What does a Respiratory Therapist Do That An RN Can't?

[steve0123]

Hi All-

I was just wondering what education/etc one needs to become a Respiratory Therapist, and what their role is in the ICU? In Australia, Registered Nurses manage almost all aspects of day to day to care in the ICU, including ventilators (obviously in collaboration with physiotherapists and intensivists). Are RT's common in US ICU's, and if so how is their contribution to the patient more beneficial/cost effective/whatever than that provided by an RN? I'm not having a go at RT's, was just curious as I'm reading about all these diverse roles being undertaken by non-nursing staff in the US that are usually carried out by RN's in other countries (staff such as RT's, Anaesthesia Assistants, Surgical Technicians, etc etc etc).

Thanks,

Steve

[fergus51]

Rick, some of us nurses actually do a lot of those things (like insert A-lines, draw and interpret gases, etc). I've actually never seen an RT insert an a-line and the RTs at my current hospital can't even change vent settings without an order from the MD and they don't intubate at all. There is a lot of variety in what RTs and RNs do in different hospitals. In some places their jobs will overlap a lot, in others they will have very different roles. I've rarely seen RNs and RTs who don't work well together fortunately.

[ZASHAGALKA, RN]

I've rarely seen RNs and RTs who don't work well together fortunately.

The only RTs that didn't play well were TBs (true believers) of the AART line that a vent is their exclusive property. I've had RTs throw fits because I wanted to know what the backup (apnea) settings were on low rate/CPAP pts. Yes, it IS my business, thank you very much. I've had RTs refuse to take my advice simply because it was an RN's advice - but that just means calling a doc at 3am to make my advice more non-negotiable.

And the biggest turf war/sin of all: making an emergency vent change (rate change, if I remember - way too basic - and RT knew that, THEY drew the gas) with a dr's order (and said dr. present) - and to do so because the RT was at breakfast, and not available. Oh Boy! What a major fit. How dare I put the pt's well-being ahead of his independent autonomy! (It didn't matter to him that my problem was he put his breakfast over both.)

But those are just turf war games, and like fergus said before, they have no business coming between pt care.

I think the catchphrase is 'multidisciplinary approach'.

I consider RTs to be vital resources. I'm a huge advocate. Unlike what the previous poster that restarted this thread thinks, I think nurses CAN be taught those skills in short order, albeit with a much more significant time lag for the theory behind it. But that WOULD alarm me. I am already forced to cover 3 pts at times due to short-staffing. Do I want to cover RT's job, too? NO, NO, NO. It goes beyond whether or not I can be taught the skills, or even concern for the extra work. Critical care is too critical not to bounce ideas off my peers constantly. "What do you think about this?" is my tagline at work. I value that RT's independent assessment. . .

But not if I have to fight them for every inch of space to take care of my pts.

And believe me, I KNOW it goes both ways. The key is respect. I absolutely respect the RT at my bedside - or most of them anyway (but then again I respect my RN collegues - or most of THEM, anyway.)

~faith,

Timothy.

[sabadah]

I agree with most that you said. A lot of it has to due with mutual respect for each other with in turns increases the efficacy of patient care. Both professions have bad apples. But the majority enjoy and take pride in what they do.

We respect that you have to sometimes take on three patients. I work very closely with the ICU nurses at my hospital and when this happens their heads start to spin around. They need all the teamwork and help that they can. Likewise, when we are short staffed we appreciate any help that we can get.

In the complicated hospital setting we would be pushed over the edge if we did not have each other to consult with.

Rick

[mabel u.k]

"A competent nurse knows respiratory stuff as well as any RT"... whatever...

i'd like to meet a nurse who can describe I:E ratios and why/when to make changes in ratio/flow, who can desribe flow slopes and why/when to change those... do nurses understand Vd/Vt ratios. There is a lot more to vent management then changing Volume/Rate/Fio2...

I am a nurse in the UK where we do not have RTs, I have worked within ICU for over 15 years and I would expect any of my nurses who have completed thier induction training to be able to describe and understand all of these. You are quite right there is far more to vent management than changing volume and rate, but this is what I would class as intensive care nursing. In fact when the new docs rotate into ICU it is the experienced nurses who provide the education about ventilation and respiratory support. I have read your forums and discussion with much interest we are fortunate in the UK we nurse our critical care patients with a 1:1 ratio and in some units have float nurses to support the more unwell patients. We work collaboratively with the physios and intensivists but essentially would manage all aspects of our patients care. I know that our healthcare system is a vastly different system to that in the US but do you not feel that many nursing duties are delegated to other professional / non professionals?

