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Optimizing Respiratory Therapy Services A Continuum of Care from Hospital to Home A Training Manual for Paediatrics & Adults Healthcare Professionals and Caregivers June 2010 Project Team Mary Bayliss Carole Hamp Dianne Johnson Rosanne Leddy Mika Nonoyama Christine Robinson Miriam Turnbull Pa...

Optimizing Respiratory Therapy Services A Continuum of Care from Hospital to Home A Training Manual for Paediatrics & Adults Healthcare Professionals and Caregivers June 2010 Project Team Mary Bayliss Carole Hamp Dianne Johnson Rosanne Leddy Mika Nonoyama Christine Robinson Miriam Turnbull Partners Acknowledgements The College of Respiratory Therapists of Ontario (CRTO) gratefully acknowledges the Ministry of Health and Long Term Care’s Health Force Ontario branch for funding this collaborative initiative entitled “Optimizing Respiratory Therapy Services: A Continuum of Care from Hospital to Home”. We would also like to thank the Toronto Central Local Health Integration Network (LHIN) for its support of this initiative. We would like to recognize the participation of our partners is this initiative. Central Community Care Access Centre Professional Respiratory Home Care Services Respiratory Therapy Society of Ontario West Park Healthcare Centre We also acknowledge the valuable contribution of the following organizations in the development of this teaching package. Funding Support for the development of this training manual was provided through HealthForceOntario’s Optimizing Use of Health Providers Competencies Fund. Hamilton Health Sciences Kingston General Hospital London Health Sciences Centre St Michael’s Hospital, Toronto Sick Kids, Toronto The Ottawa Rehabilitation Centre Ventilator Equipment Pool, Kingston We acknowledge the following Respiratory Therapists for their dedication and tireless commitment to this project. A copy of this Training Manual is available from College of Respiratory Therapists of Ontario 180 Dundas Street West, Suite 2103 Toronto, Ontario M5G 1Z8 Tel: 416-591-7800 Fax: 416-591-7890 Toll free: 1-800-261-0528 Email: [email protected] Web site: www.crto.on.ca Carlos Bautista Melva Bellefountaine Rob Bryan Noreen Chan Janet Fraser Terri Haney Chris Harris Melissa Heletea Dave Jones Jeannie Kelso Gail Lang Adrienne Leach Karen Martindale Raymond Milton Ginny Myles Patrick Nellis Margaret Oddi Regina Pizzuti Faiza Syed Renata Vaughan Special thanks to the ProResp Clinical Team. Our thanks to all of the patients/clients, families and “hands on” caregivers without whom this project would not have succeeded. Optimizing Respiratory Therapy Services A Continuum of Care from Hospital to Home A Training Manual for Paediatrics & Adults Healthcare Professionals and Caregivers June 2010 Disclaimer Information published by The College of Respiratory Therapists (CRTO) is provided for educational purposes only and is intended for Ontario residents. This educational material does not provide medical advice. Information provided is not designed or intended to constitute medical advice or to be used for diagnosis of an individual patient’s condition. Due to unique needs and medical history, patients are advised to consult their own healthcare professional(s) who will be able to determine the appropriateness of the information for their specific situation, and will assist them in making any decisions regarding treatment and/or medication. Specific products, processes or services. Reference to, or mention of, specific products, processes or services does not constitute or imply a recommendation or endorsement by CRTO and/or its contributors. Links to other sites are provided as a reference to assist you in identifying and locating other Internet resources that may be of interest. Please remember that Internet resources are no substitute for the advice of a qualified healthcare practitioner. We do not assume responsibility for the accuracy or appropriateness of the information contained in other sites, nor do we endorse the viewpoints expressed in other sites. Use of this educational material is encouraged, all we ask is that you give credit to the CRTO and this project*. Should you identify any areas that require revisions or updates please let us know. * Support for the development of this training manual was provided through HealthForceOntario’s Optimizing Use of Health Providers Competencies Fund. Please refer to the back cover of this educational package to view a complete list of the project partners. Introduction to Manual Introduction to the CD Resources Glossary of Terms Introduction & Glossary of Terms Section #1: Introduction & Glossary of Terms Section #2: Healthcare Professionals Healthcare Professionals Discharge Identification & Preparation Identification and Preparation Tool Discharge Checklists Preparation for ICU Discharge Preparation for Hospital Discharge Section #3: Patients/Clients & Caregivers Pulmonary Clearance Techniques Pulmonary Clearance Techniques Emergency Contacts and Planning Emergency Contacts and Planning Useful Web Resources Emergency Preparedness Guide for People with Disabilities/Special Needs Patients/Clients & Caregivers Education Checklists Ventilation & Tracheostomy Care Routine Tasks Home Ventilation & My Education Checklist and Learning Log Tracheostomy Care (for Adults) Oximeter Teaching Checklist Non-Invasive Positive Pressure Ventilation (for Adults) Troubleshooting Home Ventilation & Troubleshooting Guide Tracheostomy Care (for Paediatrics) Section #4: Appendices Appendix B Quick Reference Guide to LTV® 1200/1150 Series Ventilators Appendix C Quick Reference Guide to LTV® 900, 950 & 1000 Series Ventilators Appendices Appendix A Assistive Devices Program Equipment/Supply Authorization Form (Sample) Introduction & Glossary of Terms Section #1: Introduction & Glossary of Terms Introduction to Manual Introduction to the CD Resources Glossary of Terms Healthcare Professionals Section #2: Healthcare Professionals Discharge Identification & Preparation Identification and Preparation Tool Discharge Checklists Preparation for ICU Discharge Preparation for Hospital Discharge Patients/Clients & Caregivers Section #3: Patients/Clients & Caregivers Education Checklists Ventilation & Tracheostomy Care Routine Tasks Home Ventilation & My Education Checklist and Learning Log Tracheostomy Care (for Adults) Oximeter Teaching Checklist Non-Invasive Positive Pressure Ventilation (for Adults) Troubleshooting Home Ventilation & Troubleshooting Guide Tracheostomy Care (for Paediatrics) Pulmonary Clearance Techniques Pulmonary Clearance Techniques Emergency Contacts and Planning Emergency Contacts and Planning Useful Web Resources Emergency Preparedness Guide for People with Disabilities/Special Needs Appendices Section #4: Appendices Appendix A Assistive Devices Program Equipment/Supply Authorization Form (Sample) Appendix B Quick Reference Guide to LTV® 1200/1150 Series Ventilators Appendix C Quick Reference Guide to LTV® 900, 950 & 1000 Series Ventilators Introduction to Manual Introduction to the CD Resources Glossary of Terms Introduction & Glossary of Terms Section #1: Introduction & Glossary of Terms Healthcare Professionals Patients/Clients & Caregivers Appendices Introduction & Glossary of Terms Healthcare Professionals Patients/Clients & Caregivers