRAGONBERRY: With your services, are they being sought out by organizations now? Are there organizations saying, “Hey, we are needing to fill in these gaps.”
MERRIMAN: It is starting to occur that way because, as you had mentioned, we believe we’re the first very specific telerespiratory providers in the market place starting back in 2016. And it’s taken a few years just to get people aware of it, and we’re now actually getting some organic word of mouth growth with people hearing about the service and about telehealth being able to be provided for respiratory therapy patients and that. So it’s starting to come through, and we’re happy to see that. It’s been exciting.
DRAGONBERRY: So on your team, how many respiratory therapist do you have at a time or taking care of these remote patients?
MERRIMAN: Oh, great question, Tabatha. So we have 21 respiratory therapists that are providing services 24/7, 365, for our rtNOW. Those 21 therapists are typically working in point positions in various hospitals, and then, do extra above and beyond time working with rtNOW and the telehealth aspect of it. We do have a couple of people that are going to school, and rtNOW is their primary employment as well. At this point in time, with our call volumes, we typically have one therapist on at a time to cover the calls that may be coming in. But we do have redundancy and backup plans in place, so if there’s multiple calls occurring at once, that we have other therapists that we can make available to initiate and take those video chat calls.
DRAGONBERRY: In doing some research for the show, I found an American Academy of Ambulatory Nursing has a telehealth certification. I also found that there was a certification for telehealth coordinators. Just like any profession, there are different organizations, such as the American Telemedicine Association that also accredit courses. Do you believe that RTs could have their own telehealth certification one day.
MERRIMAN: I definitely think so. It does take a unique set of skills to successfully do telehealth as a respiratory therapist. It’s a different type of patient care, where we’re used to being the hands-on in the room, can see, talk to the patient, be able to assess what’s happening in the whole environment just by walking into the room. And it does take a little bit of additional training that we provide for our staff, heightening their awareness of being observant when they’re asking the nurse to move the technology, we’re using an iPad on a stand, and moving that around in the rooms. We have a good view of the patient environment, the patient, the monitoring, what’s going on in the surroundings there. And then heightening their communications skills to asking more in-depth discerning questions so that we can get a better picture. We’ll typically also have the ability to remote into the facilities EMR to get histories and that, but when we’re dealing with the emergency department where there’s not a lot of time involved and it’s more of a “just in time, we need your assistance right now,” we’re doing a lot of communication with the nurse and the provider and the patient right there in the room.
DRAGONBERRY: So with that experience and education, if there is a respiratory therapist that’s kind of looking at this as an option for their career tract, what do they need to be doing now? What education or any additional skills that they could be growing now, so that they can say, “You know what, in one or two years, maybe my old bones can’t do the floor care anymore,” or just people want to have that option of working from home because I know on social media I’ve seen questions about that, and people are always like, “I’m looking to transition, what can I do as an RT from home?” What skills do they need to start growing now?
MERRIMAN: Sure. There is information with– you had mentioned the American Telehealth Association and some others that have information about kind of enhancing your skill set. It’s still something that’s relatively new because telehealth is still a very new field in healthcare for us and specifically for respiratory therapists. One of the things that I can encourage is if you do go to our website we do have a section on there called the rtNOW Bullpen, and basically it’s a community where people can kind of talk with one another, learn a little bit more about telehealth. There’s also a LinkedIn and facebook area which is just under telerespiratory that, again, is not specific to rtNOW but is just for anybody interested for colleagues and peers to discuss amongst themselves and get ideas, share ideas. And hopefully as that community grows and people that are doing more of the telehealth themselves can be sharing their experiences also through that to get the backgrounds. And I do see that we’ll find more certifications coming available.
DRAGONBERRY: My aunt is a remote-nurse-case manager, and she holds licenses in 14 different states where she manages cases. How does the licensure work for the rtNOW therapists?
MERRIMAN: Very similarly. There’s really not at this point in time a telehealth reciprocity for a therapist to see patients in different states without requiring them to seek those licensees, so as I mentioned, we have a staff of about 21. The majority of our therapists have multiple-state licenses, and when we take on a new state will not only have our therapist gain a license for that state, but we’ll also do recruitment within that state itself of therapists that are currently working there. And that’s part of what the bullpen is all about, it’s just kind of prepping as things grow and expand. Right now, our company is Minnesota, Wisconsin, Missouri, soon to be Michigan. And as we gain more states, we’re actively recruiting and looking for therapists that have an interest and have the skill sets that we feel are important.
