Craig Hospital in Denver is a private, nonprofit, independent national rehabilitation hospital that exclusively specializes in the treatment and research of patients with spinal cord injury (SCI) and traumatic brain injury (TBI). The hospital was originally founded in 1907 as a tuberculosis center, but in 1956 turned its attention to the rehabilitation of adult and adolescent patients with catastrophic injury.
Since 1956, Craig has treated more than 26,500 patients and more patients with spinal cord injury than any other single hospital in the world.  As one of the first rehabilitation hospitals in the country, Craig has been very influential over the decades in setting the standard for quality care and outcomes in the industry. As a 93-bed hospital, I believe Craig has remained a model of excellence in an ever-changing healthcare delivery system.


In 2008, Craig treated patients from 47 U.S. states and several foreign countries. Craig is accredited by the Joint Commission and is a Magnet® Recognized Hospital – the second rehabilitation hospital in the U.S. to receive this prestigious award. Each year, the hospital treats approximately 200 newly injured people with spinal cord injuries, 100 newly injured people with traumatic brain injuries, and more than 1,600 outpatients. In 2008, Craig was ranked in America’s Top Ten Rehabilitation Hospitals by U.S. News and World Report for the 19th consecutive year.

Craig Hospital has earned a place among the world’s top SCI and TBI programs secondary to the successes achieved by its graduates. Approximately 85 percent of its patients return home after initial rehabilitation with high levels of functional independence and with less need for attendant care. Numerous medical and technological advances made over the past several decades have enhanced both the immediate and long-term survival of individuals with SCI.

In fact, as early medical management improves, greater numbers of individuals with very severe, high-level injuries are surviving the acute phase, entering into rehabilitation, and transitioning back to their communities. Furthermore, 95.2 percent of Craig’s patients on mechanical ventilation are discharged to their homes as opposed to subacute nursing facilities or nursing homes.

Beyond the Break

Spinal cord and traumatic brain injury often result in insult or injury to the cardiopulmonary system. As a consequence, a number of respiratory problems and/or diseases can ensue. At Craig Hospital, respiratory care is an integral part of the interdisciplinary team dedicated to providing excellence in care and patient outcomes. The respiratory therapists manage countless complications ranging from mechanical ventilator management, complex apneas, asthma, chronic obstructive pulmonary disease, and acute airway management.

Acute traumatic cervical SCI (tetraplegia) may necessitate mechanical ventilation to manage respiratory failure. In order to survive, many of these individuals require temporary or permanent, full- or part-time mechanical ventilation. However, the reliance on mechanical ventilation has a potentially adverse impact on long-term survival. Respiratory complications are among the leading causes of death for individuals with cervical SCI during acute hospitalization and one of the most common causes of death in subsequent years.

Appreciating the enormous impact that respiratory therapy can have on patient outcomes, decades ago, Craig developed a nationally recognized pulmonary program. Craig’s ventilator and weaning program continues as one of the largest specialty programs of its kind in the U.S. and is known for its expertise in gradually removing patients from their ventilators.

According to James Fenton, MD, pulmonary medical director for Craig Hospital, “Our success at weaning patients with spinal cord injury from mechanical ventilation is the result of teamwork between the respiratory staff and the patient. It highlights the spirit of compassionate quality care at Craig Hospital.”

The core of Craig’s respiratory department excellence lies in its unique approach to ventilator management. As an innovative pioneer in the field, the respiratory department employs a protocol that promotes the use of higher tidal volumes compared with conventional norms. It has been Craig’s experience and conviction that higher tidal volumes assist high-level SCI patients to wean more quickly from mechanical ventilation and reduce other pulmonary complications associated with SCI.


The protocol also incorporates a systematic weaning strategy that takes advantage of the patient’s volitional ability to breathe.
It is the methodical approach of handing the baton for better breathing to the patients that appears to increase their potential to wean from mechanical ventilation. We have learned that a gradual patient-centered weaning protocol works more effectively than other conventional approaches.

The “Craig Vent and Wean Protocol” was pioneered by now-retired Pete Peterson, MD, and is being continually studied and refined to meet the demands of Craig’s changing patient population. For example, the department is actively enrolling patients into a five-year prospective, randomized, controlled pilot study to compare outcomes between individuals with subacute, ventilator-dependent tetraplegia using high tidal volumes versus normal tidal volumes during mechanical ventilator support. Outcome measures being studied include: time to wean from mechanical ventilation; ventilator-associated pneumonia; improving chest X-ray results; and a number of other safety outcomes.

The Team Approach

The Craig Hospital respiratory care department consists of 27 highly specialized and skilled respiratory therapists, who average more than seven years of service at Craig. Many of the respiratory therapists have more than 20 years of service with Craig, and 70 percent have advanced registry practitioner designation.