Appendices Section #1: Introduction & Glossary of Terms Introduction to Manual Introduction to the CD Resources Glossary of Terms Introduction Introduction & Glossary of Terms Introduction to the Manual Mechanical ventilation was first developed during the polio epidemic in the 1950s when patients were placed in an iron lung. Today we use positive pressure ventilation with an endotracheal tube or a tracheostomy tube. For the majority of patients, ventilation is usually short term and is discontinued after the respiratory or ventilatory failure has resolved. Most patients are weaned off the ventilator with no problems. However, for some patients weaning is a challenge. If a patient cannot be weaned off the ventilator they are deemed ‘ventilator-dependent’. Chronic ventilated patients can be found in acute-care hospitals, ventilator step-down units, long term care facilities, and at home. It is ideal and safe to transition stable, chronically ventilated patients to their homes. A stable, ventilator dependent patient can be transitioned successfully from the ICU to home, or a long term care facility. This shift from acute care to home care has resulted in improved quality of life, decreased morbidity and mortality, and reduced care costs. Patients and families report that they are happier at home and have a better quality of life. The intent of this document is to assist respiratory therapists and other healthcare providers to transition chronically ventilated individuals from hospital to the community. A successful hospitalto-home transition requires careful planning, and plenty of patient and family education. Prior to planning the transition, the patient must meet discharge criteria, such as being medically stable. These criteria can be found in this manual. For a smooth transition to occur, the patient needs a supportive family, caregivers and a medical team that communicates well. Once the ICU discharge criteria are met, the process of educating the patient and caregivers can begin. The Education Checklist and Learning Log will assist the educator and learner track the education process. It is important to observe the caregivers participating in the care of the patient, while the patient is in the acute care setting. It is critical as a healthcare provider to document the learner’s competency. A number of checklists have been provided in this manual to assist with this documentation requirement. All must be competent and comfortable prior to discharge. The education process can take 2 - 4 weeks to complete, prior to a patient’s discharge. To ensure the skills have been mastered, and to provide ongoing support, a comprehensive follow up plan is then continued within the community. Introduction Introduction & Glossary of Terms The material provided to the patient includes basic anatomy and physiology of the respiratory system, ventilator parameters, alarms, circuit changes, and backup power sources. Also covered are suctioning, stoma and tracheostomy care and how to respond in an emergency. This information is found in the Home Ventilation & Tracheostomy Care manuals. There is also a Troubleshooting Guide, as an additional reference. For those patients on non-invasive ventilation refer to the Non-Invasive Positive Pressure Ventilation guide. There are other tools and checklists to help you prepare the patient, their families and caregivers. The Useful Web Resources and Glossary of Terms can also be helpful. Team meetings need to take place, prior to and following discharge, between the acute care healthcare providers and the Community Care worker. The intent of this document is to assist respiratory therapists and other healthcare providers to transition the chronically ventilated individual from the hospital to the community. If you have any suggestions or comments about this manual please forward them to The CRTO. 180 Dundas Street West, Suite 2103 Toronto, Ontario M5G 1Z8 Tel: 416-591-7800 Fax: 416-591-7890 Toll free: 1-800-261-0528 Email: [email protected] Web site: www.crto.on.ca Introduction to the CD The CD, found in the inside back cover, contains all the information and worksheets that are presented here in this manual. The materials are sorted by ‘tab’ or topic and are ready for print. To view the files, you must have Adobe Reader software. To obtain Adobe Reader, visit, http://get.adobe.com/uk/reader. Optimizing Respiratory Therapy Services A Continuum of Care from Hospital to Home RESOURCE CD A Training Manual for Paediatrics & Adults Healthcare Professionals, Patients/Clients and Caregivers June 2010 Glossary of Terms Introduction & Glossary of Terms Glossary of Terms The following is a list of words that you will find in the manual. Some of the terms are things you may hear your healthcare worker say. Always ask if you do not understand something. A Aerosol: Solution that is given in a mist Apnea: Not breathing Cardiopulmonary resuscitation (CPR): Artificially supporting breathing and the circulation Antibiotics: Medicines that fight infections Carina: The point of where the right and left bronchi separate Artificial nose: A device that warms and moistens the air Catheter: A small tube placed inside the body to add or remove liquids Artificial airway: A cut made in the trachea resulting in an opening that bypasses the nose and mouth. Also called “trach” or “tracheostomy” CPAP: A ventilation mode that helps a patient’s own breathing efforts. Stands for continuous positive airway pressure Aspiration: Food or liquid breathed into the airway instead of swallowed Asthma: Difficult breathing with wheezing that is caused by swelling or spasms of the airways B Cuff: The inflatable balloon on some trach tubes Cyanosis: A bluish color of the skin due to reduced oxygen in the blood D Decannulation: Removal of the trach tube Bacteria: Germs Diaphragm: The big muscle below the lungs that controls breathing Bacterial: Caused by bacteria Dysphagia: Difficulty swallowing Breathing bag: Ventilating bag used for manual resuscitation Dyspnea: Labored or difficulty breathing, shortness of breath Bronchi: The two main branches leading from the trachea to the lungs C Cap: A small cap used to plug the trach opening Cannula: The tube part of the trach tube Carbon Dioxide (CO2): Gas eliminated from the lungs with exhalation E Edema: Swelling of tissue. Encrustation: Hard and dried mucus that can build up around the inner cannula. ENT: It is a term used for type of doctor that specializes in the ‘ear nose throat’. ENT doctors do tracheotomy surgery Glossary of Terms Introduction & Glossary of Terms ET tube (endotracheal tube): A tube used to provide an airway through the mouth or nose into the trachea. Home healthcare supplier: Also called medical equipment supplier. They provide equipment, oxygen, trach care supplies. Epiglottis: “Trap door”. A piece of cartilage that hangs over the larynx like a lid and stops food, and liquids from going down into the lungs Humidity: Moisture in the air Esophagus: The tube between the throat and the stomach Exhale: To breathe out Extubation: Removal of the endotracheal tube Hydrogen peroxide (H2O2): Mild cleaning agent Hypoventilation: Reduced rate and depth of breathing Hypoxemia: A low amount of oxygen in the blood Expiration: Breathing out of air from lungs I F Fenestrated: Having an opening in the trach tube to