Evaluation of Respiratory Therapist Extender Comfort With Mechanical Ventilation During COVID-19 Pandemic

Discussion

In this study, our results indicate that overall comfort level with using critical care ventilators increased over time among CRNAs working in the ICU during the COVID-19 pandemic. CRNAs typically come from a critical care background, with a minimum of 2 y of nursing experience required for admission to CRNA programs.¹⁴ Although no statistically significant differences were found based on years of experience, the traditional role of CRNAs in the operating room lends itself to some familiarity with the basics of mechanical ventilation. The role of a CRNA is adaptable, resilient, and expert when managing airways and resuscitating patients, not only in the operating room but during clinical emergencies.^11,14

Nurse anesthetists are advanced practice registered nurses who are committed to excellence, patient safety, and providing services throughout the hospital at a reasonable cost to health care systems.¹⁴ Interdisciplinary collaboration is inherent in the CRNA role because they work primarily in the operating room and collaborate with surgeons, physician anesthesiologists, and other qualified health care professionals.^11,12,14 CRNAs have acquired all the skills required to provide specific care and technical procedures in the fields of intensive care anesthesia, which allows them to care for and manage COVID-19 patients effectively.¹⁴ The aforementioned qualities and their role in the hospital made CRNAs a suitable fit both as RTEs and for inclusion in this study.

Comfort level with mechanical ventilation did not increase significantly based on the amount of time spent training. This may be explained in a number of ways. Comments from our survey included the perceived need for more education prior to deployment. We acknowledge that rapid deployment, on short notice, could lead to some level of unease related to the technical aspects of respiratory care. However, just-in-time education is the standard for quickly deploying support staff during medical crises.^7,10,11 The recommendations from the Commonwealth of Pennsylvania Department of Health include cross-training and just-in-time education for interdisciplinary collaboration.¹³ The education we provided may have been improved by following a model similar to that used by Hester et al⁹ with medical students at the University of Michigan. They provided education designed to teach RTE-specific functions and skills in collaboration with RTs. A hybrid model was developed beginning with online, skills-based modules followed by in-person skills training sessions.⁹ Different modules provided an array of learning checks and competency assessments to assure that the RTEs were progressing appropriately. To conclude the training, the students were evaluated via in-person practical assessments to assure competency.⁹

Survey respondents reported an appropriate amount of reliance on RTs during their ICU rotations. Although the practice of respiratory therapy has been found to vary between geographic regions, the technical skills are similar (or identical).¹⁵ Some hospitals utilize RTs to the full extent of their license, while others depend on other providers for decision-making while the RTs carry out tasks.¹⁵ Still, RTs remain the clinical experts and first-line assets during times of crisis due to required competencies and their expertise in mechanical ventilation.^3,16 For these reasons, hospital systems should be selective in deciding what specialty will act as RTEs during patient surges.

One area of concern reported in our survey, which related to the RTE role, was replacing RTs with providers outside the respiratory therapy profession. Replacing experienced critical care RTs, however, was never the goal. There are a number of resources that recommend supplementing critical care RTs with nonclinical staff.^7,10,13 Project XTREME (Cross-Training Respiratory Extenders for Medical Emergencies), for example, is a disaster-preparedness guideline for providing education to nonclinical RTs and non-respiratory therapy professionals assisting in the delivery of mechanical ventilation.¹⁰ This educational model relies on interactive videos and competency validation in a laboratory setting. The authors suggest that this education can be deployed as just-in-time training.¹⁰ We also followed guidance by Rubinson et al,⁷ who similarly suggested that RTs supervise noncritical care staff.¹⁰ Regardless, 11% of the positive feedback received was related to patient care and safety as a benefit of the RTE role in the ICU. A safety concern unrelated to the role of RTE had to do with the number of ventilators that a single RT can safely manage.¹⁷ Our experience showed that the use of RTEs adequately bolstered our staffing levels so patient safety could be prioritized. Post hoc inquiry into patient safety events revealed that there were no adverse events related to the deployment of RTEs reported in our hospitals during the COVID-19 pandemic. This could be explained by the fact that we simultaneously deployed RTs in our tele-ICU as an extra layer of protection against safety events related to COVID-19.¹⁸

Resource allocation was an important aspect of planning for the initial patient surge.^7,8,10,13 As suggested in Project XTREME,¹⁰ there are 2 approaches to preparing for patient surge. First is lowering demand on the institution, and second is increasing resource supply. There are a number of approaches to accomplish this, including but not limited to discharge planning and patient diversion, as well as increasing the amount of available equipment and staff.¹⁰ Our institution stopped elective surgeries, which allowed us to utilize the CRNAs as RTEs. We are aware of several institutions, notably the University of Michigan, that utilized cross-training of other disciplines during COVID-19. In terms of resource reallocation, Indiana University Health reported successfully treating all of their COVID-19 patients without overburdening the system.⁸ Their plans also included “reverse surge” planning, a phase in which elective procedures and other out-patient care were resumed with renewed emphasis on early discharge, both from the ambulatory surgery center and within the hospital itself.⁸

The deployment of CRNAs as RTEs elucidated the idea that, as pandemics and other mass casualty events arise, as technology advances, and as new therapies are discovered, emphasis should be placed on preparedness and interdisciplinary collaboration.^7,12 Subsequently, there should be significant ongoing effort and commitment to develop protocols and training guidelines for rapid deployment of staffing resources in collaboration with clinical partners including medical directors, anesthesia physician leaders, nursing leadership, and respiratory therapy leadership.⁷ Advanced planning for times of high patient volumes may limit the need for rapid decision-making when overwhelming situations, such as a pandemic, occur and can help organizations respond effectively and enable them to provide patients with safe, high-quality care.⁷ Despite this guidance from the Chest Task Force on Mass Critical Care, the COVID-19 pandemic highlighted infrastructure needs.