Telemedicine: An Opportunity in RT Clinical Education

The COVID-19 pandemic has affected every aspect of life since being declared a national emergency by the President of the United States in March 2020.¹ In 2022, the COVID-19 pandemic continues to pose many challenges to health care institutions, including health care education programs. Respiratory therapy (RT) educational programs have experienced many changes in course delivery and clinical education. Due to concerns regarding conservation of personal protective equipment (PPE), infection transmission, and high patient volumes, hands-on patient care clinical education in almost all health care settings was restricted and even prohibited starting in early 2020. The Commission on Accreditation for Respiratory Care (CoARC) has released regular updates regarding the impact of the COVID-19 pandemic on RT education.² CoARC has consistently advocated for the continued provision of high-quality RT education that meets accreditation standards but has also allowed programs the flexibility to make necessary modifications to ensure the health, safety, and security of students and faculty. Specifically, CoARC has encouraged programs to carefully consider the appropriate uses of clinical education alternatives, including simulation and telemedicine.

Prior to the COVID-19 pandemic, telemedicine had been shown to reduce health care costs and improve health care outcomes, including access, utilization, adherence, and quality of life.³ The COVID-19 pandemic sparked significant growth in the utilization of telemedicine virtual care as a safe alternative to in-person care. In addition to providing patients with access to care, telemedicine addresses concerns related to PPE conservation and increased workload for health care providers, including respiratory therapists. Telemedicine in critical care has been utilized for several years in limited capacity and largely without RT involvement. Pierce et al⁴ describe the expansion of an existing tele-ICU service to include 24/7 coverage by respiratory therapists very early in the COVID-19 pandemic. The tele-ICU RT service provided support to the bedside respiratory therapist, ensured best practice bundles were implemented, and completed patient-ventilator assessments. The success of the tele-ICU RT service during the COVID-19 pandemic resulted in the continuation of the service beyond the initial pilot phase.

In this issue of Respiratory Care, Roberts et al⁵ report on the process and outcomes of implementing an RT student clinical rotation with the tele-ICU RT service described previously by Pierce et al.⁴ Recognizing the challenges RT education programs were having with clinical education opportunities, and recognizing the importance of continuing to develop the next generation of respiratory therapists, the authors established a new clinical rotation in the tele-ICU in early 2021.⁵ The goals of the tele-ICU clinical rotation included exposure to telemedicine technology and improvements in confidence related to managing mechanical ventilation, ARDS, and COVID-19. Thirty-three students completed data collection related to the 8 hours total spent in the tele-ICU. Each student was scheduled one-on-one with an experienced RT preceptor. The RT preceptors were experienced in terms of total years of experience and experience with the tele-ICU RT service, as well as experienced in precepting students during hands-on clinical rotations.

Findings from the study indicate that students' self-confidence in their knowledge of spontaneous breathing trials, lung-protective ventilation, patient care planning, and assessing waveforms improved pre- to post-tele-ICU clinical rotation.⁵ In addition, confidence related to interprofessional communication and knowledge of ARDS and COVID-19 increased, with confidence in COVID-19 knowledge representing the largest increase. It is important to note that even if students were allowed to return to acute care clinicals during 2021 they were often prohibited from interacting with patients with COVID-19 for the same reasons cited above. As a result, it is not surprising that the largest increase in confidence was related to COVID-19 knowledge since the students likely lacked experience with patients with COVID-19 in previous rotations. It appears this novel clinical rotation allowed the students to interact with a patient population they may not otherwise have had access to and provided an experience that would help the students successfully transition to employed respiratory therapists following graduation.

Student participants of this study did have previous hands-on ICU clinical experience within the health system covered by the tele-ICU RT service before the tele-ICU clinical experience.⁵ Whereas it is not clear the extent of this previous ICU clinical experience, both the students and preceptors likely benefited from this previous experience during the tele-ICU clinical experience. The students would have at least a minimal understanding of the mechanical ventilation policies, procedures, and protocols utilized in the ICU and would have some familiarity with the tele-ICU concept due to previous observed interactions with the tele-ICU during prior rotations.