allow speech Fenestrated inner cannula: An inner cannula with holes in it. This lets air go from the trach tube up to the mouth, and nose. The outer cannula must also have holes in it to work Fenestration: A single hole or pattern of smaller holes Flange: Part of the trach tube, also called the neck plate G Glottis: The sound producing part of the larynx that consists of the vocal cords H Heat moisture exchanger (HME): A filter device that fits into the end of the trach tube to warm and moisten the air the patient breathes Home healthcare professional: Individual who gives care at home Inflation line: The thin plastic line attached to trach tube balloon on one end and pilot balloon on the other. It is used to inflate and deflate the trach tube balloon (cuff ). Inflation syringe: A plastic syringe without needle used to inflate the trach tube balloon (cuff ) Inhale: To breathe in. Inner cannula: The inner removable tube that fits inside the outer cannula. May be removed to clean or exchanged with different inner cannula. Inspiration: To breathe in Intubation: Placement of a tube into the trachea to help with breathing. L Larynx: “Voice box” or “Adams apple”. Is just on top of the trachea. Lumen: The inside of the trach tube through which air passes. Glossary of Terms M Mucous: Slippery fluid that is made in the lungs and windpipe Mm: Short form for millimeter. One millimeter equals .039 inches Introduction & Glossary of Terms Retractions: Pulling or jerky movement of the chest and neck muscles. It’s a sign of respiratory distress S Secretions: Another word for mucous. N Nebulizer: A machine that puts moisture and or medicine into the airway and lungs Neck plate: Part of the trach tube that sits against the neck, also called the flange Speaking valve: A one way valve that lets air come into the trach tube when you breathe in. When you breathe out, the valve closes sending air out past the vocal cords and through the mouth so speech is possible. Nosocomial infection: An infection that you got during your hospital stay Speech language pathologist: A person trained to help with speaking and swallowing problems O Stoma: The hole in the neck where you insert the trach tube Obstruction: Blockage Obturator: The guide that goes in the trach tube to help insert the tube into the trachea Outer cannula: The main tube with neck plate that is placed into the trachea Oximeter: Equipment that monitors the amount of oxygen in the blood Oxygen: A gas that the body needs to stay alive Sterile: Very clean and free from germs Suctioning: One way to keep the inside of the trach tube clean and free of mucus. A small catheter is connected to a suction machine and placed into the trach tube to remove mucous Swivel neck plate: A neck plate that can swivel up and down and/or side to side. Allows for greater range of head and neck movement without discomfort. Syringe: Device to measure medicine P Patent: Open, clear airway T Pneumonia: Swelling of the lung that is often caused by germs Trach: An opening into the trachea R Trachea: “Windpipe”. The tube through which air flows between the larynx and the lungs Respirologist: A doctor who looks after the lungs Respite: A break for caregivers who care for a disabled family member at home Trach mask: A device that fits on the end of the trach tube to provide moisture Tracheal wall: The inside lining of the trachea Trach Tube: A tubular device placed into the trach Glossary of Terms Trach Ties: Cotton twill or Velcro tapes used to hold the trach tube in place. Connects to the slots in the trach tube neck plate V Ventilator: A machine that helps a person breathe Virus: A germ that can cause illness Viscid: Thick or sticky Vocal cords: Two strips of tissue in the voice box in the neck, which allows vocalization W Wheeze: A whistling sound coming from the lungs because of a narrowing in the wind pipe or airways. Introduction & Glossary of Terms Discharge Identification & Preparation Identification and Preparation Tool Discharge Checklists Preparation for ICU Discharge Preparation for Hospital Discharge Introduction & Glossary of Terms Section #2: Healthcare Professionals Healthcare Professionals Patients/Clients & Caregivers Appendices Introduction & Glossary of Terms Healthcare Professionals Patients/Clients & Caregivers Appendices Section #2: Healthcare Professionals Discharge Identification & Preparation Identification and Preparation Tool Discharge Checklists Preparation for ICU Discharge Preparation for Hospital Discharge Discharge Identification & Preparation Discharge Identification & Preparation Identification and Preparation Tool Discharge Identification & Preparation Discharge Identification & Preparation Notes Identification and Preparation Tool Identification and Preparation Tool Healthcare Professionals Evaluation and Discharge Planning Discharge Assessment The following is a high-level approach the interdisciplinary team can use during the preliminary stages of identifying a candidate for home or community placement. Assessment of the Home Environment Assessment includes geographic location, available space, and accessibility.      A home to go to Home environment prepared in advance to accommodate the patient’s needs Adequate number of grounded electrical outlets Respiratory equipment supplier is aware of individual Sturdy bedside table for the ventilator placement Assessment of Caregivers Caregivers must be motivated and able to learn the care routines.  Patient is able and willing to supervise/direct care  Individual is able and willing to participate in self care, or has sufficient caregiver assistance to adequately meet medical, respiratory, and personal care needs Education and Training There is a comprehensive education plan with learning objectives and evaluation for individual, family and caregivers.  Caregivers identified and trained prior to discharge (See Home Ventilation &   Tracheostomy Care, and Education Checklist and Learning Log provided in this manual) Adequate nutrition program is in place Successful and stable trials: for at least two weeks prior to discharge with no changes B On home equipment ventilator prior to discharge, (e.g. ventilator, monitor, oxygen, if applicable) B Leaving the hospital setting with home caregivers Page 1 Identification and Preparation Tool Healthcare Professionals Assessment of Resources This includes professional services, support systems, individual’s financial resources.  Adequate financial resources and mechanisms for reimbursement identified prior to    discharge Potential referrals in place: Respirologist, Occupational Therapist, Physical Therapist, Social Worker, Registered Dietitian, Pharmacist, Community Care Access Centres (CCAC) Appropriate application forms completed: B Assistive Devices Program: o Tracheostomy o Ventilator o Enteral feeds, if applicable B Home Oxygen Program, if applicable B Special services at home B Handicapped parking permits B Wheelchair Contact the Ventilator Equipment Pool (VEP) to discuss the most appropriate equipment available and lead time for delivery Plan of Care A written management plan for respiratory, medical care, and emergencies.  