2008 NCSRC Newsletter, Issue 2

Spotlights

The NCSRC wants to congratulate and recognize the efforts of Wendy Ayscue, BS-CPS, RRT and her second year students at Pitt Community College as well as the respiratory therapists at Pitt County Memorial Hospital in Greenville on their participation and support of beausbuddies.  Beaus Buddies Cancer Fund was formed for Beau, who was only two years old when he died of cancer.  Last fall, they hosted their first major fundraiser, an auction and golf tournament that drew support from all over their Greenville, NC, community.

The combined events raised more than $130,000, which is to assist families with everything from phone cards to make long-distance calls while their loved ones are in the hospital or to help with rent or utilities. 

You can see the article in full in the January issue of AARC times or follow this link http://www.aarc.org/members_area/aarc_times/01.09/01.09.046.pdf

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CMS 30 Minute Window Info from the AARC

Because there have been several hospitals in NC requesting something in writing from CMS regarding its acceptance of the AARC position statement on "Inhaled Medication Administration Schedules", we contacted AARC for advice as to what information we could pass along.

We have been told by AARC staff that CMS had a conference call in November 2008 with its survey and certification staff in its Regional Offices regarding AARC's position statement on its "inhaled medication administration schedule." The Regions were sent a copy of the position statement and it was pointed out that the policy was endorsed by the AARC's Board of Medical Directors as well. A list of the organizations that comprised the Board of Medical Directors was also provided. The organizations include the Society of Critical Care Medicine, American Society of Anesthesiologists, American College of Chest Physicians, American College of Allergy Asthma and Immunology, National Association for Medical Direction of Respiratory Care, American Thoracic Society and the American Academy of Pediatrics).

The regions in turn were to tell the state surveyors in the states within their jurisdiction that CMS has accepted the position statement as a general standard of practice for respiratory therapists in the delivery of inhaled medications. It is the AARC's understanding that at some point this issue will be incorporated into training for surveyors so they are aware of the AARC's position. CMS will not put anything in writing because to do so for every association or society that issues a practice standard would be difficult to manage and add to their administrative burden.

I will be sending the Medication Delivery Standards from BOMA (Board of Medical Advisors) as soon as I receive a copy from the AARC.

Terry

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PCC Respiratory Therapy Students Take 3rd in National Competition

PITT COMMUNITY COLLEGE PRESS RELEASE

Contact:

Rob Goldberg, Communications Specialist
252-493-7732

Date:

January 9, 2009

CC Respiratory Therapy Students Take 3rd in National Competition

WINTERVILLE—A team of Pitt Community College Respiratory Therapy students backed up their victory in a state quiz bowl competition in the fall with a top-five showing in last month’s American Association of Respiratory Care International Congress Quiz Bowl.

Angela Chapman, Rachel Clifford and Niya Hagans ended up placing third out of the 18 teams taking part in the national event, which was held in Anaheim, Calif. The students earned the right to represent North Carolina in the competition by winning the Sputum Bowl in September, during the N.C. Society for Respiratory Care Conference (NCSRC).

Wendy Ayscue, department chair of PCC’s Respiratory Therapy and Polysomnography programs, said her students’ thorough preparation for the national event paid off. “This was no easy feat,” she said. “They have certainly earned their bragging rights to claim third in the nation.”

In addition to the students’ impressive finish, PCC also had a good showing in the national competition’s practitioner round. Pitt graduate Rusty Sugg, who is now the director of clinical education for the college’s Respiratory Therapy program, teamed with PCC Respiratory Therapy graduate Wayne Trainor and Ray Braxton from Pitt County Memorial Hospital for the event.

The team, which won the practitioner event at the NCSRC with Ayscue as a member, won several games in California before being eliminated short of the semifinals. Ayscue was unable to attend the national competition.

