Hello everyone. Thank you for joining. My name is Ivan Garcia. I'm a respiratory therapist and clinical research coordinator at Columbia University Medical Center. Today I'll be speaking about respiratory therapists and the ongoing shortage affecting the United States. As far as disclosures, other than being a respiratory therapist myself, I have no conflicts of interest to disclose for this talk. Today's learning objectives will be to understand the role of respiratory therapists in health care, to understand the key factors contributing to respiratory therapist staffing shortages, and to discuss potential strategies to improve staffing challenges in order to build on resiliency. I would like to start by setting the scene. Your respiratory therapist is covering the ICU and you're assessing a patient who is decompensating on non-invasive therapy. The nurse from bed 12 swings by to tell you that her patient is getting emergently intubated and needs to go to CT scan right afterwards. As she leaves, you notice the patient next door has ripped off his high-flow nasal cannula and is trying to get out of bed. You call for help, but everyone's busy attending to other emergencies and your department assures staff today due to sick calls. Those familiar feelings of anxiety, helplessness, and despair start to sink in. Your inability to be in three places at once increases your stress levels, but somehow you're able to push through and assist all three patients. Crisis averted. An hour later, you're finally able to take a break only to find yourself without appetite and physically exhausted. A few more hours to go on your shift when you realize that it's only the first of three for the week. These, my friends, are some of the many challenges that respiratory therapists and other health care providers face on a daily basis. The COVID-19 pandemic has placed respiratory therapists on the national spotlight as integral members of the health care team. The fact is that even after the pandemic, America still can't breathe easy. New variants and surging respiratory illnesses have increased the demand for respiratory therapists across the U.S. Attending to a wide population and settings, respiratory therapists have proven to be valuable members of the interdisciplinary team. At the end of life of a respiratory therapist may include anything from responding to emergencies to initiation of invasive and non-invasive respiratory support, as well as patient education, telehealth services, and even clinical research. With the ongoing shortage affecting health care, I pose a following question to the audience. Which of these services would you or your institution be willing to sacrifice? The fact is that respiratory therapists interact with all members of the health care team on a daily basis. They participate in interdisciplinary teams and committees promoting the advancement of patient care. Respiratory therapists collaborate closely with nurses on a daily basis in rapid responses, patient ventilator weaning, as well as proning in the ICU, amongst many other interventions. They work with physical therapists and occupational therapists in the early mobilization of patients on respiratory support. RTs also evaluate ventilator patients with speech therapists, as well as dietitians in the ICU. We collaborate closely with clinical pharmacists in the ICU for the medication management, dosing, and safety of critically ill patients, and of course work closely with the MDs and advanced practice providers in assistance or even performance of intubations, bronchoscopies, and many other interventions. Some quick facts about the current state of the respiratory care field. As of 2021, there are about a hundred and thirty-five thousand jobs with a 20% growth expected within the next 10 years. According to the American Association of Respiratory Care, at the beginning of the pandemic, there were about a hundred and fifty-five thousand licensed respiratory therapists. That number has quickly grown to just under 200,000 respiratory therapists as of November of 2022. As you can see, it's just a drop in the bucket compared to the current size of the U.S. population. On the map to the right, you can see employment of respiratory therapists by state. As you can see, California, Texas, Florida, New York, and Ohio account for over a third of all respiratory therapist jobs in the U.S., along with Alaska, Hawaii, and Massachusetts, they lead with the highest compensation for respiratory therapists and are among amongst the most popular destination for respiratory therapists, for travel respiratory therapists. Although there's a growing number of jobs available, we continue to experience a national shortage as demand quickly outpaces supply. In fact, over a third of all U.S. hospitals reported anticipating a critical staffing shortage as of January of last year, with respiratory therapists remaining the primary need for many hospitals in the U.S. Three years of unprecedented patient volumes, as well as physical and mental burnout, have increased the competition for experienced and qualified respiratory therapists. Other factors affecting the supply and demand are the shrinking number of therapists available for employment. In fact, 92,000 RTs are expected to retire by the end of the decade. Add to that a 30% decrease in overall RT program enrollment, and the fact that, as previously mentioned, that RTs are leaving their full-time positions for lucrative travel assignments, and compare that with a 41% increase in job postings for allied health. The fact that one in five Americans is suffering from the long-term effects of COVID-19, and an overall drop in ICU level of experience providers, highlighting the need to retain as many respiratory therapists as we can. So how did we get here? As we enter the fourth year of the pandemic, recurrent surges have led to reinfections and an increase of patients suffering from the long-term effects of COVID-19. Higher patient acuity, along with hospital stays and other factors, have contributed to higher rates of retirement, burnout, and resignations. As a result, healthcare systems have resorted to hiring temporary staff, with an unsustainable increase in competition, and some states even resorting to deploying the National Guard to fill in gaps in medical personnel. As previously mentioned, caring for patients with long COVID-19 has increased hospital stays. Very briefly, this is a systematic review by Dessingroff and colleagues on the short-term and long-term effects of post-acute sequelae for COVID-19 survivors. As you can see, more than half of survivors experience lingering effects six months after recovery. This is for hospitalized patients. And that was similar to a recent U.S. study, which reported the top four symptoms as fatigue, memory impairment, loss of smell, and shortness of