2010 NCSRC Newsletter, Issue 1
Influenza Update: Are We Done Yet?
by Charles Hartis, Pharm D
In 2009, the world has seen the first influenza pandemic in 40 years. CDC estimates that as many as 80 million Americans have had Novel-H1N1 influenza as of December, 2009, resulting in at least 200,000 hospitalizations and 11,000 deaths. Spread of the virus has come in 2 waves, with a third predicted in 2010. Currently, cases have dropped substantially from the peak in Oct-Nov ’09. This strain, labeled “2009 novel H1N1” has proven different in several ways from typical seasonal flu strains.
First, H1N1 has more severely affected patients younger than 65 years old. CDC surveillance data show 257 pediatric deaths compared with only 88 in the 2007-08 season. Pregnant women , who make up only 1% of the US population have been some of the most severely affected and account for 6% of fatal pandemic flu. One publication from Michigan showed morbid obesity to be very common among influenza related respiratory failure patients. Such patients have uncharacteristically more oxygenation problems than seen with seasonal flu, requiring more interventions such as prone positioning, nitric oxide, oscillating ventilators, and ECMO. Though lengths of ICU stay have been long, overall mortality has been lower than seen with elderly patients in seasonal flu. Studies put the survival rate of patients requiring ECMO between 66 and 80%, much higher than most ECMO patients.
Antiviral medications have been a second distinct feature of H1N1 courses. Though overall, the strain is less virulent than typical seasonal flu, patients with severe courses have required longer courses, higher doses, and sometimes investigational IV antivirals. Though there have been rare reports of resistance to oseltamivir, CDC estimates only 1.4% of tested isolates are resistant to this drug. There has been no resistance seen with Zanamivir (Relenza®), though this drug is only commercially available in a dry-powder inhaler form. Peramivir is an investigational IV antiviral that has been used in severe cases.
Testing for H1N1 has been difficult thus far, but PCR tests are now becoming commercially available. Nasal washing for “rapid influenza” testing has shown to be only about 50% sensitive for H1N1, so clinical management continues to be based on presenting signs. These signs/symptoms are similar to other influenza strains: fever, cough, muscle/joint pain, sore throat, chills, and sometimes diarrhea.
Vaccination for H1N1 has been shown to be effective, but as of January only 20% or 61 million Americans have been vaccinated. To avoid influenza this season, the CDC still recommends both H1N1 and trivalent seasonal vaccinations.
At this time seasonal strains of influenza have been very rare and H1N1 cases have dramatically decreased. CDC experts predict a third wave of influenza, though the extent is unpredictable. Expanding the pool of vaccinated patients may be the best way to avert a third wave and season flu as well. Identifying patients at high risk, e.g. morbidly obese, lung disease, or on chronic steroids, may help decrease their risk as well as helping defuse the next wave of flu.
-Charles Hartis, Pharm D
AARC / NCSRC PACT 2010 Washington DC
by Lawson Millner, RRT, RCP
Lawson Millner & Tim King of the NCSRC PACT participated in the AARC’s 2010 PACT DC Hill / Lobby Day on March 8-10. We were there to ask for support for bills HR 1077 and S 343, Medicare Pt. B RT legislation. This legislation will expand a Medicare patient's access to qualified respiratory therapists in physician offices. Our approach was that hospital readmissions for Medicare patients with COPD and pneumonia are very high as is the cost for these readmissions. The June 2007 cost of these two Medicare readmissions rates is approximately $888,000,000. We offer this premise if Medicare COPD and pneumonia patients had better access to RTs post hospital, there would be a potential to decrease these readmissions.
We met with staffers from both Senators Burr and Hagan. We also met with eight other US Representatives and / or their staffers. We had an Alpha 1 patient join one of our meetings to help show why the legislation is important from a patient perspective. Our message was well received and most that we met with were aware of the legislation that both the AARC / NCSRC are supporting.
While there, we presented certificates of appreciation on behalf of the NCSRC to Congressman David Price and Congressman Heath Shuler for their continued support of respiratory issues.
The provisions of the RT Medicare PT B Initiative did not get into the final House or Senate health reform package due to a Congressional Budget Office (CBO) cost estimate. Those that we met with did sound in favor of the bill, but want to get the CBO to rescore the cost of the bill before committing to support it.
We also asked for support for legislation, not yet introduced, but coming very soon that would authorize the Chronic Disease Division at CDC to establish a permanent COPD program. This will help bring more attention and funding to COPD. COPD is the only disease in the top 10 causes of death that is on the rise.