Individual is medically stable: oxygen requirement less than, or equal to 40%; stable    blood gases; mature tracheostomy and no events requiring CPR for at least one month Comprehensive discharge plan in place The treatment plan for all medical conditions is in place B Plan does not require frequent changes B Plan is transferable to the community Discharge planning meetings in place, including the individual, caregivers, healthcare team and community services Page 2 Identification and Preparation Tool Healthcare Professionals Team Meetings Initial team meeting are to take place while the ventilator assisted individual (VAI) is in the hospital. First Team Meeting Primary aims of this meeting are:      Determine the short and long term goals Identify issues and potential barriers to discharge Create plans to manage issues and potential barriers to discharge Complete feasibility assessment of required community support Identify additional funding opportunities for the patient Team members should include the individual, their caregivers and the inter-professional team:        Individual Family and caregivers Most responsible physician Nurse (RN) Community Respiratory Therapist (RT) Social Worker (SW) Physical Therapist (PT)       Speech Language Pathologist Occupational Therapist (OT) Registered Dietitian (RD) Pharmacist CCAC Case Manager Discharge planner   Second Team Meeting Primary aims of this meeting are:     Determine if discharge to home or community facility is achievable Prioritize goals and timelines; those to be achieved prior to discharge Determine a realistic discharge date Delineate roles and responsibilities for all team members, including the caregiver and family B Care plans B Funding applications B Discharge guidelines B Learning needs assessments B Education training programs B Equipment acquisition Page 3 Identification and Preparation Tool Healthcare Professionals Additional team members at this meeting should include the community care providers:     Community RT Community PT Community OT Nursing agency provider Follow up Meetings Primary aims of this meeting are:     Monitor progress toward goals Update the patient and caregivers Identify other barriers to discharge and develop a resolution plan Communicate among the inter-professional disciplinary team Page 4 Identification and Preparation Tool Healthcare Professionals Placement Considerations in the Home Adequate Daily Care Coverage In addition to the care provided by the caregiver(s), the patient may receive additional care hours through CCAC. Access to immediate assistance is recommended for any individual who requires 24 hours ventilation or is fully dependent in their activities of daily living. This can be a trained community care provider, such as a Registered RT, Nurse, PSW or trained family member. Individuals who live in Ontario who require suctioning or catheterization as part of their normal daily routine have a legislated exemption in the Regulated Health Professional Act (RHPA) allowing non-registered professionals to provide this service, provided they are competent to do so. Additional Considerations Mobility A VAI may require a wheelchair with ventilator and oxygen carrying capacity. The vehicle used for mobility must be able to safely carry a ventilator and external battery without tipping. Home ventilators can weigh up to 35 lbs. Ventilator shelves can be attached to some standard wheelchairs, but some of these chairs may not be wide enough or balanced enough to hold the additional weight. Often a VAI has their own wheelchair that can be adapted by the supplier to carry the ventilator and battery. If this is not possible, an application for a customized wheelchair with ventilator carrying capability can be made. Assessment and applications are usually made by the OT or PT and signed by the physician. The chair supplier will need the ventilator and battery dimensions. Information that can be obtained from the RT. Other mobility devices may be required, such as ambulation aids and positioning devices (lifts). Applying early in the process will reduce delays. Check with the equipment provider for the anticipated delivery date. Page 5 Identification and Preparation Tool Healthcare Professionals Equipment Acquisition The Ministry of Health and Long-Term Care (MOHLTC) funds 75% of the cost of respiratory supplies through the Assisted Devices Program (ADP). The remaining 25% is the responsibility of the individual. Contact the VEP or alternate provider for details on equipment acquisition. Note: some individuals are not eligible for equipment through the VEP. For example, patients discharged to long term care facilities do not have access to VEP equipment. See VEP website for more information on eligibility http://www.ontvep.ca. Home Mechanical Ventilators A VAI discharged to the community is provided with:       Ventilator(s) Battery charger Heated humidifier External battery for emergency power only Battery cable Re-useable ventilator circuits The cost of this equipment is 100% covered by the MOHLTC, through ADP. Applications must be signed by the physician. The VAI should have completed several successful trials on a home mechanical ventilator, before setting them up for indefinite use. Other Respiratory Supplies Requests are made by the home respiratory care service, to the ADP. This equipment may include:  Apnea cardiorespiratory monitors  Compressors for aerosolized   medication delivery Postural drainage boards Suction machines     Tracheostomy supplies Percussors Resuscitators Positive airway pressure systems 75% of the cost of this equipment may be covered by the MOHLTC. The remaining 25% is the responsibility of the individual. Page 6 Identification and Preparation Tool Healthcare Professionals Some equipment, although necessary for some VAIs, may not be funded through ADP. The following equipment is not funded: B cough-assist devices B oximeters for individuals 18 years or older B 12 volt batteries for mobility purposes Other Medical Supplies Other medical supplies may be necessary in the community setting and eligible for ADP funding e.g. enteral feed equipment. Check with the interprofessional healthcare team for details. Individual, Home Care Providers and Family Education A successful discharge requires a simplified and comprehensive transfer of care routines from healthcare team to the community provider team. Ideally the community team would receive the transfer of skills within the acute care facility. This allows them to be in direct contact with the individual and work closely with the acute care team. This training technique serves to increase the confidence and comfort of both the community care providers, the individual and the caregivers. Information provided in respiratory teaching packages typically should cover:  Tracheostomy and ventilator care  Individual-specific training checklist that must be completed prior to discharge; can  also be used as a scheduling guide Emergency guidelines that are provided to address common problems that may arise within the home environment Respiratory Education The training should include, but is not limited to:  Respiratory anatomy and physiology  Hands-on training with tracheal    suctioning  Ventilator troubleshooting and  maintenance   Tracheostomy tube cuff care; changing  if applicable  Page 7 Use of the manual resuscitator bag Switching to ventilator battery Charging the ventilator battery Circuit assembly Emergency planning Cleaning of equipment Volume augmentation manoeuvres