1. Chapter 51 Respiratory Care in Alternative Settings

2. 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.
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3. 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.
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4. 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.
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5. 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.
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6. 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.
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7. 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.
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8. 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
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9. 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.
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10. 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
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11. 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
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12. 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.
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13. 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.
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14. 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
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15. 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.
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16. 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)
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17. 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
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18. 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
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19. Oxygen Therapy in Alternative Settings (cont.)
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20. Ventilator Support in Alternative Settings
Patient selection
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21. 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).
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22. 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.
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23. 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.
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24. Ventilator Support in Alternative Settings (cont.)
Positive-pressure ventilators
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25. 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.
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26. 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
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27. 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.
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28. 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.
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29. 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.
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30. 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.
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31. 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.
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32. 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.
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33. Other Modes of Postacute Respiratory Care (cont.)
Nasal CPAP (cont.)
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34. 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
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35. 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
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36. 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
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37. 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.
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38. 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.
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39. 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.
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