DRAGONBERRY: So I know that you were saying that in your education, you’re kind of focusing on that heightened communication and being able to observe differently because you’re not in that environment. What kind of education and training and hardware is supplied to somebody that is a new hire, as your company is expanding?
MERRIMAN: Great question. So we have online training that we’ve put together, that when we have a therapist that we’ve vetted and we feel that both they and our leadership team feels like it’s a good fit, they’re sent a link for some online training and education, which is just some basic information. It can be some things as simple as, what is the lighting like in the room that you’re going to be doing your video chatting, their Telehealth conferences? Making sure that it’s HIPAA compliant, PHI compliant. So that it’s a secluded area, at least an area that can be closed off so that people aren’t hearing information that they shouldn’t be hearing, or seeing it as well. Just kind of, I think I mentioned, the lighting, speaker sound, that type of thing. Just from a technical aspect, make sure that everything looks professional, sounds, and is professional from that standpoint. So they go through that training, some education on some of the communication skills to help heighten their questions that they might be asking. And then they do a one-on-one. Everything that we do is web-based, or browser-based, so they get our system set up on their computers and then we do some one-on-one training just to make sure that they’re comfortable, everything is functioning, they know how to navigate things through. One of the things that we do, because the therapists obviously have not set foot in any of these institutions, is when we on-board a customer, we’re seeking information from an internal champion at that facility to give us information on the respiratory equipment that they’re using, any of their respiratory medications, what’s in their formulary. So that when the therapist is seeing that patient, we’re making recommendations based on the equipment, the best practices that they have in place, any protocols they have in place, that type of thing. So we’re functioning just as if we were there on site.
DRAGONBERRY: I can imagine it in my head. I think it’s just the next step. I kind of think like Star Trek, you’re going where no respiratory therapist has ever gone before, right?
MERRIMAN: [laughter] That’s a great analogy. That’s fun.
DRAGONBERRY: Because I’m just imagine just having to work through that, and you’re seeing a patient and caring for them from however many, either thousands of miles away or hundreds of miles away, and that you’re impacting and affecting the care. And the facility’s happy to have you there and they’re wanting to have you there, even though you aren’t physically there.
MERRIMAN: Correct. There’s often times skepticism within the organization when they first start with our telerespiratory service. And many times, the nurses are wondering, well, how can you actually do this and really be of service to us via video chat? And after the nurses experience or providers experience the calls, the comments that we get are, “Wow. I didn’t realize how much you could actually do via a video chat and helping me at the bedside and just giving me the confidence that I needed to care for that patient in that crucial time when– oftentimes, their is an increase work of breathing and they’re dyspnic. They’re just having a terrible time and the amount of stress in that scenario is, oftentimes, quite high, and we can just help alleviate that with a therapist right there walking through with them.
DRAGONBERRY: Can you walk me through, like a consult, one of the RT-now-therapist may encounter?
MERRIMAN: Sure. So the two primary types of calls that we’ve experienced since we’ve started this is NIV or a new respiratory patient being admitted to the facility and the telerespiratory therapist performing an RCAT, a respiratory care assess and treat– or however you might term it. Each facility can name them a little bit differently, but. Basically, we’re viewing the medical record, looking what their histories are, what the medications they’ve been on, and their I’s and O’s, their current status, X-rays, all the type of information from a clinical standpoint just like you would be as a therapist in the facility, reviewing that before you go into the room. We’d ask the nurse, “Okay. Let’s go ahead and bring us to the room via our technology and arrange the iPad so that we can communicate easily with the patient and have a discussion with them,” to find out occupational exposures, just like you would if you were walking in the room.