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NCSRC Delegates Report

AARC House of Delegates Report
American Association for Respiratory Care
House of Delegates
Anaheim, California
December 11-12, 2008

NCSRC Delegates Report
Tom Williams, RRT, RCP
Ray Braxton, RRT, RCP

The AARC House of Delegates convened in Anaheim, California on December 11th thru 12th 2008. The following report is provided with sometimes lengthy details due to the effect that some initiatives will have on the practice and profession on Respiratory Care. Please contact Connie Paladench and/or Ray Braxton if more expansive detail is required for any of the items in the report below:

AARC REPORTS:
Executive Office by Sam Giordano, MBA, RRT, FAARC

MEMBERSHIP

• Over 48, 000 AARC members now
• Dec 2008 - 38,199 AARC Active/Life Members
• 9.5% increased in AARC members in 2008
• 29% of licensed RTs are AARC members
• North Carolina ranks 5th in new recruited active membership to the AARC (180)
• 41% of NC licensed RCP are AARC / NCSRC members
• 29% of RTs nationally are AARC members

ADVOCACY AND AWARENESS

• Peak Performance USA (PPUSA) – will be entirely web based which will include the tools that RTs can use to contact schools, educate students, teachers & school staff about asthma.
• COPD Foundation/AARC Partnership – Mobile Spirometry Unit visited 14 cities and screened over 16,000 people in 2008.
• The Joint Commission – the AARC continues to participate in the Joint Commission Standards Field Review Process. The AARC has provided direct input into 8 additional standards reviews since June, for a total of 18 reviews year to date.
• Healthcare Professionals Network (HPN) – Bill Dubbs was re-elected to the BOD for HPN. HPN is soliciting corporations to fund a $7-10 million campaign to raise awareness of opportunities in health careers (including RT).

EDUCATION

• CRCE – 18,564 people have taken online examinations on the AARC web site over the first 8 months of 2008. There are improvements in the functionality of CRCE that allows for AARC members to obtain a listing of the sessions for which they earn CRCE in the future.
• Asthma Prep Course – beginning in 2009 the AARC will be offering this course as an online web-based educational offering. This transition to online education will allow RTs and other healthcare professionals to access the course without traveling or having to wait until it comes to them.
• Aerosol Delivery Guide – has been 2 years since its last update. AARC in the process of updating this guide with an initial draft to be completed in early spring. This guidebook will exclusively offer free CRCE to AARC members.
• Professors Rounds – 8 professors & topics have been confirmed and will be offered in 2009.
• Webcasts – 18 topics and speakers are planned for the 2009 webcast program. There is now unlimited seating for any live webcast. Archived webcasts are attracting more viewers and has doubled since 2007.
• “Reimbursement College II-Continuing to Explore the Reimbursement Waters” – this is an online & DVD/CD course offered by the AARC in which CRCE is free to members. This course explores the myths and realities of reimbursement and how RTs can impact the reimbursement process.

PROJECTS

• Ethic Course Completion – is being required annually in some states in order for an RCP to renew his/her license (i.e. California). In 2009 all new members or those who renew their AARC membership will be able to take this course on-line at no-cost and will be able to get 2 CRCE
• EPA Partnership – there is a free CRCE course offering in partnership with the EPA and the AARC that being housed on the American Respiratory Care Foundation (ARCF) web site. There is new EPR-3 asthma guidelines specifically directed at the respiratory therapist.
• Benchmarking – As of 14 November 2008 there are 112 active subscribers to the AARC Benchmarking System. New to the system this fall, was the development of a metric tool to measure length of time on mechanical ventilation.

RESPIRATORY CARE JOURNAL

• Has doubled the number of original manuscripts being received & reviewed over 2008 as compared to 2007.
• Transparency - The Journal continues to advance the process of being very definite in getting authors to reveal any and all real or potential conflicts of interest. Transparency is a major issue for every medical journal and the RC Journal’s policy on transparency exceeds present standards of the industry.
• Podcasts – as of July 2008 the Journal began monthly podcasts by editor Dean Hess in which he and his staff detail the contents of the latest issue of the RC Journal. The idea is for podcast subscribers to hear a quick summary and determine the articles to read and review.
  o Journal Conferences – 2 conferences are planned for 2009 sponsored by the American Respiratory Care Foundation (ARCF).
• Journal Archiving – The Journal received funding through a foundation called Internet Archive whereby a member can now scan back issues of the Journal as far back as 1990 vs. 2003.

CONVENTIONS AND MEETINGS

• Asthma Educator Certification Preparation Course – Since July 2008, there have been 4 courses presented. The course continues to be popular with RTs and it has assisted many to achieve the proper knowledge to earn the Asthma Educator-Certified (AE-C) credential. Information on this course may be found at http://www.aarc.org/education/meetings. It was reported that this course would be offered in a web-based format in the coming year.