Identification and Preparation Tool Healthcare Professionals Emergency Plan and Recommended Physician Coverage Emergency guidelines are provided to address common problems that may arise within the home environment. These guidelines are provided for each individual and placement situation. Included are: what should be done; who should do it; what services should be called, etc. The individual's wishes regarding resuscitative efforts should be addressed and be available in the home for emergency response personnel. The individual must have:  A Family Physician who will manage day to day general medical needs  A Respirologist or other consultant who has expertise in mechanical ventilation, to  manage ventilation needs A “home-base” hospital location should an emergency occur that cannot be solved at home. Ideally this is the acute-care facility discharging the individual home For those caregivers wishing for Cardiopulmonary Resucsitation (CPR) certification, discuss this training with your healthcare provider. Guidelines are provided that include contact numbers of home care providers and support services. Communication and Transfer of Information to Community Providers With the individual’s consent, the discharge team should ensure the community care partners receive information on:  Medical history  Written consent  Care plan, preferences, daily routines, typical patterns where interventions are    required Transfer and discharge notes from the discharging physician Emergency guidelines Equipment and supplies list Page 8 Identification and Preparation Tool Healthcare Professionals References Dyson, J., Vrlak, A., & Provincial Respiratory Outreach Program (PROP). (2004). Provincial Respiratory Outreach Program discharge planning guide (User Guide). Vancouver: BC Association for Individualized Technology and Supports for People with Disabilities (BCITS). Long-term Ventilated Patient Transfer Working Group. (2007). Preparation of an ICU patient for transfer to LTV Unit. Toronto: Toronto Central Local Health Integration Network. Make, B., Hill, N., Goldberg, A., Bach, J., Criner, G., Dunne, P., et al. (1998). Mechanical ventilation beyond the intensive care unit. Quick reference guide for clinicians. Highlights of patient management. Make, B., Hill, N., Goldberg, A., Bach, J., Criner, G., Dunne, P., et al. (1998). Mechanical ventilation beyond the intensive care unit. Report of a consensus conference of the American College of Chest Physicians. Chest, 113(5 Suppl), 289S-344S. Montgomery, J. (2006). An aid for identification and considerations for community placement of the long term ventilator dependent person. London: Respiratory Community care, London Health Sciences Centre. Page 9 Identification and Preparation Tool Healthcare Professionals Notes Page 10 Discharge Checklists Preparation for Hospital Discharge Discharge Checklists Preparation for ICU Discharge Discharge Checklists Discharge Checklists Notes Preparation for ICU Discharge Preparation for ICU Discharge Healthcare Professionals Decrease Invasive Monitoring Lines  Remove arterial line  Remove Nasogastric tube (NG tube), and other invasive lines/tubes  If patient cannot have oral intake, switch NG tube to Gastrostomy tube (G-tube) or a  Jejunostomy tube (J-tube) Cap Peripherally Inserted Central Catheter (PICC) lines if possible Blood Work  Reduce blood work frequency Ventilation and Oxygenation  Reduce to lowest FiO2 to maintain SpO2 88-92%, and lowest PEEP (if at all required)  Avoid using continuous pulse oximetry once Arterial Blood Gases (ABG) and oximetry  have determined oxygen requirements. Use for periodic assessments of SpO2 If available, switch the patient from a critical care ventilator to one that would be used in the home/community setting Page 1 Preparation for ICU Discharge Healthcare Professionals Treatment Plan Ventilation & Weaning  If weaning is an option, consult/refer to Toronto East General Weaning Centre of    Excellence Have ICU staff and allied healthcare professionals refrain from using the word “weaning” Instead, encourage staff to use the phrase “ventilator free time” Encourage the patient to increase their ‘ventilator free time’, even if it is in small increments. In the event of an accidental disconnect from the ventilator at home, the longer the ventilator free time, the safer. This also reduces caregiver anxiety For mechanical ventilation, use the simplest settings. Use assist control mode whenever possible since it is the most widely used ‘invasive’ mode. Most home ventilators do not have a pressure support option. However, one can petition the Ministry of Health for a ventilator with pressure support, if this is the only approach to ventilate Tracheostomy Tube Select a tracheotomy tube that is most appropriate for the patient’s comfort and goals. The most desirable features for the new tracheostomy tube are:  Cuffless or ‘Tight to Shaft’ Cuff: This decreases secretions caused from irritation of the        cuff, increases potential for speech and increases sense of smell and taste Nonfenestrated Limitations: Tends to cause granulomatous tissue in the airway Reusable Inner Cannula: To decrease the frequency of suctioning, teach the patient to cough to the inner cannula and keep it clear Other tracheostomy tube models or characteristics are fully acceptable, if the above choices are not suitable Changing the tracheostomy tube to one of these desirable tubes is not a necessity before transferring out of the ICU, but will ease the transition If the caregivers in the community or the long-term care facility do not have access to or experience with alternative tracheostomy tubes, it would be best for the patient to wait before transitioning home If a specialty tracheostomy tube is selected, ensure that the caregivers or the long-term care facility knows how to reorder the speciality tubes Assess the patient for the ability to communicate/speak while ventilated B cuff deflation B cuffless tube B speaking valve/one way valve usage Page 2 Preparation for ICU Discharge Healthcare Professionals  Ensure that the patient is well rested and there are no nutritional deficiencies  Consider a swallowing study by a Speech-Language Pathologist, if not already completed Increase Independence  Discuss differences between ICU care and care in the home/community or long-term care           facility e.g.: B Expectation that patient will dress daily B Radically reduced “patient/staff” ratio B Increased independence Educate and train patient/family/caregivers on manual resuscitation bagging and suctioning techniques (these will be reinforced in the community) Move the patient to an area of the ICU with less activity, if possible Step down nursing complement. Consider the patient to nurse ratio Encourage use of a call bell, if able Dress the patient in his/her own clothes Encourage the patient to move to an upright chair as often as possible Have Occupational Therapy (OT) assess and begin process for obtaining equipment necessary for mobility and increased independence Consider taking the patient out of ICU for short periods of time, i.e. with staff and/or family Establish a routine bowel/bladder plan of care – regular day/night routine If going to a long-term care facility have someone from the receiving facility speak with family/caregivers about the program and