[sockov, ADN, ASN, BSN, CNA, LVN]

hi

I think RT's are very valuable, IF YOU HAVE A GOOD THERAPIST!!

My Cons are, Some of the RT's I work with are lazy, don't do PD&P, want to do the bare minimum, don't do trach care, don't change ETT tapes, don't draw ABG's..They are in their office all the time and take breaks together. No one covers the other. They usually say, "oh that's the nurses job" when it should be theirs. Just gets me so mad.

I have seen the "lazy" ones just stand at the bedside to do a vent check and walk away. Thats IT! No lung sounds, no suctioning after a treatment.

I do work with some good therapist who are excellent!, but the others are just a waste of money.

The Pros: if you have a motivated RT team, that likes to work side by side with the RN, then GREAT. They can really help out, give good advice on possible better modes of ventilation, will initiate changing tapes, doing cupping treatments, etc. Plus managing the vent and tubing etc.

I personally like to have RT's to work with, but only if they are motivated for the patient and not themselves.

Just my opinion.

[teriw]

RT's are relatively recent occurance, before them the RN's did everything with the same education we have now (or less). If you think about all the equipment you have to learn after you come to a hospital or ICU, learning vents would be the same thing. If we can do art lines and Swans and balloon pumps (not covered in school) there is no reason why we couldn't do vents.

While this is a true statement, it is also true in reverse. There are many icu's where the RCP intubates, places arterial lines, places Swan Gans and does the monitoring of these devices. They determine whether a pt. is ready to be extubated and then extubate. There are many places where a pt/therapist driven protocol is in use and does not even require a Doctors immediate oversight. RCP's are on ECMO teams and administer medications while monitoring the pump. All of these things depend on the state you are living in. They are all learned post formal education.

Recent studies have proven that when an RCP is part of the team, patients spend fewer hours on ventilators. A good RCP knows more than just lungs. Most RCP's are not paid as much as RN's, but that has become a selling point in home care. It is currently being shown that RCP's can do ALL the same tasks an RN can do, for less. Many state agencies are looking into the possibilities.

Can the nurse do everything? YES

Should the nurse have to do everything? NO

Are there bad RCP's? YES

Are there bad RN's? YES

Are there bad financial planners/lawyers/accountants etc? YES

Deal with the bad as best you can...grab the good and partner with them for the betterment of the patient.

[mojofla]

In Canada when I worked 1986-1989 we did our own resp treatments. However I am very appreciative of the resp therapists. Personally my workload is already great enough without having to give treatments and the documentation that goes with it. Resp therapists have been invaluable in responding to our distress calls and codes. I am perfectly happy to leave the respiratory care to them. I would like to say thanks to all respiratory therapists for their help and calls for assistance they have provided. THANK YOU

[gradcare, LPN]

Interesting. So..RN's in Australia must get advanced training in ventilator modalities, setups and troubleshooting? Is it part of the standardized education system there?

Maintaining and troubleshooting the ventilator is generally a shared job, mostly managed by the RRT...but yes, with a little extra education I could manage it, and would love to if i were to have a 1:1 vented patient.(very few 1:1's in my parts anymore) Pretty routine to have 2 vented patients; and they might be unstable in other systems too.

Personally I'd love to have an extra RN in my ICU , lose the RT and pick up their workload but...cheaper for the hospital to hire the RT to work several unitsd vs hiring an extra RN for EACH unit.

I also remember the pre RT days and doing my own treatments...but in those days the basic Byrd vent was the extent of volume ventilation...its more complex technologies these days.

No the trouble shooting etc is not in our basic training, it is all once you are employed by an ICU. At my unit once you are employed you spend some time at the hospital school relearning some basic concepts, being introduced to many more. You then get taught the basics and terminology and must pass comopetentcies (can' spell well) before you are allowed near a patient. Once exposed to patients you are watched like hawk. Our staffing ration is 1 pt to 1.2 nurses (or there abouts). You are given assignments to finish in you own time and are exptected by 12 months to be comptent in "basic"ventilation (CPAP, CPAP + Ps; SIMV + PEEP + PS both volume and pressure control then Bilevel [hipeep and low peep]). Being able to set up and trouble shoot the vent by the end of about a month is mandatory. Senior staff quite often "pop qiz" newer staff on vent problems, work through abg's compliance and expiratory hold pressures and their implications. We also are involved with extabating descisions (have personally kept a few pt's ventilated for an extra day) though you need to have objective evidence for saying that you don't think that they will remain extubated eg gas exchange falling off, fluctuant GCS excessivly high resp rate amongst other things. Then after 12 months for many people it is off to post graduate certificate or diploma land at the local university where the knowledge is increased further (or depending on how diligant they were during their first year maybe not).

