Chapter 57: Respiratory Care in Alternative Settings PDF

Chapter 57 Respiratory Care in Alternative Settings  Learning Objectives (1 of 4)  Describe alternative care settings in which respiratory care is often performed.  Discuss more recent developments and trends in respiratory care at alternative sites.  Identify who regulates a...

Chapter 57 Respiratory Care in Alternative Settings  Learning Objectives (1 of 4)  Describe alternative care settings in which respiratory care is often performed.  Discuss more recent developments and trends in respiratory care at alternative sites.  Identify who regulates alternative care settings.  List the standards that apply to the delivery of respiratory care in alternative settings. Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Learning Objectives (2 of 4)  Describe how to help formulate an effective discharge plan.  List factors to evaluate when assessing alternative care sites and support services.  Discuss how to justify, provide, evaluate, and modify oxygen (O2) therapy in alternative care settings.  Explain how to select, assemble, monitor, and maintain O2 therapy equipment in alternative settings. Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Learning Objectives (3 of 4)  Identify the special challenges that exist in providing ventilatory support outside an acute care hospital.  Describe how to instruct patients and caregivers and confirm their ability to provide care in alternative settings.  Identify which patients benefit the most from ventilatory support outside acute care hospitals.  Identify the most appropriate device needed to treat patients in the post-acute setting. Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Learning Objectives (4 of 4)  Explain how to select, assemble, monitor, and maintain portable ventilatory support and continuous positive airway pressure equipment, including applicable interfaces or appliances.  Describe proper documentation regarding patient evaluation and progress in alternative settings.  State how to ensure safety and infection control in alternative patient care settings. Copyright © 2021 Elsevier, Inc. All Rights Reserved. More Recent Developments and Trends (1 of 2)  Introduction  The Patient Protection and Affordable Care Act (ACA) of 2010 has expanded health care coverage to many uninsured Americans, prohibits the exclusion of preexisting conditions, and increases the scope of coverage for certain types of preventive care.  Medicare introduced prospective payment system (PPS) in 1990s  System limits reimbursement for RC equipment to predetermined monthly payment Copyright © 2021 Elsevier, Inc. All Rights Reserved. More Recent Developments and Trends (2 of 2)  Introduction  Reimbursement for care provided by RTs in homecare setting not provided by Medicare  Indication that RTs may reduce cost of care and achieve better outcomes in skilled nursing facilities Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Relevant Terms and Goals (1 of 4)  Most common respiratory care services provided in postacute care facilities are:  Continuous O2 therapy  Long-term mechanical ventilation  Aerosol drug therapy  Airway care  Sleep apnea treatment and monitoring  Pulmonary rehabilitation Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Relevant Terms and Goals (2 of 4)  Long-term subacute care hospitals (LTACHs)  Provide highly focused care to patients with complex medical conditions, including patients who have been ventilator dependent and difficult to wean  Employ a highly experienced clinical staff, including RTs, to provide integrated interdisciplinary care using the latest equipment and protocols Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Relevant Terms and Goals (3 of 4)  Subacute care  Comprehensive level of inpatient care for stable patients who: Have experienced an acute event from injury or illness Have a determined course of treatment Require diagnostics or invasive procedures  All age groups found at these sites Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Relevant Terms and Goals (4 of 4)  Home care  Most postacute respiratory care is provided in the home  Common clinical conditions treated at home: COPD Cystic fibrosis Chronic neuromuscular diseases Chronic restrictive disease Carcinoma of the lung Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Standards (1 of 3)  Standards for providing respiratory care in subacute and home settings derived from:  AARC clinical practice guidelines  Federal (CMS) and state laws  Private-sector accreditation standards Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Standards (2 of 3)  Regulations  Medicare (CMS) is largest payer and therefore plays major role in setting standards for care outside the hospital  Institutions undergo certification surveys to determine their compliance with standards  Each state also has regulations in place for quality assurance Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Standards (3 of 3)  Private sector accreditation  Primary organization responsible for setting patient care standards in subacute care setting is The Joint Commission  Approximately 90% to 95% of health care organizations voluntarily subscribe to The Joint Commission accreditation Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Traditional Acute Care versus Alternative Setting Care  Respiratory therapists working in alternate care settings  Have less equipment and resources  Work more independently  Complete more paperwork  Are often on-call  Are part of a team approach Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Discharge Planning  Multidisciplinary team  All team members must be part of the discharge.  