quality improvement put into practice carl mottram, ba rrt rpft faarc director - pulmonary function...

Quality Improvement Put into PracticeQuality Improvement Put into PracticeQuality Improvement Put into PracticeQuality Improvement Put into Practice

Carl Mottram, BA RRT RPFT FAARCCarl Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs & RehabilitationDirector - Pulmonary Function Labs & Rehabilitation

Assistant Professor of Medicine - Mayo Clinic College of Assistant Professor of Medicine - Mayo Clinic College of MedicineMedicine

Carl Mottram, BA RRT RPFT FAARCCarl Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs & RehabilitationDirector - Pulmonary Function Labs & Rehabilitation

Assistant Professor of Medicine - Mayo Clinic College of Assistant Professor of Medicine - Mayo Clinic College of MedicineMedicine

Case PresentationCase PresentationCase PresentationCase Presentation

• 31 y.o. female 31 y.o. female

• History of present illnessHistory of present illness• Non-specific cough, tightness in throat and Non-specific cough, tightness in throat and

episodic shortness of breath following URIepisodic shortness of breath following URI• No wheezing noted by patient or on examNo wheezing noted by patient or on exam• Exam normal other than obesity (BMI 38)Exam normal other than obesity (BMI 38)

• LMD orders CXR and spirometry with LMD orders CXR and spirometry with diffusing capacitydiffusing capacity

• 31 y.o. female 31 y.o. female

• History of present illnessHistory of present illness• Non-specific cough, tightness in throat and Non-specific cough, tightness in throat and

episodic shortness of breath following URIepisodic shortness of breath following URI• No wheezing noted by patient or on examNo wheezing noted by patient or on exam• Exam normal other than obesity (BMI 38)Exam normal other than obesity (BMI 38)

• LMD orders CXR and spirometry with LMD orders CXR and spirometry with diffusing capacitydiffusing capacity


• CXRCXR

• Spirometry & DLCOSpirometry & DLCOPrePre PostPost PredPred

FVC FVC 2.102.10 2.112.11 62%62%

FEVFEV11 0.890.89 1.361.36 31%31%

RatioRatio 42.442.4 64.564.5

DLCODLCO 8.08.0 30%30%

Impression: Severe obstruction with a severe Impression: Severe obstruction with a severe reduction in DLCO. Some improvement with BDreduction in DLCO. Some improvement with BD

• CXRCXR

• Spirometry & DLCOSpirometry & DLCOPrePre PostPost PredPred

FVC FVC 2.102.10 2.112.11 62%62%

FEVFEV11 0.890.89 1.361.36 31%31%

RatioRatio 42.442.4 64.564.5

DLCODLCO 8.08.0 30%30%

Impression: Severe obstruction with a severe Impression: Severe obstruction with a severe reduction in DLCO. Some improvement with BDreduction in DLCO. Some improvement with BD

External Pulmonary Laboratory

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Predicted


• LMD Action PlanLMD Action Plan• Orders a CT scanOrders a CT scan• Referred to Mayo Clinic for further Referred to Mayo Clinic for further

evaluationevaluation

• LMD Action PlanLMD Action Plan• Orders a CT scanOrders a CT scan• Referred to Mayo Clinic for further Referred to Mayo Clinic for further

evaluationevaluation

Case PresentationCase PresentationCase PresentationCase Presentation• Outside CT negativeOutside CT negative

• Pulmonary, ENT, and GI consults Pulmonary, ENT, and GI consults scheduledscheduled

• Pulmonary physicianPulmonary physician• Negative examNegative exam• Lungs clear, patient had coughing spell Lungs clear, patient had coughing spell

during exam, no wheezing or stridor notedduring exam, no wheezing or stridor noted• Questioned outside spirometry results and Questioned outside spirometry results and

orders PFT’sorders PFT’s

• Outside CT negativeOutside CT negative

• Pulmonary, ENT, and GI consults Pulmonary, ENT, and GI consults scheduledscheduled