take a tour of the facility Other  Co-payment charges should be discussed with the family  Possible equipment and service charges such as TV, telephone, chiropody, hairdressing Page 3 Preparation for ICU Discharge Healthcare Professionals Notes Page 4 Preparation for Hospital Discharge Preparation for Hospital Discharge Healthcare Professionals Hospital Discharge Checklist Tasks Patient/client is Medically Stable Successful Trial on Home Equipment Decrease Invasive Monitoring Initials of HCP      Stable blood gases           Home ventilator obtained Oxygen less than, or equal to 40% Established tracheostomy No CPR required for at least one month Plan for family/caregivers to do more independent care Patient/Client set-up on home unit Hospital walks, off unit Trial car ride Car seat test, if applicable Monitors Oxygen Feeding pump Remove any invasive lines Ensure education for lines that will remain in place at home  Ensure feeding is established B NG tube B G-tube B J-Tube B oral  Reduce blood work frequency  Switch over to home ventilator  Ensure patient is weaned on current settings  Self inflating resuscitation bag to be with patients at all times Treatment Plan  Use simplest ventilation settings, if possible  Use a trach tube that is appropriate for the patient’s comfort/goals  Ensure schedule is established for other therapies Page 1 Date Completed Preparation for Hospital Discharge Healthcare Professionals Tasks Caregiver and Family Education        Initials of HCP Suctioning Tracheostomy mask Breath stacking In-Exsufflator Speaking valve Other: ____________________________ Caregiver education is complete (See My Education Checklist and Learning Log)  Plan for caregivers to do more independent care (including walks off the unit and trial car rides)  CPR Certification  Care by parent completed (at least 24 hours unassisted) using own home equipment.  Tour of ICU/NICU Education of community caregivers (including Daycare or School).  Family/Caregiver visit to current home ventilated patient  Ensure the home care company has provided all the necessary equipment and training in the use of equipment provided to the family, i.e. compressor, cardiorespiratory monitor, suction unit and their accessories Documents  Discuss ADP funding  Complete ADP applications (contact ADP if help is required)  Equipment from the Ventilator Equipment Pool; Ventilators, Oximeters, Bilevel devices. Contact VEP for estimated delivery time; often takes 2-4 weeks  For other related respiratory supplies, contact the vendor of client’s choice  Complete Assistance for Children with Severe Disability (ACSD) application with physician letter, if appropriate  Complete HOP form with qualifying oximetry strip, if appropriate Page 2 Date Completed Preparation for Hospital Discharge Healthcare Professionals Tasks Initials of HCP  Insurance contacted  Contact Ontario Disability Support Program (ODSP) or other funding agency for battery to be mounted on wheelchair, if appropriate  Family to contact private insurance, if appropriate  Social worker to assist in securing additional funds  Phone contact list for family/caregivers  “Who to call and when” list to family/caregivers  Ensure family/caregivers have teaching material, manuals needed  Letters given to family to provide to police, ambulance, hydro, and telephone facilities (to alert community providers)  Application for Accessible Parking Permit  Discharge summary  Rehab reports and referrals; including respite care  Prescriptions provided and medications ordered Equipment Needs      Confirm delivery date of equipment Car seat test done Specialty seating and mobility devices set up Equipment set up on wheelchair or stroller For patients that are off their ventilators for short periods or all day, a trach hood and appropriate humidity set ups are also required  Contact OT for assistance in mounting ventilator on wheelchair Follow-up  Community paediatrician identified and patient summary delivered  Follow-up appointments made Page 3 Date Completed Preparation for Hospital Discharge Healthcare Professionals Tasks Home and Community     Initials of HCP Date Completed Home ready including electrical needs Emergency action plan has been devised Enhanced respite funding (CCAC) Letter to police, fire, ambulance, hydro, and telephone facilities  Arrangements made with pharmacy  Calendar of appointments  Contact List: “Who to call and when” list to family/caregiver Healthcare Provider (HCP) Name/Designation Signature Page 4 Initials Pulmonary Clearance Techniques Pulmonary Clearance Techniques Education Checklists Routine Tasks My Education Checklist and Learning Log Oximeter Teaching Checklist Healthcare Professionals Ventilation & Tracheostomy Care Home Ventilation & Tracheostomy Care (for Adults) Non-Invasive Positive Pressure Ventilation (for Adults) Home Ventilation & Tracheostomy Care (for Pediatrics) Introduction & Glossary of Terms Section #3: Patients/Clients & Caregivers Troubleshooting Troubleshooting Guide Patients/Clients & Caregivers Emergency Contacts & Planning Emergency Contacts and Planning Useful Web Resources Acknowledgement of Source Emergency Preparedness Guide for People with Disabilities/Special Needs Appendices Introduction & Glossary of Terms Healthcare Professionals Section #3: Patients/Clients & Caregivers Ventilation & Tracheostomy Care Home Ventilation & Tracheostomy Care (for Adults) Non-Invasive Positive Pressure Ventilation (for Adults) Home Ventilation & Tracheostomy Care (for Pediatrics) Pulmonary Clearance Techniques Pulmonary Clearance Techniques Education Checklists Routine Tasks My Education Checklist and Learning Log Oximeter Teaching Checklist Appendices Patients/Clients & Caregivers Troubleshooting Troubleshooting Guide Emergency Contacts & Planning Emergency Contacts and Planning Useful Web Resources Acknowledgement of Source Emergency Preparedness Guide for People with Disabilities/Special Needs Ventilation & Tracheostomy Care Home Ventilation & Tracheostomy Care Teaching Manual for Adults Non-Invasive Positive Pressure Ventilation (for Adults) Teaching Manual for Paediatrics Ventilation & Tracheostomy Care Home Ventilation & Tracheostomy Care Ventilation & Tracheostomy Care Ventilation & Tracheostomy Care Notes Home Ventilation & Tracheostomy Care Teaching Manual for Adults Table of Contents Introduction ...................................................................................................................... 1 The Normal Respiratory System ........................................................................................ 2 What Happens When I Breathe? ............................................................................................ 6 Preventing Infection .......................................................................................................... 7 What can I do to Prevent Infections? ..................................................................................... 7 What is Pneumonia? ............................................................................................................... 8 What are the signs of an infection? ........................................................................................ 8 What should I do if I have an infection? ................................................................................. 