FEDERAL GOVERNMENT AFFAIRS
Cheryl A. West, MHA – Director of Government Affairs

LEGISLATION

• HR 552/S 329 – The Cardiac and Pulmonary Rehabilitation Act – With the enactment of this bill in July 07, pulmonary rehabilitation services became a Medicare benefit. The actual implementation date for the benefit will be January 1, 2010, giving CMS the next 12 months to set the parameters for what will now be a nationwide and consistent Medicare benefit. Information is available on how to structure a Pulmonary Rehab program including the services and coding being effectively used at this moment on the following website – http://www.aarc.org/resources/pulmonary_rehab_coverage.pdf
• HR 3968/S 2704 – The Medicare Respiratory Therapy Initiative Act – will add respiratory therapy services to the “medical and other health services” benefit category under Medicare Part B. This legislation will permit Respiratory Therapists with a RRT credential and a bachelor degree to deliver respiratory therapy services without the physician being physically present when the services are being furnished (i.e., under general physician supervision). The provisions of this act have been written so as not to infringe on Respiratory Therapists who are currently working in a physician’s office or other site and who do not meet both the required credential and educational criteria. This act will be reintroduced early 2009 with new bill numbers.
• HR 621/S 1484 – The Home Oxygen Patient Protection Act of 2007 – Provisions of this bill allow for Medicare to maintain a payment cap of 36 months, but will no longer turn ownership of the oxygen equipment over to the beneficiary (patient); instead, it will remain with the Durable Medical Equipment (DME) provider.

COALITION ACTIVITIES

The AARC continues its tradition of participating in a number of Coalitions of like-minded associations and organizations to advance particular legislation and regulations. The AARC participation in select coalitions varies from urging greater funding for research to promoting issues that will enhance the clinical support of patients with particular illnesses. The following is a listing of some of these coalitions that the AARC presently participates in:

• The Centers for Disease Control and Prevention (CDC) Chronic Disease COPD Program Appropriations Request – In 2008 the AARC partnered with the US COPD Coalition to support a public health program that would address COPD in the Chronic Disease and Health Prevention Division of the Centers for Disease Control and Prevention (CDC).
• HR 1108/S. 625 – The Family Smoking Prevention and Tobacco Control Act – For nearly two decades the AARC has worked with public health associations organized under one coalition umbrella (Tobacco Free Kids) sponsored by the American Lung Association, American Cancer Society and the American Heart Association. The key focus of the Coalition’s legislative efforts has been to pass legislation (HR 1108/S 624) that will give the FDA greater regulatory authority over the tobacco industry, including advertising and promotion to public. This legislative push will resume with the new Congress for 2009.
• HR 224/S 1340 – The Geriatric Assessment and Chronic Care Coordination Act – The AARC is supporting this Coalition effort spearheaded by the American Geriatrics Society to enact legislation that would provide Medicare coverage for geriatric assessments and chronic care coordination services.
• National Sleep Foundation Roundtable – The AARC has been asked to participate and send representatives to a Washington, D.C. based coalition of organization involved in sleep research and federal policy issues. A meeting in early January is scheduled to set Roundtable’s priorities for 2009.
• 2009 PACT Meeting - will be held March 9-10, 2009. The key focus for our legislative efforts this year will be to gather more co-sponsors for our Respiratory Therapy Medicare Initiative legislation.

REGULATIONS

Based in the Washington, DC area, Anne Marie Hummel as AARC’s Director of Regulatory Affairs is raising the AARC’s profile in the area of health policy and regulations. Below is a listing of several regulations that Anne Marie is presently working on and their progress:

