Using nurses for respirator exams can save your clients big dollars
Using nurses for respirator exams can save your clients big dollars
Rules flexible enough to allow exam by nurse instead of physician
Specially training nurses to provide respirator fitness exams instead of physicians is a better use of staff time, according to clinicians at one occupational health program where the policy has dramatically improved the testing system. In addition, nurse exams save employers thousands of dollars a year.
And even better, nurse exams do not represent a step down in quality. Rather than a lesser but acceptable level of expertise for the important exams, the nurse exam system allows clinic staff to concentrate more closely on the few patients who need special attention. In that way, the system results in a significant improvement in the overall quality of the exams.
The nurse exam policy has been in place for about six months at WorkMed, the occupational health program at Wilson N. Jones Hospital, a 250-bed facility in Sherman, TX. Because respirator physicals are a significant portion of the program’s workload, clinical director Karen Barrett, RN, COHN-S, and medical director Lilly Ramphal, MD, MPH, began looking for ways to make the exams less onerous.
Federal standard open to interpretation
Ramphal had seen occupational health programs provide the respirator physicals in different ways, so she knew it was not necessary for a physician to provide each one. The federal standard requiring respirator physicals is so loosely worded that some programs rely only on a questionnaire and forgo a physical examination, but Ramphal had no intention of going that route.
Instead, she wanted a system that would provide high-quality respirator exams without requiring her to devote all of her time to them.
"I’ve seen companies that just have respirator exams done by EMTs and nurse practitioners, but I didn’t want to provide cursory exams that just barely complied with the standard," Ramphal explains. "We wanted to provide exams that ensured the worker was healthy enough to wear a respirator, but it didn’t seem necessary to have me do every single thing."
The federal standard requires regular testing of any employee who may have to wear a respirator, with the goal of determining whether the person’s overall health is good enough to safely wear a respirator in dangerous atmospheres. The standard is not specific regarding exactly how the respirator exams must be conducted, saying only that the exams must be supervised by a physician. That has been broadly interpreted by some health professionals.
Ramphal and Barrett take a middle route. They ensure quality by having the medical director closely involved in all respirator exams, but they allow registered nurses to actually conduct all of the initial exams.
About 80% of the employees pass the respirator exam with no problem. Even for those patients, the doctor reviews the test results and the nurse’s notes from the exam before making the final decision as to respirator fitness. For the 20% in which the nurse finds some abnormality or reason to question the patient’s fitness, patients are referred to Ramphal for a second exam. The doctor reviews the results from the first exam and then conducts a second physical exam herself.
"I’m very comfortable with nurses doing the initial exams," the doctor explains. "I think the nurses actually do a more thorough job than doctors when the majority of physicals are going to be normal. I think they pay better attention to detail overall."
Ramphal provides annual training sessions to the nurses, and they all operate with protocols established by the doctor. The materials guide the nurses through the exam process and indicate what results mean the patient should be referred on to the doctor for a more thorough review. (For the testing guidelines, see p. 75. For the form the nurses use to question the patient and record test results, see p. 78.)
Having nurses provide the exams instead of a physician might initially sound like a compromise in quality. Ramphal says it is just the opposite. By allowing a number of nurses to conduct the exams instead of one physician, the system helps avoid the tedium that can lead to carelessness, she says. And since the doctor still is involved in all exams, there is a double layer of inspection instead of just one.
"When most of the exams are normal, it gets relatively boring and tedious," she says. "Companies often block out a month to do all of their respirator exams at once, so there are periods when I could be doing nothing but providing respirator exams all day, every day."
Let doctors be doctors
Instead, the doctor’s time can be spent on activities that clearly require a physician. Ramphal also reports that the two-tiered exam system keeps her and the five nurses on their toes. The nurses know the doctor will be checking their work with each exam, and she knows that the nurses are savvy enough to expect a good explanation if she contradicts any of their assessments.
"It’s much better than having the physician do the exam and that’s the end of it, with no one checking each other’s work," says Ramphal.
In addition to the tedium caused by scheduling the physician to do each exam, the doctor would be unavailable to treat injuries. In the past, Ramphal has seen situations in which she would visit an employer’s worksite and conduct respirator exams all morning. Meanwhile, the company was sending injuries out for care by non-occupational health physicians. That just didn’t make sense.
On the other hand, she also has seen situations in which companies relied on vendors who provided respirator exams that were not closely supervised by physicians. In those cases, the nurses often take a cautious approach and disqualify more employees than necessary.
One of WorkMed’s current clients had that problem, finding that 40% of its employees were disqualified from respirator use by a company providing respirator exams with a mobile testing unit. After switching to WorkMed, the disqualification rate fell to a typical 20%.
Relying on nurses for most of the respirator exams allows WorkMed to charge about $75 less per exam than if the physician conducted them all. Some clients have as many as 500 employees who need a respirator exam every year, so that amounts to a savings of $37,500 per year.
"That makes their bottom line look a lot better," Barrett says. "The program doesn’t cost us anything, really, and saving the client money is the name of the game. With so much competition in this field now, customer satisfaction is very important."
For some employers who have their own in-house nurses, Ramphal trains them to conduct the testing and provides the same physician oversight that she does with the WorkMed nurses. Those usually are larger clients where the physician makes weekly on-site visits anyway, but the nurse exams leave the doctor free to treat injuries and perform other duties at the work site.
"It’s clear that nurses are capable of this sort of exam, and the standard makes it possible," Barrett says. "It’s out-of-the-box thinking, and that’s what you have to do these days to provide quality service and still keep it affordable."
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