If you have not written to your representatives, we still need your support. Simply follow this link and choose appropriate links http://capwiz.com/aarc/issues/?style=D
Other legislation on Capital Hill is a key issue for the HME/DME providers, HR 3790. HR 3790 is a bill introduced by Congressman Meek of Florida that will repeal the implementation of the Medicare competitive bidding program for DME. (Home oxygen, oxygen supplies and oxygen equipment will be part of the competitive bid program). The AARC is in support of the Meek legislation. The AARC has written to Congressman Meek stating their support and that the legislation is good for the patient, a sound Medicare policy and is fiscally responsible. The AARC also has a statement on home oxygen reform efforts and competitive bidding. Constant changes in Medicare coverage policy for durable medical equipment, highlighted by the impending implementation of the competitive bid program, have had a negative impact on the pulmonary patient’s home care, making it ever more difficult to receive the full range of Medicare services for which they are eligible and which they desperately need. Further expansion of the program as proposed under health care reform could be detrimental to quality patient care.
The Role of the Respiratory Care Practitioner in Sleep Medicine
by Bill Kiger, RRT, RCP
I have had the honor and privilege of participating in a little known profession known as Respiratory Therapy for the past 29 years. Over the course of those years I have seen my profession grow beyond my wildest dreams. I could not be any prouder of the patient care I have provided, the knowledge I have gained, the relationships formed by being a passionate advocate for my patients, nor the many professional relationships I have been lucky enough to enjoy over these years and still enjoy today. However, I want to share with you what I believe is yet another opportunity for a skilled Respiratory Care Practitioner to apply his or her unique skill set to a whole new group of patients that desperately need our help. I’m talking about the millions of patients suffering from obstructive sleep apnea (OSA) as well as other sleep disorders.
I was officially diagnosed with OSA in 1987 during the second year of my marriage. My wife, the Registered Nurse, had finally had enough of my choking and gasping and snoring and issued “The Ultimatum”! I responded appropriately to “The Ultimatum” and made an appointment with my primary care physician (a pulmonologist) to discuss my situation. He sent me to a Sleep Medicine specialist and I had a polysomnogram and subsequent CPAP titration. I have been a CPAP patient for years and graduated to bi-level PAP in 2000. Both my airway and my marriage were saved!
In 2006, my Director, Shelbourn Stevens, asked me to start a sleep center at Forsyth Medical Center. I was honored to be asked to start such a venture, and scared at the same time. For the first time in my professional life I was about to lead clinical staff that I did not share a credential with, nor did I share their clinical education experience. Not to bore you with my story, but I successfully initiated this new clinical offering and Forsyth Sleep Center was accredited by the American Academy of Sleep Medicine as a comprehensive sleep disorders center in March, 2009.
I want to share with you some key learnings from my biased clinical perspective on sleep medicine. I am sharing these key learnings because I see yet another opportunity for our profession to make a positive impact on excellent patient care in multiple care settings.
*The opinions expressed here are mine and mine alone and in no way reflect on my employer, Novant Health/Forsyth Medical Center.*
The first thing I learned is that the RPSGT credential, awarded by the Board for Registered Polysomnographic Technologists (BRPT), is not equivalent to the RRT credential awarded by the National Board for Respiratory Care (NBRC). The pathways that lead an individual to attain one of these two credentials are entirely different in content, character and competency and in no way should one consider them to be in the vicinity of equivalent. That being said, I have gained an appreciation for those practicing sleep medicine technology as “Sleep Techs” as expert in the field of diagnosing sleep disorders, 80% of which are airway obstructions or obstructive sleep apnea. In fact, the path to getting the RPSGT credential reminds me of the way we used to get to the RRT credential in the infancy of our profession-not a lot of well-organized, formal, didactic education or schools, but a lot of technical, on-the-job, hands-on practice with physician oversight and a test at the end. And, like Respiratory Therapy evolved, Sleep Technology is evolving as evidenced by the formal education programs offered in some of the same Community Colleges in North Carolina as the Respiratory Therapy programs are. This is a very good thing for the patients being cared for because their safety, and an accurate diagnosis and treatment, are really the only things that matter in the end. The recent North Carolina statute requiring registration of all RPSGT in the state is evidence that the safe practice of sleep technology is important enough to the safety of the citizens of North Carolina that our Legislature deemed it necessary to have all practicing Sleep Technologists hold the RPSGT credential and register with the State.