• Proposed Rules to Revise Definition of Respiratory Therapist – The proposed 2009 update to the physician’s fee schedule contained certain Comprehensive Outpatient Rehabilitation Faculties (CORF) provisions, among them a proposed revision to the definition of “respiratory therapist.” The changes would eliminate the services of “respiratory therapy technicians” (a term that we have emphasized to CMS is obsolete), and only permit registered respiratory therapists to furnish services in the CORF setting.
• Nursing Home Ventilator Standards – Gene Gantt, Long Term Care Section Chair to the AARC, has been instrumental in working with the Tennessee state government to successfully advocate for the adoption of practice standards for ventilator patients in nursing homes. In May 2008, the AARC submitted comments regarding the possible use of these ventilator standards in conjunction with a new CMS initiative to create a 5-star rating system for nursing homes and recommended that Medicaid state agencies use the Tennessee ventilator standards as a “best practice” in state nursing homes.
• 30 Minute Medication Delivery Rule – As most of you know, the NCSRC & AARC have taken action on this CMS regulation over the past year. An outcome of this was the development of the “AARC’s Board of Medical Advisors” endorsement of a new AARC position statement involving the administration of inhaled medications that may result in a delivery time that exceeds the current survey interpretive guidelines of 30 minutes before or after the scheduled delivery time. A copy of the position statement was submitted to CMS in early September 2008. At this point the AARC continues to be seeking advice from CMS on how to respond to this issue.
• Regulations Banning the Sale and Distribution of Certain Metered-Dose Inhalers – The AARC continues to work with the Asthma & Allergy Network Mothers of Asthmatics (AANMA) as part of its MDI Transition Workgroup to get the word out about the required transition to HFA MDIs.
• Interpretive Guidelines Affecting Standing Orders and Protocols – The AARC, working with the American Hospital Association and other stakeholders, provided written comments and participated in a group conference call in August with CMS regarding problems hat have occurred since new interpretive guidelines regarding standing orders and protocols were issued for surveyors earlier this year. The guidelines only affect the conditions dealing with administration of drugs and biologicals (not ventilator protocol). Taking into account the stakeholders concerns, CMS released revisions to the interpretive guidelines on October 24, 2008. The agency clarified that use of standing orders be documented as an order in the patient’s medical record and signed by the practitioner responsible for the patient’s care but the timing of the documentation should not be a barrier to patient safety and emergency care. CMS essentially eliminated the controversial “note” that was included in the earlier guidelines that required a standing order to be first, ordered by the patient’s practioner before it could be initiated.

LOCAL COVERAGE DETERMINATIONS (LCDs)

• Positive Airway Pressure (PAP Devices for the treatment of Obstructive Sleep Apnea (OSA – CMS currently covers CPAP devices for the treatment of OSA for an initial 12-week period; coverage beyond the initial period is conditioned on the patient’s improved health. The four CMS regional contractors recently implemented new policies that established additional coverage beyond the initial 12-week period by setting compliance and adherence requirements that are more restrictive than the improved health criterion. AARC believes these policies put patients at risk by not being able to continue with therapies that may improve their overall health.
  AARC submitted comments in mid-August questioning the scientific evidence considered in the policy formation and the need for patient compliance to be based on objective evidence of adherence via downloadable data from the device. The contractors released a revised policy in October that some have referred to as “softer”. One significant change of interest to the AARC was the elimination of the need for high-end CPAPs by allowing the “acceptance of visual inspection” versus direct downloadable data as means of adherence.
• Sleep Disorders Testing – As part of the transition to Part A/B Medicare Administrative Contractors (MACs) Highmark Medicare Services released a draft LCD on sleep disorders testing that did not address examples of personnel qualified to perform the tests and only cited the American Academy of Sleep Medicine as an example of an entity qualified to accredit sleep facilities. Consistent with comments AARC has made on other similar contractor policies, we advocate for revisions that would include specific references to personnel qualified to perform sleep tests, such as RTs, registered polysomnographic technologists, specially-trained nurses or other health professionals who have been competency tested by nationally recognized accreditation entities. The AARC also requested that other accrediting bodies, such as The Joint Commission, be added to the examples of accrediting bodies.

STATE GOVERNMENT AFFAIRS
Cheryl A. West, MHA, Director of Government Affairs

LEGISLATION SPECIFICALLY AFFECTIVING RESPIRAORY THERAPY LICENSURE– Eight (8) states over the past year have had legislation submitted that directly address revisions to the respiratory therapy licensure law or practice. Of these, five (5) bills were passed and enacted:

• Maryland - enacted changes requirements for temporary licenses.
• West Virginia – enacted a bill revising the RC Licensure Board duties including the process for RT student applications and work permits.
• Ohio – enacted a bill requiring RT background checks for licensure. This year Ohio issued extensive regulatory revisions to RT licensure procedures relating to educational programs, recognized examinations, license application procedures, continuing education and ethical and professional conduct.
• Vermont – enacted legislation that deleted the specific reference to the NBRC as the sole testing entity and would permit the Board to decide the appropriate test provider. The same bill also deleted the grandfather provision that permitted those without formal education to obtain a RT license.
• Alabama – enacted legislation to extend the sunset for RC Licensure Board

