Chapter 57: Respiratory Care in Alternative Settings PDF

Chapter 57 Respiratory Care in Alternative Settings  Learning Objectives 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...

Chapter 57 Respiratory Care in Alternative Settings  Learning Objectives 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.  Learning Objectives Describe how to help formulate an effective discharge plan. List factors to evaluate when assessing alternative care sites and support services. Loading… 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.  Learning Objectives 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.  Learning Objectives Explain how to select, assemble, monitor, and maintain portable ventilatory support and continuous positive airway pressure equipment, including applicable interfaces or appliances. Loading… Describe proper documentation regarding patient evaluation and progress in alternative settings. State how to ensure safety and infection control in alternative patient care settings.  Post-acute Care Facilities Most common respiratory care services provided in post-acute care facilities are: Continuous O2 therapy Long-term mechanical ventilation Aerosol drug therapy Airway care Sleep apnea treatment and monitoring Pulmonary rehabilitation  LTACH 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  Subacute Care 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  Home Care 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  Home Care Home is not the best setting for subacute care when: The patient is unable to perform self care Adequate caregivers are unavailable Home is an unsuitable environment  Standards Standards for providing respiratory care in subacute and home settings are derived from: AARC clinical practice guidelines Federal (CMS) regulations and state licensing laws Loading… Private-sector accreditation standards  Standards 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  Standards 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  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  Discharge Planning Multidisciplinary team All team members must be part of the discharge process Review table 57-2 on page 1282 (covered on next slide) Site and support service evaluation Discharge site and patient evaluation Appropriate site for discharge is determined by the needs of the patient For discharge to home, caregivers must be trained and provided travel Patients and caregivers must be educated A reliable durable medical equipment supplier may need to be involved  Durable Medical Equipment Provider What to consider: Accreditation Cost Availability  Oxygen Therapy in Alternative Settings O2 therapy prescription must include: Flow rate in liters/minute and/or concentration Frequency of use Duration of need Diagnosis Laboratory evidence (ABGs) Prescriptions for therapy must be supported by documentation of hypoxemia 6 minute walk or ABG may satisfy this requirement  Oxygen Therapy in Alternative Settings Supply methods Compressed O2 cylinders Primarily used for ambulation (small cylinders) or as backup to liquid or concentrator systems Liquid O2 systems Recommended for very mobile patients (lighter) Oxygen concentrators—most common method Separates Oxygen from Nitrogen in room air (also called molecular sieve) 2) % 18 % Problem solving and troubleshooting  Oxygen Therapy in Alternative Settings 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  Ventilator Support in Alternative Settings Invasive versus noninvasive ventilatory support Noninvasive ventilatory support becoming increasingly popular Patients receiving NIV must meet certain criteria (e.g., patient must be cooperative and not need high FiO2) Ventilatory support can be provided by: Fi02 < 40 % Invasive PPV via tracheostomy NIV with negative pressure (via upper airway or chest cuirass/abdominal displacement) NIV via upper airway  Criteria for Ventilatory Support in Alternative Care Settings Ability to tolerate mechanical ventilation ABG values Acceptable ABG values Relatively low FiO2 needs (Generally < 40%) Absence of life limiting comorbidities Cardiac dysfunction PEEP should not exceed 10 Ability to clear airway secretions by cough or suction Tracheostomy tube rather than Endotracheal tube No readmissions expected for < 1 month  Ventilator Support in Alternative Settings Planning Caregiver education To prepare patients, family members, and other caregivers properly for home discharge, a comprehensive educational program must be undertaken and completed Families should be trained in how to handle: Basic ventilation with BVM Suctioning Artificial airway care and maintenance Ventilator circuit care and maintenance Ventilator power failure  Essential Equipment for Ventilator Dependent Patients Review Box 57.3 on page 1290  Ventilator Support in Alternative Settings 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.  Ventilator Support in Alternative Settings 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 Ensure there is space for ventilator and equipment Ensure correct amperage of power supply available Outlets to be used must be grounded Survey for other hazardous appliances  Ventilator Support in Alternative Settings 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  Other Modes of Postacute Respiratory Care 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 Distilled water is most commonly used for humidification in home equipment Using tap water causes hard calcium/lime deposits in equipment  Other Modes of Postacute Respiratory Care Aerosol drug administration Bronchodilators and antiinflammatory agents are given via metered dose inhalers, dry powder inhalers, or small volume nebulizers Loading… Reimbursable expenses related to aerosol drug therapy in the home are limited  Other Modes of Postacute Respiratory Care Airway care and clearance methods Patients with tracheostomies require daily care Tube changes should be done only by nurse, RT, or physician Routine care can be performed by patient, RT, nurse, or caregiver Transtracheal O2 catheter Routine removal and cleaning should be performed by patient Suctioning provided using a portable electrically powered suction pump Mechanical insufflation-exsufflation (MIE)  Other Modes of Postacute Respiratory Care 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  Other Modes of Postacute Respiratory Care 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  Other Modes of Postacute Respiratory Care CPAP Common problems with nasal CPAP are: Nasal discomfort Conjunctivitis Skin irritation Pinte Prevent skin irritation by: Replace mask every 3 months Adjust mask straps for good seal but not tight enough to irritate skin Clean mask daily  Patient Assessment and Documentation In institutions providing subacute or long-term care, the assessment and documentation process involves: Screening Treatment planning Ongoing assessment Discharge summary Homecare plan  Patient Assessment and Documentation Home care Factors to consider when determining the frequency of home visits include: Patient’s condition and therapeutic objectives Level of family or caregiver support Type and complexity of home care equipment Overall home environment Ability of patient to provide self-care  Patient Assessment and Documentation Home care Functions of the RT during a home visit: Patient assessment Patient compliance with treatment plan Administer prescribed therapies Equipment assessment Identification of any patient problems Statement related to patient goals and treatment plan Appropriate documentation  Infection Control Proper hand washing by all caregivers in the home Use of disposable equipment and supplies Visits by those with respiratory infections discouraged Distilled water is first choice for humidifiers used in the home  Patient Transport Intra-hospital Moving patient within the hospital Procedures, transfer to different levels of care Inter-hospital Moving patient from one hospital or facility to another Transfer to different levels of care Transfer during a disaster for patient safety  Patient Transport Equipment Needed: Intubation equipment Be prepared for accidental extubation Portable O2 Pulse ox ECG monitor Stethoscope Appropriate medications Manual resuscitation device (w/mask) Transport ventilator Portable/lightweight Troubleshooting: If patient RR or Vt decreases check the power source and gas cylinders  Patient Transport Mode of Transport Depends on: Urgency/patient condition, weather, medical interventions needed during transport, availability of resources Transport Type Depends on: Distance to be traveled 0 – 80 miles: ambulance 81 – 150 miles: helicopter over 150 miles: fixed wing aircraft (plane)  Patient Transport Transport is successful when the patient arrives at their destination without complications from the transport Remember: Oxygen partial pressure will decrease as altitude increases during transport (whether the aircraft is pressurized or not) Cuff pressure and volumes will vary with changes in altitude Reassess cuff with a pressure manometer