This study was based on in-depth interviews with 32 “key stakeholders” (15 respiratory care practitioners, 10 physicians, and seven nurses) from seven institutions recognized as “high performers” in the use of noninvasive ventilation (NIV) to treat acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The research methodology employed (“positive deviance”) posits that solutions to complex problems can be gleaned from extensive interviews that elucidate strategies and contextual factors from institutions that have overcome barriers to success. Audiotaped interviews were subjected to multiple rounds of thematic analysis, which distilled features essential to success under the rubrics: processes, structural elements, and contextual features.
Identified processes were timely identification of AECOPD patients, early initiation of NIV, and the ability of clinicians to devote the time necessary to ensure sustained compliance with therapy through frequent reassessment. Structural features encompassed what are essentially economic aspects such as the availability of sufficient, appropriate supplies placed in proximity to need (e.g., equipment storage rooms in the ED).
In particular, supplying ventilators specifically designed with NIV capabilities and the availability of a wide variety of mask interfaces both were crucial in ensuring patient comfort and compliance with therapy. Moreover, the allocation of sufficient respiratory care staffing to execute what is an intensive, time-consuming therapy also was critical. Contextual factors included global clinician advocacy, respiratory care practitioner autonomy, interdisciplinary teamwork, and a commitment to continuing education and training. Finally, a systems-level approach was characterized by institutional commitment to NIV as a front-line therapy signified by advocacy for and development of clinician-directed protocols.
COMMENTARY
Over the past 40 years, there has been tremendous flux in the structure and delivery of hospital care in terms of economics, regulations, technology, and culture. To be fully appreciated, the effect of these changes must be viewed from the perspective that the practice of medicine is as old as civilization itself. Historically, medicine has been based on a hierarchical structure. This was impressed on me back in the 1970s, when a medical anthropology professor pointedly emphasized that hospitals were the only civilian enterprise in Western culture run on a strict military paradigm.
However, in the mid-1990s an inkling of a paradigm shift began in what the authors described as a “flattening of hierarchy.” In part, this was brought about by societal demands for cost containment through evidence-based care that demonstrated improved patient-centered outcomes.
As a consequence, reimbursement for healthcare has begun to shift slowly from volume-based to quality-based measures. This has necessitated the development of standardized protocols/guidelines to drive practice and measure outcomes.
One of the results from this confluence of events has been the emergence of respiratory care practitioners as an integral part of the multidisciplinary team. What began in its nascent stage as loading dock workers delivering H cylinders of oxygen to the wards in the late 1940s evolved into a technical specialty coinciding with the advent of critical care in the mid-1960s. By the mid-1980s, the development of microprocessor-controlled ventilators and other sophisticated respiratory care devices moved the profession further, as out of practical necessity it precluded other inundated professions from gaining mastery. However, until very recently, this reality has tended to outpace perceptions within the hospital culture.
Beginning in the mid-1990s, large randomized, controlled trials increasingly demonstrated the efficiency of protocolized care for numerous medical conditions. An overlooked lesson from the successful NHLBI ARDS Network trials was the fact that very complex protocols governing mechanical ventilation and fluid/vasopressor management were executed competently and efficiently by respiratory care practitioners and nurses alike.
As a former ARDSNetwork site coordinator, it was deeply gratifying to witness the enthusiasm with which these bedside professionals responded to this challenge. Similar results have been reported by other large protocolized studies examining different aspects of care, such as weaning and sedation practices and prone positioning for acute respiratory distress syndrome.
In this study, Fisher et al affirmed that giving allied health professions autonomy to execute care within well-structured, supervised protocols/guidelines is an efficient solution to many of the current obstacles in providing patient care in an increasingly fractured environment. However, there was not enough emphasis in the Fisher et al study on the indispensible need for physician and administrative leadership to give their full-throated support to this endeavor. As alluded to previously, any expectation that a culturally ancient and hierarchical entity will undergo fundamental transformation readily within a few brief decades would be naïve.
It will take dogged perseverance by those in leadership positions to foster this emerging care paradigm and guarantee its success. To paraphrase an old movie cliché: “If you build it, they will come.” The study by Fisher et al is a very important contribution that gratifyingly highlights the contributions of one particular profession still struggling for its place at the table.
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