Chapter 51 Respiratory Care in Alternative Settings

Objectives Describe alternative care settings in which respiratory care is often performed. Describe the recent developments and trends in alternative site respiratory care. Describe who regulates postacute care. List the standards that apply to the delivery of postacute respiratory care. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont.) Describe how to help formulate an effective discharge plan. List factors to evaluate when assessing alternative care sites and support services. Describe how to justify, provide, evaluate, and modify oxygen (O2) therapy in postacute care settings. Describe how to select, assemble, monitor, and maintain O2 therapy equipment in alternative settings. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont.) State the special challenges that exist in providing ventilatory support outside the acute care hospital. Describe how to instruct patients or caregivers and confirm their ability to provide postacute care. Identify which patients benefit the most from ventilatory support outside acute care hospitals. Describe how to select, assemble, monitor, and maintain portable ventilatory support and continuous positive airway pressure (CPAP) equipment, including applicable interfaces or appliances. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont.) Describe proper documentation regarding patient evaluation and progress in postacute care. State how to ensure safety and infection control in alternative patient care settings. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Recent Developments and Trends Introduction Medicare introduced the prospective payment system (PPS) in the 1990s. This system limits the reimbursement for respiratory care equipment to a predetermined monthly payment. Other legislation has limited payment for home O2 therapy. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Recent Developments and Trends (cont.) Introduction (cont.) Reimbursement for the care provided by respiratory therapists in the homecare setting is not provided by Medicare. Recent research is showing that respiratory therapists can reduce the cost of care and achieve better outcomes for patients in skilled nursing facilities. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Definitions and Goals The 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Definitions and Goals (cont.) Subacute care A 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 can be found at these sites. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Definitions and Goals (cont.) 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Standards Standards for providing respiratory care in subacute and home settings are derived from: AARC clinical practice guidelines Federal and state laws Private-sector accreditation standards Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Standards (cont.) Regulations Medicare plays a major role in setting the standards for care outside the hospital. Institutions undergo certification surveys to determine their compliance with the standards. Each state also has regulations in place for quality assurance. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Standards (cont.) Private sector accreditation The primary organization responsible for setting patient care standards in the subacute care setting is The Joint Commission. Approximately 95% of health care organizations voluntarily subscribe to The Joint Commission accreditation. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Traditional Acute Care Versus Postacute Care Respiratory therapists working in alternative care settings Have less equipment and resources Work more independently Complete more paperwork Are often on-call Are part of a team approach Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Discharge Planning Multidisciplinary team All team members must be a part of the discharge. Site and support service evaluation The 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Oxygen Therapy in Alternative Settings The O2 therapy prescription Must include: Flow rate in liters/minute and/or concentration Frequency of use Duration of need Diagnosis Laboratory evidence (ABGs) Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Oxygen Therapy in Alternative Settings (cont.) Supply methods Compressed O2 cylinders Primarily used for ambulation (small cylinders) or as a backup to liquid or concentrator systems Liquid O2 systems Oxygen concentrators Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Oxygen Therapy in Alternative Settings (cont.) Delivery methods The most common O2 delivery system for long-term care is the nasal cannula. Transtracheal O2 therapy is used in selected patients; it conserves the use of O2 and has cosmetic advantages. Demand-flow O2 systems Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Oxygen Therapy in Alternative Settings (cont.) Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings Patient selection Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings (cont.) Invasive vs. noninvasive ventilatory support Noninvasive ventilatory support is becoming increasingly popular. Noninvasive positive-pressure ventilation (NPPV) is most often used. Patients receiving NPPV must meet certain criteria (e.g., patient must be cooperative and not need high FIO2). Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings (cont.) Selecting the appropriate ventilator The choice of a ventilator depends on the needs of the patient. A backup ventilator should be provided for patients who cannot maintain spontaneous ventilation for more than 4 hours. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings (cont.) Selecting the appropriate ventilator (cont.) Ventilators used in alternative sites must be dependable and easy for caregivers to operate. The ventilator must be portable for patients who are mobile. Electrically powered ventilators are often the best choice in alternative health care sites. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings (cont.) Positive-pressure ventilators Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings (cont.) Positive-pressure ventilators (cont.) Most patients, especially those with COPD, prefer pressure-limited over volume-cycled ventilation. Those with neuromuscular disorders may prefer volume ventilation. The biggest challenge with NPPV is getting a good, comfortable, leak-free interface. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings (cont.) Negative-pressure ventilators Iron lung has been replaced with the chest cuirass and wrap or “pneumosuit.” Rarely used for ventilatory support in postacute care settings Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Ventilator Support in Alternative Settings (cont.) Evaluation and follow-up Vital signs, lung sounds, and sputum production should be monitored on a daily basis. ABGs and lung compliance only on an as-needed basis. Routine follow-up visits by a respiratory therapist help ensure the success of patient management in the home. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

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 the primary risk. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Other Modes of Postacute Respiratory Care (cont.) 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Other Modes of Postacute Respiratory Care (cont.) Airway care and clearance methods Patients with tracheostomies require daily care. Tube changes should be done only by a nurse, respiratory therapist, or physician. Suctioning is provided using a portable electrically powered suction pump. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Other Modes of Postacute Respiratory Care (cont.) Airway care and clearance methods (cont.) 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Other Modes of Postacute Respiratory Care (cont.) Nasal CPAP An accepted form of therapy to treat sleep apnea For Medicare reimbursement, the diagnosis must be confirmed by a polysomnogram. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Other Modes of Postacute Respiratory Care (cont.) Nasal CPAP (cont.) Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Assessment and Documentation In the institution providing subacute or long-term care, the assessment and documentation process involves: Screening Treatment planning Ongoing assessment Discharge Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Assessment and Documentation (cont.) 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Assessment and Documentation (cont.) Home care (cont.) Functions of the respiratory therapist 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Equipment Disinfection and Maintenance 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Equipment Disinfection and Maintenance (cont.) Proper hand washing by all caregivers in the home is important. Visits by friends with respiratory infections are discouraged. Distilled water is the first choice for humidifiers used in the home. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

Palliative Care Maximizing comfort of the patient who is terminally ill is a goal of home care. Palliative care involves control of symptoms such as pain and dyspnea in the terminally ill patient while maximizing the psychological and spiritual well-being of the patient. Respiratory therapists may play a key role when lung disease is present in the terminally ill patient. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.