NBRC AND LICENSURE REQUIREMENTS – The NBRC requires those respiratory therapists who graduated after 2002 to renew their credentials every five years by either taking a more advanced examination or meeting continuing educational requirements. Failure to meet the requirements will result in the expiration of the credentials and prohibition to use the trademarked credentials.
The question has been raised as to what state licensure laws contain provisions requiring the applicants for licensure to maintain NBRC credential. Clearly, initial state licensing requires that the applicant has taken the NBRC exam. Therefore, for initial licenses NBRC credentials are required.
The North Carolina Respiratory Board licensure process initially requires verified passage of the NBRC CRT exam. There is a short reinstatement time, whereby, if you have not practiced RT in one year or more, you must have the CRT credentials to reapply for a license, but renewal and reciprocity does not require a current CRT credential at this time. Look for more discussion and action on this matter in the coming year as licensure boards address this issue.

STATE POLYSOMNOGRAPHY EFFORTS – In several states efforts to license those engaged in providing sleep disorder services continue. A majority of the procedures involved and described in the scope of practice for polysomnography are respiratory services. Therefore, it is not only appropriate but also essential that state societies closely review any proposed polysomnography legislation for education and competency requirements. Moreover, since respiratory therapists have for decades been providing sleep disorder services under their own scope of practice, with absolutely no negative incidence, no provisions that license polysom personnel should infringe on the licensed respiratory therapist’s ability to continue to provide this part of their own scope of practice.

The AARC does not oppose the licensure or regulation of polysomnography personnel. The AARC, however, is opposed to any provisions that not only will jeopardize patient safety through porous competency and education requirements, but will undermine the established scope of practice of respiratory care and require the licensed respiratory therapist to obtain additional training and credentialing.
Over the past year (2008) five (5) states had legislative bills introduced that address the licensure of polysomnography. The AARC anticipates that activity at the state level will increase significantly in 2009. The AARC stands ready to assist the state societies during these challenging times.

AMERICAN RESPIRATORY CARE FOUNDATION (ARCF)
Michael Amato / John D. Hiser, MEd, RRT, FAARC

JOURNAL CONFERENCE – In 2008 the Foundation presented tow Journal Conferences:

• The 42nd Respiratory Care Journal Conference - “Controversies and Emergency Concepts of Non-Invasive Ventilation in Acute Care” was held on March 7-9, 2008 in Cancun, Mexico.
• The 43rd Respiratory Care Journal Conference – “Cystic Fibrosis” was held in Scottsdale, Arizona, September 26-28, 2008.

The proceedings of presentations will be published in the Journal in 2009.

EPA PARTNERSHIP - Over 5,600 register on-line for the Train-the-Trainer web based module and 3320 have received their CRCE for completing and passing the test. This particular module has seen over 15,000 RTs register since it was placed on the web site in 2007. The ARCF has produced an additional 3 hours of train-the-trainer asthma related education. This has been made possible from a grant extension from the EPA. This web-based presentation will be available the first week of January 2009. The topics cover the expanding role of the RT in smoking cessation and allergy testing. There will be a discussion of the impact of the new EPR-3 asthma guidelines specifically related at the respiratory therapist. This will be a free CRCE course offering that will be housed on the ARCF web site.

INTERNATIONAL FELLOWSHIP PROGRAM – In 2008 the International Committee received 46 applicants for International Fellows from 24 different countries. Of these, 6 fellows have been accepted for the coming year to take place in 12 cities. An outcome from this fellowship program this past year is the translation of the AARC’s “Guide to Aerosol Delivery Devices” to Chinese and Spanish.

NATIONAL BOARD FOR RESPIRATORY CARE
Sherry L. Barnhart, RRT, RRT-NPS, FAARC, President NBRC

SLEEP DISORDERS TESTING AND THERAPEUTIC TEST DEVELOPMENT – This new Specialty Examination for Respiratory Therapists Performing Sleep Disorders Testing and Therapeutic Intervention will consist of 160 scored items and 20 pretest questions; candidates will be given 4 hours to take the examination. The NBRC Board approved the following admissions policies for this specialty examination:
Be a CRT or RRT having completed a CAAHEP accredited respiratory therapist program including a sleep add-on track, OR
Be a CRT with 6 months of full time* clinical experience in a sleep diagnostics and treatment setting under medical supervision (MD, DO or PhD), OR
Be a RRT with 3 months of full time* clinical experience in a sleep diagnostics and treatment setting under medical supervision (MD, DO or PhD).