• Pulmonary physicianPulmonary physician• Negative examNegative exam• Lungs clear, patient had coughing spell Lungs clear, patient had coughing spell

during exam, no wheezing or stridor notedduring exam, no wheezing or stridor noted• Questioned outside spirometry results and Questioned outside spirometry results and

orders PFT’sorders PFT’s


• Spirometry & DLCOSpirometry & DLCO

PrePre PostPost PredPred

FVCFVC 2.552.55 2.482.48 75%75%

FEV1FEV1 2.272.27 2.252.25 79%79%

RatioRatio 8989 90.790.7

DLCODLCO 24.224.2 99%99%

Impression: Borderline restriction most likely 2Impression: Borderline restriction most likely 2 to to obesity with no evidence of airflow obstruction or BD obesity with no evidence of airflow obstruction or BD responseresponse

• Spirometry & DLCOSpirometry & DLCO

PrePre PostPost PredPred

FVCFVC 2.552.55 2.482.48 75%75%

FEV1FEV1 2.272.27 2.252.25 79%79%

RatioRatio 8989 90.790.7

DLCODLCO 24.224.2 99%99%

Impression: Borderline restriction most likely 2Impression: Borderline restriction most likely 2 to to obesity with no evidence of airflow obstruction or BD obesity with no evidence of airflow obstruction or BD responseresponse

Mayo Pulmonary Function Laboratory

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Mayo Pulmonary Function Laboratory

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• Further testingFurther testing

• Labeling (COPD, Labeling (COPD, Asthma, etc)Asthma, etc)

• MedicineMedicine

• DisabilityDisability

• Further testingFurther testing

• Labeling (COPD, Labeling (COPD, Asthma, etc)Asthma, etc)

• MedicineMedicine

• DisabilityDisability

PFT results affect people!!!PFT results affect people!!!PFT results affect people!!!PFT results affect people!!!

Guidelines and StandardsGuidelines and StandardsGuidelines and StandardsGuidelines and Standards

• American Thoracic SocietyAmerican Thoracic Society•1987 Revised Spirometry Standards1987 Revised Spirometry Standards•1991 Reference Values & Interpretation1991 Reference Values & Interpretation•1994 Revised Spirometry Standards1994 Revised Spirometry Standards•1995 Diffusing Capacity1995 Diffusing Capacity• 1999 Guidelines for Methacholine and Exercise 1999 Guidelines for Methacholine and Exercise Challenge TestingChallenge Testing•ATS/ERS 2005 Series; General Laboratory, ATS/ERS 2005 Series; General Laboratory, Spirometry, Diffusing Capacity, Lung volumes, Spirometry, Diffusing Capacity, Lung volumes, and Interpretation and Interpretation


• American Association of Respiratory American Association of Respiratory Care (AARC)Care (AARC)• Clinical Practice Guidelines (52)Clinical Practice Guidelines (52)

• SpirometrySpirometry• Static lung volumesStatic lung volumes• PlethysmographyPlethysmography• Diffusing CapacityDiffusing Capacity• Infant/Toddler Pulmonary Function Infant/Toddler Pulmonary Function

TestsTests

• American Association of Respiratory American Association of Respiratory Care (AARC)Care (AARC)• Clinical Practice Guidelines (52)Clinical Practice Guidelines (52)

• SpirometrySpirometry• Static lung volumesStatic lung volumes• PlethysmographyPlethysmography• Diffusing CapacityDiffusing Capacity• Infant/Toddler Pulmonary Function Infant/Toddler Pulmonary Function

TestsTests


• American Thoracic SocietyAmerican Thoracic Society • ATS Pulmonary Function Laboratory ATS Pulmonary Function Laboratory

Management and Procedure ManualManagement and Procedure Manual• Updated 2005Updated 2005

• www.thoracic.orgwww.thoracic.org• EducationEducation• Education ProductsEducation Products

• American Thoracic SocietyAmerican Thoracic Society • ATS Pulmonary Function Laboratory ATS Pulmonary Function Laboratory