Most of the time– at this point in time, we’re relying on the nurse’s auscultation techniques. And one of the things that our therapists are doing is asking, again, a lot of discerning questions. As many of us know, that one person’s definition of a wheeze is not the same as the next person sitting by them. So the therapists are asking some really discerning questions about what that wheeze or that particular breath sound actually sounded like to determine what it is that they’re looking for. There are technologies, Bluetooth stethoscopes that we’ve done some evaluation on and we’ll probably be deploying them soon, actually. But in the meantime, we’re just relying on the nurse’s communication with us and what they’re hearing. And we’ll then make the recommendations remotely in the medical record as if we were a therapist working right there at the bedside and make the recommendations for medications, treatment modalities, frequency, that type of thing, any airway clearance that may be required, supplemental oxygen, all those kind of things.
DRAGONBERRY: So we all know that advances in healthcare move faster than government legislation. Where you guys are working now and operating, is there any government regulations that it’s making it easier to provide this service or is it just such an untapped market that we’re kind of cowboys figuring it out as we go because there isn’t regulations?
MERRIMAN: Yeah. That’s a great question. So so far, there really has not been a lot of regulations that we can follow from a respiratory therapist standpoint and reimbursement there. There are currently a couple of different pieces of legislation in DC, the BREATHE Act and the CONNECT ACT, probably the two most prominent ones. Both of those acts, if they get forwarded on and pass, would allow and identify a respiratory therapist as being a telehealth provider. And that would open up something significant doors for us to be able to really take what we’re doing to the next level, and it also would identify the patient’s home as a location that we could be providing those services to those individuals. So again, by doing the virtual visits, we could help do that chronic disease management, education, self-management care, and just ensuring that the patient safety in their home surroundings and keep them out of the hospital and in their own environment, can truly learn better about their disease process and how to manage it better, and again help reduce the hospital readmission’s. There are some new things that have changed in this past year with remote patient monitoring, with some codes that I think are really going to play into the whole telehealth process. So it’s allowing respiratory therapists to be a part of that and seeking out in obtaining data from a patient that we can use those early indicators for them going into having some difficulties in trying to get them before, I mean, or contact them before they’re being rushed to the emergency room.
DRAGONBERRY: With some of those acts, I know previously that they required a bachelors degree. Do you know the ones that are currently pushing through with the CONNECT or BREATHE, is it saying that that respiratory therapist needs to have a bachelors degree to be considered for the reimbursement purposes?
MERRIMAN: Well, neither of those acts have a– because they haven’t been passed yet into law, those kinds of regulations and rules will be written after the fact. But what we do know is that typically, for any type of reimbursement from a healthcare professional, the standard practice is to have a Bachelors of Science degree, whether it’s specifically in respiratory therapy, or it may be just a Bachelor of Science in some other health-related degree along with a respiratory therapy diploma that they have and a degree as well. So those details have not been worked out, but it’s pretty much the standard practice that it would require a Bachelors of Science or greater. Masters, PhD, that type of thing.
DRAGONBERRY: So I know a while back, I actually took a telehealth course, and the professor mentioned a company that was in New Zealand, and they hired American doctors, relocated them overseas to provide telemedicine in the US. Because when it’s nighttime in the US, it’s daytime in New Zealand. So the whole thought process and their promotion was that, you’re always going to get that fresh doctor versus waking somebody up in the middle of the night. And we should be sleeping, naturally, I know that night shift has wreaked some havoc on my body. So what do you think on that whole aspect of that Innovative–? We’re taking telehealth, and now it’s an even totally different innovative thought.
MERRIMAN: Well, that’s actually quite interesting, and I’ve read about some of that as well, and it does make some good sense to be able to do that. A lot of it is really getting it to kind of come down to the logistics and the reimbursement and the fiscal ability to make that happen. Because we are a global world now, we could be providing those kinds of services with providers here in the United States for people on the other side of the world. Again, that would be the day shift there, the night shift here and vice versa. And it could work out quite well. So far, with our experiences with the therapists that are sometimes being woken up in the middle of the night, we have not had areas of concern with that. The vast majority of the calls seem to come in more on evenings and on day shifts and on weekends. Some of the night shifts, but not as many as I think we initially anticipated.
DRAGONBERRY: That’s interesting to know because I feel like– I don’t know, when I worked night shifts, 2:00 AM seems to be the magic hour.