• Full time experience is defined as a minimum of 21 hours per week*

The NBRC Board has filed applications for federally registered trademarks for the credential acronym to be awarded to successful candidates for this specialty examination that will be tied to an individual’s primary respiratory therapy credential(s). The credential acronyms are CRT-SDS or RRT-SDS to indicate Sleep Disorders Specialist.

NEW TEST SPECIFICATIONS TO BE INTRODUCED FOR CRT AND RRT EXAMINATIONS – New test specifications for the CRT Examination will be implemented with examinations administered in July 2009. A revised practice test and self- assessment examinations will be available in January 2009. Test content for the RRT Examinations will change with examinations administered in January 2010 and an updated practice test and self-assessment examinations will be available in July 2009.

CONTINUING COMPETENCY PROGRAM – The Board of Trustees of the NBRC considered and approved two changes to the Continuing Competency Program at its November 2008 meeting. This is in reference to the renewal fee charged by the NBRC for a respiratory therapist (graduate after 2002) to renew his/her credential(s) that takes affect January 1, 2009:
$0 – if they have continuously maintained their active status by paying the $25 annual renewal fee in each year after earning their credential, OR
Pay the difference between $125 and what they have paid in annual renewal fees since earning their credential(s).

Reinstatement for Expired Credentials – If an individual’s credential(s) expire, they are required to retake and pass the respective examination(s) and pay the new applicant fees as well as a lapsed credential fee of $150 per credential. (Example: An individual whose CRT and RRT credentials have expired would pay a total $880 to retake the examinations on their first attempt.
As of January 1, 2009 the NBRC implemented a six (6) month grace period for individuals whose credential(s) expire to document their CE (provided it was completed prior to their credential expiration date), pay a reinstatement fee of $250 and waive the requirement for these individuals to retake and pass the respective examination(s).

IMPORTANT TO NOTE FOR THE RESPIRATORY THERAPIST (Graduate after 2002)

It is imperative that the respiratory therapist maintains a current mailing address with the NBRC in order to receive reminders (x3) from the NBRC in reference to deadline for expiration of credentials. It is also more prudent to renew your active status with the NBRC annually with a fee of $25 while ensuring active mailing address is on file.

COMMITTEE ON ACCREDITATION FOR RESPIRATORY CARE (CoARC)
Shelly Mishoe, PhD, RRT, FAARC, Chair

ACCREDITED RESPIRATORY CARE PROGRAMS – The Commission on Accreditation of Allied Health Education Programs (CAAHEP) upon the recommendation of CoARC currently has a total of 372 accredited Respiratory Care Programs. An additional 52 programs hold a Letter of Review (LoR) which is a CoARC status signifying that a program seeking initial Accreditation has demonstrated sufficient compliance with the accreditation Standards through the Letter of Review Self Study Report (Letter of Review SSR) and other documentation. A LoR authorizes the sponsor to admit its first class of students. A LoR is recognized by the National Board for Respiratory Care (NBRC) toward eligibility to the Respiratory Care credentialing examination(s). Thirty of the accredited programs are Certification-level (100 level) and 342 are Registry-level (200-level).
CAAHEP upon the recommendation of CoARC also accredits polysomnography program as add-ons to accredited Respiratory Care Programs. There are also a total of 10 Satellite campuses, 3 evening formats, and 1 distance program (all domestic).

ENROLLMENT AND GRADUATION FROM ACCREDITED RESPIRATORY CARE PROGRAMS – Based on analysis of the 2008 Reports of Current Status (the annual reports that were submitted on September 19, 2008):

• Total combined enrollments for 2007 for all programs = 8861 (6.7% decrease fr 2006)
• Total combined graduates for 2007 for all programs = 6762 (5.8% increase fr 2006)

STANDARDS REVISIONS PROCESS – CoARC reviews its current standards every five years. CoARC will be working with its sponsoring organizations to develop progressive drafts over the next several months. In addition to the input from CoARC sponsors, open hearings will be scheduled on the proposed Standards to permit consideration from all applicable communities of interest regarding what should and what should not be included in the Standards. Once the final draft is reviewed and approved, it will be sent to CoARC’s sponsoring organizations for formal endorsement.

