+

Introduction to Research for the Respiratory Care Practitioner

Presented to the CTICU Core RCPsOctober 18, 2013

By Leo Langga, Dr.PH(c), MBA, RCP, RRT-NPS

+Objectives

Why do we need research? What qualities are in a good research article? Identify some research tools Practical Case Examples How do I get started?

+How Does Research Tie Into Organizational Cycles The “sigmoid” curve

Time

Growth cycle

Reinvention

CHLA Vision: to be the health system of choice & serve as region’s leading provider of child and adolescent health

Strategic Plan:1. Premier Pediatric Academic

Center (Clinical, Research & Education)

2. Reaching out to more families3. Partnering with community4. Cost effective value for patients

and payors5. Complete system of care6. Premier Pediatric Research &

Innovation and Health Center7. Voice & champion for children

+Why is research necessary?

Sound way to obtain scientific knowledge about practice problems

Magnet Hospital benchmark Critical to the scientific advancement of respiratory care

Generates relevant theory and behavior Develops and test theories that form the basis of specific

practices and treatment approaches Needed in the development and evolution of research methods

Guide for policy development Evidence Based Practice

+A Framework for RCP Professional Growth and Development (Ref. Kevin Taylor)

Practitioner Leader

Content Expert

Teaching

Scholarship

IPC Business of Healthcare

Admin /Management

Systems Thinking

Leadership Communicatio

n & ChangeThe complete RCP

Professional

+Why is research necessary cont…? Critical to personal and professional development Patients benefit from the use of respiratory care research

Enhanced quality of patient care Reduced costs of services Increased satisfaction with care

Respiratory care staff benefits from use of research in respiratory care practice Increased job satisfaction and professionalism Feelings of empowerment Enhanced recruitment and retention

+Is research necessary to provide excellent care? What are your thoughts? “We can do excellent care without research, however,

the importance of research is that it will attract the brightest doctors, nurses,…..respiratory therapists.”

+What is Research?

Multiple systematic strategies to generate knowledge about human behavior, human experience, and human environments Qualitative, naturalistic inquiry

Focus groups Quantitative inquiry-experimental type

Survey

+What is a good research article?

Logical way of thinking Understandable Confirmable Useful

+Research Tools

Medline Cochrane Library Professional Journals

www.aarc.org

CINAHL

+Some Case Examples

Trigger Sensitivity of Four Pediatric Ventilators During Pressure Support Ventilation and Continuous In-Line Flow. 1994 Respiratory Care Journal.

Case Study ~ Aerosolized Cidofivir In Recurrent Respiratory Papillomatosis: A Case Report. Respiratory Care Journal

Quality Improvement/Management-Pediatric Utilization Review Therapist. Respiratory Care Journal

UPS ~ Uninterruptible Power Supply. 2012 Respiratory Care Journal.

Current Projects Bench Studies

Aerosol placement and effective delivery, HFO tidal volumes delivery, INO placement

Case Reviews Cardiac patients and INO utilization

+Case Examples

Trigger Sensitivity of Four Pediatric Ventilators During Pressure Support Ventilation and Continuous In-Line Flow. Langga LM, Garton D, Rogers MS, Scott JR, Malinowski T. (Presented Dec., 1994 American Association for Respiratory Care Convention)

+Case Examples

Aerosolized Cidofovir in Recurrent Respiratory Papillomatosis: a Case Report. Benton, G., Fanous, Y., Pfeifle, J., Terry, M., Langga, L. Respiratory Care. 2006; 51 (11): 1352.

+Case Examples

The Rationale for Therapist Involvement in The Delivery and Utilization Review of Nebulized Medication and Chest Physiotherapy in Acute and General Care Settings. Scott, R., Benton G., Langga L., Gold P., Terry K. Respiratory Care. 2003; 48 (11): 1129. 

+

EVALUATION OF AN UNINTERRUPTABLE POWER SUPPLY SYSTEM TO IMPROVE PATIENT SAFETY DURING HFOV

Justin Hotz, RCP, RRT-NPS; Edwin Khatchetourian, MS, RCP, RRT-NPS; Aaron Clute, RCP, RRT-NPS; Ed Guerrero, BS, RCP, RRT-NPS; Dan Villareal, MBA, RCP, RRT; Leo Langga, MBA, RCP, RRT-NPS

Children‘s Hospital Los Angeles, Los Angeles, CA

The Sensormedics High Frequency Oscillator Ventilator (HFOV) 3100A and 3100B are frequently used in the management of critically ill neonatal and pediatric patients. Currently, these ventilators do not have a backup battery, and are at risk of terminating ventilation during a power failure. There is few published literature addressing this patient safety risk. We evaluated an uninterruptable power supply (UPS) system for use with the Sensormedics 3100 A and B as a power back-up to provide uninterrupted ventilation during power failure.

The TRIPP-LITE UPS system supporting the Sensormedics 3100B gave its first warning alarm at 35 minutes of use. Five minutes later, it gave its second warning alarm, and completely turned off after a total of 1 hour and 10 minutes of use. The TRIPP-LITE UPS system supporting the Sensormedics 3100A gave its first warning alarm at 1 hour of use. Twelve minutes later, it gave its second warning alarm, and completely turned off after a total of 2 hours and 4 minutes of use.