Site and support service evaluation  Appropriate site for discharge is determined by the needs of the patient  For discharge to home, caregivers must be trained and prepared  A reliable durable medical equipment supplier may need to be involved Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Oxygen Therapy in Alternative Settings (1 of 3)  O2 therapy prescription must include:  Flow rate in liters/minute and/or concentration  Frequency of use  Duration of need  Diagnosis  Laboratory evidence (ABGs) Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Oxygen Therapy in Alternative Settings (2 of 3)  Supply methods  Compressed O2 cylinders Primarily used for ambulation (small cylinders) or as backup to liquid or concentrator systems  Liquid O2 systems  Oxygen concentrators—most common method  Problem solving and troubleshooting Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Oxygen Therapy in Alternative Settings (3 of 3)  Delivery methods  Nasal cannula is most common O2 delivery system for long-term care  Transtracheal O2 therapy used in selected patients; it conserves the use of O2 and has cosmetic advantages  Demand-flow O2 systems  Selecting delivery system  Purpose, patient, and performance Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Ventilator Support in Alternative Settings (1 of 5)  Invasive versus noninvasive ventilatory support  Noninvasive ventilatory support becoming increasingly popular  Noninvasive ventilation (NIV) most often used  Patients receiving NIV must meet certain criteria (e.g., patient must be cooperative and not need high FiO2) Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Ventilator Support in Alternative Settings (2 of 5)  Planning  Caregiver education  To prepare patients, family members, and other caregivers properly for home discharge, a comprehensive educational program must be undertaken and completed  Invasive vs noninvasive ventilatory support Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Ventilator Support in Alternative Settings (3 of 5)  Selecting the appropriate ventilator  Choice of a ventilator depends on the needs of the patient  Backup ventilator should be provided for patients who cannot maintain spontaneous ventilation for more than 4 hours. Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Ventilator Support in Alternative Settings (4 of 5)  Selecting the appropriate ventilator  Ventilators used in alternative sites must be dependable and easy for caregivers to operate  Ventilator must be portable for patients who are mobile  Electrically powered ventilators often best choice in alternative health care sites Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Ventilator Support in Alternative Settings (5 of 5)  Positive pressure ventilators  Most patients, especially those with COPD, prefer pressure-limited over volume-cycled ventilation  Those with neuromuscular disorders may prefer volume ventilation  Biggest challenge with NPPV is getting a good, comfortable, leak-free interface Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Other Modes of Postacute Respiratory Care (1 of 5)  Bland aerosol therapy  Delivered by jet or ultrasonic nebulizers  May be intermittent or continuous  May be useful in patient with thick secretions as an adjunct to airway clearance procedures  Infection is primary risk Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Other Modes of Postacute Respiratory Care (2 of 5)  Aerosol drug administration  Bronchodilators and antiinflammatory agents are given via metered dose inhalers, dry powder inhalers, or small volume nebulizers  Reimbursable expenses related to aerosol drug therapy in the home are limited Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Other Modes of Postacute Respiratory Care (3 of 5)  Airway care and clearance methods  Patients with tracheostomies require daily care  Tube changes should be done only by nurse, RT, or physician  Suctioning provided using a portable electrically powered suction pump  Mechanical insufflation-exsufflation (MIE) Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Other Modes of Postacute Respiratory Care (4 of 5)  Airway care and clearance methods  Patients can be taught to independently apply coughing, forced exhalation, active cycle of breathing, and autogenic drainage methods  Caregivers can be trained to apply chest physical therapy and mechanical devices when retained secretions are a problem Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Other Modes of Postacute Respiratory Care (5 of 5)  Nasal CPAP  The proper CPAP level for a patient is determined by one of several methods  The most common method is to conduct the sleep study while titrating different levels of CPAP  Sleep Remote Tele-Monitoring  Accepted form of therapy to treat sleep apnea  For Medicare reimbursement, the diagnosis must be confirmed by a polysomnogram  Apnea monitoring Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Patient Assessment and Documentation (1 of 3)  In institution providing subacute or long-term care, the assessment and documentation process involves: 1. Screening 2. Treatment planning 3. Ongoing assessment 4. Discharge summary 5. Homecare plan Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Patient Assessment and Documentation (2 of 3)  Home care  Factors to consider when determining the frequency of home visits include: Patient’s condition and therapeutic needs Level of family or caregiver support Complexity of home care equipment Overall home environment Ability of patient to provide self-care Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Patient Assessment and Documentation (3 of 3)  Home care  Functions of the RT during a home visit: Patient assessment Patient compliance with treatment plan Equipment assessment Identification of any patient problems Statement related to patient goals and treatment plan Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Equipment Disinfection and Maintenance (1 of 2)  The American Respiratory Care Foundation has developed guidelines for disinfecting home respiratory care equipment  AARC has produced clinical practice guidelines that outline accepted infection control techniques Copyright © 2021 Elsevier, Inc. All Rights Reserved.  Equipment Disinfection and Maintenance (2 of 2)  Proper hand washing by all caregivers in the home is important  Use of disposable equipment and supplies  Visits by friends with respiratory infections discouraged  Distilled water is first choice for humidifiers used in the home Copyright © 2021 Elsevier, Inc. All Rights Reserved.