More Deregulation?

Somewhere in Texas, an RT is administering a STAT nebulizer treatment in the emergency department to a patient with asthma who is struggling to breathe. Another RT in the NICU monitors the ventilation settings on a premature baby unable to breathe on its own. In the adult ICU, an RT is conducting a spontaneous breathing trial to determine whether or not the patient can be weaned from the ventilator to breathe on their own. In yet another room, an RT is removing ventilatory support from a dying cancer patient as the family waits to say goodbye to their loved one.

A typical day or night in the life of an RT can include any of the above situations. He or she must possess a working knowledge of respiratory diseases and disorders, modes of ventilatory support, various respiratory medications and therapy modalities, acid-base balance, X-ray interpretation and hemodynamics. The RT must be able to assess patients and make recommendations to physicians regarding treatment and ventilation strategies. The RT in each of these scenarios has attended a minimum of 2 years of college and has earned an associate of science degree. Now more than ever, many RTs possess bachelor of science degrees and even master’s degrees in the interest of staying current in their field. He or she has completed hundreds of laboratory and real-world hospital clinical hours and has taken the Certified Respiratory Therapist Licensing exam as well as the additional exam for the Registered Respiratory Therapist Credential. He or she has obtained a state license to practice after an extensive background check. This license must be maintained by continuing education credits. These requirements are in place to ensure the RT has the knowledge and critical-thinking skills to provide quality patient care.

However, if the State of Texas has its way, RTs will no longer need to be licensed to practice and this profession of 14,568 individuals be will negated from the roster of specialties regulated by the Department of State Health Services. The Texas Sunset Commission has placed RTs on the proverbial chopping block. You read correctly. In the not-too-distant future, respiratory care in Texas may not have state oversight. This will mean that, in the state of Texas, a license will be required to operate a vehicle, but not a ventilator. One will need a license to marry, but will not need a license to deliver medication. One will need a license to serve alcohol, but not nitric oxide or heliox.

The Texas Respiratory Care Practice Act
The Texas Respiratory Care Practitioners Act, signed into law in 1985, provides for regulation of the respiratory care profession. This act requires RTs in Texas to have a high school diploma or equivalent, completion of an accredited respiratory care degree program at a college or university, and completion of the National Board for Respiratory Care (NBRC) credentialing exam.1 Once a state license is issued, the RT must maintain the license in with a certain amount of continuing education units. Put succinctly, the act ensures RTs are held to strict educational and professional standards so patient care and safety arenot put in jeopardy.

What Is the Texas Sunset Commission?
The Texas Sunset Commission serves the Texas Legislature by reviewing agencies within the state to assess efficacy and solvency. The commission first does an extensive evaluation of the agency under review and compiles a report of its findings. It then holds public hearings where the report is presented and the agency under review presents its response. Public testimony is also heard and considered. After this hearing, the commission meets again to vote on recommendations and presents those recommendations to the Texas Legislature. From here, the legislature makes final determinations and a bill is drafted and debated on the floor. Once a decision is reached, the agency is either allowed to continue, or is abolished with the option to continue operations for one year.2 The Texas Sunset Commission has made the determination that the deregulation of the respiratory care profession carries “Low risk to public health” as it takes place in a “highly regulated environment” such as a hospital.3 Using perfusionists as an example, the report goes on to imply that as RTs work under the supervision of fellow healthcare professionals such as doctors and nurses, they do not need regulatory oversight by a state agency.3 To follow the above line of logic would be to imply that as nurses work in a highly regulated environment, their professional licensure is unnecessary.