MERRIMAN: Well, when we do get the nighttime calls, that’s about the time that they do come through, you are correct.
DRAGONBERRY: I think it’s interesting how those types of trends, you notice them when you’ve been working in the industry for a while.
MERRIMAN: Yes. Exactly.
DRAGONBERRY: Curt, thank you for joining us here at the vent room. It’s great to see RTs are making strides in telehealth and being successful and showing that they’re other opportunities, and that we can move to the bedside but in a digital perspective.
[music]
MERRIMAN: Well thank you. I’ve been a respiratory therapist for 40 years, and I still believe that this profession offers many opportunities in– the telehealth is now one of the newest forms that I think is certainly going to be in the forefront for many years to come. And I appreciate you reaching out to me and taking the time to chat about respiratory and how RT’s , and definitely take a part in the continuum of care.
By Chuck Stadler, Jr – President and CEO of rtNOW.
One of my nursing instructors/mentors (Mona White) told me years ago, “The gauge of a great nurse is not to know everything, rather to know what questions to ask and where to find the answer”. Nobody can be comfortable and knowledgeable with every aspect of nursing, and anyone who claims to be is crazy. Nurses have all been taught to lean on their clinical peers for guidance. A respiratory therapist has always been a pivotal member of the clinical team, offering specialized respiratory expertise.
Using Minnesota as an example state1, in urban areas 1 respiratory therapist has the potential to serve 2,647 patients. In small rural towns, the ratio is 1 respiratory therapist to 5,746 patients. On the far end of the spectrum, in isolated rural areas the gap widens to an enormous 1 therapist to 29,143 patients. During the 2018 – 2019 data collection period a projected 104 openings across the state with a supply of 81 graduates to fill these openings2.
This is one example of respiratory therapist shortages that continue nationwide. They are a problematic reality in today’s healthcare landscape, but current technology can also provide an answer.
PDPM provides a unique opportunity for skilled nursing facilities to grow their respiratory resources through telerespiratory care while capturing PDPM dollars.
Whether you have partial respiratory coverage or no coverage at all, telerespiratory care is emerging as a viable way to increase the number of medically complex patients your staff can successfully handle, while capturing PDPM dollars. Nurses can quickly connect with a respiratory therapist via phone and video chat, who can then consult on equipment, perform respiratory assessments, make recommendations for treatment plans (i.e. NIV, CPAP, trach care), and serve as a supportive bedside resource to nurses, providers, and patients/residents. Once telerespiratory is integrated into a culture, experience has shown that it can be key to avoiding transfers. For examples of this, look at these case studies from rtNOW.
And the good news is that it makes financial sense. For all the change that is happening there are 9 stackable NTA codes3 specific for patients with respiratory comorbidities (Chart 1). As you know, there are many other codes that would be also associated with some of these patients with multiple comorbidities. PDPM provides a unique opportunity for skilled nursing facilities to grow their respiratory resources via telerespiratory care while capturing PDPM dollars.
Chart 1 – Stackable NTA Codes for Respiratory Diseases and Procedures
If your organization is planning to take on the medically complex population, you will start to get pressure from all sides on how to care for them properly. It may be that your organization has been fortunate in finding and maintaining a respiratory therapist on day shifts, but what about the nights? Your evening/night shift clinical team probably has less experience and different staffing ratios than the day shift. Who are evening/night shift team supposed to use for guidance through the night? The administrator? DON, ADON? Will they wake up one of your day shift RT’s? Or will they continue to transfer the patient to the hospital? These are important questions, and thankfully we now have an answer.
I would like to propose that an easy solution is to give them a team of licensed RRT’s available with the touch of a button via telerespiratory. Pricing packages range between $4-5/hr depending on the amount of coverage desired. A small price to pay to add a knowledgeable team member at the immediate time and place your staff has a need.
A couple of weeks ago we asked our rtNOW agents to give us some examples of calls they have had. It was exciting to hear agents come out with story after story of how rtNOW helped staff and patients at hospitals and in nursing homes. Particularly exciting to us were the transfers avoided, and how well our agents interacted with remote staff members as part of the team.
Here is a compilation video of some real-world case stories in which our telerespiratory therapists saved the day.