8 Washing Your Hands at Home ................................................................................................ 9 Sterilizing Distilled Water...................................................................................................... 10 Tracheostomy Care ......................................................................................................... 11 What is a Tracheostomy?...................................................................................................... 11 How do I Prepare to go Home With a Tracheostomy? ......................................................... 12 Where should I do my trach care? ........................................................................................ 13 Description of Tracheostomy (Trach) Tubes ......................................................................... 14 Types of Trach Tubes ............................................................................................................ 17 How do I know when I should replace my trach tube? ........................................................ 19 Stoma Care ............................................................................................................................ 20 Trach Tube Care .................................................................................................................... 22 Other Information About Trach Tubes ................................................................................. 26 Speaking Valves..................................................................................................................... 29 Trach Kit ................................................................................................................................ 32 Special Considerations .......................................................................................................... 29 Tracheal Suctioning ............................................................................................................... 33 Other Helpful Tips ................................................................................................................. 37 Changing the Trach Tube ...................................................................................................... 38 Mechanical Ventilation ................................................................................................... 41 What is Mechanical Ventilation? .......................................................................................... 41 Why is Mechanical Ventilation Needed? .............................................................................. 41 Ventilator Settings ................................................................................................................ 42 Modes of Ventilation ............................................................................................................ 42 Ventilator Rate ...................................................................................................................... 43 Ventilator Power Sources ..................................................................................................... 45 The Ventilator Circuit ............................................................................................................ 50 Ventilator Safety and Trouble Shooting................................................................................ 54 Other Equipment ............................................................................................................ 57 Using and Cleaning the Portable Suction Unit ...................................................................... 57 The Manual Rescusitation Bag .............................................................................................. 59 Humidifiers ............................................................................................................................ 63 Inhaled Medicine .................................................................................................................. 68 Other Issues .................................................................................................................... 69 Assistive Devices Program (ADP) Funding for Respiratory Supplies ..................................... 69 The Ventilator Equipment Pool............................................................................................. 71 References ...................................................................................................................... 73 Home Ventilation and Tracheostomy Care Training Manual for Adults Introduction This Manual has been written to help you learn how to care for your ventilator and tracheostomy. It will provide instructions on the basic care of a tracheostomy tube and will be yours to keep as a reference guide. This Manual will give you some instruction on how to suction, change the trach ties, change the trach tube, and some general safety guidelines. This book is only a guide. If you have any questions, ask any of your healthcare professionals. Important terms are used in this manual. Please refer to the Glossary of Terms for a complete list of definitions. A Troubleshooting section is also available. Page 1 Home Ventilation and Tracheostomy Care Training Manual for Adults The Normal Respiratory System The respiratory system is made up of the: Upper Respiratory Tract  Nose  Mouth  Larynx (voice box) Lower Respiratory Tract  Trachea (windpipe)  Right and Left Lung  Airways (bronchi)  Alveoli (air sacs)  Capillaries Respiratory Muscles  Diaphragm (largest muscle)  Intercostals (rib cage muscles)  Abdominal Muscles Figure 1: Respiratory System Illustration used with permission from Hamilton Health Sciences The nose is the best way for outside air to enter the lungs. In the nose the air is cleaned, warmed and moistened. There are hairs lining the inside of the nose that filter the air. When you breathe through your mouth you are not filtering the air, but it will be warm and moist. When you have a cold and your nose is blocked you may not be able to breathe through your nose. Page 2 Home Ventilation and Tracheostomy Care Training Manual for Adults The larynx (voice box) contains the vocal cords. This is the place where air, when breathed in and out, creates voice sounds. It is also used to build up pressure for a strong cough. Figure 2: Larynx Reproduced with permission from Ottawa Rehabilitation Centre The epiglottis is a flap of tissue that hangs over the larynx (voice box). When you swallow food or drink this flap covers the voice box and windpipe so you do not choke. Figures 3 & 4: Epiglottis Reproduced with permission from Ottawa Rehabilitation Centre The trachea (wind pipe) is the tube leading from the voice box to the lungs. Figure 5: Trachea Reproduced with permission from Ottawa Rehabilitation Cente Page 3 Home Ventilation and Tracheostomy Care Training Manual for Adults The bronchi are tubes that let air in and out of the lungs. The bronchi lead to tiny air sacs called the alveoli. Mucous is made in the smaller tubes. The mucous traps dust, germs and other unwanted matter that has been breathed into the lungs. Tiny hairs called cilia move back and forth moving the mucous up toward the throat where