Management and Procedure ManualManagement and Procedure Manual• Updated 2005Updated 2005

• www.thoracic.orgwww.thoracic.org• EducationEducation• Education ProductsEducation Products

CLSI’s CLSI’s Quality System In Quality System In Respiratory Care – HS4-A2Respiratory Care – HS4-A2CLSI’s CLSI’s Quality System In Quality System In

Respiratory Care – HS4-A2Respiratory Care – HS4-A2

Patientassessment

ClinicalinterpretationapplicationPath of workflow

QSE

Patient

• Spirometry in Primary Care PracticeSpirometry in Primary Care Practice**• 30 primary care clinics, 15 trained group 30 primary care clinics, 15 trained group

/15 usual group/15 usual group• 3.4% in usual group and 13.5% in 3.4% in usual group and 13.5% in

trained group met ATS acceptability and trained group met ATS acceptability and reproducibility criteriareproducibility criteria

• 1,012 pt. tests, 2,928 blows (2.89) 1,012 pt. tests, 2,928 blows (2.89) • * * Eaton et al, Chest 1999; 116:416-423Eaton et al, Chest 1999; 116:416-423

• Spirometry in Primary Care PracticeSpirometry in Primary Care Practice**• 30 primary care clinics, 15 trained group 30 primary care clinics, 15 trained group

/15 usual group/15 usual group• 3.4% in usual group and 13.5% in 3.4% in usual group and 13.5% in

trained group met ATS acceptability and trained group met ATS acceptability and reproducibility criteriareproducibility criteria

• 1,012 pt. tests, 2,928 blows (2.89) 1,012 pt. tests, 2,928 blows (2.89) • * * Eaton et al, Chest 1999; 116:416-423Eaton et al, Chest 1999; 116:416-423

Evidence of Quality TestingEvidence of Quality TestingEvidence of Quality TestingEvidence of Quality Testing


• Improving the Quality of Bedside Improving the Quality of Bedside SpirometrySpirometry

• Audit of testing outside the PF lab - Audit of testing outside the PF lab - Cleveland ClinicCleveland Clinic

• 15% - ATS acceptability/reproducibility 15% - ATS acceptability/reproducibility criteriacriteria

• CI Project - 63.5% CI Project - 63.5% acceptability/reproducibilityacceptability/reproducibility

• Stoller JK. Orens DK. Hoisington E. McCarthy K. Stoller JK. Orens DK. Hoisington E. McCarthy K. Bedside spirometry Bedside spirometry in a tertiary care hospital: The Cleveland Clinic experiencein a tertiary care hospital: The Cleveland Clinic experience . . Respiratory Respiratory Care. 47(5):578-82, 2002 MayCare. 47(5):578-82, 2002 May

• Improving the Quality of Bedside Improving the Quality of Bedside SpirometrySpirometry

• Audit of testing outside the PF lab - Audit of testing outside the PF lab - Cleveland ClinicCleveland Clinic

• 15% - ATS acceptability/reproducibility 15% - ATS acceptability/reproducibility criteriacriteria

• CI Project - 63.5% CI Project - 63.5% acceptability/reproducibilityacceptability/reproducibility

• Stoller JK. Orens DK. Hoisington E. McCarthy K. Stoller JK. Orens DK. Hoisington E. McCarthy K. Bedside spirometry Bedside spirometry in a tertiary care hospital: The Cleveland Clinic experiencein a tertiary care hospital: The Cleveland Clinic experience . . Respiratory Respiratory Care. 47(5):578-82, 2002 MayCare. 47(5):578-82, 2002 May


• Wanger J, Irvin C Wanger J, Irvin C Resp Care 36 (12): 1991Resp Care 36 (12): 1991

• 13 hospitals, 7 13 hospitals, 7 different systems, 5 different systems, 5 Bio-QC Bio-QC (3 men, 2 women)(3 men, 2 women)

