A Dose of Reality: Using Available Resources as an

Agent for Change

Jim Fink, MS, RRT, FAARC

Fellow, Respiratory Science

Nektar Therapeutics

Mountain View, CA

jfink@ca.nektar.com

Background

• BS in Philosophy– Student of Eastern Philosophies

– Breathing as center of the universe

– Conversant with practices to improve pulmonary delivery

• Looking to make sense of the universal truths• What’s a lad to do?

– Consult Your Spiritual Advisor

Time to Find a Career: What to Be When I Grow Up?

I searched the literature.

Healthcare Looked Like A Promising Profession

Heroic Expectations for Respiratory Care

• Make a difference• Help people• Be An Area Expert• Be An Active Member of the Team

• Role in decision making• Sharing expertise • Problem solving

• Interesting and varied work• Reasonable quality of life

Inhalation Therapy Florida 1971

• Staring salary $2.10/hour• On the Job Trained - Two weeks training

– Best hospital training in town– No Respiratory Training Programs in the Community

• First treatment given– IPPB to 24 year old bunionectomy– IPPB was 80% of floor therapy

• >50% of patients in hospital • Oh yes, IT departments were revenue centers

• Crowning achievement – 20 IPPB Txs before Breakfast trays

Puff Parlors for COPD Pts

IPPB was killed…Due to Over Utilization and Lack of Evidence

• Evidence suggested little support for use

• Feds did not want to pay millions without proof of benefit

• But respiratory was still a cost center– Substitution to maintain revenues

• Incentive spirometry

• Chest physiotherapy

• Aerosol therapy

Later … NPPV filled the unmet medical need

• Better patient selection

• Better Clinical Evidence Base

• More appropriate utilization

Evidence Based Medicine

• Most medicine does not have a sufficient evidence base– Practice based on evidence alone is not

practical

• Most clinician practice is based on what we learned (or didn’t learn) in school

• As evidence base is established, it is not readily adopted into practice

We Are Area Experts

• Respiratory Therapists as a whole get more training in mechanical ventilation, airway management, oxygen therapy, aerosol therapy, and respiratory pharmacology than any other allied health group, and all but a few physicians

• Stay current, know your stuff, share it with the team and your patients.

Training in Aerosols:A Textbook Example

• Physicians – 1 -2 pages

• Nurses– 5 – 10 pages

• Respiratory Therapists– 30 – 40 pages

• 3% of typical 1200 page textbook

• 60 – 80% of RT practice

Management of chronic disease (such as asthma, CF and COPD)

is10% medication

and 90% education

• pMDIs, DPIs and Nebulizer can be equally efficacious• Key consideration for device selection

– Device/drug availability– Clinical setting– Patient age and ability to use the device correctly– Device use with multiple medications– Cost and reimbursement– Drug administration time– Convenience in both inpatient and outpatient setting– Physician and Patient preference

Device Selection and Outcomes of Aerosol Therapy: Evidence-Based GuidelinesDolovich et al. Chest 2005; 127:335-371

Scope of Problem

• 28 – 63% of patients do not use their pMDI or DPI well enough to get benefit of the drug – More than 500 million pMDIs or DPIs are produced

each year – At an average retail cost of $50/inhaler total retail of

$25 Billion

• $7 – 15.7 Billion wasted • Increased ER visits and hospital admissions• Increased morbidity and mortality

Clinicians Can’t Teach What They Don’t Know

• 28 – 68% of patients do not know how to use their pMDI sufficiently to gain full benefit of the medication

• This correlates with 39 – 67% of RNs, MDs and RTs unable to use devices.

• Clinicians are typically 5 – 8 years behind introduction of new devices

• Need to upgrade clinician skills

Problems in Clinician Teaching

• Lack of familiarity with use of specific devices

• Inadequate time to teach

• Poor training techniques

• Poor training materials

• Lack of followup

Literacy

• Approximately 25% of the adult population in the US can not read and comprehend basic written instructions– Take a pill after a meal– How to use your DPI

• There is an inverse relationship between reading grade level and correct performance of MDI technique

Harvard Literacy Project, 1999

Literacy

• In a study of 483 patients presenting to ED or asthma clinic– 66% claimed to be high school graduates– 27% actually read at the high school level

• Poor MDI technique (≤ 3 correct steps)– 89% of patient reading at 3rd grade level– 48% of patient reading at high school level