The second thing I learned was that Sleep Techs are not as reactive as RCPs to hypoxia. My first night working alongside an RPSGT in the Sleep Center was agonizing. Every fiber of my being screamed for me to get up immediately and treat that oxygen saturation of 82%!! Wake that man up right now and put some oxygen on him before he dies!! And look at that heart rate! Don’t they know that the tachycardia he has is directly from that last desaturation! And now that he’s not moving any air at all, don’t they know that bradycardia is also from his sats of 80%? OMG!!!!! I thought I was going to explode. The RPSGT told me “He’s probably been doing this for years. If we don’t let this happen, he’ll never qualify for a CPAP. If he starts to crash, we’ll go in.” Now, I’m no stranger to the wicked ways of Medicare and the lengths you have to go to qualify for simple oxygen therapy. I understand that Medicare, as well as all of their minions in the rest of the insurance industry, feel that you must have actual cellular level tissue death to show that you need oxygen to live a productive life before they will pay for it, but I thought that only applied to oxygen therapy. Now I know it applies to sleep disordered breathing also! It’s not bad enough to be apneic for long periods of time, but you have to do it frequently (more then 15 times per hour) and you have to simultaneously be clinically hypoxic! Wow!
The third thing I learned was that when you put an RPSGT and an RRT/RCP together in a room and perform a polysomnogram or a PAP titration, it is a perfect storm of knowledge. What I mean by that is that when the skill and knowledge the RPSGT has about neurophysiology and the pathophysiology of sleep is joined to the cardiopulmonary anatomy and physiology and pulmonary pathophysiology of the RRT/RCP, the perfect therapist/technologist is formed. Now, before I offend the sensibilities of my friends in Sleep and my friends in Respiratory Care, I believe these two skill sets compliment each other in ways yet unrecognized by either profession independently. The potential power that harnessing these two forces together is awesome! And most importantly, the result of this collaboration in the care of the patient is awesome! I only wish that the current factions in this turf war would realize that excellent patient care is the only goal, and that diagnosis and treatment of sleep related breathing disorders is an area where each group brings only strengths, not weaknesses. For instance, some of the current issues in the Respiratory world surrounding non-invasive ventilation have already been addressed in the Sleep world, and learning from each other would benefit both and benefit the patient. Conversely, the Sleep world is just now realizing and recognizing the terms tidal volume and minute ventilation in relation to adaptive servo ventilation to treat not only obesity hypoventilation and hypercarbic respiratory failure, but central sleep apnea as well.
The fourth thing I have learned, and the last thing I’m telling you about today, is that OSA is an epidemic. Over the last two years at Forsyth Medical Center, we developed a screening program and applied it to all orthopaedic total joint replacement surgery patients. While the research shows that up to 15% of adults in the US may have OSA, our data shows that 80% of those screened pre-operatively for OSA, using the Berlin Questionnaire, screened positive for probable OSA! The Berlin Questionnaire is 89% predictive of OSA when followed by a polysomnogram. Every day in hospitals across the state, patients have surgery. Of all of those patients undergoing surgery, most receive post-op opiods for pain. How many times have you been called to see a patient who is having trouble breathing or is experiencing low oxygen saturations after surgery? How many of those patients were screened pre-op for OSA? How many times have you walked by a patient’s room and heard them snoring way before you got to the room? How many times have you heard them gasping? Can you imagine how long you must have to be apneic or nearly apneic to set your pulse oximetry alarm off, especially if you have nasal O2 on? We must be more proactive in screening for sleep disordered breathing and less reactive. There is a huge opportunity for Respiratory Care Practitioners to take the lead in advocating for screening for OSA, in appropriate monitoring of patients with suspected OSA, in treating symptomatic OSA, and in making sure everybody that screens positive goes to see a Sleep Medicine Physician. We must then advocate for diagnostic polysomnography and PAP titration and make sure the patient is treated and re-assessed post treatment to monitor compliance. Respiratory Care Practitioners practice in all of these settings. If the truth be told, there are not enough sleep centers, not enough sleep doctors, not enough sleep techs and not enough respiratory care practitioners to screen, diagnose or treat everyone who has OSA today. But we have to start somewhere. Why not us, and why not now?
Employer Support of the Guard and Reserve
by Jill Saye, BS, RRT, RCP
On March 1, 2010, the management team of the Cardiopulmonary Services Department at Forsyth Medical Center in Winston-Salem, NC received the designation of Patriotic Employer by the Employer Support of the Guard and Reserve (ESGR). An employee in their department was called upon for duty in late 2009. He would require an extensive leave to serve our great country. Without hesitation, the management team assisted the employee with everything necessary for a smooth transition. Before he left, he was given a small party to recognize his bravery and commitment. After many hugs and tears, he left us for a greater cause - protecting his country and our freedom.
Retired Brigadier General Bud Martin presented Director Paula Mendenhall and Manager Jill Saye with certificates recognizing them as patriotic employers for contributing to national security and protecting liberty and freedom by supporting employee participation in America’s National Guard and Reserve Force. Not present to receive his certificate was Clinical Coordinator John Wilson.
Paula Mendenhall, General Bud Martin and Jill Saye