• DLCO CV 11.5 - 18.6 DLCO CV 11.5 - 18.6 with the largest diff. with the largest diff. 24 units24 units

• Wanger J, Irvin C Wanger J, Irvin C Resp Care 36 (12): 1991Resp Care 36 (12): 1991

• 13 hospitals, 7 13 hospitals, 7 different systems, 5 different systems, 5 Bio-QC Bio-QC (3 men, 2 women)(3 men, 2 women)

• DLCO CV 11.5 - 18.6 DLCO CV 11.5 - 18.6 with the largest diff. with the largest diff. 24 units24 units

Quality Improvement Put into Quality Improvement Put into PracticePractice - - Quality AssuranceQuality Assurance

“ “Systematic” approach of monitoring Systematic” approach of monitoring and evaluating quality.and evaluating quality.



• CLSI’s “Path of workflow” ModelCLSI’s “Path of workflow” Model• Pre-testPre-test• Testing sessionTesting session• Post-testPost-test

• CLSI’s “Path of workflow” ModelCLSI’s “Path of workflow” Model• Pre-testPre-test• Testing sessionTesting session• Post-testPost-test

Quality Improvement Put into PracticeQuality Improvement Put into Practice Pre-testPre-test Quality AssuranceQuality Assurance


• Pre-test instructionsPre-test instructions

• Appropriate orderAppropriate order

• Questionnaire Questionnaire

• Height* and weightHeight* and weight

• Networked systemsNetworked systems

• Equipment quality Equipment quality assurance programassurance program

• Pre-test instructionsPre-test instructions

• Appropriate orderAppropriate order

• Questionnaire Questionnaire

• Height* and weightHeight* and weight

• Networked systemsNetworked systems

• Equipment quality Equipment quality assurance programassurance program

Quality Improvement Put into Quality Improvement Put into PracticePractice Pre-testPre-test Quality AssuranceQuality Assurance

Quality Improvement Put into Quality Improvement Put into PracticePractice Pre-testPre-test Quality AssuranceQuality Assurance

• Equipment quality Equipment quality assuranceassurance

•Validation/VerificationValidation/Verification•Preventive Preventive maintenancemaintenance•Documentation and Documentation and records (logbooks) records (logbooks)

• Equipment quality Equipment quality assuranceassurance

•Validation/VerificationValidation/Verification•Preventive Preventive maintenancemaintenance•Documentation and Documentation and records (logbooks) records (logbooks)

• Mechanical Mechanical modelsmodels

• Biological Biological modelsmodels

• Mechanical Mechanical modelsmodels

• Biological Biological modelsmodels



• Mechanical ModelMechanical Model•3-liter syringe3-liter syringe

• 0.5, 1-2, 6 second flows0.5, 1-2, 6 second flows

•Leak checked Leak checked •Stored and used in such a way as to maintain the same temperature and humidity of the testing site•Validated based on Validated based on manufacturer recommendationsmanufacturer recommendations

• Mechanical ModelMechanical Model•3-liter syringe3-liter syringe

• 0.5, 1-2, 6 second flows0.5, 1-2, 6 second flows

•Leak checked Leak checked •Stored and used in such a way as to maintain the same temperature and humidity of the testing site•Validated based on Validated based on manufacturer recommendationsmanufacturer recommendations

2005 ATS/ERS Standards 2005 ATS/ERS Standards Standardization of SpirometryStandardization of Spirometry



Mechanical Model - Mechanical Model - PlethysmographyPlethysmography

• Validation using a known Validation using a known volume should be performed volume should be performed periodicallyperiodically

• Model lung with thermal Model lung with thermal mass to simulate isothermal mass to simulate isothermal conditions of the lung.conditions of the lung.

• Accuracy 50 ml or 3%Accuracy 50 ml or 3%

Mechanical Model - Mechanical Model - PlethysmographyPlethysmography

• Validation using a known Validation using a known volume should be performed volume should be performed periodicallyperiodically

• Model lung with thermal Model lung with thermal mass to simulate isothermal mass to simulate isothermal conditions of the lung.conditions of the lung.