AD-HOC SUBCOMMITTEE ON INDEPENDENT ACCREDITOR STATUS – At the November 2008 Board meeting, CoARC made the decision to proceed with the process of separating from CAAHEP and become a freestanding accreditor for respiratory therapy programs. In the current structure, CoARC is a committee that makes recommendations to CAAHEP as the accreditor. CoARC formed an ad-hoc subcommittee in July 2008 to conduct a detailed assessment of its current relationship with CAAHEP, as well as to determine the advantages and disadvantages that such a decision might have on our communities of interest and the profession. The CAAHEP, CoARC’s sponsors and the educational programs were notified by letter on November 17th 2008, along with the National Network of Health Career Programs in Two Year Colleges (NN2) and the Association of Schools of Allied Health Professions (ASAHP).

This decision has been made after a thorough review and consideration of the pros and cons of pursuing independent accreditor status. With almost 40 years of operation, first as part of the AMA’s Committee on Allied Health Education and Accreditation (CAHEA), and then under the Commission on Accreditation of Allied Health Education Programs (CAAHEP system, the CoARC feels they have gained the maturity and experience to function as a freestanding organization. Reportedly, timely steps are being taken to assure recognition as the official accrediting agency for respiratory therapy education programs by the sponsors, National Board for Respiratory Care, state licensing boards, and other appropriate entities. CoARC is proposing a target separation date of January 15, 2010.

HOUSE OF DELEGATES RESOLUTIONS (DEC 11-12, 08)

#94-08-24 – Resolve that the AARC provide the option of direct deposit of state affiliate’s quarterly revenue sharing checks into affiliate’s checking account

• HOD - PASSED
• AARC BOD – referred to Executive Office to implement – AARC is investigating the potential of instituting this process of direct deposit.

#80-08-25 – Resolve that the AARC Chartered Affiliates Handbook (latest edition 1/08) be revised to delete: Officers Duties Sections: Treasure, line VII; Secretary, line X, and from the General Information Form, line #6 to no longer require the submission of budget information to the AARC. That the ARRC cease requiring such information from the chartered affiliates, effective immediately.”

• HOD – This resolution was withdrawn by the resolution’s author once it was brought to the floor for consideration.
  

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Message from the President

Theodore Roosevelt said,
Far and away the best prize that life offers is the chance to work hard at work worth doing. <http://www.quotationspage.com/quote/2056.html>
Our work is worth doing! However such challenges as the dangers of therapist apathy and cynicism are real the defeatism and self-doubt characteristic of a pessimistic attitude will undermine and destroy such values as idealism, hope and trust if we are not proactive!

To be proactive I believe the NCSRC must represent and reflect all therapists that practice Respiratory Care in The State of North Carolina. The NCSRC also needs to make public statements on issues that affect the public health, safety, and welfare of the Respiratory patient in North Carolina and be recognized. Our organization must also represent and reflect all aspects of Respiratory Care in The State of North Carolina as well as to be seen and understood as an organization in order to promote the public health, safety, and welfare of the Respiratory patient in North Carolina.

Who are the therapists in the state?

The majority (83.7%) practice in hospitals,

followed by home health (9.6%)

long-term care settings (2.2%)

rehabilitation (1.2%)

practice/clinic (0.9%)

education/research (1.0%)

sleep center (0.5%)

other (0.9%)

Source: American Association for Respiratory Care, Respiratory Therapists Human

Resources Study - 2000. AARC Times, December 2000.

Source: North Carolina Respiratory Care Board, 2004.