Each therapist must complete a rigorous four-week orientation process upon hire and pass annual exams and competencies. Every therapist is certified in advanced cardiac life support. The department staff embraces the dedication to ongoing education and competency. In fact, it is the therapists who develop and proctor most of the monthly quizzes and competencies.

Personally, I employ a philosophy I learned in the United States Army: the “see one, do one, teach one” methodology. It was the teaching session that helped the soldier to more fully learn the material. We have instituted a similar approach to staff education in our department. We believe it is critical to have the bedside clinicians become the experts of our competency program.


Craig’s respiratory therapy staff is also challenged with performing mock intubation scenarios every 60 days to ensure competency with the low-volume, high-risk procedure.

For their dedication and creativity, working their way into a professional development program called a “clinical ladder” can reward Craig’s respiratory therapists. The ladder provides respiratory therapists with a pathway for clinical advancement, to promote excellence in respiratory practice and to enhance quality patient care. The ladder provides a structured process that acknowledges the respiratory therapist who strives for continuous improvement.

At Craig, staff therapists are expected to function as physician extenders. For example, the professional growth of therapists focuses on employing a mentality of how their daily treatments impact long-term goals and outcomes. The process begins during the patient’s initial evaluation, where pulmonary and respiratory therapy goals are identified and documented.

These goals are far-reaching and link the patient to their ultimate potential. The respiratory staff participates in daily rounds with midlevel practitioners and physicians and has a significant voice in the overall patient treatment plans. The department promotes protocol-driven decisions within the interdisciplinary team. Currently, respiratory therapists employ 48 protocols in their decision-making tree. It is these protocols that lay the foundation for clinical excellence, expectation, and advancing bedside autonomy in the department.

On an annual basis, the department develops and implements a strategic plan with goals identified by management and staff. In 2009, there are 19 goals that focus on improving work functionality, enhancing customer service outcomes, and advancing various patient care initiatives.

Craig’s respiratory department embraces a culture of shared governance. In 2008, the department developed a staff-led subcommittee named “Team Council.” The purpose of the council is to work on solutions for ongoing interdepartmental objectives. The council is currently working on improving on-call employee retention, improving the overall consistency of shift-to-shift communication and patient reports, and implementing a respiratory therapy resource center on the hospital’s Intranet site for nurses.

There are also respiratory therapists who are represented in the pulmonary section, the hospital’s governing board for the respiratory program. Their involvement is fundamental to linking bedside practice with programmatic development. The shared governance culture appears to be working: in the February 2009 hospital-wide staff satisfaction survey, 100 percent of the respiratory department members “strongly agreed” with the statement “I am member of a team that works well together, and the day-to-day decisions and activities in my workgroup demonstrate that quality is top priority.”

Craig’s respiratory therapy staff is also part of the interdisciplinary teams who take patients on therapeutic outings into the community. This allows patients on ventilator, for example, and their families to learn the necessary skills for being outside the hospital, in preparation for going home. Outings can include Denver Broncos, Nuggets, Avalanche, and Mammoth games, movies, parks, malls, supermarkets, etc. Respiratory staff values their role in these out-of-the-hospital experiences and have an enjoyable time in the process.

Respiratory therapy is also a key component to Craig Hospital’s “Flight Program.” The flight program consists of a respiratory therapist and a nurse accompanying a ventilator-dependent patient home upon discharge. Upon arrival to the patient’s home, the therapist and nurse help the patient get settled, educate the patient’s family and caregivers who were not able to attend hospital training, and help problem-solve any equipment and home-modification issues.

The flight team typically spends a day and night at the patient’s home. The transition home can be a difficult endeavor for the patient and their family, but with assistance from Craig’s respiratory staff, the transition is made easier. The flight program also provides a high level of personal satisfaction for the therapists.

“Taking a patient home is one of the highlights of my job,” says Gregg Gibson, CRT. “You get to see the patient get to the place they worked so hard to get back to. It gives you a higher degree of pride knowing that you played a role in assisting them reach this goal.”

A New Standard

Craig Hospital has earned a place among the world’s top SCI programs, and one of the reasons is the quality of its respiratory therapy department and ventilator-dependent and weaning programs. The department has been successful in developing a high-quality staff and blending competency and compassion in each therapist.

Our responsibility is to help give the patient their life back. We try our best to live by this vision by continuously improving our program. Whether it is researching and implementing best practices, participating in daily rounds, challenging and improving staff competencies, revising a policy, participating in a research study, or in Team Council and caring for patients and families, Craig’s respiratory department is a model of excellence.

— Lonnie Martinez, BS, RRT, is the director of Respiratory Care at Craig Hospital in Denver. Questions and comments can be directed to editorial@therapytimes.com.