To evaluate the effective operational time of the TRIPP-LITE UPS system (SMART 1200 XLHG), we tested it on a Sensormedics 3100 A and 3100 B with a standard neonatal and pediatric workload. Both ventilators were calibrated and set-up according to manufacturer specifications. A 2.5 mm I.D. endotracheal tube connected to a Maquet neonatal test lung was attached to the Sensormedics 3100A and placed on settings of: Amplitude 30 cmH20; Mean Airway Pressure of 12 cmH20; 10 Hertz; FiO2 of 0.60, I-time 33%, and Bias Flow of 20 LPM. A 5.5 mm I.D. endotracheal tube, connected to an adult Maquet test lung, was used with the Sensormedics 3100 B on settings of: Amplitude 40 cmH20; Mean Airway Pressure of 16 cmH20; 7 Hertz; 100% oxygen; I-time 33%; and Bias Flow of 30 LPM. Both ventilators were connected to two separate fully charged TRIPP-LITE UPS systems, and were then run continuously until the UPS system was completely exhausted.

The TRIPP-LITE UPS system is able to provide effective short term back-up support for the Sensormedics 3100A and 3100B in the presence of a power failure. More studies need to be performed to better understand the relationship better power consumption and ventilator load.

LOGOLOGO

Our concern for patient safety drove us to find additional power back-up support for our High Frequency Oscillatory Ventilators (HFOV). Prior to our implementation of the TrippLite UPS system for our HFOVs, a power failure would cause interruption of ventilation until a clinician could restart the oscillator. However, our High Frequency Jet Ventilators were equipped with an UPS system that could provide immediate temporary support during a power failure or when our back-up generators were undergoing testing. It was also important that we found an UPS system that had a wider tolerance for the fluctuations in power levels we were experiencing. We worked closely with our biomedical engineers to find an UPS system that had this tolerance, yet be able to provide the power required to support the HFOVs and keep them operating normally. Patients on HFOV support can rapidly decompensate even for brief periods in which ventilatory support is not provided. This patient population is generally critically ill and have very little lung reserve placing them at greater risk for negative outcomes. Despite this risk, we have found that there are still many hospitals that do not use an UPS system for their HFOVs. However, there is a general trend in which more hospitals are using an UPS system to provide back-up support. This practice can improve the safety for our patients and may play an important role in disaster preparedness.

BACKGROUND DISCUSSION

MATERIALS AND METHODS

RESULTS

CONCLUSIONS

Sensormedics3100A

Sensormedics3100B

Ventilator Settings

Amp 30; MAP 12; Hz 10; FiO2 0.60; IT 33%; Bias Flow 20

Amp 40; MAP 16; Hz 7; FiO2 1.0; IT 33%; Bias Flow 30

UPS Run Time (minutes)

124 70

UPS System

High Frequency Oscillatory Ventilator

Test Lung

TABLE

+Characteristics of Delivered Tidal Volumes During Nasal Cannula IMV: A Bench Study in an Infant Model Justin Hotz RRT-NPS, Edward Guerrero BS. RRT-NPS, Leo Langga MBA, RRT-NPS

+Effect of Nebulizer Placement on Aerosol Delivery Efficiency in a Mechanically Ventilated Infant ModelJustin Hotz RRT-NPS, Al Tostado RRT, Edward Guerrero B.S. RRT-NPS, Liz Salazar, RRT, Leo Langga, MBA, RRT-NPS 

+Research Involvement of Respiratory Care Staff…getting started Find something you are interested in changing in the PICU, CTICU,

NICCU, 5 West, Med Surg, ED, or department… Conceptual awareness of state-of-the-art research in specialty area

Regular reading of research and clinical journals, especially of integrative and systematic reviews

Participating in journal clubs Surfing the Internet for relevant research Participating in respiratory care research activities Attendance at clinical research conferences Active participation in professional respiratory care organizations Active participation in organizations that focus on specific diseases related to

one’s work

Use relevant clinical research to promote best evidence-based practice

+Getting started….

Journal Club~4th Friday each month Professional Organizations-CSRC, AARC……join! Other Professional Organizations/Meetings

American Thoracic Society High Frequency Meeting at Snowbird, Utah Extracorporeal Life Support Organization American Academy of Sleep Medicine Pediatric Critical Care Medicine American Lung Association Cystic Fibrosis Foundation Children’s Hospital Association Undersea and Hyperbaric Medical Society

+Research Tools at CHLA

To go to the Research Database: Start from website: http://insidechla.org/

Select “Clinician Quicklinks” Select “Health Sciences Library” Select “Research Databases”

+

+

+

+

+

+

+

+

+Other Tools

Smart Phone/iPAD Apps: EBSCO NRC PubMed Lite ATS Journals RC Journal CHEST

+Final Remarks

Conclusions from recent study on evidence based practice: The primary reason why more RCPs did not apply evidence

based practice was because they lacked proper training in applying evidence based practice

You have the power to change and impact your profession

“We can transform our organizations by transforming ourselves.” R. Quinn

+References

Lecture notes from Dr. Felicitas dela Cruz, RN, DNSc, FAANP

Clinical Research in Practice: A Guide for the Bedside Scientist. Janet Houser, PhD

Theoretical Frameworks in Qualitative Research. Vincent Anfara, Norma Mertz