Texas Society for Respiratory Care’s Response to Sunset Commission
The Texas Society for Respiratory Care (TSRC), in a letter to Sen. Jane Nelson, Chair of the Texas Sunset Advisory Commission, stated that deregulation of respiratory care would “be a step backward”4 for not only RTs, but for the patient population at large. Writes the TSRC, “Without the license requirement, employers (hospitals, home health agencies, skilled nursing facilities, and home medical equipment companies) would be free to hire untrained and unqualified personnel ‘off of the street to provide services that require a very high level of skill and expertise for which there would be no regulation or oversight.”4 The society also cited the impact to Texas colleges and universities that offer respiratory education programs stating these programs will suffer drops in enrollment as students would not want to spend 2-4 years in college to do a job when those without professional credentials could realistically be hired to do the same job. No oversight will lead to higher healthcare costs due to the rise of medical mistakes and subsequent malpractice lawsuits.4 Gaylene Lee, Central Region president of the TSRC, wrote an article for the San Antonio Express-News in which she brought up another consequence of deregulation. Applicants previously denied licensure in another state or those who have criminal backgrounds could work unchecked in Texas.5 Texas would become the proverbial Wild West of respiratory therapy.

Other Organizations Stand Up for Patient Safety
It is not only the TSRC that has sounded off on potential deregulation of the profession. The Cystic Fibrosis Foundation has written to Sen. Nelson of the Sunset Commission, citing the need for competent RTs in the ever-changing healthcare environment. “The complexity of the current healthcare system, the speed with which new drugs and treatment options reach the market, the technical expertise required of RCPs demands that multiple layers of oversight exist.”6 The foundation recommended in their letter that RTs remain under the jurisdiction of the Department of State Health Services or be transferred to the Texas Department of Licensing and Regulation. The American Association for Respiratory Care and the Alpha-1 Foundation have also appealed to the Sunset Commission. In a letter to Sen. Nelson, John W. Walsh, President and CEO of the Alpha-1 Foundation, stated that “The ability to access qualified respiratory therapists is critical to the quality of life for people with Alpha-1 and an important component of the disease management.”7 Walsh also went on to underline the point that deregulation in Texas would open the floodgates for those denied licensure in other states.7

Regulation and oversight exist for a reason, and that is patient safety and welfare. No one would ever want an unlicensed physician or nurse to care for them or one of their family members. Deregulation of RTs in Texas is not the “Low risk to public health”3 cited by the Sunset Commission. It carries the potential for patients to be harmed by untrained, incompetent RTs. It would create higher healthcare costs due to increased malpractice suits. No oversight would open the doors for those who have been denied licensure in other states or those with criminal records to practice in Texas. Somewhere in Texas, a patient with asthma will visit the emergency department repeatedly and never receive education concerning peak flows and exacerbation triggers. A patient on life support will die because an unqualified individual who does not understand how to troubleshoot ventilator alarms keeps pressing the “silence” button. Deregulation of RTs in Texas could set a dangerous national precedent. Other states looking to trim fat from their budgets may take aim at their own RTs. This must not be allowed to happen. RTs must take ownership of their profession and stand up for patients who depend on their skill and expertise. State licensure must stand.

Christin Gruben is a registered respiratory therapist at Freeman Neosho Hospital, Neosho, M.O.

1. Texas Department of State Health Services. Respiratory Care Practitioners Certification Program Advisory Committee-Annual Report . Available at: Accessed July 18, 2014.
2. Texas Sunset Advisory Commission. How Sunset Works. Available at: Accessed July 18, 2014.
3. Sunset Advisory Commission Staff Report. Available at:
Accessed July 18, 2014.
4. Letter from the Texas Society for Respiratory Care to Sunset Commission Chair Senator Jane Nelson. Available at: Accessed July 19, 2013.
5. Lee, G. Deregulating respiratory care a risk to public health. Available at: risk-to-public-5565311.php. Accessed July 21, 2014.
6. Letter from the Cystic Fibrosis Foundation to Sunset Commission Chair Senator Jane Nelson. Available at: respiratory.html. Accessed July 21, 2014.
7. Letter from Alpha-1 Foundation to Sunset Commission Chair Senator Jane Nelson.
Available at: Sunset-Commission-Letter-5.30.2014.pdf. Accessed July 21, 2014.

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