Williams et al. Chest 1998 114:1008-1015

The Inhaler Device with Highest Adherence: The Cigarette

• Aerosol devices 1 – 5 µm

10 - 20% pulmonary deposition

Patients have problems using

• Cigarettes0.01 – 0.1 µm

80% pulmonary deposition

No problem taking a deep hit with breath hold

Particle size and deposition

Tobacco smoke Medical Aerosol

Phillip Morris

Wall Street Journal, Thursday Oct 17, 2005

Education is key

– Medication plan

– Treatment plan

– use of pMDI or DPIs

– use of accessory devices

– Use of nebulizers

– Cleaning and maintenance of the device

Common Myths

• Inhalers are so Simple They Don’t Require Training

• DPIs and Nebulizers Require Less Training than pMDIs

• Package Inserts are Sufficient

Problems with Inhaler Use - pMDI

• Inhale – too early– too late– too often– too many times

• Failure to shake• Failure to prime• Use in cold weather• Cold freon effect

Problems with Inhaler Use - DPI

• Inhale too slow • Exhale into device prior to breath• Failure to hold in proper orientation• Failure to prime• Failure to pierce capsule or open blister pack• Failure to keep flow path open• Failure to breath hold

Dry Powder Inhalers-USADevice Dementia

Accuhaler/Diskus: salmeterol; salmeterol plus fluticasone; fluticasone; (albuterol)

Aerolizer: eformoterolDiskhaler: fluticasone (relenza)Handihaler: tiotropiumRotahaler: (albuterol)Turbuhaler: budesonideTwisthaler: (mometasone)

www.thoracic.orgwww.thoracic.org

Diskhaler – label instructions

Clinician’s Role

• Device selection• Teaching• Demonstration• Return Demonstration• Evaluate adherence• Teaching/Demonstration• Return Demonstration• Evaluate adherence . . .

Match the Device to the Patient

• Some inhaled drugs have multiple device options• Device selection is key to adherence• Can the patient afford the device?• Can the patient use the device?• Will the patient use the device?• Does the patient use the device?• If not, why?

Sources of Information

• Product Label

• National Standards

• Patient instruction sheets

• Journals – Respiratory Care

• Published research

• Internet

• Text books

Questions Clinicians Should Answer:• What should the drug do - why is it being prescribed• How to know the drug is working• How to know if the drug is not working• What are expected side effects• What are unexpected or less common side effects• How to take it• How will it taste, feel, ect• When to take it• How much to take• How often• When should dosing and frequency change• When should you call for help.

Simplicity and Repetition• Match the Device to the patient

• Use the same device when possible

• Take time to teach

• Use demonstration with placebo

• Observe return demonstration

• Follow up with each patient visit

• Inquire -– what patient likes and dislikes about each device and

medication

Improving adherence

EducationMake it easyMake it important

Make it sexy

Activism Makes A Difference

• AARC

• Chicago Asthma Consortium

• Lung Association

• ACCP

How To Get Started

• Show up

• Show interest

• Get involved

• Take small steps

• Take ownership

• Make things happen

What About the “Good Old Boys?”

• Many organizations have the same leadership for extended periods because not enough members step up to participate

• CSRC Experience– 1979 move to CA, attend district meeting– 1981, President of CSRC

Easy to Make a Difference

• Chicago Asthma Consortium– Attended meeting– Patient education project– Chaired Patient Education Committee

• Produced Asthma Tool Analysis

• 20 hours over 6 months

– Chair of CAC

ACCP Experience

• ACCP Opened Category for Allied Health– Went to early meeting– Allied Health infiltrated major committee– Appointed to Health Science Policy – Initiated Aerosol Evidence Document– Appointed to Patient Education Committee

• Initiated Asthma Education Brochure– International distribution

• Became Chair of Patient Education

RTs are Valuable to Physician Organizations

We add valuable perspective

We tend to be able to get things done

Establish valuable PEER relationships

RTs - Acceptance Worldwide in Promoting Projects of Interest

• AARC – primary group

• ATS

• SCCM

• ACCP

• ISAM

• ERS

• ESICM

Involvement in physician and allied health based organizations help promote

the agenda of the AARC, and our profession.

What are the responsibilities of a professional?

• Excel in providing services to patients

• Contribute to scientific knowledge

• Advance clinical practice

How have other professions guided practice and the future of their profession?

• Physical Therapy: Vision that all PTs will have Doctorate by 2020 - entry will be DPT– Advancement via education

• Nursing: Advancement via clinical practice– Changed scope of practice -licensure act

– Advance practice defined as Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP)

Practice Comparison:Ability to Order Medications

• Nurse practitioner • Physician Assistant • Physical Therapist

• Respiratory Therapy training offers more hours of respiratory pharmacology than any of the above.

• Shouldn’t we aspire to order limited therapies in the future

Where do we want to be in 2020?

• Advance Scope of practice– Consider advancing scope of practice such as

prescriptive authority for particular therapy

• Facilitate advanced practice thru education– Prescriptive authority will require coursework

• RTs reimbursed for patient education services

– Doctors don’t listen to us– Nurses don’t like us– Patients don’t appreciate us– Not enough staff– Too much to do– No respect– No opportunities for growth– No future– No Hope

Common Dissatisfiers

For those who feel that this describes your reality in Respiratory Care

I offer the following Public Service Message

Stop Whining Step Up

Make A Difference