breath. So what are the factors contributing to respiratory therapist burnout? Andrew Miller developed a survey consistent of quantitative and qualitative questions in which respiratory therapists were asked to report self-perceived and overall perceived levels of burnout. Not surprisingly, 93% of respondents agreed that burnout is a major problem in health care. Shockingly, though, the survey determined that only 10% of respiratory care departments measured burnout and fatigue at all. The top three drivers were identified as staffing, high workload, and poor leadership, with only 32% of respiratory therapists feeling that their leadership provided adequate support for those experiencing burnout and fatigue. Those findings were similar to a survey by Sharma and colleagues, which reported that health care practitioner burnout was highest amongst nurses, advanced practice providers, and respiratory therapists. The same group of health care professionals reported poor communication with their leadership, as well as concerns for transmitting COVID-19 or other illnesses to others or becoming sick themselves. Some other factors or daily stressors contributing to respiratory therapists on a daily basis are personal safety concerns, the inability to take proper breaks, lack of necessary equipment including PPE, a poor work environment, and a lack of work-life balance. These factors are equally important and have been mapped to Maslow's hierarchy of needs. According to Robert and colleagues, these factors such as personal safety, physiological needs, and belongingness are needs that, if unmet, contributed to respiratory therapist burnout. So when it comes to staffing ratios, the AARC does not present specific recommendations. In fact, California is one of a few states that has a set ventilator to respiratory therapist ratio of one to four. Now, although that sounds nice on paper, actual ratios or average internal AARC data suggests that average ratios are about six ventilators per RT, with actual ratios of about eight to one, and a standard practice of about 10 to 12 ICU beds per respiratory therapist. These ratios are dynamic and usually worsen during the acute shortages and busy winter months. On the chart to the right, you can see that the average ventilator to respiratory care practitioner was about eight vents about 80% of the time, and almost 10 vents almost 100% of the time. Although this data is from 2014, unfortunately most of these statistics have remained unchanged and, if anything, have gotten worse with the COVID-19 pandemic. So what is the ideal staffing model for respiratory therapists? Unfortunately, the problem continues to be the lack of robust evidence to support safe and cost-effective patient-to-respiratory therapist ratios, or patient-to-any provider ratio for that matter. Another problem is the use of unweighted metrics that only account for billable procedures rather than value-based or acuity-based systems for staffing. This, in turn, leads to inefficient staffing, with chronic over and under staffing promoting low morale and exacerbating respiratory therapist burnout. So in order to stay prepared, we should have critical staffing strategies during acute shortages. These strategies can be divided into three categories, conventional, contingency, and crisis. Some conventional measures may include understanding regional epidemiology in order to anticipate demand, adjusting minimal respiratory care staffing according to hospital acuity, and perhaps utilizing multi-interface devices to streamline workflow and potentially reduce response times. Some contingency measures include developing and utilizing critical staffing protocols for respiratory care departments, potentially deferring or canceling non-essential procedures or treatments, and redirect the resources and staff to needed areas with some training and orientation required. Lastly, some crisis measures may include training and deploying of medical students and other providers as RT extenders, such was the case in Michigan at the height of the pandemic, activating organizational and regional emergency plans, such as we saw in New York City, and transferring of patients to designated medical facilities with adequate staffing, such as we saw with the big healthcare systems in the East Coast. So two ways we can improve RT retention is strengthening leadership and employee satisfaction. Strengthening leadership should include leadership development classes for management, employee engagement and team building, such as establishing or supporting unit practice councils for respiratory care departments, and of course, mitigating stress and measuring stress and mitigating fatigue and reducing burnout within the staff. Employee retention should include career advancement opportunities for RTs, promoting wellness programs and well-being for RT staff, and most importantly, enterprise-wide recognitions of respiratory care practitioners and the important job that they perform on a daily basis. What other measures work? Organizational strategies should include strategies that are inclusive, promoting teamwork, a sense of belonging and appreciation, of course positively impacting patients and career growth, which will ultimately lead to professional fulfillment. Again, going back to Roberts and colleagues, these qualities have been mapped to Maslow's hierarchy of needs and are important in order for the professional self-actualization of respiratory therapists and any provider, in my opinion. So as we forge ahead, it is important to address current and future challenges within the respiratory care field. To do this, we must participate in local and national campaigns geared towards promoting the respiratory care profession, partnering with regional respiratory care programs to streamline clinical training of students and hiring of graduates, which will in turn help increase education capacity and offering competitive salaries and retention bonuses for new and existing staff. In summary, respiratory therapists are valuable members of the interdisciplinary team providing critical services in all facets of health care. Four years of the COVID-19 pandemic have exacerbated an already existing crisis of shortage of respiratory therapists. The main drivers unfortunately continue to be staffing workload and poor leadership amongst respiratory therapists and other health care practitioners. Implementing short and long-term strategies during acute shortages is important for resiliency and of course RT advocacy and recruitment and retention remain key with the need for national coalitions to raise awareness on all health care staffing shortages. Thank you very much for your time and we'll open up for some questions.

respiratory therapist shortage

healthcare providers

COVID-19 pandemic

respiratory care field

respiratory therapist burnout