• Accuracy 50 ml or 3%Accuracy 50 ml or 3%

2005 ATS/ERS Standards 2005 ATS/ERS Standards Standardization of Lung VolumesStandardization of Lung Volumes



• Mechanical Model – Mechanical Model – Dilution techniquesDilution techniques

• Analyzer accuracy and linearity

• N2 washout: Monthly, exhalation volumes should be checked with the syringe filled with room air, and inhalation volumes with the syringe filled with 100% O2.

• Mechanical Model – Mechanical Model – Dilution techniquesDilution techniques

• Analyzer accuracy and linearity

• N2 washout: Monthly, exhalation volumes should be checked with the syringe filled with room air, and inhalation volumes with the syringe filled with 100% O2.

2005 ATS/ERS Standards 2005 ATS/ERS Standards Standardization of Lung VolumesStandardization of Lung Volumes



• Mechanical Models – DLCOMechanical Models – DLCO

• Syringe DLCO weekly or Syringe DLCO weekly or whenever problems occur whenever problems occur

•VVAA BTPS ~ 3.3L BTPS ~ 3.3L

• DLCO Simulator or BioQCDLCO Simulator or BioQC

• Mechanical Models – DLCOMechanical Models – DLCO

• Syringe DLCO weekly or Syringe DLCO weekly or whenever problems occur whenever problems occur

•VVAA BTPS ~ 3.3L BTPS ~ 3.3L

• DLCO Simulator or BioQCDLCO Simulator or BioQC

2005 ATS/ERS Standards 2005 ATS/ERS Standards Standardization of DLCOStandardization of DLCO



• Biological ModelBiological Model• Normal laboratory subjectsNormal laboratory subjects• Two individuals (13)Two individuals (13)• Establish mean and SD Establish mean and SD

(minimum 20 samples)(minimum 20 samples)

• Biological ModelBiological Model• Normal laboratory subjectsNormal laboratory subjects• Two individuals (13)Two individuals (13)• Establish mean and SD Establish mean and SD

(minimum 20 samples)(minimum 20 samples)



Biological Control - PlethysmographyBiological Control - Plethysmography• At least monthly or whenever errors are suspect 2 reference At least monthly or whenever errors are suspect 2 reference

subjects (biologic controls) should be testedsubjects (biologic controls) should be tested

Biological Control - PlethysmographyBiological Control - Plethysmography• At least monthly or whenever errors are suspect 2 reference At least monthly or whenever errors are suspect 2 reference


TLC and FRC from PlethysmographyBioQC Technologist #2

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M eas ur ement Number

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FRC-P leth

TLC and FRC from PlethysmographyBioQC Technologist #2

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2005 ATS/ERS Standards - S2005 ATS/ERS Standards - Standardization of Lung Volumestandardization of Lung Volumes



Biological Control – NBiological Control – N22 washout washout• At least monthly or whenever errors are suspect 2 reference At least monthly or whenever errors are suspect 2 reference


Biological Control – NBiological Control – N22 washout washout• At least monthly or whenever errors are suspect 2 reference At least monthly or whenever errors are suspect 2 reference

subjects (biologic controls) should be testedsubjects (biologic controls) should be testedTLC and FRC in Nitrogen Washout

BioQC Technologist #2

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FRC-Nitrogen Washout

TLC and FRC in Nitrogen WashoutBioQC Technologist #2

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TLC-Nitrogen Washout

FRC-Nitrogen Washout




Biologic Control – He dilutionBiologic Control – He dilution• At least monthly or whenever errors are suspect 2 reference At least monthly or whenever errors are suspect 2 reference


Biologic Control – He dilutionBiologic Control – He dilution• At least monthly or whenever errors are suspect 2 reference At least monthly or whenever errors are suspect 2 reference