We pretty much are taught or rather are expected to learn as much as we can including the application of NOx. Physio is not really covered though we can call them in anytime we feel the need (normally they come in a flash). Probably sounds like heaven to those in the US and we are hoping to keep it that way.

[RTreformed]

At our hospital the RT's go home for the night, so apparently the RN's are just as capable. We call them for a new vent set up, that's it. But during the day you don't dare give a neb without permission...complete rip off in my opinion.

For those with good RT's- what if you got trained to do the vents, and then got 1-1 RN ratios with vent patients. That's what we did before RT's, and it certainly seemed nice.

ive been an RRT for 6 yrs, i could quit, right now, and you could work as an RN for the next 20 yrs, go back to school for an RT, and work at it, and you would still not have the grasp and understanding of mechanical ventilation that i have right now. im so tired of RNs like you, "we can do what RT's do" listen, i had 4 yrs of education on a system of the body that you spent 2 weeks on in nursing school. yeah, any idiot of the street can be a "neb jockey", but true RT's know more about ventilation and the pulmonary system than you ever will...

[Nurseboy1]

In my unit the RNs and RTs are very team oriented. I work in a large teaching facility in the MICU and the majority of out admits are pulmonary related. Our therapists function under the vent protocol when the patients are intubated and we collaborate with them for vent manangement.

In my orientation to the unit, I spent several days exclusively with the RT learning to manage the vent, and to have a basic understanding of what all the numbers on the display meant.

The RTs I work with can intubate, provide nebs, to ABG sticks, insert arterial lines, but most of all provide an invaluable source of information on pulmonary physiology and gas flow within the body. I wouldn't want to work on my unit without our RTs, and if I ever roll in this unit as a patient I want to see any of our RTs at my head any day of the week.

[lovemyjob]

work in the NICU and our RRT's are amazing.

I can not make any vent changes because it would be equivalent to them going and changing the rates on my IV's......I let them handle what they trained for and I handle the rest. They collaborate witht the docs and often make changes and call the residents to tell them what is going on and what needs to be done. If I notice a problem I call them. They come in a reasonable amount of time...they see the patient as being "their patient" too.....they have a liscence to defend as well. Now, I can change FiO2 to wean and if the pt requires more O2, we notify RRT of the changes we make. There is no power struggle, just a mutual respect.

They teach residents and nurses and know a lot about the other diseases our patients have and are just great resources all around. I love having them.

*they are the primary people called when a pt extubates....residents called when there is time, not usually time, though...

please excuse the choppiness...sleeeepy!

[canoehead, BSN, RN]

ive been an RRT for 6 yrs, i could quit, right now, and you could work as an RN for the next 20 yrs, go back to school for an RT, and work at it, and you would still not have the grasp and understanding of mechanical ventilation that i have right now. im so tired of RNs like you, "we can do what RT's do" listen, i had 4 yrs of education on a system of the body that you spent 2 weeks on in nursing school. yeah, any idiot of the street can be a "neb jockey", but true RT's know more about ventilation and the pulmonary system than you ever will...

FYI it was the respiratory department that decided that the RN's could takeover respiratory care on the offshifts. Then we took over nights, weekends, and days when they had a sick call too. I'm not basing our (nursing's) ability to take over RT responsibilities on anything more than the fact that they said we could do it, and we have been doing it, for a couple years now. Unfortunately, when we took over their work we didn't get any of their funds, and they still charge our treatments through the RT department.

I agree that RT's have more knowledge, but to benefit the patient they need to actually be at the bedside assessing and doing care. Every hospital I've been in the RT wasn't based on the floor and said they didn't have time to come and do extra assessments if things were changing, unless we were changing treatments, or calling a code. I think the whole point should be to assess before the crisis, and for the RT to decide and call for a change in treatments, not just to show up after it has already happened.