Additional qualitative analysis of student comments following the tele-ICU clinical rotation indicated one of the benefits of the rotation was the ability to focus on ventilator waveforms and mechanics.⁵ Students and preceptors often find it challenging to focus on those items during an in-person clinical due to the urgency associated with other patient care activities and due to concerns about having discussions at the bedside with the patient and family present. The one-on-one student and preceptor matching allowed for individually tailored learning and maximization of time spent on ventilator waveforms and mechanics as part of the tele-ICU RT services provided.

The innovative clinical education rotation demonstrated some positive self-reported student outcomes based on a self-reflection of confidence level related to specific aspects of ICU RT practice.⁵ Exploration of the impact of the improvement in confidence on assessment of knowledge acquisition and/or skill acquisition during hands-on ICU clinicals and tele-ICU clinicals will be important validation of the value of the tele-ICU clinical experience. In addition, the focus on interprofessional communication during a tele-ICU clinical rotation may also transfer to other clinical rotations and be a demonstrated benefit of a tele-ICU clinical rotation. Development of clinical preceptors with tele-ICU clinical experience that can facilitate discussions of remote patient monitoring, troubleshooting, and problem-solving and can encourage effective and efficient interprofessional communication will be necessary for establishing best practices for incorporating students in telemedicine clinical rotations.

The COVID-19 pandemic has led to the acceleration of innovation in almost all aspects of life, including RT clinical practice and education. Telemedicine has been incorporated into critical care, pulmonary rehabilitation, pulmonary diagnostics, sleep disorders management, and many aspects of post-acute and ambulatory pulmonary disease management.^4–8 RT education programs should consider including remote patient assessment and management skills in didactic, laboratory, and clinical education to ensure RT graduates are prepared for the practice settings they will encounter. As with many cognitive, behavioral, and psychomotor competencies, it is likely that there will be a significant amount of crossover between telemedicine competencies and hands-on practice competencies. This translation of skills will allow the RT program to maximize the opportunities during laboratory and clinical telemedicine experiences to focus on communication, interpretation, care planning, critical thinking, and problem-solving skills, all of which are highly valued by patients and employers in all practice settings.⁹ Telemedicine clinical experiences may also facilitate meaningful inclusion of interaction with diverse patient populations that may not be otherwise accessible to students.¹⁰ These experiences should be used as part of a strategy to ensure RT graduates are prepared to provide equitable care to all patients they will encounter.

It is time for thoughtful consideration and discussion of the changes to health care and to RT education that will persist in the aftermath of the COVID-19 pandemic. This includes consideration and discussion of the competencies RT graduates of the near future need and the best way to ensure these needed competencies are mastered during clinical education. Roberts et al⁵ demonstrated the successful implementation of a tele-ICU clinical rotation with positive student outcomes, suggesting that a tele-ICU clinical rotation is feasible and beneficial. Due to the very interactive and highly psychomotor nature of RT practice, it is unlikely that tele-ICU clinical education can be used to replace hands-on ICU clinical rotations. However, this rotation was used to supplement hands-on ICU clinicals and reinforced and augmented patient assessment and evaluation skills that are foundational to problem-solving and critical thinking in the ICU. It is likely that the tele-ICU clinical rotation created some new teachable moments during a challenging period in RT clinical education.

This article also illustrates the value of the partnership between RT education programs and their clinical partners.⁵ The joint effort between educational institutions and health systems demonstrated in this article is to be commended and encouraged. RT education continues to face many challenges, some of which were present before the COVID-19 pandemic. Declining enrollment and difficulty securing clinical rotation placements for students continue to persist and will require creative and collaborative solutions between RT education programs and RT employers moving forward. Recognition of the symbiotic relationship between RT education and RT employers will be crucial to success and may represent a pandemic silver lining for the RT profession.

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