TLC and FRC in He DilutionBioQC Technoligist #2

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T LC-He Di lution

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TLC and FRC in He DilutionBioQC Technoligist #2

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T LC-He Di lution

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Biologic Control – Diffusing CapacityBiologic Control – Diffusing Capacity• At least weeklyAt least weekly• OrOr whenever errors are suspect whenever errors are suspect• OrOr whenever a calibration tank is replaced whenever a calibration tank is replaced

Biologic Control – Diffusing CapacityBiologic Control – Diffusing Capacity• At least weeklyAt least weekly• OrOr whenever errors are suspect whenever errors are suspect• OrOr whenever a calibration tank is replaced whenever a calibration tank is replaced

DLCO and VA from Diffusing Capacity BioQC Technologist #3

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CO

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DLCO and VA from Diffusing Capacity BioQC Technologist #3

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CO

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2005 ATS/ERS Standards - 2005 ATS/ERS Standards - Standardization of DLCOStandardization of DLCO

Quality AssuranceQuality AssuranceBiological Quality Control - PF LabBiological Quality Control - PF Lab

• Results “Out of range”Results “Out of range” Repeat with another technologistRepeat with another technologist Second tech is within limits - record out of range dataSecond tech is within limits - record out of range data Second tech out of range - trouble-shoot and Second tech out of range - trouble-shoot and

documentdocument

BioQC1: BioQC1: ULNULN LLNLLN SDSD CVCV

FEVFEV11 2.952.95 2.732.73 0.050.05 0.020.02

FVCFVC 3.623.62 3.353.35 0.070.07 0.020.02TLC (Pleth)TLC (Pleth) 6.096.09 5.655.65 0.110.11 0.020.02

DDLLCOCO 24.524.5 21.521.5 0.750.75 0.040.04

Quality AssuranceQuality AssuranceBiological Quality Control - DLCOBiological Quality Control - DLCO

Quality AssuranceQuality AssuranceBiological Quality Control - DLCOBiological Quality Control - DLCO

Bio QC Technologist Comparison

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Bio QC Technologist Comparison

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Model A versus B: Mean difference 0.5Model A versus B: Mean difference 0.5

Quality AssuranceQuality AssuranceSubject comparisons: DLCOSubject comparisons: DLCO

Quality AssuranceQuality AssuranceSubject comparisons: DLCOSubject comparisons: DLCO

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Model A versus B - Mean difference 1.5 Model A versus B - Mean difference 1.5

Quality Improvement Put into PracticeQuality Improvement Put into Practice TestTest Quality AssuranceQuality Assurance


• Testing room environmentTesting room environment• Environmental interferenceEnvironmental interference

• Technologist’s performance & Technologist’s performance & training - QSE: Personneltraining - QSE: Personnel

• Second technologistSecond technologist

• Meeting ATS/ERS acceptability and Meeting ATS/ERS acceptability and repeatability criteria repeatability criteria ((new guidelinesnew guidelines))

• Testing room environmentTesting room environment• Environmental interferenceEnvironmental interference

• Technologist’s performance & Technologist’s performance & training - QSE: Personneltraining - QSE: Personnel

• Second technologistSecond technologist

• Meeting ATS/ERS acceptability and Meeting ATS/ERS acceptability and repeatability criteria repeatability criteria ((new guidelinesnew guidelines))

Quality Improvement Put into PracticeQuality Improvement Put into Practice Test Quality AssuranceTest Quality Assurance - - QSE: PersonnelQSE: PersonnelQuality Improvement Put into PracticeQuality Improvement Put into Practice Test Quality AssuranceTest Quality Assurance - - QSE: PersonnelQSE: Personnel

• TechnologistsTechnologists• Job qualificationsJob qualifications• Job descriptionsJob descriptions• OrientationOrientation• TrainingTraining• Competency assessmentCompetency assessment• Continuing educationContinuing education• Performance appraisalPerformance appraisal