it is can be coughed out or swallowed. Figure 6: Bronchi Reproduced with permission from Ottawa Rehabilitation Centre The capillaries are blood vessels that are in the walls of the alveoli (air sacs). Blood flows through the capillaries, removing carbon dioxide from the air sacs and picking up oxygen. Figure 7: Capillaries and Air Sac Diagram courtesy of SIMS Portex Inc Tracheostomy Care Handbook 1998 The ribs are bones that support and protect the chest cavity. They move up and out, helping the lungs expand and contract. Figure 8: Rib Cage Reproduced with permission from Ottawa Rehabilitation Centre Page 4 Home Ventilation and Tracheostomy Care Training Manual for Adults The diaphragm is a large strong muscle that separates the lungs from the belly. When the diaphragm contracts it moves downward, creating a suction effect, drawing air into the lungs. The intercostals are the muscles in-between the ribs. There are two types of intercostals muscles. The external intercostals help you take deep breaths in, such as when you prepare to cough. The internal intercostals help you forcefully breathe out, such as when you cough or sneeze. The abdominal muscles help create a good strong cough. Figure 9: Intercostal and Abdominal Muscles Reproduced with permission from Ottawa Rehabilitation Centre Page 5 Home Ventilation and Tracheostomy Care Training Manual for Adults What Happens When I Breathe? Breathing In When you breathe in a large muscle called the diaphragm contracts causing air to be sucked into the lungs. The air that is carried into the lungs contains oxygen that your body needs to survive. When you breathe in, the diaphragm moves down and the ribs move out and up. This causes a suction effect that lets air come into the lungs. The air comes into the nose where it is warmed, filtered and moistened. The air then goes down the windpipe past the voice box. From there it moves into two large main branches of the lungs called the left and right bronchi. The air moves through airways that get smaller and smaller until they reach tiny air sacs. These air sacs let oxygen into the capillaries. The blood flows from these capillaries to the heart where it is pumped out to the body. Breathing Out When you breathe out the lungs remove carbon dioxide, a gas that your body does not need. Just before you begin to breathe out the carbon dioxide goes across from the capillaries into the air sacs. The air sacs begin to relax and the air begins to move out of the lungs. Then the diaphragm and the muscles between the ribs also relax. This causes the ribs to gently fall, helping to push the air out from the lungs. Under normal conditions, the diaphragm and rib cage muscles are relaxed when you breathe out. However, when you cough or sneeze, these muscles work hard to push the air out quickly. Normally breathing takes place without any thought. Some conditions can cause breathing problems. Every condition is different. So talk to your healthcare professionals about how your condition affects your breathing. Page 6 Home Ventilation and Tracheostomy Care Training Manual for Adults Preventing Infection What can I do to Prevent Infections? Keep Things Clean! Hands  Insist that everyone wash their hands, often  Buy hand sanitizers for your home Air  Make your home smoke free. Insist that no one smoke around you  Tell friends and family to stay away if they have a cold or the flu. If they need to be near you they must wear a mask and wash their hands often Trach  Follow trach care instructions carefully. Clean trach tubes  Keep the trach dressings and the stoma (opening) clean and dry Equipment  Clean equipment regularly, such as ventilator tubing and suction equipment  Replace equipment on a regular schedule. Ask your healthcare professional when supplies are to be thrown out IMPORTANT! It is very important that everyone wash their hands. Wash your hands before and after doing anything with the trach tube or the stoma. Page 7 Home Ventilation and Tracheostomy Care Training Manual for Adults What is Pneumonia? It is important to protect the lung from viruses and germs. If the air you breathe is clean and moist, it will stop an infection from happening. Breathing in dry, dirty air can cause germs and viruses to get into the lung, which can lead to pneumonia. Pneumonia is a lung infection where the airways swell and more mucous than normal, is made. Pneumonia can lower the amount of air getting into the lungs. It can also lower the amount of oxygen getting into the blood. IMPORTANT! Wash your hands before and after doing anything with the tracheostomy. What are the signs of an infection? If you have any of these signs, it may mean you have an infection. You are:      coughing more have a fever or the chills feeling unwell or are really tired more short of breath having chest tightness You need:  to be suctioned more often  to take your puffers more often Your ventilator:  has higher than normal pressures Your mucous: Your stoma:  is thick and/or there is more of it  is yellow or green  has an unpleasant smell  is red, swollen or is painful What should I do if I have an infection?  Call your doctor or healthcare professional if think you have an infection.  Follow your doctor's orders on taking medicine, such as antibiotics.  If you have an action plan, go over it with your healthcare professional. Do not be afraid to ask for advice. Page 8 Home Ventilation and Tracheostomy Care Training Manual for Adults Washing Your Hands at Home Figure 10 : Hand Washing Reproduced with permission from the World Health Organization Accessed on July 7, 2009 from: http://www.who.int/gpsc/tools/GPSC-HandRub-Wash.pdf Page 9 Home Ventilation and Tracheostomy Care Training Manual for Adults Sterilizing Distilled Water Why do I need sterile distilled water? You will be instructed to use sterile distilled water several times in this manual. To help stop infections from happening you need to make sure you use sterile distilled water. You will need sterile distilled water when you:     Suction the trach tube Fill a pass over humidifier Clean the tracheostomy opening Clean the trach tube inner cannula Legionella is a germ that can grow in water. To stop germs from growing, use sterile distilled water. You can buy sterile distilled water or you can boil distilled water to sterilize it. You can buy distilled water from your home care company, drug store or supermarket. IMPORTANT! Only use distilled water that has been sterilized. This will help stop lung infections from happening. 1 How do I make sterile distilled water? 2 Follow the directions below to make enough sterile distilled water to last 2 or 3 days. Do not use the water after the 3rd day. Make or buy more. 1. Find one pan with a lid, large enough to boil enough water for 2-3 days. Use this pan for sterilizing distilled water only. Do not use this pan to cook with 2. Bring the distilled water to a boil. Let boil for 5 minutes 3 3. Turn off heat and cover the pan. Never leave the pan unattended. Use the boiled distilled water as soon as it has cooled or put it in a clean container and seal. It does not need to be refrigerated 4. To sterilize the containers, put the containers in the water and let the water boil for 10 minutes. Turn off heat and cover the pan with a lid 5. Leave the lid on the pan while the water is cooling. Do not use ice