Notes: N=3,038. Licensees with missing employment

My plan is to;

1. MARKETING THE PROFESSION OF RESPIRATORY
2. CONTINUE TO ENHANCE AND UTILIZE THE NCSRC WEB PAGE
3. PROVIDE EDUCATIONAL OPPORTUNITIES
4. SUPPORT THE GOALS OF THE AARC/NCSRC POLITICAL ADVOCACY CONTACT TEAM (PACT)
5. RECRUIT & RETAIN MEMBERSHIP INTO THE NCSRC & AARC
6. Represent the therapist in LEGAL CREDENTIALING OF THE RESPIRATORY THERAPIST/PRACTITIONER

Terry Smith

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Management of the Difficult/Failed Airway
Jhaymie L Cappiello BS RRT

Successful airway management involves both the ability to perform the procedure skillfully and to be able to recognize the signs that you may be dealing with a difficult airway. Even in the most advanced setting, the potential for a failed airway is always present. The failed airway can be defined in one of two ways, the inability to intubate and ventilate the patient to maintain an oxyhemoglobin saturation of > 90%, or the unsuccessful passage of the endotracheal tube after three attempts by an experienced clinician. The potential consequences for the patient with a failed airway can be catastrophic. It is therefore essential that a thorough evaluation be performed for each airway management situation. This evaluation should include patient anatomy, pathology and available support services to assist in optimizing conditions. Preparation and recognition of the difficult airway will optimize the clinicians’ chance for successful airway management.

Reaction to the Difficult Airway

Prevention of the ‘can’t intubate /can’t ventilate’ airway failure is of paramount importance. Confidence in basic airway management techniques will yield positive results and will assist the team in establishing a definitive airway in a timely manner. When having difficulty with manual ventilation, check mask size and placement, head/jaw position, ventilation status with the insertion of an oral/nasal airway, and is there a removable upper airway obstruction or fluids that require suctioning? 
Direct vision laryngoscopy affords the clinician the chance to determine if the airway is manageable with conservative techniques. An inability to visualize the vocal chords may be due to an inappropriate laryngoscope blade and/or technique. Re-establishment of the approach paying attention to detail may help. Firm posterior rightward cricoid manipulation may bring the hard to visualize chords into view, or gentle retraction of the patients’ lip may be necessary. Support personnel with airway management skills are invaluable in assisting with these techniques. Inability to visualize any part of the vocal chords, a blind airway, should be immediately made known to assisting personnel. This will initiate early preparation for a ‘failed airway procedure’ should the need arise.
A smooth passage of an endotracheal tube is not guaranteed once the vocal chords are visualized. The clinician should have an array of different sized endotracheal tubes available, allowing for a change in tube size if resistance is met, without loss of visualization. This technique will minimize laryngoscopies, a known cause of pharyngeal edema, which could impede future visualizations.
It is important that the support personnel are aware of what the clinician is experiencing. They are monitoring the patient, providing feedback to the clinician on the patients’ condition, and will make available additional resources should the need arise.

The Failed Airway

All airways have the potential for failure. The ‘can’t intubate/can’t ventilate’ airway failure typically results in an emergent cricothyrotomy. The decision for this procedure is made when the most skilled clinician is unable to maintain a patent functioning airway and the need for a definitive airway is absolute. This decision is best made early. When a skilled operator is unable to obtain an airway following three attempts, this too is a ‘failed’ airway. With oxygenation and ventilation being supported, there is time to consider airway adjuncts and call for additional personnel if needed. The use of airway adjuncts such as bougies, introducers, LMAs’, and intubating bronchoscopes can resolve this dilemma. Readily available airway adjuncts, transtracheal jet and an emergency cricothyrotomy kit should be standard equipment for a failed airway box.  It is important to clearly discern and communicate the difference in order to pursue the proper course of action.

Conclusion

The recent article in The Journal of Clinical Anesthesia, Volume 19, Issue 1 ‘Urgent tracheal intubation in general hospital units: an observational study’, Benedetto et al, reported their most common complications noted for general care unit emergent and elective intubations were multiple attempts. Anesthesia and Analgesia Volume 99, Issue 2, Mort et al, reported a significant increase in airway related complications with laryngoscopies >2. The management of the airway should be approached with consistency and respect. When facing a difficult airway, the clinicians’ skill and knowledge must be accompanied by support systems with familiarity of both the procedure and the equipment. Appropriate preparation and response in action to each obstacle by the team of providers will enable positive airway outcomes.

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NCSRC-2008-2009 Officers and BOD Members

Officers:

Past-Pres:

Bill Kiger

Pres:

Terry Smith

Pres-Elect:

Jimmy Phillips

Vice-Pres:

Myra Stearns

Treasurer:

Tim King

Secretary:

Jill Saye

Delegate:

A. Ray Braxton

Delegate:

Connie Palandench

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