• TechnologistsTechnologists• Job qualificationsJob qualifications• Job descriptionsJob descriptions• OrientationOrientation• TrainingTraining• Competency assessmentCompetency assessment• Continuing educationContinuing education• Performance appraisalPerformance appraisal

Quality Improvement Put into PracticeQuality Improvement Put into Practice Test Quality AssuranceTest Quality Assurance - - QSE: PersonnelQSE: PersonnelQuality Improvement Put into PracticeQuality Improvement Put into Practice Test Quality AssuranceTest Quality Assurance - - QSE: PersonnelQSE: Personnel

• Competence AssessmentCompetence Assessment• Training and on-going performance Training and on-going performance

evaluationsevaluations• NIOSH Spirometry Training CourseNIOSH Spirometry Training Course

• cdc.gov/NIOSH/topics/spirometrycdc.gov/NIOSH/topics/spirometry

• AARC’s Spirometry Training AARC’s Spirometry Training • National Board for Respiratory CareNational Board for Respiratory Care

• CPFT and RPFT examsCPFT and RPFT exams

• Competence AssessmentCompetence Assessment• Training and on-going performance Training and on-going performance

evaluationsevaluations• NIOSH Spirometry Training CourseNIOSH Spirometry Training Course

• cdc.gov/NIOSH/topics/spirometrycdc.gov/NIOSH/topics/spirometry

• AARC’s Spirometry Training AARC’s Spirometry Training • National Board for Respiratory CareNational Board for Respiratory Care

• CPFT and RPFT examsCPFT and RPFT exams



• Lung volumes - DLCO VLung volumes - DLCO VA A 500 ml 500 ml larger than TLC - ???larger than TLC - ???

• Technologist Driven ProtocolsTechnologist Driven Protocols

• Reference equationsReference equations

• Lung volumes - DLCO VLung volumes - DLCO VA A 500 ml 500 ml larger than TLC - ???larger than TLC - ???

• Technologist Driven ProtocolsTechnologist Driven Protocols

• Reference equationsReference equations

• Technologist Technologist Driven ProtocolsDriven Protocols

• Flowcharting the Flowcharting the processprocess

• Technologist Technologist Driven ProtocolsDriven Protocols

• Flowcharting the Flowcharting the processprocess

Technologist Driven Protocol For Complete Pulmonary Function Testing with Bronchodilator

SPIROMETRYFVC, FEV1, FEV%, MVV

Give BronchodilatorSkip if restrictive pattern with

previous documentation of no response to Rx

DLCO

TLC

Normal TLCLow FEV1 or FVC

Normal FEV1%

AbnormalVA

Airway Resistance

RestingOXIMETRY

TLC

Resting SpO2

< 88% on room air or oxygen

ExerciseOXIMETRY

Repeat OximetryPost BD FVC's

PF TESTING COMPLETE

>4% Fall in SPO2 &Normal Resting Saturation &

Normal PF

1: Abnormal MVV2: Abnormal Flow,

Volume, orMD requested TLC

Normal Spirometry

No

Yes

Yes

No

Yes

Yes

No

No

MVV< FEV1 x 30

Neuro-muscularDisease

Upper Airway

Technologist Discretion

Maximal Respiratory Pressures (if neuromuscular diagnosis)

and / orFIVC Maneuvers

Yes

Yes

No

Yes

No

No

Alltests are

normal with no hx of pulm. vascular

disease

No

No

Yes

SpO2 < 80% or patientis intolerant to

testing

Terminate Testing

Call MD if resting SpO2 < 88% or exercise SpO2 <

85% to recommend ABG's

Yes PATIENT ASSESSMENT

Did the patient comply with pre-test instructions?

Prior to testing a patient with suspected room air hypoxemia place pulse oximeter. If resting SpO2 < 80 on room air perform spirometry on oxygen (if prescribed) and cancel lung volumes and DLCO

Report room air SpO2, do not exercise



Quality Improvement Put into PracticeQuality Improvement Put into Practice Post-TestPost-Test Quality AssuranceQuality Assurance

Quality Improvement Put into PracticeQuality Improvement Put into Practice Post-TestPost-Test Quality AssuranceQuality Assurance

• Maneuver selectionManeuver selection

• Quality review by second technologistQuality review by second technologist

• “While in-house training may achieve the desired goals, laboratory directors should strongly consider the benefits of formal training programs from outside providers.”

• Feedback to the technicians concerning their performance should be provided on a routine basis

• Maneuver selectionManeuver selection

• Quality review by second technologistQuality review by second technologist

• “While in-house training may achieve the desired goals, laboratory directors should strongly consider the benefits of formal training programs from outside providers.”

• Feedback to the technicians concerning their performance should be provided on a routine basis 2005 ATS/ERS Standards 2005 ATS/ERS Standards

General LaboratoryGeneral Laboratory

Technician Training and Feedback Improve Technician Training and Feedback Improve Test QualityTest Quality

Technician Training and Feedback Improve Technician Training and Feedback Improve Test QualityTest Quality

Lung Health StudyLung Health StudyEnright: Am Rev Respir Dis 143:1215, 1991Enright: Am Rev Respir Dis 143:1215, 1991

4.04.0

3.53.5

3.03.0

2.52.5

2.02.011 22 33 44 55 66 77

GPAGPA

YearYear

Quality controlQuality controlfeedback startedfeedback startedSite visits andSite visits andtraining updatetraining update

Volume gradeVolume grade

Flow gradeFlow grade

Quality Improvement Put into Quality Improvement Put into PracticePractice Post-TestPost-Test Quality AssuranceQuality Assurance

Quality Improvement Put into Quality Improvement Put into PracticePractice Post-TestPost-Test Quality AssuranceQuality Assurance

• Turn-around timeTurn-around time• Average TRT: <1 day (15%), 1-2 d Average TRT: <1 day (15%), 1-2 d

(30%), 3-4 d (27%), 5-6 d (15%), >7 d (30%), 3-4 d (27%), 5-6 d (15%), >7 d (3%)(3%)• ATS PFL Registry Abstract AARC 2005, ATS PFL Registry Abstract AARC 2005,

OF-05-037OF-05-037

• Electronic Medical RecordElectronic Medical Record

• Turn-around timeTurn-around time• Average TRT: <1 day (15%), 1-2 d Average TRT: <1 day (15%), 1-2 d

(30%), 3-4 d (27%), 5-6 d (15%), >7 d (30%), 3-4 d (27%), 5-6 d (15%), >7 d (3%)(3%)• ATS PFL Registry Abstract AARC 2005, ATS PFL Registry Abstract AARC 2005,

OF-05-037OF-05-037

• Electronic Medical RecordElectronic Medical Record

Quality Improvement Put into Practice Quality Improvement Put into Practice Does it Work?Does it Work?

Quality Improvement Put into Practice Quality Improvement Put into Practice Does it Work?Does it Work?

• Retrospective review of 18,000 consecutive pts. at Mayo Clinic

• Ninety percent of the patients were able to reproduce FEV1 within 120 ml (6.1%), FVC within 150 ml (5.3%), and PEF within 0.80 L (12%).

• Enright PL. Beck KC. Sherrill DL. Repeatability of spirometry in 18,000 adult patients. American Journal of Respiratory & Critical Care Medicine. 169(2):235-8, 2004 Jan 15.

• Retrospective review of 18,000 consecutive pts. at Mayo Clinic

• Ninety percent of the patients were able to reproduce FEV1 within 120 ml (6.1%), FVC within 150 ml (5.3%), and PEF within 0.80 L (12%).

• Enright PL. Beck KC. Sherrill DL. Repeatability of spirometry in 18,000 adult patients. American Journal of Respiratory & Critical Care Medicine. 169(2):235-8, 2004 Jan 15.

“This is fine as far as it goes. From here on, it’s who you know.”

quality improvement put into practice carl mottram, ba rrt rpft faarc director - pulmonary function...

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